Herts Valleys Clinical Commissioning Group...To ensure transparency and openness, individuals should notify the Chair of any potential conflicts of interest in relation to agenda items,

January 2019

Herts Valleys Clinical Commissioning Group Board meeting held in public Thursday 30 January 2020, 09:00am

Three Rivers District Council, Three Rivers House, Northway, Rickmansworth, WD3 1RL Note concerning HVCCG management of conflicts of interest. A conflict of interest occurs where an individual’s ability to exercise judgement, or act in a role is, could be, or is seen to be impaired or otherwise influenced by his or her involvement in another role or relationship. In some circumstances, it could be reasonably considered that a conflict exists even when there is no actual conflict. In these cases it is important to still manage these perceived conflicts in order to maintain public trust. Members and attendees of the Committee are reminded of their responsibilities.

To ensure transparency and openness, individuals should notify the Chair of any potential conflicts of interest in relation to agenda items, even if the interest is already formally recorded.

January 2019

The Nolan Principles

In May 1995, the Committee on Standards in Public Life, under the Chairmanship of Lord Nolan, established the Seven Principles of Public Life, also known as the “Nolan principles”. These principles are the basis of the ethical standards expected of all public office holders. The Herts Valleys CCG Constitution recognises that in all its work it must seek to meet the highest expectations for public accountability, standards of conduct and transparency. It will therefore ensure that the Nolan principles, set out below, are taken fully into account in its decision making and its policies in relation to standards of behaviour. 1. Selflessness. Holders of public office should act solely in terms of the public interest. 2. Integrity. Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships. 3. Objectivity. Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias. 4. Accountability. Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this. 5. Openness. Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing. 6. Honesty. Holders of public office should be truthful. 7. Leadership. Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs.

Agenda

Board Meeting held in Public Thursday 30 January 2020 9:00 am

Three Rivers District Council, Three Rivers House, Northway, Rickmansworth, WD3 1RL

Meeting Quorum:

Eight board members, GPs from three localities, one lay member and one executive member

Note to representatives of the press and members of the public Members of the public are reminded that CCG Board meetings are meetings held in public, not public meetings. However, the Board provides members of the public at the start of each meeting the opportunity to ask questions that relate to the agenda items. The Chair will not normally allow more than one question per person due to time constraints. The time given over to questions will need to be limited in order for the board to cover their agenda fully within the given time Members of the public are urged, if possible, to give notice of their questions at least 48 hours before the beginning of the meeting in order that a full answer can be provided; if notice is not given, an answer will be provided whenever possible but the relevant information may not be available at the meeting. If such information is not available, the CCG will provide a written answer to the question as soon as is practicable after the meeting. The Secretary can be contacted by email ([email protected]), by telephone (01442 284074), or by post to: Board Secretary, Herts Valleys Clinical Commissioning Group, First Floor, The Forum, Marlowes, Hemel Hempstead HP1 1DN Audio Visual Recording The CCG will be recording the board meeting to provide access to proceedings for people unable to attend the meeting in person. We would like to inform you that the CCG assumes you have given consent to being recorded by registering your attendance on arrival at this meeting. The CCG does not permit any other audio or video recording of the board meeting unless expressly agreed by the Chair in advance of the meeting and with prior agreement of all members of the public present at the meeting. Anyone found using such a device without prior agreement will be asked to cease recording and may be asked to leave the meeting.

mailto:[email protected]

Herts Valleys Clinical Commissioning Group

Board agenda Thurs 30 Jan 2020 contd.

Meeting in public Led by Administrative items 1. Chair’s introduction and apologies for absence For information Nicolas Small 9:00 2. Interests to declare and how they will be managed For information and

agreement Nicolas Small

Link to registers of interest: Managing conflicts of interest : Herts Valleys CCG 3. Minutes of meeting held on 28 November 2019 For approval Nicolas Small 09:10 4. Matters arising and action log:

– Update on action B/117/4/19 – Better Care Fund – Update on action B/115.4/19 – Staff survey action plan

For approval Nicolas Small 09:15

5. Questions received prior to meeting from members of the public

For information Nicolas Small 09:30

Strategic discussion 6. CEO’s report For discussion David Evans 09:35 7. Board assurance framework (BAF) For approval Rod While 09:50 8. Board arrangements for 2020/21 For approval Rod While 10:05 9. West Herts Integrated Care Partnership Update

Report For discussion David Evans 10:20

Break: 10.45 - 11:00 Performance 10. Finance report (inc. planning update 2020/21) For assurance Elke Taylor 11:00 Governance and assurance 11. Communications and engagement report For discussion Juliet Rodgers 11:15 12. Audit committee report For assurance Paul Smith 11:25 Committee minutes 13. - Quality Committee

- Performance Committee - Audit Committee - Finance Committee - Commissioning Executive - Patient & Public Involvement - Primary Care Commissioning Committee

(public)

For information Diane Curbishley Diane Curbishley

Rod While Elke Taylor

David Evans Rod While

Lynn Dalton

11:35

Administrative items 14. Reflection on equality and diversity in relation to

decisions For agreement Nicolas Small 11:40

15. Risks identified during the meeting For discussion Nicolas Small 16. Date and time of next meeting: 26 March 2020,

09:00am, St Albans Chambers Room, Civic Centre, St Peters Street, St Albans, AL1 3JE

Verbal Nicolas Small

17. Close of meeting Verbal Nicolas Small 11:45

https://hertsvalleysccg.nhs.uk/download_file/view/3444/223

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Meeting

:

NHS Herts Valleys CCG Board Meeting in Public

Date : 28 November 2019

Time : 9:16 – 10:36am

Venue

: Hertsmere Council Committee Room, Elstree Way, Borehamwood, WD6 1WA

Members present: Nicolas Small (NS) CCG Chair Stuart Bloom (SB) Lay member Daniel Carlton-Conway (DCC) GP member and Locality Chair (St Albans and Harpenden) Diane Curbishley (DC) Deputy CEO and Director of Nursing and Quality Alison Gardner (AG) Lay member Rami Eliad (RE) GP member (Watford and Three Rivers) Asif Faizy (AF) GP member and Locality Chair (Watford and Three Rivers) Trevor Fernandes (TF) GP member (Dacorum) Kathryn Magson (KM) Chief Executive Officer Richard Pile (RP) GP member (St Albans and Harpenden) Paul Smith (PS) Lay member Thelma Stober (TS) Lay member In attendance: Jill Ainsworth-Beardmore (JAB) Patient Representative Lynn Dalton (LD) Director of Primary Care David Evans (DE) Director of Commissioning Elizabeth Eyitayo (EE) Executive Clinical Lead for Primary Care Iram Khan (IK) Corporate Governance Support Manager (minutes) Ian Macbeth (IM) Director of Adult Care Services, Herts County Council Elke Taylor (ET) Acting Chief Finance Officer John Wigley (JW) Patent Representative Rod While (RW) Head of Corporate Governance There were 3 members of staff and the public observing the meeting. B/127/19 Welcome and apologies 127.1 The Chair welcomed the board to the public session and made the following comments relating

to public attendance at the meeting: • The meeting was being recorded to provide access to the proceedings for people unable to

attend the meeting in person. • Apologies for the meeting were received from Kate Page. • The meeting was quorate.

B/128/19 Declarations of interest 128.1 • All GP members could be conflicted on any of the items as practicing GPs in the area and as

possible providers of services. This was acknowledged and noted. • There were no other specific declarations in respect of the agenda items requiring a decision.

128.2 The board noted that there were no other specific declarations in respect of the agenda items.

DRAFT Item 03

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B/129/19 Review of previous minutes 129.1 The Board approved the minutes of the public meetings held on 26 September 2019. B/130/19 Action log and matters arising 130.1 The following updates were noted:

• B/126.5/18 – Priorities for joint working with HCC public health – presentation has been given to Commissioning Executive and can be closed on the board action log.

• B/115.4/19- Board Assurance Framework – RW advised BAF risk 3.4 has been repositioned as a transformation risk – action closed.

• B/117.4/19 – Better Care Fund Plan - DE will provide an update on 30 January 2020. • B/115.4/19 – Staff survey action plan – KM informed that this year’s current survey is due to

close in February and that the outcomes will be shared with the board as usual and an action plan developed based on the findings with the staff. In relation to last year’s survey there continues to be a number of organisational development sessions. .

130.2 The board noted the updates on the action log. B/131/19 Questions from the public 131.1 RW advised the board that a question came in from a member of the public on 27 November;

this will be responded to in writing and shared with the board accordingly. B/132/19 CEO Report 132.1 KM introduced the paper with the following points:

• This is the final report as Accountable Officer for the CCG. Expressing thanks to the staff, Execs, board GPs, lay members, patients and wider membership.

• The organisation has been through significant transformation and noting that it is in a great place to drive the transformation forward.

• ICP development work is continuing and progress is being made across the system, noting alignment across the boards and providers and engagement with lay members and non-executive directors.

• EU Exit – assurance process has been carried out and is now marked as green. There is continued work within care homes, providers and medicines management.

• ET is the Senior Responsible Officer for EU Exit for the CCG. • Two final audit reports have provided substantial assurance and one with reasonable

assurance. This represents excellent progress in the strength of assurances to the board on internal audit assignments.

• Operational: funding of an evidence based early years prevention weight management programme (HENRY) for parents of 0-5 year olds for Herts Valleys families jointly with Public Health and Herts County Council (HCC) has been approved and will be rolled out in September 2020.

• Social prescribing grants with Primary Care Networks (PCNs) have been sent out and are awaiting responses.

• Clinical directors meeting provided good engagement around the direction of travel, noting positive feedback.

• There are support packages proposed for PCNs. • Effective Resource Management (ERM) meetings are scheduled for December for all the

providers. • Progress has been made within Children and Young People Continuing Care (CYPCC), focus is

on provision, noting pressures within workforce. • CAMHs – DE will co-chair the CAMHs board meeting from January. Demand and capacity

review is taking place and will be presented to board once completed. • Central London Community Healthcare Trust (CLCH) – focus is on transformation. KM

commented that at this point in the year there is community bed capacity. IM added that approximately there are 800 discharges a month from Hertfordshire hospitals however in October there has been 1100, noting a huge increase.

• Human resources – midyear appraisals for all staff members will be carried out online

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through ESR. 132.2 The following points were made in discussion:

• TF commented that he would welcome the support in the PCN development and moving the PCN agenda forward through the Primary Care Commissioning Committee.

• KM commented that there continues to be significant investment in mental health and the team are now looking at next year’s investments. There will be a presentation at the GP forum to show what they have done and what they are looking at next year.

• PS noted the transformation and the importance of monitoring performance through internal audits.

• As the social prescribing service is developed it is important to share this through a public communication.

• It was noted that through winter pressures it is important to measure the benefit for the support provided to the GPs and the Trust. This will be carried out through daily monitoring of capacity, A&E activity, system resilience meetings and ERM meetings.

• Leadership and talent management is crucial within the organisation and developing leaders within the organisation. It is noted that there has been 100% compliance in appraisals which also looks at individual personal development plans and individual development. DC commented that the board will have an oversight of the talent management and success planning report following discussion at performance committee.

• NS commented that the leadership for the organisation and as part of the system by KM has been exemplary. There has been a strong sense of patient focus and transparency, highlighting the community transformation. There is an excellent foundation left by KM to drive the organisation forward in the ICP transformation. NS added that KM is not only shown great leadership but also compassion individually and towards the patients.

132.3 The board noted the CEO report. B/133/19 Board Assurance Framework (BAF) 133.1 RW introduced the board assurance framework with the following points:

• Executive team and board sub-committees continue to review all risks within the BAF. • Changes noted are; Risk rating for BAF risk 4.3 is reduced to 8 from 12. • BAF risk 3.4 is now repositioned as a transformation risk.

133.2 The following points were made in discussion: • PS commented that going into next year if there can be a view on what the wider system and

providers are identifying as risks and to note consistency over the system. • TS commented that as the organisation moves into an ICS it is important to note how risks

are identified and managed. 133.3 The board approved the BAF. 133.4 ACTION: Review of system wide risks and how they are managed – R While. B/134/19 Performance Report 134.1 DC introduced the report with the following points:

• Report has been presented at performance committee this month with validated July data. • A&E performance in West Hertfordshire Hospital Trust (WHHT) is at 81.3% noting a small

steady increase. • Referral to treatment (RTT) also shows a small and steady improvement. 52 week breaches

remain low. RTT was the subject of the Deep Dive at the November performance committee. • Cancer performance has improved from the July report which will be reflected in the next

report. • WHHT and HVCCG are working closely together on improvement plans. • CLCH has been in a mobilisation phase and is moving into business as usual.

134.2 The following points were raised in discussion: • Ambulatory care workshops will be taking place looking at the type of patients that are going

through the clinic and providing training around linking the clinical and community pathways. • The improvement plan at Connect is well underway particularly increased staff that have

been recruited to meet increased demand. As well as keeping the locums on as they work

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through the back logs and close off the outstanding actions from the improvement plan. Connect is the subject of the next Quality Committee Deep Dive session.

• AG commented that it is important to include positive stories around Connect in the public domain and to portray the positive improvements that have taken place.

• SB highlighted the quality and improvement in the committee papers as some meetings have been reduced to bi-monthly therefore noting the clarity and good assurance that is provided to the board.

134.3 The board noted the performance report. B/135/19 Finance Report - Month 6 135.1 ET introduced the paper with the following points:

• Month 6 report; reporting surplus and continue to report break even. • Delivering to financial plan and activity is in line with the plan. • Only area that shows a variance from plan is in prescribing due to increase in short supply

drugs. The board can be assured that this can be met through non recurrent reserves and there is no associated risk.

135.2 The following points were made in discussion: • The board noted that within the report it is good to see the mitigations that are in place for

any risks that may occur within the financial position of the CCG. 135.3 The board noted the finance report. B/136/19 Communications and engagement report 136.1 KM introduced the paper:

• There is significant work currently takin place with patient groups and focus is on winter. • There is now patient representation on the Primary Care Contracting Panel. • Patient Participation Group (PPG) programme was signed off at the Primary Care Committee.

136.2 The following points were made in discussion: • AG commented that as patient group representatives are involved in meetings there is a

session taking place in January for them to get together and share their experiences and difficulties they face.

136.3 The board noted the communications and engagement report. B/137/19 Audit Committee Report 137.1 PS introduced the audit committee report with the following points:

• Noting the importance of the decision register and conflict of interests within the organisation and how it is managed.

• Gifts and hospitality – this is looked at on individual basis and also for any patterns that may be visible or any issues.

• Information governance toolkit has been changed to increase the level of security. Noting there are plans in place.

• Annual self-effectiveness review – formal reporting to the board. • Whistle-blowing – process is understood by all staff and assurance is in place. • There is assurance in place through internal audit reports.

137.2 The following points were made in discussion: • It was clarified that all staff members are required to complete the conflict of interest

training. 137.3 The board noted the audit committee report. B/138/19 Health and Safety strategy and policy 138.1 ET introduced the health and safety strategy and policy with the following points:

• Key change to note is that the line managers and heads of department will be taking more direct responsibility for health and safety training within their teams.

• A check list will need to be completed annually to show relevant responsibilities within the teams are being covered.

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138.2 The following points were made in discussion: • Managers will be provided with training to understand their responsibilities. • It is noted that the corporate team will continue to support the line managers to ensure

health and safety is adhered to in the organisation. • PS requested for the next workforce report to include health and safety statistics following

the training. • NS questioned if there has been an impact following the move to the forum; KM commented

that there was a full health and safety review with a collective responsibility with the Council. 138.3 The board approved the health and safety strategy and policy. 138.4 ACTION: Workforce report to include health and safety statistics following training – H

Scheffer. B/139/19 Committee Minutes and work plan 139.1 The board noted the committee minutes. B/140/19 Reflections on equality and diversity in relation to decisions 140.1 Health and Safety strategy and policy. B/141/19 Risks identified in the meeting 141.1 The board noted that it is important not to lose sight of overarching risks across the STP system. B/142/19 Next meeting 142.1 The next meeting in public would take place on 30 January 2020 at 09:00am at Three Rivers

District Council, Three Rivers House, Northway, Rickmansworth, Herts WD3 1RL. B/143/19 The meeting closed at 10:36

Action Log Date of Meeting Subject ActionResponsible

OfficerDue Date Comments Status

B/116.4/19 26.09.19

Proposal for the development of an

Integrated Care Partnership in West

Hertfordshire

K Magson to ensure paper is updated with in line with board suggestions.

K Magson 31.10.19

19.11.19 - KM updated: paper is being updated in line with all stakeholders feedback and a final product will be shared

Open

B/117.4/19 26.09.19Better Care Fund (BCF)

PlanD Evans and E Knowles to produce an easy to read word version of the plan

D Evans31.10.1930.01.20

28.11.19 - update to board in Jan 2020Open

B/115.4/19 26.09.19 Staff Survey action planJ Roberts to strengthen actions regarding bullying and harassment

J Rodgers31.12.1930.01.20

28.11.19 - update to board in Jan 202020.01.20 - JR updated: SIG and Exec to consider responses in current survey due January 2020 and agree as part of the next action plan.

Open

B/113.4/19 28.11.19Board Assurance

Framework

Review of system wide risks and how they are managedR While 28.05.20

14.01.20 - RW update: Following the Q4 BAF reports in April, we will then start preparing for 2020/21 BAF – as well as trying to align our risks with the other two CCGs and see where any collective actions sit

Open

B/138.4/19 28.11.19Health and Safety strategy

and policyWorkforce report to include health and safety statistics following training

H Scheffer30.01.1926.03.20

Open

Completed by due datePlans in place to meet due or revised due date

Herts Valleys CCG Public Board Action Log

Overdue or no update providedOpen (rearranged completion date)

Item 04

Please refer to further guidance here N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201819\Current versions for front sheet reference when completing this front sheet. Title CEO report to Board Agenda item 06 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be

damaging to the CCG, another NHS body or a commercial partner if improperly accessed.

NHS Official Sensitive Personal ☐ Check the box if paper contains personal information relating to an identifiable individual where inappropriate access could have damaging consequences.

Purpose* (click appropriate box)

Decision ☐ Approval ☐ Discussion ☒ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Executive Team Interim Chief Executive Officer

Interim Chief Executive Officer

Short summary of paper

Report provides an overview of key activities since the last board meeting.

Recommendation(s) The Board is being asked to discuss the report

Engagement with patients/public/staff and other stakeholders

Links to Strategic Objectives (click on all boxes that apply) Effective Engagement. We will continually improve engagements with member practices, patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG.

☒

Quality. We will commission safe, good quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well.

☒

Transforming Delivery. We will work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire and its fit with the wider STP strategy, “A Healthier Future”.

☒

Affordable & Sustainable Care. We will ensure that we fulfill our statutory duty to deliver a financially sustainable and affordable healthcare system in west Hertfordshire.

☒

Board Assurance Framework Refer to latest BAF report here for current and target risk scores: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201819\Current versions for front sheet reference Ref. Risk

Owner Risk description Current risk

score and movement

Target risk score

*Assurance Level

All BAF and CRR risks are potentially relevant. Resource implications

None

CFO Signature

Potential conflicts of interest

None

NHS Herts Valleys Clinical Commissioning Group

Board Meeting Date of Meeting: 30th January 2020

1. Leadership

Equality and quality impact analyses (EQIA and QIA)

N/A

Equality delivery system (EDS2)

N/A Better Health Outcomes ☐ Improved Patient Access and Experience ☐ A Representative and Supported Workforce ☐ Inclusive Leadership ☐

Data Protection Impact Assessment (DPIA)

N/A

Report history

None

Appendices

Progress is being made in the development of our Integrated Care Partnership and Integrated Care System across Hertfordshire and West Essex. Integrated Care Partnership: All boards within the west Hertfordshire system have received and discussed the case for change documents during the autumn. The case for change highlighted a number of questions that need to be addressed as we develop the Integrated Care Partnership, and which fall into 4 categories: vision, aims, objectives and principles; scope and pace; service design; and form and enablers. A programme of work has been developed which will be presented to Chief Executives and Chairs on 31st January for discussion with a view the begin the next steps of the design work. Integrated Care System: As we develop our local Integrated Care Partnership it is important we also ensure we have a strong and effective integrated care system (ICS). To date the development of the Integrated Care System has been slower than the Integrated Care Partnership development, and it has been recognised by partners across Herts and West Essex (HWE) that we have a responsibility to commit time and resource to this programme of work. As a system we have signed up to becoming an Integrated Care System by April 2021 and are currently part of the NHSE accelerator programme. There are four areas of focus: leading partnerships, system architecture, system payment mechanisms and population health management. Update on Board membership At a time of great change we do not consider it to be desirable to change the membership of the board in 2020/21.

2. Operational Areas

As described in a later paper on this board agenda, it is proposed to maintain current board membership for the year 2020/21. Four GPs would, under normal circumstances leave or stand for re-election in March. However we propose to maintain the current membership of both GPs and lay members for a further year. We also propose to maintain current arrangements for chair, deputy chair and deputy clinical chair for 2020/21.

2.1 Children Young People and Maternity

Hertfordshire Local Transformation Plan for Child and Adolescent Mental Health Services

The Hertfordshire-wide Local Transformation Plan (LTP) for Children and Adolescent Mental Health Services (CAMHS) was refreshed in December 2019. It builds on the detail outlined in the 2018 plan and provides updates on how Hertfordshire has continued to make positive progress towards improving the emotional and mental wellbeing of the county’s children and young people (CYP). The key areas of focus for the refreshed LTP are improving the availability of early help, expanding support for children and young people with Autism and/or ADHD, and whole-system support for those children and young people with more complex needs.

Hertfordshire remains committed to ensuring that the emotional and mental wellbeing of our children and young people is a shared system responsibility, fostering continued partnership working to ensure our young people are well supported and provided with the opportunity to have the best start in life. We continue to invest in and work towards, increasing access to evidence based mental health interventions in a timely way to help CYP at the earliest opportunity, developing support for parents and carers, and improving support for children and young people experiencing crisis, and trauma and engaging in sexually harmful behaviours.

The refreshed LTP has been published on the CCG website - https://hertsvalleysccg.nhs.uk/future-plans/plans-and-strategies/camhs. Formal feedback from NHS England regional colleagues will be provided in due course, but initial review highlights Hertfordshire as being fully compliant in a number of key areas.

Children Looked After Review

A recent review has been concluded into the current mental health support offer available to our Children Looked After (CLA) population. This review concluded with a set of recommendations to support an improved offer of support to meet the needs of this vulnerable group of children and young people and develop a more cohesive and joined up system of support.

These recommendations have been grouped into the following themes:

Theme 1 – Outcomes Framework

Theme 2 – Commissioning

Theme 3 – Assessment and Care Planning

Theme 4 – Workforce

Theme 5 – Residential and Fostering

https://hertsvalleysccg.nhs.uk/future-plans/plans-and-strategies/camhs

https://hertsvalleysccg.nhs.uk/future-plans/plans-and-strategies/camhs

A series of task and finish workshops will be held with key front-line professionals, both technical and clinical, to develop the recommendations from concept to reality. These task and finish groups will be scheduled to take place early in the New Year.

2.2 Integrated Clinical Advisory Group update The focus of the ICAG meeting held on 17th December 2019 was an overview of the current integrated and coordinated services across the West Herts children’s system. Updates on the following were provided – 1. Children’s Observation and Rapid Assessment Service - CORAS 2. IV Antibiotics – night service 3. Paediatric Task Force 2.3 CAMHS The context for the update reconfirmed the context of the Integrated Care Systems (ICS) and Integrated Care Provider, and in particular focused on: • Planning to integrate and coordinate children and young people services at ICP level • Number of children and young people’s projects underway • Activity being coordinated by a fortnight Paediatric task force group chaired by CCG • Children and young people activity being included in the eERM group There was positive feedback on the children’s work from ICAG members on the current integrated and co-ordinated services, and there is an ambition for these services to be extended and at pace. There was commitment from ICAG for the children’s agenda to be part of local delivery boards from 2020 with a view this will form part of the West Herts ICP. 2.4 West Herts Delivery Board

The MOU has undergone several amendments since it was first created following feedback from partners. However, this has mainly been focussed on ensuring that all organisations are represented as partners, providers, and board members or elaborating further our ethos of collaborative working across the multi-agency organisations. Before Christmas, we received feedback from Hertsmere and St Albans localities which has informed the final version. With a request that partner organisations work towards achieving sign off by the 27th of January.

We undertook an expression of interest for the clinical lead role, and received a small number of applications. Reflecting on the applications and process, we have ascertained that the advert and role description needs to emphasise that we are looking for leaders to push the programme forward from a range of professional backgrounds and organisations. The revised advert and role description was circulated out on 20th of January.

We had a good response to the expressions of interest for the PMO roles from staff within Hertfordshire County Council, HVCCG, HPFT and a local GP federation. We have successfully recruited to the programme manager and project support officer roles. Additional support is being provided by the Programme Manager within the Integrated Care Partnership team and the transformation managers based within the Integrated Care Partnership Team and Hertfordshire Community Trust. We will be undertaking another round of expressions of interest launching the week of the 20th January to fill the remaining roles.

We are expecting the full programme management structure to be in place in March 2020.

2.5 Update on Social Prescribing Link Workers in West Herts HVCCG Small Grants Process to Support Link Worker roll-out CCG has launched a mini procurement to support projects at a Primary Care Network (PCN) level to address the social determinants of health so that people’s wellbeing improves and preventable/inappropriate reliance on the NHS (and social care) is reduced. To date, CCG has had approximately 40 enquiries from groups interested in bidding for these grant monies (£20k+ available per PCN area). The closing date for bids is 7 February. The CCG will work with Hertfordshire County Council (HCC) and PCNs to shortlist, according to the criteria to ensure bids are evidence based and to prevent duplication of funding/maximise value. Announcement of successful bidders will be early March to support implementation during 2020/21. Update on recruitment of Primary Care Network (PCN) Social Prescribing Link Workers • To date 10 PCN Link Workers are now in post, recruited by the HertsHelp Hospital and Community

Navigator Service (HCNS) and are in the process of inducted • 3 are still in the recruitment process with HomeStart and Herts Hearing Advisory Service (in

partnership with HCNS) – these organisations are joining the HCNS partnership • 3 PCNs have recruited/are recruiting their own workers. They are being offered opportunities to

link in with the HCNS as associated partners (providing access to training and skills within the award-winning partnership.

2.6 Update on PCNs, the new DES, Extended Access and Supporting Practices Winter plans.

Primary Care Networks

In December 2019 the Primary Care Commissioning Committee gave approval for the proposal for utilisation of NHS England GP Forward View (GPFV) funding to support the development of Primary Care Networks (PCN’s). The funding of £438k will provide PCNs with support, training and development. This includes population health management training for Clinical Directors and a successor and PCN management training for the Clinical Directors management lead.

Primary Care Network Directed Enhanced Services

NHS England (NHSE) released the five new draft Directed Enhanced Services (DES) service specifications shortly before Christmas. The five DES are for medicines optimisation, enhanced health care in care homes, anticipatory care, personalised care and supporting early cancer diagnosis. NHSE release the DES each year and the CCG is required to offer the services to General Practice/ Primary Care Networks (PCNs)

Locally and nationally GP practices, PCNs, Local Medical Committees (LMC) and CCGs have raised their concerns on the content of the draft specifications, on the basis of the expectations and scale of what is being expected with the proposed timeframe, with the existing workforce and resources available and the requirement to deliver all or nothing will risk destabilising General Practice.

NHSE have invited feedback on the specifications through a national portal by 15 January and requested examples of good care. The CCG have submitted a response and recommended our Care Home Improvement Team (CHIT) model as good practice. In view of the position the CCG has assured our GP practices that we will be submitting a response to NHSE with their views and feedback taken from Locality Chairs, Clinical Directors, Clinical Leads, practice managers and through our internal discussions and with the LMC. The LMC has taken the same approach as the CCG.

NHSE are due to review the specifications towards the end of January 2020. The Royal College of General Practitioners have urged NHSE to review and renegotiate the specifications. It is currently

anticipated refreshed specifications will be issued in late January/ early February 2020. In the interim the CCG commissions a care home service and we will continue to commission this service until further notice. In view of the position the CCG has added DES general practice engagement to the risk register. The Board will be updated on the progress of the five new DES.

2.7 Primary Care - Extended Access Service to GP appointments evenings and weekends Direct Booking of GP appointments by 111 into Extended Access Herts Urgent Care has now confirmed they were able to complete their upgrade to Adastra version 3.30 in December 2019 following initial problems faced in November. As there was a national change freeze in the three weeks until the Christmas period no progress was made during this time. As all change freezes have now been lifted work will progress with Herts Urgent Care and NHS Digital to commence testing for direct booking of GP appointments by 111. A date for Adastra version 3.31 is still unknown, and the CCG continue to liaise with NHS England/Improvement and NHS Digital to seek progress on this matter. Paediatric (Protected) Appointments in Extended Access All locality federations are now providing Extended Access appointments which are protected for the 0-4 age group. Once all providers had commenced their provision the CCG was able to publish a press release to publicise the appointments via the CCG website and on social media channels. The federations and their member practices have also been advertising this to their own patients. Leaflets have now also been finalised with a print run due to be finalised shortly for distribution across practices and the wider community in west Hertfordshire. As the service is new to implementation the CCG does not hold sufficient appointment utilisation data and further information will be provided to the Committee in the March report. NHS England provided additional winter pressure funding that enabled the CCG to commission additional extended access appointments on the three week period before during and after Christmas period. The locality federations were able to respond to the request and provided additional capacity at short notice. 2.8 Supporting Practices Winter Plans (SPWP) The Supporting Practices Winter Plans (SPWP) scheme commenced 1st October 2019 and completes on 31st March 2020. It is in its fifth year and is welcomed by primary care and allows practices to increase capacity provide additional appointments in core hours of 8am to 6.30 pm Monday to Friday. Practices have submitted data for the first two months of the scheme that shows they have generated 16,597 additional appointments across HVCCG; of which 28% has been delivered by a blended workforce - advanced nurse practitioners, paramedics, pharmacists, practice nurses and healthcare assistants. It is hoped, as in previous years that the additional appointments being delivered by a blended workforce has freed up time for GPs to see patients with more complex needs or long term conditions. Of the 16,597 additional appointments, 18% of the appointments have been delivered after 4pm for paediatric consultations. Practices have also encouraged care homes to contact surgeries before 11am to discuss with duty doctors or a specified GP if they require a visit and/or advice, 1,816 requests for care home visits has been received within this timeframe. By putting these measures in place, it ensures that general practice is able to support prioritisation of continuity of care for their patients over an extremely busy time, as well as supporting reducing the demand on urgent care services. .

2.9 Planned Care Cancer – Early Diagnosis Herts Valleys have been working with GPs, WHHT and partners across the STP to help diagnose people with cancer earlier to support improved outcomes for patients and help to deliver against the NHS England long term plan through: • Quicker access to diagnostics • Streamlined Pathways • Education of staff In March 2019 the CCG commissioned a 6 month pilot for GPs to have direct access, to Head MRI and CT for Abdomen and Pelvis for the exclusion of brain, CNS (central nervous system) and pancreatic cancer. At the end of the pilot an evaluation identified the service was being used appropriately and that cancers had been identified within the service. In light of this evaluation Herts Valleys CCG Commissioning Executive has agreed to commission GP direct access to diagnostic tests for MRI Head and CT Abdomen and pelvis for the exclusion of brain and CNS and pancreatic cancer for GPs, on an on-going basis. The Cancer Programme team are exploring the next wave of diagnostics which needs to be commissioned in line with the streamlined pathways to enable quicker access to diagnostics which will improve the performance on rest of the indicators for cancer. Update on Adult Community Health Services

Following contract award to Central London Community Healthcare NHS Trust (CLCH) for Adult Community Services (ACS) in January 2019, the services went live on the 1st October 2019. The services being delivered are:

• 17 core and specialist community services • 81 community rehabilitation and 16 community stroke/ neuro rehabilitation beds • 4 mandated sub-contracts for End of Life Care (Hospices and Marie Curie) • A subcontracted leg ulcer service with HertsOne, GP federation The services were transferred to CLCH from Hertfordshire Community Trust (HCT) on October 1st 2019 on a ‘lift and shift basis’. There were 642 members of staff TUPE transferred to CLCH on October 1st 2019. The services operate across 14 sites with CLCH’s corporate hub located at HemelOne. The service locations are listed below:

• HemelOne • Hemel Hempstead Hospital • Marlowes Health & Wellbeing Centre • Gossoms End • Potters Bar Community Hospital • Elstree Way Clinic • Harpenden Memorial Hospital • St Albans City Hospital • Langley House • Skidmore Way Clinic • The Avenue - Watford, • BRE Building - Watford The mobilisation programme was formally closed down on 30th September2019 and the transition of any outstanding actions went into to the CLCH relevant business as usual (BAU) forums.

The ACS Transformation Group has now commenced a transformation programme to ensure delivery of the commitments set out in the CLCH bid for the services. The transformation programme has a governance structure in place and full transformation plan. The CCG is maintaining oversight of the delivery of the transformation programme through bi-weekly meetings. A transformation scorecard is in place to support monitoring.

Key aspects of the transformation include:

• A current service is operating from 8.00 – 6.00 pm 7 days a week. The new enhanced service will provide a SPA for all commissioned adult community services, there will also be a clinician available for clinician to clinician discussion.

• Enhanced Multi Disciplinary Teams with Geriatrician and GP Input that are aligned to the Primary Care Networks (PCNS). This service will provide Multi-Disciplinary Team administration and care management service for complex patients in each locality.

• Weekly Frailty Clinics in each locality with Multi Disciplinary Team and Consultant Geriatrician input from March 2020.

• New Discharge Home to Assess Model from April 2020 • New Rapid Response Pathways from April 2020, which will include access to a Consultant

Geriatrician and will be available 8.00 am – 8.00 pm 7 days per week. • Review of the community bed model across the 81 Rehabilitation and 16 Stroke Neuro Beds.

During the winter months CLCH have been very successful in expediting discharge from our acute hospitals into their bed base. They have also reduced the length of stay in the community hospitals which has given additional capacity during the winter and negated the need to buy additional beds. Harpenden Memorial Hospital working group established to take forward the redevelopment of the site to provide additional clinics in the community.

Frailty including End of Life Care

Good progress is being made under the Frailty Programme. With the mobilisation of the new provider for Adult Community Health Service, Central London Community Health Trust (CLCH) are on track to implement a number of key interventions under the frailty programmes as outlined above. In addition the CCG Board approve 2 key business cases under the frailty programme which are currently being implemented. These include:

• Early Intervention Vehicle to support patients aged 65 and over who have fallen in their own homes, has been approved by the CCG board in December. This service will be a 2-year contract with East of England Ambulance Service Trust (EEAST) as lead provider and Hertfordshire County Council (HCC) providing the therapy input. It is proposed the phased implementation of the service will commence from 1st April 2020.

• Acute Frailty Unit at front end of West Hertfordshire Hospital Trust which is in line with the NHS Long Term Plan. An in-reach service into A&E is currently in place with a physical unit to be launched from April 2020.

• In light of the closure of Michael Sobell Hospice, the CCG reviewed is demand and capacity for hospice beds for the local population and agreed to commission 4 additional hospice beds, 2 from Rennie Grove hospice and 2 from Hospice of St. Frances. This has been commissioned via the lead provider for adult community services who subcontract end of life care services via hospices. These beds opened on the 1 December to support the winter pressure.

• One of the gaps identified when implemented end of life care pathways was access to a 24-hour palliative care advice line to professionals and families. This service went live on the 6 January and is delivered by the three hospices with Peace hospice taking the lead.

• In addition, the Prime Ministers announced £25M pledge for palliative and end of life care. The funding is non-recurrent and is to sustain or develop the following services across adults and children.

• Personalised care and support planning including advance care planning • Specialist palliative care MDT services • 24/7 access to palliative and end of life care support and advice • Palliative and end of life care education and training

• Palliative and end of life care services including o Support for people in their own home or preferred place of care

• Specialist palliative inpatient care • Education and Training for Staff • Support to families and carers Following discussion and agreement across adult and children hospice providers and community providers for palliative care, the CCG agreed to allocated the funds between the providers based on their contractual value with a view to seek their commitment to develop sustainable education and training across west Hertfordshire. This is in line with west Hertfordshire end of life strategy.

2.10 Redevelopment of West Herts Hospitals Trust estate Members will remember that in autumn 2019, in response to the strategic outline case (SOC) submitted by the Trust in July, government announced funding for the redevelopment of the west Hertfordshire hospital estate. At a visit from the prime minister in October, he confirmed funding in the sum of £400m with more details to follow. In late November senior representatives from the Department of Health and Social Care (DHSC) and regulators met with the Trust and CCG. At this very productive meeting, next steps were discussed and the funding amount was confirmed, with clarification that the figure of £400m included an allowance for inflation, hence being greater than the £350m requested in the SOC. There was also clarification that the funding was earmarked for the substantial rebuild/redevelopment of the Watford site, together with redevelopment of both St Albans and Hemel Hempstead hospitals, along the lines outlined in the SOC. This redevelopment plan is part of what is known as the national ‘HIP 1’ (health infrastructure programme) and final allocations are dependent on the submission of more detailed business cases. The Trust is now embarking on next steps and the team is conscious that the HIP 1 requires the Trust to deliver on their plan by 2025. Planning is underway that includes developing the clinical model and establishing the project team. The latter involves establishing governance arrangements for the programme and seeking partners to help deliver this highly complex project. Board members will also be aware that there is a judicial review claim pending that challenges the process undertaken by Herts Valleys CCG in approving the SOC. The current status of that claim is that the court gave permission for it to go ahead, but it has a ‘stay’ in place which means it is currently paused. We are expecting this stay to be lifted shortly and proceedings will then resume, with a court hearing being listed for some time in the coming months. 2.11 Update on Urgent Care Urgent Treatment Centres (UTC) A key focus for 2019/20 has been implementation of Urgent Treatment Centres (UTC) across Herts Valleys. After a successful procurement in October 2019, Greenbrook Healthcare have been awarded the contract to deliver UTC at the front door of the Emergency Department of Watford General Hospital. Engagement from both Greenbrook and West Hertfordshire Hospital Trust (WHHT) continues to be positive, and good progress continues to be made in all areas of the mobilisation in terms of regular programme meetings, issues raised discussed and resolved, readiness for IM&T, workforce and estates, and all preparations requiring collaborative work across the key parties. The joint programme board between WHHT and the CCG also have regular oversight of the project including various workstreams and have not raised any major concerns which would prohibit or hinder

3. HR and organisational development and learning update

further development at this stage. A joint audit of UTC suitability was completed in December, identifying areas of focus for the clinical workstream going forward and providing reassurance to the WHHT clinical teams regarding Greenbrook UTC methodologies as well as corroborating the necessary activity assumptions. The audit in December 2019 demonstrated the potential for up to 59% of attendance activity to be diverted to the UTC once fully operational. It is proposed for the review to be repeated after a month to ensure there is a shift in the levels of confidence and clinical engagement between the new UTC provider and WHHT clinicians. Enhanced Effective Resource Management (eERM) The 2019/20 Effective Resource Management (ERM) programme has successfully reduced Type 1 A&E activity. There was an increase in Type 3 activity, but this is low cost activity and also means patients are receiving better outcomes because they are treated in the most appropriate setting for their presenting needs. Additionally, the programme worked on reducing non-elective admissions via A&E; being broadly successful, as only a 7% rise in Herts Valleys was seen against a national back drop of 8-9% increases in non-elective admissions. High Intensity Users (HIUs) of A&E were also identified. Through patient reviews and ‘case management’; each monthly cohort of HIUs has seen their A&E activity reduce following identification. To ensure an integrated social and clinical response, since April 2019, 3 x Community Navigators have implemented a social prescribing response for suitable HIUs, successfully reducing A&E activity of those worked with by 44%. To enhance the 2019/20 ERM programme, and to capitalise on opportunities for improved collaboration across the health and social care system; wider system providers will be working alongside primary care, facilitated by local delivery provider boards, to implement Enhanced Effective Resource Management (eERM) between 2020 to 2021. The aim is to further reduce avoidable Type 1 A&E activity, reduce HIUs and reduce avoidable hospital admissions through effective collaborative practices across system partners. Ambulatory Emergency Care Good progress has been made working collaboratively with the Trust on review of the Ambulatory Emergency Care provision in West Herts. The aim of the changes in Ambulatory care will be to utilise an additional 6 bays to increase capacity, focus on those patients who will benefit from same day emergency care (SDEC) and reduce the level of 0-3-day length of stay for patients with an ambulatory care condition. This in turn will provide the opportunity for reducing short stay capacity in line with the intention and aspirations of the minimum income contract

3.1 Staff survey

The NHS National Staff Survey 2019 was launched on 7 October 2019 and closed on 29 November 2019. Herts Valleys CCG response rate was 89.7% (183 employees) an increase year on year (Response for 2018 - 84%; 2017 – 80%) and higher than the average response rate for CCGs surveyed by Picker at 80%.

Results from the survey will be published during February 2020. Following which the results will be reviewed and any actions as a result of the valuable feedback received will be taken jointly by the CCG and the Staff Involvement Group. 3.2 Appraisals

Following the launch of the full e-Appraisal system on ESR during November 2019; Herts Valleys CCG saw a 99% returns rate of appraisals for 2019/2020.

3.3 Leadership Development

The Senior Leadership Team (SLT) leadership development programme which launched in October 2019 continues to be delivered and is due to conclude by March 2020. Training and development remains a high priority across the CCG with the Henley Partnerships programme being renewed for a further 12 months in order to continue with the development of Senior leaders within the CCG. In addition an in house bespoke leadership development programme is due to be launched from January 2020 for May 2020 intake.

3.4 Apprenticeships

The CCG have now has 7 members of staff on apprentice programmes across the organisation with a further 1 due to commence shortly. The Government Department of Education states 2.5% of organisations workforce should be undertaking apprenticeships by 2021; the CCG has already exceeded this figure with 3.10% of its workforce completing apprenticeships.

3.5 Annual workforce equality data report

The CCG is currently preparing its annual workforce equality data report in order to comply with the data publication requirements of the Equality Act 2010. The report includes data on pay grade comparisons, recruitment and selection and training opportunities by protected characteristics; enabling the CCG to identify any areas of work to address any potential inequality. The report will be published during March 2020.

3.6 Time to Change pledge

As part of the CCG’s commitment to the Time to Change pledge ten employees will receive mental health first aid training. It is anticipated that this will commence during March 2020 and aims to support a positive culture in relation to mental health and ensure excellent staff support across the organisation.

Terms/acronyms used in report

HVCCG Herts Valleys Clinical Commissioning Group CAMHS Child and Adolescent Mental Health Services HCT Hertfordshire Community NHS Trust HPFT Hertfordshire Partnership University NHS Trust

IAPT Improving Access to Psychological Therapies ENHCCG East and North Herts Clinical Commissioning Group NHSE NHS England PCN Primary Care Network APMS Alternative Provider of Medical Services DES Direct Enhanced Service CLCH Central London Community Health Trust HRM Human Resources Management HPMA Healthcare People Management Association ODL Organisational Development and Learning BLMK Bedfordshire, Luton and Milton Keynes TUPE Transfer of Undertakings (Protection of Employment) CSU Commissioning Support Unit ESR Electronic Staff Record

G1 HVCCG Front Sheet October 2019 v2.9

Please refer to further guidance here Z:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201920\Current versions for front sheet reference when completing this front sheet. Title BAF 2019/20, Q3 Agenda item 07 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging

to the CCG, another NHS body or a commercial partner if improperly accessed. NHS Official Sensitive Personal ☐ Check the box if paper contains personal information relating to an identifiable

individual where inappropriate access could have damaging consequences. Purpose* (click appropriate box)

Decision ☐ Approval ☒ Discussion ☐ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Katy Patrick Deputy Head of Corporate Governance

Rod While Head of Corporate Governance


The paper presents in summary a proposal for the Board Assurance Framework (BAF) for 2019/20 at the end of quarter 3 (Q3), tracking changes since Q4 2018/19 and proposing changes to risks on the BAF since the Q2 2019/20 report was discussed in September 2019.

Recommendation(s) The Board is being asked to: • Review and approve the BAF 2019/20, Q3 position as agreed by the

Executive team; • Note the BAF and Corporate Risk Register assurance summaries in

appendices.


BAF and CRR risks have been reviewed and updated by individual SLT and Executive members and their teams as appropriate and discussed at Committees of the Board.


☒


☒


☒


☒

Board Assurance Framework Refer to latest BAF report here for current and target risk scores: Z:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201920\Current versions for front sheet reference All of the risks on the Board Assurance Framework (BAF) and Corporate Risk Register (CRR) are relevant to this report. *Refer to assurance levels table below. New strategic risks identified by this report None


Board Meeting in Public Date of Meeting: 30 January 2020


Other significant risks related to this report (from the Corporate Risk Register) None Resource implications

None CFO Signature


Conflicts of interest are published in the CCG registers and any specific interests relating to agenda items are notified to the Chair in advance of the meeting.


N/A




N/A

Report history

BAF/CRR updates are submitted monthly to the Executive team for approval and discussed quarterly at committees and the board.

Appendices 1. BAF summary 2019/20, Q3 2. CRR summary 2019/20, Q3

*Assurance levels – use this guide to identify the level of assurance indicated in the risk table above. Level Details **N.B. The executive summary for this paper should explicitly point to the evidence to support the assurance level indicated. For example: Very high – Where in the report is the evidence is to support the current strong position & how it will be sustained? High – Where in the report is evidence of what is being done to strengthen controls and mitigate the likelihood of this risk materialising? Medium – Where in the report is the evidence of what is being done to address gaps in assurance and how successful is this action proving? Low – Where in the report is a statement of the urgent actions planned to address the lack of assurance? Very high Taking account of the issues identified in this report, the Board can take reasonable assurance that

the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective.

High Taking account of the issues identified in this report, the Board can take reasonable assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective. However, we have identified issues that, if not addressed, increase the likelihood of the risk materialising.

Medium Taking account of the issues identified in this report, whilst the Board can take some assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective, action needs to be taken to ensure this risk is managed.

Low Taking account of the issues identified, the Board cannot take assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied or effective. Action needs to be taken to ensure this risk is managed.


Introduction

1.1 The Board Assurance Framework (BAF), as part of the fundamental core of HVCCG’s internal control systems, identifies all risks which potentially threaten achievement of HVCCG’s strategic objectives. Authors of all papers presented to the board and committees are asked to relate the subject matter explicitly to HVCCG’s strategic risks and explain how it impacts on them.

1.2 The nature and relative sizes of the current threats are summarised in section 4.1 below. This chart also notes the in-year forecast and ultimate target scores. The BAF summary document at Appendix 1 includes graphs showing the relationship between inherent, current, forecast and target risk scores. The target score is the level of risk to the achievement of that strategic objective that the Executive Team considers to be tolerable and justifiable. Timescales for achievement vary and differences between forecasts and targets are explained in Appendix 1.

2. BAF proposal 2019/20, Q3. 2.1 All of the narrative assurance summaries have been reviewed and updated at multi-disciplinary

meetings since the last report to board in September and reviewed by the Executive. 2.2 There are two changes to current risk scores in the BAF for Q3.

BAF RISK 2.2a: ‘Risk that we are unable to ensure good quality, safe and sustainable services for the population and patients of west Hertfordshire.’ It is proposed that the current risk score should be reduced to meet the target and in-year forecast of 8. BAF RISK 4.3: ‘Risk that we do not achieve financial balance in 2019/20.’ The current risk score has been reduced to 8 following discussions at the board meeting held on 28 November 2019, with the target and forecast of 4 expected to be achieved in-year.

3. CRR 2019/20, Q3. 3.1 Whilst the BAF framework identifies the strategic risks which may threaten achievement of

HVCCG’s strategic objectives, any related risks requiring specific mitigating actions are cross- referenced and documented fully within HVCCG’s Corporate Risk Register (CRR). No new risks have been added to the CRR in Q3 and there have been no changes proposed to CRR risk scores. It is proposed that risk SO5/04: ‘Risk that a 'no deal' EU exit scenario impacts on HVCCG's statutory duties,’ is now closed as a deal has been agreed.


4. Strategic risks 2019/20, at end of Q3. 4.1 Relative size and position of strategic risks, including current, forecast and ultimate target

scores.

4.2 Summary of change over time for current risk scores (2018/19, Q4 to 2019/20, Q3).

Key: Risk Deteriorating ↓ No Movement → Risk improving ↑ New risk ¤

Ref Owner(s) Risk description 18/19 Q4 19/20 Q1 19/20 Q2 19/20 Q3

1.1 JR Public and stakeholders 12 12 12 12→

1.2 LD/AS Members and other partners 12 12 12 12→

1.3

JR/HS Staff 8 8 8 8→

2.1 DC National targets 16 16 16 16→

2.2a DC Quality and safety 12 12 12 8↑

2.4 ET System IM&T 16 16 16 16→

2.5 AS/LD/ET Capacity to commission 12 12 12 12→

2.6 ET GDPR 12 8 8 8→


3.1 DE Capital resource 16 16 16 16→

3.2a AS/JR Local support 12 12 12 12→

3.2b LD GP & Fed capability 16 12 12 12→

3.3 AS/HS Workforce 16 16 16→ 16→

3.4 AS ACS mobilisation 16 12 9 9→

3.5 AS Health inequalities 12 8 8 8→

4.1 ET Sustainable system 20 20 20 20→

4.2 AS/DC Transformation value 12 16 16 16→

4.3 ET Financial balance 2019/20 4 12 12 8↑

4.4 ET Legal challenge 10 8 8 8→

5. Recommendations. 5.1 The Board is asked to:

• Review and approve the BAF 2019/20 end of Q3 position as agreed by the Executive team; • Note the assurance summaries at appendix 1 and 2.

6. Appendices Appendix 1 BAF summary 2019/20, end of Q3 Appendix 2 CRR summary 2019/20, end of Q3

1

BAF 2019/20 Q3 as updated at 21 January 2020 Effective Engagement:

We will continually improve engagements with member practices, patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG. BAF RISK 1.1: Risk that we do not engage effectively with a range of our patients, population and stakeholders.

RISK OWNER: Associate Director of Communications & Engagement CAUSES: (A) Lack of commitment; (B) Unclear approach and absence of strategy; (C) Availability of funding; (D) Limited workforce capacity and capability.

Inherent risk score Current risk score Target risk score Forecast for end of 2019/20 20 12→ 8 8

ASSURANCE SUMMARY (10 January 2020) Acute hospitals transformation - The board decisions and submission of the SOC in July marked the end of the engagement phase on the refresh. In relation to the SOC engagement phase there is a judicial review pending with the claimant arguing that the CCG should have formally consulted with the public before making the decision about which option to pursue. We are defending the judicial review. HCC health scrutiny will also examine our engagement on the SOC – though this has been postponed until after the judicial review. Again HVCCG will participate fully in this process. Updates have provided to stakeholders and the wider public following the government funding announcement (following submission of the strategic outline case). The next phase of engagement will focus on the development of the OBC. A programme of communications and engagement is being developed to support this. Adult community health services A communications and engagement plan has been developed to support the transformation and shared with the steering group. This is is a living plan that will be subject to ongoing review as transformation work progresses. This will be supplemented by mini communications and engagement plans for particular pieces of work. The target risk score of 8 is expected to be achieved in year, supported by the following initiatives: •A refreshed stakeholder participation strategy that supports greater public engagement, particularly among disadvantaged groups. • A programme of communications around our new community pathways, including working with providers to improve public and patient engagement in developing services. The CCG’s expectation of providers around engagement is being reinforced by including stipulations around engagement in provider contracts by early 2020. • Further development of our work with Patient Participation Groups. • Planned increase in the number and work of community health ambassadors who share information through networks such as Trans and Gypsy and Traveller community, health walks, dementia cafes, Herts Equality Council. We are continually recruiting to the ambassador project. • Improved reporting of engagement activities - particularly demonstrating to patients and the community how engagement has made a difference. • On-going improvements to the CCG website to strengthen our engagement by ensuring up-to-date and useful information and improving accessibility. Implementation of local delivery plans is being taken forward on a Herts Valleys geography basis by a partnership of all our main provider organisations including primary care (GP Practices and the new Primary Care Networks, adult community services (CLCH), mental health service (HPFT, acute services (WHHT with other secondary care providers invited), and social services (HCC). Other local partners are also involved. Smaller providers in planned care are being actively engaged in the process of developing an Integrated Care Partnership (ICP) in West Hertfordshire. The CCG are ensuring that other acute providers outside of our system are aware of the plans for West Herts and Herts and West Essex STP but not overburdened by them. CCG Improvement and Assessment Framework (IAF) Patient and Community Engagement Indicator - We have now received feedback on our 2018/19 submission and scores. The communications and engagment team is now gathering evidence for our submission for 2019/20 - taking on board feedback from the 2018/19 assessment to strengthen our evidence in those areas where we didn't meet the criteria. The Public Participation and Engagement Strategy is being refreshed in response to feedback from the 2018/19 IAF assessment - gaining strategic endorsement for the improvements to our engagement approach.

0

5

10

15

20

25

Q4 18/19 Q1 19/20 Q2 19/20 Q3 19/20

Inherent

Current

Target

Forecast

2

Campaigns: - Delivery of winter pressure awareness campaigns is underway. In line with ERM this year’s plan is targeted to the populations within the CCG that have higher and avoidable use of A&E. Particular areas this year include encouraging people seek advice from local pharmacist, promotion of children’s GP extended access appointments and promotion of NHS111. Delivery is via CCG communications channels including social media, e-bulletins and website. Working with ENHCCG we have created and distributed through schools and the family centre service to target young families. Communications are also going out to food banks and care homes. Communications activity is reflected in a winter communications plan which feeds both into a wider STP plan as well as into CCG winter resilience planning. This plan is also being shared with local delivery boards for Dacorum and Hertsmere. - An awareness raising campaign is supporting new Fitness for Surgery arrangements being implemented in January 2020. Communications have been developed jointly with ENH CCG including leaflets delivered to GP surgeries and information on websites. - A communications campaign has been developed ready to support roll-out of WaitLess App which has been procured by the STP technology work stream. This will be rolled out to health professionals initially to help with signposting patients to urgent treatment centres.

BAF RISK 1.2: Risk that member practices, local providers, local authorities and other partners do not respond constructively to engagement. RISK OWNERS: Director of Primary Care and Director of Commissioning

CAUSES: (A) Failure to communicate effectively with member practices, local providers, local authorities and other partners; (B) Pressures in general practice, providers, local authorities & others; (C) Unclear approach and absence of strategy.

Inherent risk score Current risk score Target risk score Forecast for end of 2019/20

16 12→ 8 8

ASSURANCE SUMMARY (14 January 2020) The Primary Care Commissioning Committee approved the PCN Development Programme funding and the CCG continues to liaise with PCN Clinical Directors and Management Leads to initiate the mobilisation of the programme. The CCG is developing a programme of protected time for PCN CD development sessions throughout 2020/21. New Risk: The five new national PCN DES service specifications have been issued in Draft and initial review and feedback nationally from CCGs, LMCs and General Practice/PCNs is that these specifications are not workable in their current form. Locally discussions are already happening within PCNs regarding withdrawing from the PCN DES in its entirety and recruitment process for additional workforce has been halted until the outcome of the feedback is known. Actions: The CCG is collating an organisational response to the national specifications and this will be shared with the LMC. The LMC are also submitting a response. A holding email has been circulated to PCNs and Management Leads to provide assurance and to encourage feedback through the national survey; deadline 1pm 15th January 2020. The communication urged PCNs not to make any drastic decisions until the outcome of the national negotiations are known and further discussions had with PCNs regarding the CCGs position. The target of 8 is expected to be achieved in year. This reflects the further work necessary to develop and operationalise all of the Primary Care Networks established so that they can be effective as a focus for the implementation of local delivery plans

3

BAF RISK 1.3: Risk that we have an unengaged staff body and wider clinical workforce. RISK OWNERS: Associate Director of Communications & Engagement; Director of Primary Care; Director of Workforce

CAUSES: (A) Failure to implement internal communications strategy; (B) Failure to adhere to specific timetables for circulation; (C) Clinical leads not sufficiently engaged with the HVCCG board, committees and sub-groups and key work streams.


16 8→ 8 8

ASSURANCE SUMMARY (10 January 2020) The 2019 staff survey launched w/c 7 October 2019 and included bespoke questions for Herts Valleys CCG staff to pick up on particular areas of feedback from the 2018 survey. The staff involvement group (SIG) have worked with HR and communications and engagement colleagues to implement an action plan to address issues raised as part of a Herts Valleys follow-up questionnaire to the 2018 NHS staff survey and communicated this to the rest of the CCG staff. Speak up champions have been identified and trained to further address bullying and harassment with bespoke questions to be asked in this year's staff survey to establish root causes. The Neyber staff assistance service was delayed and is now launching during November. This will be promoted to all staff and line managers are encouraged to speak to their teams about it where additional support or advice may be helpful. The staff involvement group also continues to consider relevant policies and recently reviewed the refreshed health and safety policy. The group also considers all staff suggestions that are submitted. The November SIG meeting received feedback from a staff survey on internal communications. This will inform development of new internal communications and engagement strategy. Work continues to develop a health and wellbeing of programme for staff with a calendar of events planned. Many activities are taking place jointly with Dacorum Borough Council. The executive and senior leadership teams met together in late September to consider the future direction of the CCG in the context of system changes and the long term plan and to consider how to support staff through the forthcoming changes. Discussions are being translated into some simple messages for staff, particularly explaining progress towards an ICP. Staff briefings have kept staff up to date on wider system changes for the last four months. In addition the Chief Executive has held drop-in sessions to provide people with an opportunity to discuss this further and ask questions.

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Quality We will commission safe, good quality services that meet the needs of the population, reducing health inequalities and supporting local people to avoid ill health and stay well.

BAF RISK 2.1 Risk that we do not deliver on all NHS Constitutional pledges, key national targets and priorities. RISK OWNER: Director of Nursing & Quality.

CAUSES: (A) Availability of funding, (B) Limited workforce capacity and capability, (C) Competing priorities in the west Herts health and social care economy; (D) Increased attendance at A&E; (E) Delays in progressing through ED; (F) Demography.

Inherent risk score Current risk score Target risk score achievement March 2021 Forecast for end of 2019/20 20 16→ 8 12

ASSURANCE SUMMARY (16 January 2020)

A&E 4 hour standard 95% HALO appointed until March 2020 Daily system call increased to 3 times a day whilst system under severe pressure The new medical take pilot (SMART) is underway with regular review meetings being held. There has already been a reduction in both LOS and conversion to admission. Work with system partners is ongoing to develop the urgent care strategy which includes the development of Urgent Treatment Centres (UTCs) across all 3 trust sites. 4 Middle Grades have been recruited but await visas. Consultant recruitment has not been as successful. The department is reviewing the possibility of joint posts and being supported by recruitment agencies. There have been no 12 hour trolley breaches to date Delayed Transfers of Care (DToCs) WHHT reported a DTOC position of 3.4 % for November 2019, a significant improvement on October’s position of 6.5%. The most noteworthy improvement was health delays with a 55% improvement in bed days lost, however improvement was also seen in social care, with a 22% improvement in bed days lost. This marked improvement is possibly due to the new incoming community providers and the constant availability of IMC/rehab beds Weekly LOS meetings continue with MDT attendance. DIscharge and Review Team (DART) rounds continue every Monday and Tuesday whereby all patients > 21 days are reviewed by a senior clinical team. Difficulties remain with three very long LOS patients with multiple complex needs. DToC position was 6.5% in October; increase due in part to transition of Simpson Ward back to the Trust and the high volume of people awaiting social care support. There was significant decrease in flow through the IMC beds during the provider transition period that has now dissipated.

Referral to Treatment (RTT).

WHHT planned trajectory remains on track. The elective performance review group considers performance, risks, and barriers to agree actions. The improvement plan is monitored through this group and exceptions raised at the CQRG. RFL data validation extended until October 2020. Trust report 192, 52-week waits of which 5 are Hertfordshire patients. HVCCG continue to support RFL through the steering group and operational groups. Ambulance capacity challenge has been anticipated with a work plan with executive ownership and accountability agreed with CCGs and underpinned by an integrated action plan. The focus is on maximising local management actions to increase the number of hours put out and mapping the next 12 months in terms of capacity. This is to ensure that planned hours will support safe service delivery. There will be a close focus in upcoming contractual and performance meetings around the ongoing concerns relating to vacancies. There are currently no vacancies within the NEPTS contract. Arrival to Handover (A2H) delays at Watford General Hospital continue to impact the Trust’s ability to release vehicles back on the road. HVCCG is not the lead commissioner for this contract but does now have a dedicated resource monitoring the contractual performance much more closely and escalating any local issues to the host commissioner via the sector meeting.

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BAF RISK 2.2a: Risk that we are unable to ensure good quality, safe and sustainable services for the population and patients of west Hertfordshire. RISK OWNER: Director of Nursing & Quality and Deputy CEO

CAUSES: (A) Poor systems for monitoring and escalating provider quality issues; (B) Lack of responsiveness of HVCCG due to vacancies; (C) Ambiguity over quality assurances required from partners; (D) Poor quality of assurances from providers commissioned directly and indirectly, (E) Availability of funding, (F) Limited workforce capacity and capability (G) Lack of communication between partners and providers.


16 12↑ 8 8 ASSURANCE SUMMARY (21 January 2020):

All vacancies within the quality team have been recruited to. Band 5 commences employment January 2020. Systems and processes are in place for monitoring all provider contracts and escalation of concerns. Quality reporting streamlined and minimum data set for all providers agreed. Contracting round 2020/21 will ensure all quality reporting for all contracts.

It is proposed that the current risk score is reduced to the target and in-year forecast for 2019/20 of 8.

BAF RISK 2.4 Risk of lack of adequate system capability and interoperability in the management and security of information, data and technology. RISK OWNER: Chief Finance Officer

CAUSES: (A) Historic under-investment in IT; (B) Lack of vision of using IT to support clinical services; (C) Lack of joined up approach for providers.


ASSURANCE SUMMARY (19 November 2019): The Local Digital Roadmap (LDR) is due for refresh in 2019/20. All providers are meeting regularly to co-ordinate plans and increase the amount of STP and regional collaboration. The “medical information gateway” is being used to view GP records across all three acute trusts. The CCG is aware of challenges with the capacity of GP network infrastructure and all existing N3 lines are being upgraded to HSCN lines to deliver better speed and reliability. We are also looking for ways to facilitate PCNs and the interoperability they will need, both for clinical record sharing but also for facilitating sharing of other digital assets across practices such as policies, documents and training plans. The STP Digital work stream has recently re-structured to support delivery of the NHS Long Term Plan, with the introduction of a Primary Care sub-group and a citizen-focused work stream. These will concentrate on how Primary Care Networks will use technology but also how we empower patients with telehealth, assistive technology and look to make the use of ‘Apps’ mainstream. Challenges remain, particularly in the acute trusts that may delay full achievement across the system. The three-year plan for WHHT to have electronic patient records in place was flagged by the board as an issue at the June 2018 meeting. WHHT have now transitioned to their new IT provider contract and are developing plans to move their infrastructure forward. The Trust plans to re-invigorate its IT refreshment programme and the CCG will be working to ensure that what is delivered in their recovery plan for the digital roadmap aligns with system priorities so that valid information is coming back from WHHT. The CQC report of their re-inspection off WHHT, published on 28 February 2019, noted particular challenges with slow information technology systems and access to computers being an issue for some staff in the hospital and community setting. Although the STP work stream does monitor progress it is not able to mandate individual organisational change. Head of IM&T has discussed assurances with WHHT and will liaise with colleagues to monitor progress against IM&T actions. In-year forecast for 2019/20 is 12 with the expectation that current risk score will reduce to 12 by March 2020. The target

0

2

4

6

8

10

12

14

16

18

Q4 18/19 Q1 19/20 Q2 19/20 Q3 19/20

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achievement will take longer and is currently estimated as March 2021. At an STP level there is an acknowledgement that Digital has not been resourced to level that allows delivery of significant transformation programmes. The STP Digital work stream are tasked with presenting a specification to STP CEOs in December with recommendations on how to progress and develop the Digital work stream such that it enables the LTP. The yearend forecast remains at 16.

BAF RISK 2.5: Risk that we are unable to commission good quality and sustainable healthcare for the population of west Hertfordshire. RISK OWNERS: Director of Primary Care, Director of Commissioning and Chief Finance Officer

CAUSES: (A) Range of outstanding contractual, performance and procurement issues to be addressed in the transition plan of primary medical services commissioned by NHSE passed to HVCCG; (B) Shortages of clinical and non-clinical staff to provide the appropriate services in general practice and primary care; (C) General practice as a provider is struggling with a number of individual practices facing

specific difficulties and challenges; (D) Patient numbers and demand continue to increase and yet general practice will struggle to respond to our strategic plan of moving patients from secondary to primary care; (E) Lack of capacity and capability within HVCCG to manage multiple procurements, transformation and business as usual.

Inherent risk score Current risk score Target risk score achievement June 2020 Forecast for end of 2019/20

16 12→ 8 12

ASSURANCE SUMMARY (14 January 2020) The CCG has supported the development of PCNS and has introduced an organisational development programme in 19/20 to support the 16 HVCCG PCNs and their Clinical Directors. ICS/ICP development, with dedicated CCG support alongside all partners is progressing well. Future risks related to mobilisation of new contracts, the associated CCG resource requirements. Risk associated with the transformation of the Adult Community Health Services contract and other new services in the community, plus the embedding of new services throughout 2019/20 has been planned for and resourced. MC Jan update: The Primary Care Commissioning Committee approved the PCN Development Programme funding and the CCG continues to liaise with PCN Clinical Directors and Management Leads to initiate the mobilisation of the programme. The CCG is developing a programme of protected time for PCN CD development sessions throughout 2020/21. New Risk: The five new national PCN DES service specifications have been issued in Draft and initial review and feedback nationally from CCGs, LMCs and General Practice/PCNs is that these specifications are not workable in their current form. Locally discussions are already happening within PCNs regarding withdrawing from the PCN DES in its entirety and recruitment process for additional workforce has been halted until the outcome of the feedback is known. Actions: The CCG is collating an organisational response to the national specifications and this will be shared with the LMC. The LMC are also submitting a response. A holding email has been circulated to PCNs and Management Leads to provide assurance and to encourage feedback through the national survey; deadline 1pm 15th January 2020. The communication urged PCNs not to make any drastic decisions until the outcome of the national negotiations are known and further discussions had with PCNs regarding the CCGs position.

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BAF 2.6 Risk that we do not comply with the General Data Protection Regulation (GDPR). RISK OWNER: Chief Finance Officer (SIRO)

CAUSES: (A) Inadequate preparation; (B) Failure to monitor compliance Inherent risk score Current risk score Target risk score Forecast for end of 2019/20

20 8→ 4 4

ASSURANCE SUMMARY (15 Janaury 2020): HVCCG is compliant with GDPR and the internal audit in January 2019 confirmed this. Mandatory training for all CCG staff on the practical aspects of GDPR compliance has been introduced an the compliance figure is 95.45% The Data Security and Protection Toolkit 2019/20 action plan is progressing well. Training in cyber security is to be delivered to the board and roll out has been arranged for all staff. A SIRO report will be presented to Audit Committee on 23 January 2020 including assurance in relation to cyber security across STP and ICS links.

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Transforming Delivery. We will work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the Strategic Review in west

Hertfordshire and its fit with the wider Sustainability and Transformation Partnership (STP) strategy, “A Healthier Future”. BAF RISK 3.1: Risk that the joint submission to obtain additional capital resource to successfully transform the delivery of care in west Hertfordshire is unsuccessful.

RISK OWNER & LEAD: Director of Commissioning CAUSES: (A) Failure to make a compelling case for transformation; (B) Failure to communicate effectively with national bodies, key stakeholders and patients; (C) Limited workforce capacity and capability;

(D) Requirement for Estates Strategy. Inherent risk score Current risk score Target risk score achievement March 2021 Forecast for end 2019/20

20 16→ 8 12

ASSURANCE SUMMARY (11 November 2019): WHHT and HVCCG submitted the SOC for capital resource to transform hospital services in line with the board’s decision in July. Confirmation that WHHT will receive a capital allocation has been received. HVCCG and WHHT are currently in discussions with regulators NHSE/I and the Department of Health and Social Care as to the details.

BAF RISK 3.2a: Risk that there will be insufficient support from local bodies, the public, politicians and other key stakeholders to transform the delivery of care in west Hertfordshire.

RISK OWNER: Director of Commissioning and Director of Primary Care CAUSES: (A) Failure to make a compelling case for transformation; (B) Failure to communicate and engage effectively with national bodies, key stakeholders, patients and carers;

(C) Limited system workforce capacity and capability. Inherent risk score Current risk score Target risk score achievement December 2019 Forecast for end of 2019/20

20 12→ 8 8

10 November 2019 HVCCG’s Chair, CEO and members of the executive team continue to meet with local members of Parliament to discuss plans and promote understanding and support. We are also working closely with the chair and officer lead of the county council health scrutiny committee. A judicial review of the decision making process of the CCG – around whether or not we should have formally consulted - in relation to the SOC has been granted by the courts and there will be a hearing before a judge in the coming months. The CCG has requested a ‘stay’or pause in proceeding due to a lack of clarity on the next steps from NHSE/I. CCG is liaising with the lawyers to progress the case and requesting that this is dealt with in a reasonable timeframe, once we are able to lift the stay . The forecast risk score for 2019/20 is 8, with the target risk score achievement date delayed to March 2020 to reflect the latest information about timescales.

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BAF RISK 3.2b Risk that there will be insufficient capacity for GP practices, primary care networks and federations to deliver the transformation of care in west Hertfordshire. RISK OWNER: Director of Primary Care RISK LEAD: Deputy to Assistant Director Localities and Primary Care Development.

CAUSES: (A) Pressures in general practice; (B) Insufficient pace in the organisational development of primary care networks; (C) Insufficient collaboration between local delivery partners. Inherent risk score Current risk score Target risk score Forecast for end of 2019/20

20 12→ 8 8

ASSURANCE SUMMARY: (14 January 2020) Both Commissioning Executive and Primary Care Commissioning Committees agreed that the risk description needed to be amended in 2019/20 to reflect the increasing demands on general practice whilst they develop and mature their primary care networks (PCNs). The current risk score was reduced to a cautious 12 in June 2019, maintaining the in-year forecast and target of 8. The primary care team continues to work monitor and develop the GP Forward View transformational programme. The GP Enhanced Commissioning Framework (GP ECF) has started to take practices on the journey towards an Integrated Care System (ICS) and Integrated Care Partnership (ICP). The GPFV training plan for 19/20 is being developed with feedback requested from practice managers at the CCG wide PMs forum on 24th October. The NHS 111 direct booking functionality is progressing and are currently completing the "on-boarding" process for NHSE/I & NHS Digital; however there is still no date for the upgrade for Adastra to enable extended access direct booking. PCN Maturity Matrix's have been returned and have been reviewed to ensure the PCN Development programme is aligned to need. CCG has plans to further support PCN development and will discuss this at the next PCN CD development session being held on 21 November 2019. The CCG is also developing and reviewing services to be commissioned from PCNs from April 2020 onwards and are engaging with the PCN CD at every stage. Jan update: The Primary Care Commissioning Committee approved the PCN Development Programme funding and the CCG continues to liaise with PCN Clinical Directors and Management Leads to initiate the mobilisation of the programme. The CCG is developing a programme of protected time for PCN CD development sessions throughout 2020/21. Following the Christmas period, the change freeze has been lifted in relation to the Adastra system used by HUC. Discussions with NHE/I, NHS Digital and HUC will now recommence to progress the NHS 111 direct booking functionality into Extended Access. New Risk: The five new national PCN DES service specifications have been issued in Draft and initial review and feedback nationally from CCGs, LMCs and General Practice/PCNs is that these specifications are not workable in their current form. Locally discussions are already happening within PCNs regarding withdrawing from the PCN DES in its entirety and recruitment process for additional workforce has been halted until the outcome of the feedback is known. Actions: The CCG is collating an organisational response to the national specifications and this will be shared with the LMC. The LMC are also submitting a response. A holding email has been circulated to PCNs and Management Leads to provide assurance and to encourage feedback through the national survey; deadline 1pm 15th January 2020. The communication urged PCNs not to make any drastic decisions until the outcome of the national negotiations are known and further discussions had with PCNs regarding the CCGs position.

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BAF RISK 3.3 Risk that workforce issues prevent us from transforming the delivery of care across the local health and social care system. RISK OWNER: Director of Commissioning /Director of Workforce

CAUSES: (A) Unclear approach and absence of strategy; (B) Limited workforce capacity and capability; (C) Workforce culture not congruent with required changes; (D) Poor communication with health and social care partners; (E) Uncertainty associated with EU Exit

Inherent risk score Current risk score Target risk score achievement June 2021 Forecast for end of 2019/20

20 16→ 8 16

.ASSURANCE SUMMARY (19 November 2019): The local workforce action group (LWAB) has developed a ‘one workforce strategy’, which incorporates the seven work-steams of (1) HR integration; (2) attraction, recruitment and retention; (3) bank and temporary staffing; (4) alternative ways of working; (5) workforce planning; (6) learning and development; and (7) primary care workforce. Progress is being made on all fronts of this strategy and individual organisations across the STP are aligning their work plans and HR and ODL activity to bring the ‘one workforce’ workforce strategy alive. NHS E/I also confirmed that the H&WE STP Workforce strategy is well aligned with the Interim People Plan published by NHS England/Improvement at the end of the first quarter of 2019. HVCCG is currently working to align its HR and ODL strategy to support the system workforce strategy, in support of the interim people plan and the long term plan. Each of the seven work streams provide monthly updates to the LWAB, with quarterly deep dives into what has been achieved. Early indicators is the development of a talent academy, which will focus more on school children, offer support to students, and guarantee placements across STP organisations to attract and retain more people in our own workforce. The focus of the bank and temporary staffing has now moved towards medical staffing, to ensure that the same efficiencies are being achieved with West Herts Hospitals NHS Trust leading on this work with an offer to support the wider East of England in this regard. A workforce planning model has also been developed with the assistance of Attain consulting service and that is being tested across the STP and has been demonstrated to the CEOs. Alternative ways of working continues to being explored, with progress being made with Higher Education Intuitions (HEI’s) in the development of new ways of working for and the development of physician associates roles; nurse specialists; allied health professionals; and a focus on hard to recruit to areas. Of concern remains the significant reduction in both Mental Health and Learning Disability nurse places with the local universities, as these areas remains hard to recruit to, in at a time when the profile of these professions are at an all-time high. Additional resources have been appointed to support the system workforce planning and Attain has been procured to assist with the development of a system wide workforce plan including primary care. In addition a virtual Leadership Academy is being developed to support ‘growing our own’ for Hertfordshire and West Essex, whilst the integration of HR services is making good progress with the development of one payroll provider and one occupational health service provider across the system. East North Hertfordshire NHS Trust will be the system lead role on this important service in support of our system workforce moving forward, plus agreeing to step up as system shared service lead Primary Care, changes to the General Medical Services (GMS) contract in 2019/20 include the introduction of Primary Care Networks (PCNs) from July 2019 (see BAF risk 2.5). PCNs are being developed nationally to ensure the longer term sustainability or primary medical care service contractors, to enabled integration with the wider healthcare system. PCNs will receive additional funding for workforce over the next 5 years starting in 2019 with each PCN receiving funding for a Clinical Pharmacists and Social Prescriber. The workforce will increase year on year over 5 years to include clinical and social prescribers, paramedics, physicians’ associates, mental health practitioners. HVCCG has supported the development of its PCNs and will continue to do so in 2019/20 onwards through the introduction of a PCN organisational development programme that will commence in HVCCG with the aim of rolling out across the STP. Progress of PCNs is being monitored and reported to NHS England and will be monitored by the STP primary care oversight and workforce groups which includes reporting to LWAB and the Primary Care Commissioning Committee. The forecast for 2019/20 is to maintain the current risk score of 16, with the target expected to be achieved in 2 years’ time

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BAF RISK 3.4: Risk that we are unable to manage satisfactorily all transformation, quality, communication and finance requirements during the mobilisation of the new community services contract. RISK OWNER: Director of Commissioning

CAUSES: (A) Lack of engagement from incumbent provider; (B) Lack of progress by new provider in mobilising the service; (C) Unable to successfully resolve issues with data in a timely manner; (D) Unable to transfer properties in a timely manner; (E) Potential disruption to services before new pathways are embedded; (F) Delays caused by legal challenge; (G) Unable to retain staff in the interim period.

Inherent risk score Current risk score Target risk score Forecast for end of 2019/20 16 9→ 3 3

ASSURANCE SUMMARY (10 January 2020) The Oversight Board approved the Post Go Live PMO approach on 13 September 2019 SRO group formally closed in October 2019 All workstream groups closed with open actions and associated risk transfer arrangements completed A new Transformation Group commenced as planned post Go Live in October with weekly meetings The new CQRM Contracts and BI group commenced post Go Live to focus on Performance ACS Transformation Group meets fortnightly. Terms of reference agreed for this Group. Transformation score card covering all service lines that are undergoing transformation with the associated timelines are rag rated and monitored to ensure delivery timelines are met.

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BAF RISK 3.5 Risk that our plans do not focus on prevention of ill health and reduction of health inequalities. RISK OWNER: Director of Commissioning

CAUSES: (A) Lack of focus on prevention, early intervention and diagnosis when implementing strategic plans; (B) Limited workforce capacity and capability for implementation. Inherent risk score Current risk score Target risk score Forecast for end of 2019/20

16 8→ 4 4 ASSURANCE SUMMARY (10 January 2020) The urgent care programme for 2019/20 sets out plans to have an urgent care offer in every locality, with the default route into urgent care over time to be booked through the NHS 111 service so that the number of walk-ins will be reduced. These will support access and improve quality of services with the default for patients who need continuity of care being access urgent care through their practices. The Hemel Urgent Treatment Centre (UTC) is live and plans are developed to upgrade the Minor Injuries Unit (MIU) in St Albans by December 2019. A long-term vision for Watford is being discussed with WHHT and an interim solution is being planned for Hertsmere until a bookable community alternative to A&E is available via a designated urgent care base. Demand management in localities and revisions to processes for Individual Funding Requests (IFRs) focus attention on protected characteristics and health inequalities. All programmes and service transformations undergo an equality impact assessment and quality impact assessment which helps to ensure health inequalities are considered and measures put in place to reduce where possible. Programmes & service transformations developed in the commissioning team take into account prevention of ill health and reduction of health inequalities, for example: • Diabetes includes the roll out and monitoring of the national Diabetes Prevention Programme. This includes identification of people at high risk of developing diabetes and supporting them to reduce their risk. This will be delivered by all practices STP wide from August, with progress monitored monthly through the STP steering group. • The CCG is developing a cardiology referral management model with WHHT which will include the implementation of an end-to-end pathway, in particular for atrial fibrillation and heart failure. • Frailty pathways have now been approved across the STP. The CCG has commissioned a pilot with the community provider for identification and management of frail patients in the community. The GP Enhanced Commissioning Framework (ECF) includes the use of an electronic framework and Rockwood score to identify moderate frail patients to review and put the appropriate support in place. WHHT has already implemented the use of Rockwood for any patient over 65 who is attending via A&E which will enable the earlier identification of these patients. • The Enhanced Commissioning Framework for west Herts GPs is a positive development, including the implementation of a prevention dashboard to record GP referrals for services such as weight management and smoking cessation, as well as a ‘five ways to wellbeing’ initiative. • A pilot across two practices for the early identification of non-alcoholic fatty liver disease is underway whereby patients are being identified earlier and managed through the gastro-hepatology unit in the acute trust. • STP wide consideration of identification and management of patients at risk of liver disease and uncontrolled management of hypertension to prevent other cardiovascular disease. • The CCG commissioned specification for a new model of care for community adult health services is currently being mobilised with the services going live on 1 October 2019. One of the key requirements of this model is to address health inequalities within localities as well as at primary care network level, to ensure the right level of workforce to address local needs. As part of delivery of place-based care each locality is currently developing their locality transformation plan which will also highlight how they are tacking health inequalities at locality and PCN level. Draft proposals are for discussion at the Local Delivery Partnership at end of March 2019. • A refreshed stakeholder participation strategy was approved by the board in November 2018 and an implementation plan is being drawn up. This will support greater public engagement, particularly among disadvantaged groups. Forecast and target achievement for 2019/20 are 8 with target achievement expected by September 2019. January 2020 -A new BI system, GEMIMA, is being implemented which will provide a new primary care portal, which will include capabilities for risk stratification and the foundations for population health management. This will underpin the changes in primary care such as the formation of Primary Care Networks, the Local Delivery Plan programme, Enhanced Effective Resource Management, the new ECF and the frailty programme. Enabling the CCG to ensure it commissions services that reduce health inequalities and focus on prevention of ill health. This functionality of GEMIMA will be launced in APril 2020. -The CCG are also working closely with the STP Population Health Managemenr workstream to esnrue that across the STP we are workign to reduce health inequalities.

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Affordable & Sustainable Care: We will ensure that we fulfill our statutory duty to deliver a financially sustainable and affordable healthcare system in west Hertfordshire.

BAF RISK 4.1 Risk that we do not deliver a financially sustainable integrated healthcare system in collaboration with our partners in the STP. RISK OWNER: Chief Finance Officer

CAUSES: (A) Reliant upon the engagement of partners in a common financial strategy for both STP (5 years) and Your Care Your Future (10 years); (B) Continued challenges in the wider system, particularly in acute


ASSURANCE SUMMARY (15 January 2020): A refreshed draft medium term financial sustainability plan has been drawn up, and the system wide Long Term Plan for the period to 2023/24 has been submitted to NHSE. This incorporates the work of the STP programme groups. The CFOs have agreed a joint, system-wide, approach to 19/20 planning based on shared assumptions on activity planning. A minimum income contract has been agreed with WHHT in line with the plans for an Integrated Care Partnership (ICP). This includes risk sharing arrangements to protect both parties and limits financial pressures. However there is a risk that other ICPs in the STP cannot fully mitigate the financial risks. A joint long term plan has been agreed across the STP to deliver financial targets over the next 4 years

BAF RISK 4.2 Risk that we do not drive the required value and level of transformation through our identified QIPP schemes.

RISK OWNERS: Chief Finance Officer, Director of Commissioning; Director of Nursing & Quality and Deputy CEO. RISK LEAD: Assistant Director Transformation. CAUSES: (A) Failure to identify schemes early enough; (B) Failure to identify alternative schemes for lost savings; (C) Failure to validate and embed schemes in partnership with providers; (D) Lack of ownership of

individual schemes; (E) Lack of consistent programme management approach; (F) Failure to derive the benefits available from engagement with the programme boards and wider STP partners. Inherent risk score Current risk score Target risk score Forecast for end of 2019/20

20 16 → 8 8

ASSURANCE SUMMARY: (9 January 2019) The QIPP value for 2019/20 is £15.4m and the full QIPP value has been identified. Schemes are monitored monthly with reports to Finance Committee for review. The required process improvements have been put in place following an internal audit review. Continued focus is still required to ensure that required information is provided in a timely manner and content is sufficiently detailed to allow oversight. Further work has taken place to embed more transformation in the acute providers, for example, in outpatients and frailty pathways. For this reason the current risk score for 2019/20 has been reset at 16 and will be reviewed against delivery as the year progresses. QIPP performance at Month 8 is 95.1% and this position is expected to be reflected in year-end performance. Under-delivery has been allowed for in forecast figures. Deep dives are taken forward for schemes that are below plan. Remedial actions are identified. Pipeline schemes are also being scoped to be reported on in year. The QIPP target for 2020/21 is £16 million. £12.5 million has been identified and work is ongoing to identify remaining amount. A New Ways of Working Joint QIPP/CIP Task and Finish group has been set up with WHHT to agree transformation priorities to support delivery of remaining requirement. The PMO is working with teams to ensure this QIPP is fully identified in time for the next planning round.

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BAF RISK 4.3 Risk that we do not achieve financial balance in 2019/20. RISK OWNER: Chief Finance Officer

CAUSES: (A) Acute activity levels and/or (B) Financial values of activity above those detailed in the 2019/20 financial plan (C) Risks around QIPP delivery. Inherent risk score Current risk score Target risk score Forecast for end of 19/20

20 8↑ 4 4

ASSURANCE SUMMARY (15 January 2020 ): The CCG set a realistic activity and financial plan for 2019/20 supported by agreed contracts with providers. A resultant savings scheme of £15.4m was fully identified to balance the plan. In addition to the establishment of a contingency of 0.5% of allocation, budget areas were reviewed and any surplus reassigned. Prime financial policies have been reviewed. Internal audit of key financial controls has resulted in substantial assurance without any actions or recommendations. There is an ongoing process of reviewing limits of budgetary delegation and necessary training for budget holders. At month 8 (M6) the CCG is reporting a surplus of £0.4m. It is forecasted that the CCG will deliver to plan at the end of the financial year. The main risks identified at M8 relate to risk shares associated with the revised contractual forms and activity levels with the community contracts. The risks are assessed as being fully mitigated by non-recurrent and prior year benefits. QIPP performance is currently at 95.1% and this position is expected to be reflected in year-end performance. Under-delivery has been allowed for in forecast figures. The current risk score is proposed as 8, but the in-year forecast is that the target score of 4 will be achieved.

BAF RISK 4.4 Risk that we do not have sufficient financial resource to manage the increase in legal challenges to our commissioning decisions.

RISK OWNER: Chief Finance Officer RISK LEADS: Director of Commissioning; Associate Director Communications and Engagement. CAUSES: (A) An increase in legal challenges, claims and legal costs; (B) The need to take commissioning decisions that are sometimes unpopular in order to achieve transformation and long term sustainability.


16 8→ 8 8

ASSURANCE SUMMARY ( 15 January 2020) Full Stakeholder engagement has taken place to support transformation of healthcare services Appropriate procurement processes are being followed by the CCG; due diligence is undertaken; legal advice is sought as required; and learning from previous procurements is supported. Contingency arrangements are included in the financial planning process in order to be able to offset any unexpected costs incurred. Continuous improvement approach to governance and internal control arrangements mitigates any likelihood of challenge. All risk scores have been reset for 2019/20 in line with the management and assurance information provided.

CORPORATE RISK REGISTER SUMMARY 2019/20, Quarter 3 - updated 21 January 2020

Effective Engagement. We will continually improve engagements with member practices, patients, the public, carers and our staff to contribute to and influence the work of Herts Valleys CCG.

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Target

Risk

SO1/24 Risk that public and stakeholders are not informed effectively. ASSURANCE SUMMARY (7 January 2020): Hospital transformation: We continue to work jointly with WHHT to inform residents. This includes updating our websites to reflect the latest position (confirmation of funding from government) and communicating developments via patient networks, social media and local media. New community pathways: We are working with providers on communications about new community services. This includes providing information via the CCG website, reviewing patient communications and explaining new services at patient network events, at GP locality events and at local authority meetings. We have developed communications for GP surgery staff to help them in signposting patients and have developed information to go on GP websites. This will be sent to practices in January.

Campaigns: - Delivery of winter pressure awareness campaigns is underway. In line with ERM this year’s plan is targeted to the populations within the CCG that have higher and avoidable use of A&E. Particular areas this year include encouraging people seek advice from local pharmacist, promotion of children’s GP extended access appointments and promotion of NHS111. Delivery is via CCG communications channels including social media, e-bulletins and website. Working with ENHCCG we have created and distributed leaflets through schools and the family centre service to target young families. Communications are also going out to food banks and care homes. Communications activity is reflected in a winter communications plan which feeds both into a wider STP plan as well as into CCG winter resilience planning. This plan is also being shared with local delivery boards for Dacorum and Hertsmere. - An awareness raising campaign is supporting new Fitness for Surgery arrangements being implemented in January 2020. Communications have been developed jointly with ENH CCG including leaflets delivered to GP surgeries and information on websites. - A communications campaign has been developed ready to support roll-out of WaitLess App which has been procured by the STP technology workstream. This will be rolled out to health professionals initially to help with signposting patients to urgent treatment centres.

20

12

6


Inherent Risk

Current Risk

Target Risk

SO2/15b Risk that CHC performance is inadequate. ASSURANCE SUMMARY (13 January 2020): Substantive recruitment has been completed with start dates for 3.0 WTE during February and March 2020 (2 permanent and 1 fixed term for 1 year).

The upgrading of QA and data cleanse remains on track and quality premium targets continue to be met.

16 12 8

SO2/26 Risk to the CCG of not meeting NHSE objectives for people with learning disabilities and/or autism and complex needs, including mental health issues and behaviour that challenges. ASSURANCE SUMMARY (31 December 2019): The Transforming Care Partnership continues and provides regular and ad hoc reports to NHS England (NHSE) on performance as required. Data as at the end of September 2019 indicates overall adults patient trajectories will be met for Q4 19/20. From April 2019 there are separate inpatient targets for Adults and Children and Young People (CYP). A C&YP recovery plan is in place to ensure that the CCG meets the required inpatient trajectories. Regular monitoring visits continue to all patients placed in CCG commissioned LD inpatient units to review the quality and safety of these placements, and to meet the new NHSE requirements for 8 weekly visits to people placed out of area. NHSE has expanded Transforming Care (TC) to include the national programmes for LeDeR (Mortality Review for people with learning disabilities) and STOMP (Stop Over Medicating People with Learning Disabilities). Transforming Care continues to become business as usual as the programme formally came to an end in March 2019. However, NHSE TC structures and processes remain in place until September 2019 and the priorities developed under Transforming Care have now become part of the NHS Long Term Plan so will continue to be priorities for the CCG.

12

9

6

SO2/30 Risk that patients are not assessed with a management plan and exited/admitted or discharged out of the Emergency Department (ED) within 4hrs. ASSURANCE SUMMARY (8 January 2020):

HALO appointed until at least March 2020 Progress against the ED improvement plan: The new medical take model pilot is underway with regular review meetings being held. There has been a reduction in both LOS and conversion to admission. Work with system partners is ongoing to develop the urgent care strategy which includes the development of Urgent Treatment Centres (UTCs) across all 3 trust sites. Review of the risk at performance committee agreed that the rating should remain at 16.

16

16

8

SO2/31 Risk that we do not reduce delayed transfers of care (DTOCs) to the target of 3.5%. ASSURANCE SUMMARY (8 January 2020): DToC position was 6.5% October; increase due in part to transition of Simpson Ward back to the Trust and the high volume of people awaiting social care support. There was significant decrease in flow through the IMC beds during the provider transition period that has now dissipated.

16

16

8

SO2/32 Risk that we do not deliver on the constitutional pledge to refer to treatment within 18 weeks at WHHT. ASSURANCE SUMMARY (15 January 2020): WHHT planned trajectory remains on track. The elective performance review group considers performance, risks, and barriers to agree actions. The improvement plan is monitored through this group and exceptions are raised at the CQRG.

RFL data validation extended until October 2020. Trust report 192, 52-week waits of which 5 are Hertfordshire patients. HVCCG continue to support RFL through the steering group and operational groups.

16

16

8

SO2/33 Risk that we do not deliver on priority ambulance key performance indicators (KPIs). ASSURANCE SUMMARY (10 January 2020):

Ambulance capacity challenge has been anticipated with a work plan with executive ownership and accountability agreed with CCGs and underpinned by an integrated action plan. The focus is on maximising local management actions to increase the number of hours put out and mapping the next 12 months in terms of capacity. This is to ensure that planned hours will support safe service delivery. There will be a close focus in upcoming contractual and performance meetings around the ongoing concerns relating to vacancies. There are currently no vacancies within the NEPTS contract. Arrival to Handover (A2H) delays at Watford General Hospital continue to impact the Trust’s ability to release vehicles back on the road. HVCCG is not the lead commissioner for this contract but does now have a dedicated resource monitoring the contractual performance much more closely and escalating any local issues to the host commissioner via the sector meeting

16

16

8

SO2/38a Risk that we do not achieve national HCAI indicators* and/or provide the CCG with adequate assurance regarding standards of IPC within all provider organisations ASSURANCE SUMMARY (6 January 2020): IPC risks and progress against work plan reported quarterly to the STP IPC Group which reports to the Quality Committee of each CCG

16

9

8

SO2/41 Risk that we are unable to maintain good quality, safe and sustainable services within the non-emergency patient transport service. ASSURANCE SUMMARY (7 January 2020) - Monthly Contract review meetings as well as quarterly quality review meetings continue to monitor EEAST. - Monthly locality meetings with EEAST and WHHT also in place to review and address any operational concerns. - Since last update in October 2019 - 20/21 contract extension agreed to March 2021. - External review and benchmarking exercise of the service to be commissioned. The findings of which will support EEAST and the CCG's in developing improvements to NEPTS service and will provide a baseline to model a re-procurement of the service.

20

16

8

SO2/42 Risk that children and young people eligible for CYPCC will not receive a package of care to meet their assessed need in a timely and continuous way due to capacity within the HCT CYPCC team. ASSURANCE SUMMARY (13 January 2020) Commissioning of CYPCC packages continues to be embedded as business as usual within the CCG team. Work is underway to engage with more providers that can deliver CYPCC packages and this is progressing well. PHB is becoming business as usual.

16

16

6

Transforming Delivery. We will work with health and social care partners to transform the delivery of care through the implementation of “Your Care, Your Future”, the Strategic Review in west Hertfordshire and its fit with the wider Sustainability and Transformation Partnership (STP) strategy, “A Healthier Future”.

Inherent

Risk

Current

Risk

Target

Risk

SO3/05 Risk that we fail to successfully transform health and social care through use of the Better Care Fund. ASSURANCE SUMMARY (31 December 2020): HVCCG engagement and involvement in plan includes sessions at a number of CCG committees, led by AD for Integration. Governance improvements have been made: the section 75 agreement with Hertfordshire has been re-written and was approved by the board in June; the HVCCG-HCC Strategic Partnership Board meets regularly. A joint audit of the BCF was conducted by RSM with the ‘reasonable assurance’ outcome reported in March 2019 and an assurance paper relating to management actions presented to the Audit Committee in October 2019.

16

12

8

SO3/09 Risk that there will be increased pressure on health services due to a reduced level of provision for social care services. ASSURANCE SUMMARY (31 December 2020): HVCCG is kept appraised of developments in social care and potential impact on health through the HCC-HVCCG Strategic Partnership Board. The first step to improving the current position will be publication of the long-awaited green paper on Social Care, but no date for publication has been advised. No formal planning guidance has been received from NHSE for the Better Care Fund 2019/20 and no confirmation as to whether additional social care grants will continue in 2020/21.

20

12

8

SO3/10 Risk that lack of progress on integration across health services and between Health and Social Care will hinder HVCCG's delivery of its statutory duties and strategic objectives. ASSURANCE SUMMARY (31 December 2020)

Terms of References and reporting structures are in place. Stronger arrangements around integrated commissioning and greater clarity about how locality boards will deliver STP/ICP priorities need to be developed. The West Hertfordshire Integrated Care Partnership (ICP) is being developed.

12

8

4


Inherent Risk

Current Risk

Target Risk

SO4/22 Risk that there are higher levels of activity than planned/anticipated. ASSURANCE SUMMARY (15 January 2020):

HVCCG has partly mitigated the financial risk to 2019/20 by agreeing financial year end positions with its main Acute providers. However, higher levels of activity over and above that planned will impact on the baseline positions for 2020/21. Particular pressures are from NEL admissions and the acuity of admitted patients. The main element of this risk now comes from the Community contracts, which are delivering activity levels significantly above the levels included within their financial envelopes. This is being managed through non-recurrent measures in 2019/20 and recurrent pressures will be worked through in financial planning. Introduction of ‘new ways of working’ contractual forms means that cost, rather than activity levels, will need to be the driver of savings generated by transforming pathways and levers for demand management.

16

12

8

SO4/23 Risk that additional expenditure will occur which is not budgeted for. ASSURANCE SUMMARY (15 January 2020): More robust budgetary controls are now in place at HVCCG and improved financial reporting and cross-CCG working means that recurrent emerging issues and non-recurrent pressures are identified earlier. The risk of spending more than we have budgeted for in 2019/20 is therefore assessed to be lower than in recent years. The CFO and CEO continue to undertake monthly reviews with budget holders to ensure any emerging cost pressures are managed and mitigation actions put in place. Budget holders are supported by the finance team to review their expenditure in detail each month. Some delegation of budgets has been resumed, and is subject to Executive approval and the satisfactory completion of training by the budget holder. The Finance Committee receives monthly Finance reports which detail performance against the budget lines have been set for the individual contract lines.

16

8

6

Risks related to all four strategic objectives Inherent Risk

Current Risk

Target Risk

SO5/02 Risk that HVCCG is not protected from cyber attacks ASSURANCE SUMMARY (9 January 2020) HVCCG has improved oversight of shared service, receiving a number of self-assessment and audit assurances. Awareness is regularly raised among HVCCG staff about cyber threats, with specific threats also being notified. All staff have been reminded that failure to follow policy and procedures in relation to cyber security may be subject to disciplinary action. The CCG has nominated an executive lead for cyber security in response to the WannaCry report. Information and Cyber Security Policy now available to staff and board and staff training being rolled out. RSM audit being carried out January 2020

20

8

4

SO5/03 Risk that conflicts of interest will not be managed effectively. ASSURANCE SUMMARY (31 December 2019): There is a good level of awareness in the organisation about the need to declare conflicts of interest. New staff are made aware of the policy and procedure as part of their induction. All registers were updated and republished for 2019 and additional processes are being put in place to ensure that all agency and contracted staff complete declarations of their interests. Members are now being requested to renew their declarations on a rolling monthly basis. The Standards for Business Conduct Policy has been reviewed and reissued. The CCG now has fully delegated primary care commissioning arrangements, which represents an additional challenge in effectively managing the perception of conflicts of interest when decisions are made which affect the business of individual practices. The first phase of a review of provider governance has been completed and reported to the Audit Committee in February 2019. A further desktop analysis of evidence to support the initial survey is being conducted in Q1 of 2019/20 and will be reported to the Audit Committee in July 2019. Additional advice about standards in public life and declaration of interests prior to meetings is now sent out with all Board and Committee papers and a review of how interests were managed in the meeting is now a standing item on all agendas. NHSE has confirmed national mandatory training requirements for 2019 and all staff are now being asked to undergo training on the NHSE conflict of interests training module. 100% compliance was reported for relevant staff in 2018/19. HR are supporting the Corporate Governance team to ensure that all staff who have not completed this training will now undertake it. An audit of COI in 2019/20 found reasonable assurance.

20

8

4

SO5/04 Risk that a 'no deal' EU exit scenario impacts on HVCCG's statutory duties. Risk recommended for closure. ASSURANCE SUMMARY (9 January 2020) A deal has now been agreed.

20

4

4

SO5/05 Risk that the uncertainty surrounding the possible collaboration between the three CCGs in the Herts and West Essex STP could have an impact on: 1) effective VSM executives; 2) immediate reports; and 3) the wider organisation in terms of staff retention. ASSURANCE SUMMARY (31 December 2020): High level plans now agreed and changes are being enacted.

16

16

8

Please refer to further guidance here Z:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201920\Current versions for front sheet reference when completing this front sheet. Title CCG Board Membership 2020/21 Agenda item 08 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging



Decision ☐ Approval ☒ Discussion ☐ Assurance ☐ Information only ☐

Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Rod While Head of Corporate Governance



It is proposed to maintain current board membership for the year 2020/21. Four GPs would, under normal circumstances leave or stand for re-election in March. However we propose to maintain the current membership of both GPs and lay members for a further year. We also propose to maintain current arrangements for chair, deputy chair and deputy clinical chair for 2020/21.

Recommendation(s) The Board is being asked to: 1. Approve the GP membership for 2020/21. 2. Note lay membership for 2020/21. 3. Approve the arrangements chair, deputy chair and deputy clinical chair for 2020/21.


Discussed at GP forum on 11 December 2019


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☒

Board Assurance Framework Refer to latest BAF report here for current and target risk scores: Z:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201920\Current versions for front sheet reference Ref. Risk


score and movement

Target risk score

*Assurance Level

ALL BAF RISKS APPLY New strategic risks identified by this report


Board Meeting in Public Date of Meeting: 30 January 2020

Other significant risks related to this report (from the Corporate Risk Register) Resource implications

NOT APPLICABLE CFO Signature


This agenda item cannot be chaired by the current chair, deputy chair or deputy clinical chair as they have a direct conflict of interest. The item should be chaired by a lay member as no decisions are requested regarding lay membership.


NOT REQUIRED


NOT APPLICABLE

Better Health Outcomes ☐ Improved Patient Access and Experience ☐ A Representative and Supported Workforce ☐ Inclusive Leadership ☐


NOT APPLICABLE

Report history

This is a new paper

Appendices

Introduction The aim of this paper is to ask the board to approve the recommended structure and membership for 2020/21. GP board members are elected by practices and have a term of office of four years. The CCG board appoints the chair and deputy clinical chair from the pool of GP board members. The chair appoints lay members to the board and one of the four lay members is given by the board the responsibility of deputy chair. Confirmation of GP board membership 2020/21 Four GP members of the CCG board will complete their four year term of office at the end of March 2020, having been elected by member practices in the four localities in 2016. These members are

• Nicolas Small (Hertsmere) • Trevor Fernandes (Dacorum) • Rami Eliad (Watford and Three Rivers) • Richard Pile (St Albans and Harpenden)

2020/21 is a year of transition with the establishment of a “shadow” integrated care system (ICS), shadow integrated care partnership (ICP) and increased joint working between the three CCGs in the Herts and West Essex STP. Under normal circumstances the above named GPs would either leave the board or stand for re-election, however given the system changes ahead we are proposing not to make any changes to the GP membership of the board. The CCG membership unanimously approved this proposal at the GP Forum on 11 December 2019. The board is asked to approve the GP membership for 2020/21. Board lay membership 2020/21 It was the intention of the chair to begin the process of “staggering” the end date of the four lay members’ terms of office to maintain continuity. However we have now reconsidered this and in view of the system changes anticipated in 2020/21 we do not believe it would be appropriate to recruit a new lay member at this time, thereby losing the experience and leadership of our current lay membership. We are therefore continuing with our current lay membership for the duration of 2020/21. The board is asked to note lay membership for 2020/21. Confirmation of chair, deputy chair and deputy clinical chair for 2020/21 We propose to maintain current arrangements in 2020/21: Chair: Nicolas Small (GP board member) Deputy Chair: Stuart Bloom (Lay board member) Deputy Clinical Chair: Trevor Fernandes (GP board member) The board is asked to approve the arrangements chair, deputy chair and deputy clinical chair for 2020/21

Please refer to further guidance here N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201819\Current versions for front sheet reference when completing this front sheet. Title West Herts Integrated Care Partnership Update Report Agenda item 09 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be

damaging to the CCG, another NHS body or a commercial partner if improperly accessed.

NHS Official Sensitive Personal ☐ Check the box if paper contains personal information relating to an identifiable individual where inappropriate access could have damaging consequences.

Purpose* (click appropriate box)


Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. David Evans Interim Chief Executive Officer

David Evans Interim Chief Executive Officer


The purpose of this paper is to provide an update on recent progress towards the developing West Herts Integrated Care Partnership (ICP). It also references work happening at the Herts and West Essex Integrated Care System (ICS) level and developments relating to the mental health and learning disabilities ICP (MH/LD ICP).

Recommendation(s) The Board is being asked to discuss the report


Engagement is currently being planned as part of the programme plans and will include patients, public and staff. Herts Valleys PPI Committee has been updated.


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☒


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Board Meeting Date of Meeting: 30 January 2020



score and movement

Target risk score

*Assurance Level

All BAF and CRR risks are potentially relevant, but particularly those related to engagement and transformation. 1.1 JR Risk that we do not engage effectively with a

range of our patients, population and stakeholders.

12→

8

Medium

3.2a AS Risk that there will be insufficient support from local bodies, the public, politicians and other key stakeholders to transform the delivery of care in west Hertfordshire.

12→

8

Medium

3.2b AS Risk that there will be insufficient capacity for GP practices, primary care networks and federations to deliver the transformation of care in west Hertfordshire.

12→

8

Medium

3.3 AS/HS Risk that workforce issues prevent us from transforming the delivery of care across the local health and social care system.

16→

8

Medium

3.5 AS Risk that our plans do not focus on prevention of ill health and reduction of health inequalities.

8→

4

Medium

4.1 ET Risk that we do not deliver a financially sustainable integrated healthcare system in collaboration with our partners in the STP.

20→

5

Medium

New strategic risks identified by this report None Other significant risks related to this report (from the Corporate Risk Register) SO5/05

HS Risk that the uncertainty surrounding the possible collaboration between the three CCGs in the Herts and West Essex STP could have an impact on: 1) effective VSM executives; 2) immediate reports; and 3) the wider organisation in terms of staff retention.

16→

8

Medium

Resource implications

None CFO Signature


None


N/A




N/A

Report history

Updates have been provided via previous CEO reports.

Appendices Appendix 1: DRAFT core narrative for west Herts ICP

Herts Valleys CCG Board

West Herts Integrated Care Partnership Update Report

1. Purpose

1.1 The purpose of this paper is to provide an update on recent progress towards the

developing West Herts Integrated Care Partnership (ICP). It also references work happening at the Herts and West Essex Integrated Care System (ICS) level and developments relating to the mental health and learning disabilities ICP (MH/LD ICP).

2. Discussion

2.1 All boards within the west Hertfordshire system have received and discussed the

case for change documents during the autumn. The case for change highlighted a number of questions that need to be addressed as we develop the ICP, and which fall into 4 categories: vision, aims, objectives and principles; scope and pace; service design; and form and enablers. In the first instance, the directors’ group focused on the questions in the first category, as it is important to be clear about the vision and principles before working out how that vision will be delivered. The group has also started to consider the issues relating to scope and place, particularly in the context of the planned mental health ICP and the move to a single Joint Accountable Officer across the three CCGs.

2.2 A workshop was held for chief executives, chairs, and some additional executive

and non-executive directors on 20 November. The meeting agreed a definition of integrated care; a vision statement and a set of principles that will form the basis of staff and public engagement over the next few months.

2.3 The workshop also discussed the need for the ICP to provide a clear steer about the commissioning functions that will be delegated by the CCG to the ICP. The context for this is that the ICP is likely to want to manage of a number of budgets and contracts that currently sit within the CCG, to better enable it to change pathways and join up care. To do this, the CCG will need to delegate authority to the ICP to manage the contracts on their behalf and potentially second or TUPE the relevant staff to manage those contracts. Similarly, there may be some statutory functions that the CCG would wish to delegate to the ICP to undertake on their behalf (while maintaining the accountability). As the CCG within the ICP, we need to consider how to plan and manage these opportunities to take on responsibilities where approved over the next 2-3 years and ensure that they are maintained within a locality (HVCCG area) CCG team in the interim rather than consolidated at the ICS level.

2.4 While the directors’ group was set up to produce content for debate and sign off,

in practice we have found that we spend half our time building relationships and unpacking differences in views and understanding. This has been immensely valuable and through these discussions it has become increasingly clear that issues relating to differing views of the what we consider to be the ultimate state

we are aiming for, are driving different assumptions and behaviours. This means that a set of ‘working hypotheses’ is needed so that we are all working towards the same end point, while recognising that it may need to change if work over the next couple of years indicates that a different end point will better deliver the outcomes we are trying to achieve. The hypotheses that we are developing relate to the future organisational form (integrated care partnership or integrated care trust) and contractual form (several possibilities including contractual joint venture and lead provider model). The Chief Executives are meeting on 24 January to discuss the hypotheses ahead of the next joint workshop for chief execs, chairs and other directors on 31 January.

2.5 Mental health - The discussions have also led to greater clarity and acceptance

of the need for an ICP at Hertfordshire level focused on people with severe and long term mental health needs and people with learning disabilities, and so there is now agreement that the working hypothesis that this ICP will be set up separately. The important thing to note is that the ICP will meet all the physical health, mental health and care needs of those population groups and so primary, community and acute providers will need to play a strong role in that ICP, in the same way that HPFT will need to be a strong partner in the West Herts ICP to ensure that the mental health needs of the wider population are met. We will work closely with the lead for the mental health ICP to ensure that our developmental work remains consistent and joined up, with no gaps for patients or confusion for staff. There have been discussions about how children’s services are managed at the ICP and ICS levels (including Hertfordshire only geography).

2.6 Organisational Development - The workshop on 20 November began to

explore the important issue of OD. There is a need for clarity about what we mean by OD and where we want to focus over the next few months. We are therefore planning a workshop for HR directors in January, with appropriate input from the directors’ group, to plan our approach.

2.7 Staff engagement – We have been keen to make sure we informed Herts Valleys staff of developments with the ICP, alongside the work at ICS level. But inevitably our engagement has been limited while we have focused on aligning our thinking and developing some clear agreed messages. Once we have established the communications and engagement workstream we will need to plan our approach to staff engagement. We will need to share and engage regarding the vision and principles, and we also need to make integrated working feel real for all staff. Early conversations have started about how to use the learning from existing integrated working such as the integrated diabetes contract to engage clinical staff.

2.8 Following the agreement of the minimum income contract (MIC), WHHT and

HVCCG have been focusing internal engagement on the finance, BI and contracts team to support the move away from the PbR contract. Two half day workshops were held during November to help staff to understand the ICP and the MIC, and to help them start to think about how they can refocus the work that they do to support the new direction of travel. Four task and finish groups have been established to consider four key questions relating to: a single data set; moving from income monitoring to costs; developing a single CIP/QIPP plan; and jointly forecasting activity trends. Milestones have been set relating to operating

the contract for the remainder of 19/20, agreeing and monitoring the 20/21 contract and then the longer term vision for joint working.

2.9 Public involvement - Experience elsewhere has shown that strong patient involvement, is a key success factor for ICPs. Each organisation in the ICP currently undertakes patient involvement activities to a greater or lesser extent, but we have not yet established our ambition for the ICP or how we will join up activities across the ICP. A workshop is planned for late January to share learning and set our ambition. A lead from the NHSE personalised care programme will speak at the event and provide support going forward.

2.10 Integrated Care System - In addition to establishing the ICP we also need to

ensure we have a strong and effective integrated care system (ICS). To date the development of the ICS has been slower than the ICP development, and it has been recognised by partners across Herts and West Essex (HWE) that we have a responsibility for that as the ICS is currently seen as ‘them’ rather than as ‘us’. As a system we have signed up to becoming an ICS by April 2021 and are currently part of the NHSE accelerator programme. There are four areas of focus: leading partnerships, system architecture, system payment mechanisms and population health management.

3. Next steps

3.1 Work across the ICP has now reached a point where we need to move from the informal directors’ group to a full programme approach with clear milestones and work streams, led by SROs from across the organisations within the ICP and appropriately resourced. We are in the process of agreeing those milestones, work streams and SROs and should be ready to launch the work early this year. The CCG is funding full time PMO support. The milestones will be a focus for the discussion on 31 January.

Appendix 1:

DRAFT core narrative for west Herts ICP

Appendix 1:

DRAFT core narrative for west Herts ICP

This note tells you about some changes we are making to health and social care in this area. One of these is setting up an integrated care partnership (ICP) for west Hertfordshire.

We want local people to live healthier lives and to make sure that when people do become ill or have a health condition, their care is consistently good, well organised and planned around them as individuals.

This is particularly important as people are living longer and more people have complex health and care needs that need help from lots of different professionals. Sometimes this care can be confusing and complicated for patients to manage.

We also want to pay more attention to avoiding illness, and to really shift our efforts towards preventing people from becoming unwell, avoiding unpleasant and expensive treatments. As part of this, patients will also have more control over their own care.

Patients are already feeling the benefit of some new community-based services that are based around these principles as part of the Your Care, Your Future programme.

We are now taking these principles a step further and our own organisations are now committing to working very differently and establishing what is called an ‘integrated care partnership’ – an ICP.

In doing this the organisations that patients deal with daily and those that are more behind the scenes will be much more closely connected with each other. And this includes the way we manage our money. This is similar to what is happening in other parts of the country – in line with the NHS plans for the whole of England.

Moving towards making the health and care system simpler – by different parts of the NHS being more closely connected – will mean patients will experience more joined-up care.

And we think we will be far more successful with all of the changes we want to see, if we drive them forward as a more formally co-ordinated body – the ICP.

Juliet Rodgers

21 January 2020

Please refer to further guidance here N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201819\Current versions for front sheet reference when completing this front sheet. Title Month 8 Finance Report Agenda item 10 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging



Decision ☐ Approval ☐ Discussion ☐ Assurance ☒ Information only ☒

Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Nicola Peters, Acting Deputy Chief Finance Officer

Elke Taylor Acting Chief Finance Officer


This report details the financial performance of the CCG at month 8, November 2019 and the Forecast Outturn for the financial year 2019/20. At the end of November the CCG is reporting a surplus of £0.423m and is forecasting to achieve a ‘breakeven’ position at the end of 2019/20, with allocation being matched by expenditure. This is substantially unchanged since month 3. There are no unmitigated risks against that position that have been identified to date. Identified risks are fully mitigated by the release of prior year benefits and reserves.

Recommendation(s) The Board/Committee is being asked to: Note the financial performance year to date and resultant Outturn.


Engagement has taken place with provider organisations


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☒


☐


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Board Assurance Framework Ref. Risk


score and movement

Target risk score

*Assurance Level

*Refer to assurance levels table below. Risk that we do not deliver a financially

NHS Herts Valleys CCG Board Meeting

Date of Meeting: 30th January 2020

4.1 ET sustainable integrated healthcare system in collaboration with our partners in the STP.

20 5 (March 2025)

Medium

4.2 DE, DC Risk that we do not drive the required value and level of transformation through our identified QIPP schemes

16

8

Medium

4.3 ET Risk that we do not achieve financial balance in 2019/20

12

4

Low

4.4 ET Risk that we do not have sufficient financial resource to manage the increase in legal challenges to our commissioning decisions.

8

8

Medium

New strategic risks identified by this report

Other significant risks related to this report (from the Corporate Risk Register) Resource implications

Not applicable. This report provides a general update on key financial issues and performance.

CFO Signature


No, this report is for information and discussion.


N/A


Better Health Outcomes ☐ Improved Patient Access and Experience ☐ A Representative and Supported Workforce ☐ Inclusive Leadership ☒


N/A

Report history

N/A

Appendices Month 8 Finance Report

Finance Report Month 8 – November 2019

Elke Taylor – Acting Chief Finance Officer

Produced by: Nicola Peters – Acting Deputy CFO

David Baker – Interim Head of Financial Reporting

1

2

Contents Slide refExecutive Summary 3Finance Report:Acute Commissioning 5Non-Acute Commissioning 6Primary Care Commissioning 7Other Programme Costs 8Running Costs 9Financial Position:Risks & Mitigations 11Underlying Position 12QIPP 13Cash & Balance Sheet:Statement of Financial Position 15Cash Drawdown 16Better Payment Practice Policy 17

Executive Summary (1)

Report for financial period ending 30th November 2019 Financial Performance • At month 8 the CCG is reporting a surplus on programme budgets of £0.423m

(expenditure less than available resources). The current forecast is that the CCG will deliver to plan at the end of the financial year.

• Within programme budgets, acute contracts are broadly on plan, although the performance by individual providers varies. Both the Mental Health and Primary Care service lines are showing underspends year to date, which is partly offset by the pressures in Continuing Cares.

• Running costs are reporting to plan. • Most service lines have a predicted year end position of reporting to plan, with

the exception of Prescribing. This area is forecast to overspend by 1.32m, due to the pressures on short supply and contract pricing on certain drugs. This will need to be met by the use of contingency reserves.

Risks and Mitigations • The main risks to the year end position relate to Prescribing, outlined above,

some Community contracts, where there are activity pressures above plan, a high level of emergency activity through some of the Acute providers, and under delivery of QIPP.

• The risks are assessed as being fully mitigated by reserves, and non-recurrent and prior year benefits.

QIPP • QIPP performance is currently at 95.1% and this position is expected to be

reflected in year end performance. Under-delivery has been allowed for in forecast figures.

• As stated above, there is identified risk to the QIPP requirement in acute contracts.

3

Financial Performance

Programme BudgetsYear to Date Spend £602.738m Better than planYear To Date Surplus £0.423m Better than planForecast Outturn £910.921m In line with planRunning CostsYear to Date Spend £7.711m Better than planYear To Date Surplus £0.001m In line with planForecast Outturn £11.57m In line with planOverallFOT Surplus/(Deficit) £0m In line with planYear To Date Surplus £0.423m Better than planCumulative Forecast £8.438m In line with plan

Risks & MitigationsNet risk NilRisk adjusted position Breakeven

Underlying Position2018/19 Closing Position £6.0m surplus2019/20 Position £3.997m

QIPPYTD Plan £9.509mYTD Actual £9.043m Marginally under planFull Year Plan £15.396mForecast Outturn £14.644m Marginally under plan

Financial Duties

4

Description of Financial Duties YTD Variance

RAGForecast Variance RAG

RAG Explanation

1.To ensure expenditure in a financial year does not exceed the allocated budget.

Position less than or equal to Plan

£922.5m -£0.424m £0.000 The CCG is reporting a YTD surplus and has a forecast breakeven equivalent to Plan

2.To ensure that the CCG’s revenue resource use on administrative costs does not exceed the ‘running costs’ allowance

Position less than or equal to Plan

£13.3m -£0.00m £0.000 The CCG is reporting a YTD surplus and has a forecast breakeven equivalent to Plan

3.Maintain expenditure within the allocated cash limit

Cash Drawdown less than or equal to ACDR

£918.17m +£8.91m £0.000 The CCG has drawn down slightly more (+1.48%) of YTD cash forecast. However, additional allocations have been profiled later in the year, so it has only drawn down 65.8% of the total cash available.

4. Ensure a minimum of 0.5% contingency is held as a Reserve

Greater than or equal to 0.5%

£4.596m £0.000 £0.000 The CCG is holding its full contingency against unforeseen pressures.

5. Ensure compliance with the better payment practice code (BPPC)

Greater than or equal to 95% by Number/Value

95% +2% +3%The CCG meets its obligations with regard to the payment of non-disputed invoices within contractual terms.

6. Ensure compliance with Mental Health Investment Standard

Spend more than or equal to budget

£84.809m -£0.4m £0.000 The CCG has underspent against budget due to the receipt of additional allocations in month 4 and the need to identify additional schemes in year to a value of £1.5m to match budget availability.

7. Maintain capital expenditure within the delegated limit from the Area Team

N/A

Notes:As well as the financial duties required above, there are additional requirements relating to maintenance and submission of accounting records and bank accounts. The CCG is fully compliant in these aspects and has submitted all financial returns required this year within the deadlines imposed by NHS England.

Target

Acute Commissioning

Year to Date performance above is based on month 7 flex activity, together with an assessment of month 8 expected activity. The values shown for West Herts Hospitals NHS Trust is for the main Acute contract and excludes Diabetes and Urgent Care. Information on the performance of provider contracts is included in the Acute Contracts Report. Values in the above table are based on the reported position at month 8 and may not align with the contract report which is based on month 7 SLAM. Adjustments include extrapolation for latest month plus other adjustments where extrapolation may distort the reported position.

5

2019/20 Acute Commissioning BudgetsApplication of Funds

BUDGET

£000

ACTUAL

£000

VARIANCEfavourable /

(adverse)£000

BUDGET

£000

FORECAST

£000


(adverse)£000

MAIN TRUSTSWest Hertfordshire Hospitals 179,393 179,393 0 268,600 268,600 0Royal Free London 38,152 38,487 (335) 57,296 57,800 (504)Luton & Dunstable 17,556 17,169 387 26,275 26,275 0East & North Hertfordshire 10,937 10,376 561 16,381 15,845 536Buckinghamshire Healthcare 10,866 11,218 (352) 16,269 16,799 (530)University College London 8,208 8,169 39 12,312 12,253 59Royal National Orthopaedic Hospital 4,642 4,136 506 6,971 6,500 471East of England Ambulance 14,297 13,948 349 21,405 21,056 349Other Contracts 30,728 29,069 1,659 46,065 44,077 1,988TOTAL ACUTE CONTRACTS 314,779 311,965 2,814 471,574 469,205 2,369

0OTHER ACUTE 5,411 8,225 (2,814) 7,790 10,160 (2,370)

0TOTAL ACUTE COMMISSIONING 320,190 320,190 0 479,364 479,365 (1)

YTD MONTH 8 ANNUAL FORECAST

Non - Acute Commissioning

6

NON ACUTE COMMISSIONINGBUDGET

£000

ACTUAL

£000


(adverse)£000

BUDGET

£000

FORECAST

£000


(adverse)£000

Mental Health 56,567 56,156 411 84,809 84,809 0Community 52,042 51,999 43 78,120 78,120 0Continuing Care 34,671 34,863 (192) 52,123 52,123 0TOTAL NON ACUTE CONTRACTS 143,280 143,018 262 215,051 215,051 0Mental Health


In order to meet the CCG's obligations in respect of MHIS (mental health spend to grow by 0.7% more than other Programme spend), the entirety of the mental health budget needs to be spent. At month 8, there is a shortfall in expenditure of £0.4m which needs to be caught up. The finance team are in regular contact with the joint commissioners and administrators of the pooled budget.

There are a number of community contracts that are seeing higher levels of activity than was forecast and allowed for in the procurement of the services. Although it is anticipated that any rebasing required would be met from Community reserves, in-year financial performance reflects these pressures.

Continuing care is on budget. The forecast outturn remains at breakeven.

Community Services Continuing Healthcare

Primary Care Commissioning

7

At month 8, Primary Care expenditure broadly on plan YTD. • Additional budget for Primary Care Network payments are included within Enhanced Services • Additional allocations have been received to fund Extended Access payments. • Although Prescribing costs are on plan year to date, there are concerns around the impact of price concessions

(NCSO) and Category M price adjustments. As a result, the Forecast outturn is profiled at £1.32m over plan and this will need to be adjusted against available contingency reserves.

PRIMARY CARE COMMISSIONINGBUDGET

£000

ACTUAL

£000


(adverse)£000

BUDGET

£000

FORECAST

£000


(adverse)£000

Prescribing 52,268 52,270 (2) 77,695 79,015 (1,320)Delegated Primary Care 53,247 53,246 1 79,867 79,867 0Enhanced Services 6,233 6,241 (8) 9,342 9,342 0Other Primary Care 10,709 10,683 27 16,057 16,057 0TOTAL PRIMARY CARE 122,457 122,439 18 182,961 184,281 (1,320)


Other Programme Costs

Other Programme Costs are reporting a Year-to-Date underspend of £0.144m. Contributing factors include: • A year-to date underspend on Patient Transport, due to activity levels. The main contract has been reviewed and a collar

has been applied at 90% of the contract value. However, additional support agreed means that this line is forecast to spend to plan.

• A marginal underspend on Non-Recurrent Programmes. The budget for admittance avoidance schemes is profiled to be utilised across winter as part of the Systems Resilience Programme and is expected to spend to plan by the end of the year.

• Counselling (within the ‘Other’ category) is reporting a small underspend due to activity levels. While there are efforts to commission services with other providers, these have yet to come on line. Spend in this area contributes to achievement of the Mental Health Investment Standard, so it is important that spend is in line with Plan.

• Other areas within the ‘Other’ category are reporting small overspends, which more than offsets the Counselling underspend above.

8

OTHER PROGRAMME COSTSBUDGET

£000

ACTUAL

£000


(adverse)£000

BUDGET

£000

FORECAST

£000


(adverse)£000

Better Care Fund 7,961 7,961 0 11,941 11,941 0Patient Transport 2,557 2,036 521 3,836 3,836 0Non Recurrent Programme 2,106 1,893 213 3,402 3,402 0Other 4,611 5,201 (590) 6,325 6,325 0TOTAL OTHER PROGRAMME 17,235 17,091 144 25,504 25,504 0


Running Costs Commentary: The CCG has received an allocation of £13.3m to support the running costs of the CCG, also referred to as the ‘Admin’ allocation. Against this allocation, budgets have been identified of £11.57m. As the CCG is due to ‘breakeven’, the excess allocation has been transferred to support Programme expenditure. However, the use of Programme allocation is not allowed to support Admin costs. Running costs are costs not directly linked to the provision of healthcare for the CCG’s population. The costs are pay and non-pay costs for staffing, plus some additional infrastructure and professional charges. Where pay costs can be linked to the provision of healthcare, these costs have been included within the Programme budget. At month 8, running costs are reporting close to budget.

9

RUNNING COSTSBUDGET

£000

ACTUAL

£000


(adverse)£000

BUDGET

£000

FORECAST

£000


(adverse)£000

Administration & Business Support 128 128 (0) 192 192 0Assurance 209 191 18 313 313 0Business Development 0 0 0 0 0 0Ceo/ Board Office 371 397 (26) 557 557 0Chair And Non Execs 667 588 80 1,001 1,001 0Commissioning 1,043 1,192 (149) 1,565 1,565 0Communications & Pr 257 253 4 386 386 0Contract Management 446 465 (19) 669 669 0Corporate Costs & Services 911 586 325 1,369 1,369 0Education and Training 0 69 (69) 0 0Emergency Planning 142 133 8 212 212 0Estates And Facilities 206 207 (0) 310 310 0Finance 705 715 (10) 1,057 1,057 0Human Resources 128 117 11 192 192 0Nursing Directorate 254 401 (147) 381 381 0Performance 864 946 (81) 1,297 1,297 0Primary Care Support 781 661 120 1,172 1,172 0Executive Management Team 599 659 (61) 898 898 0Medical Directorate 0 1 (1) 0 0 0

TOTAL RUNNING COSTS 7,712 7,711 1 11,570 11,570 0


Financial Position Analysis

10

Risks & Mitigations

Commentary: This table summarises the identified risks for the CCG as at month 8, as a ‘most likely’ case. Main areas of risk relate to the performance of the Acute Contracts and to the Prescribing profile of expenditure. CHC expenditure is also being closely monitored, including the ‘run rate’ which may be impacted by cost, volume and the transition to Personal Health Budgets. Other risks are fully mitigated by available non-recurrent benefits and Reserves and therefore the CCG is reporting a nil net risk.

11

Risks and Opportunities - Month 7 2019/20 Total£m Comment

RisksAcute pressures 1.20 For contract positions not agreed at year endWHHT Risk Share 2.00 Risk share in addition to the MIG contractCommunity contracts 1.00 Activity pressures on procured Community contractsCHC costs above forecast 1.00 Run rate risk

Prescribing (QIPP and NCSO) 0.50 £1.32m of pressure assumed within the forecast - additional in excess of profile

Total risks 5.70

Total risks 5.70

MitigationsRecurrent

General reserve 1.10£3.4m reserve included in financial plan; plus surplus budgets vired into reserves

Subtotal recurrent reserves 1.10

Non-recurrentContingency 0.5% 4.60Subtotal non-recurrent reserves & contingencies 4.60

Total opportunities 5.70

Net risk (-) /opportunity (+) 0.00

Underlying Position

The underlying position is arrived at by removing expenditure and income assessed to be non-recurrent in nature e.g. one-off QIPP savings and the full year effect of in-year investments.

12

2019/20 Budgets - Source & Application of Funds

BUDGET

£000

FORECAST

£000


(adverse)£000

REMOVE NON-RECURRENT

ALLOCATIONS£000

NON-RECURRENT

SPEND /INCOME

£000

CLOSING RECURRENT

POSITION 2018/19

£000

FULL YEAR EFFECT OF

QIPP£000

OTHER FULL YEAR

EFFECTS£000

OPENING RECURRENT

POSITION 2019/20

£000

Revenue Resource Limit 922,491 922,491 0 (3,473) 0 919,018 919,018

APPLICATION OF FUNDS -ProgrammeAcute Commissioning 479,364 479,364 (0) 0 (1,000) 478,364 478,364Non acute Commissioning 215,051 215,051 0 (519) 900 215,432 215,432Primary care Commissioning 182,961 184,281 (1,320) (3,407) (2,000) 178,874 178,874Other Programme Costs 25,504 25,504 (0) 453 (2,096) 23,861 23,861Total Commissioned Services 902,880 904,200 (1,320) (3,473) (4,196) 896,531 0 0 896,531

Running Costs 11,570 11,570 0 0 200 11,770 11,770

Reserves, Contingency & Provisions:Contingency (0.5%) 4,596 4,596 0 0 0 4,596 4,596Other Reserves & Provisions 3,444 2,124 1,320 0 0 2,124 2,124Total Reserves 8,040 6,720 1,320 0 0 6,720 0 0 6,720

Total Applications 922,490 922,490 (1) (3,473) (3,996) 915,021 0 0 915,021In-year Surplus / (deficit) 1 1 1 0 3,996 3,997 0 0 3,997

OUTTURN

QIPP

13

QIPP performance at month 8 is reported as 95.1% of the year to date plan and is forecast to be 95.1% of the annual plan. There is a shortfall of £0.75m, the impact of which is included within the forecast financial position.

£m £m £m % £m £m £m %9.509 9.043 -0.47 95.1% 15.396 14.644 -0.75 95.1%

% Achieved

TOTAL QIPPYear to Date Forecast

Plan Actual Variance%

AchievedPlan Actual Variance

Cash & Balance Sheet

14

Statement of Financial Position

Commentary: The Statement of Financial Position at month 8 represents a point in time snap shot of the CCGs balance sheet at 30th November 2019. The table compares balances with the previous month and to the closing position for 2018/19. Balances reflect the relative timing of cash drawdown, amounts payable and receivable and reflects the impact from payment of invoices and payroll. The most significant issue is the amount of cash still left to draw down. The CCG should not hold significant cash balances and times it is drawings in line with payments due, which depend on approved invoices and payment runs. The trade and other payables figure includes un-validated and disputed invoices, against which the CCG has undrawn cash. As these are cleared, the value of liabilities will reduce.

15

Asset /Liability30

November 2019

31 October 2019

Opening - 31 March 2019

£000 £000 £000Non-current assets: 0 0

Current assets:Trade and other receivables 5,037 4,488 3,478Cash and cash equivalents 4,306 174 381Total current assets 9,343 4,662 3,859

Total assets 9,343 4,662 3,859

Current liabilities:Trade and other payables (85,587) (82,210) (73,461)Provisions (3,454) (3,927) (3,460)Total current liabilities (89,041) (86,137) (76,921)

Non-Current Assets plus/less Net Current Assets/Liabilities (79,698) (81,475) (73,062)

Financed by Taxpayers’ Equity:General Fund (79,698) (81,475) (73,062)Total taxpayers' equity: (79,698) (81,475) (73,062)

Cash Drawdown

16

£000Opening Revenue Resource 919,151 Working Capital Movement (4,323)Allocations received in-year 3,340 Cash profiled for 2019/20 918,168

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Unprofiled Total£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Forecast Drawdown including Top Slice for Drugs 75,050 71,550 73,550 74,050 75,550 75,550 74,550 75,050 76,050 74,550 75,050 82,809 14,809 918,168

Actual drawdown 69,000 65,500 74,000 69,000 69,500 68,500 67,000 72,500 555,000Actual top slice 5,520 6,148 5,988 6,259 5,923 6,666 5,885 6,425 48,814Total 74,520 71,648 79,988 75,259 75,423 75,166 72,885 78,925 0 0 0 0 0 603,814

Difference 530 (98) (6,438) (1,209) 127 384 1,665 (3,875) 76,050 74,550 75,050 82,809 14,809 314,354Undrawn balance 314,354

Proportion remaining 34.2%

Amendments to Forecast DrawdownNotes1. The CCG did not draw its maximum cash availability in 2018/19 by £21.2m, so has a high level of Payables. It has therefore held this cash in reserve for a payables 'catch up'.2. Additional allocations of £7,259k were received in month 3, which have been profiled to month 12.3. Additional allocations of £131k were received in month 4, which has not been profiled.4. Additional allocations of £8k were received in month 5, which has not been profiled.5. Additional allocations of £1,494k were received in month 6, which has not been profiled.6. Reduction in allocation of £4,440k in month 7, which has not been profiled.7. Reduction in allocation of £1,112k in month 8, which has not been profiled. The Working Capital Movement has been restated to allow for a movement in Provisions.

Better Payments Practice

The percentage of invoices paid within payment terms up to November (15 days for NHS and 30 days for non NHS) was 97% by number and 98% by value compared to a target of 95%. The in-month performance for number of NHS invoices has fallen below the target of 95%, which has also impacted on the cumulative performance for this area. This is as a result of low value Non-Contractual Activity invoices missing the mid-month payment run by a few days.

17

Nov-19NHS NON-NHS TOTAL TOTAL

Number of invoicesPercentage of target achieved in period

93% 97% 96% 96%

Value of invoicesPercentage of target achieved in period

97% 97% 97% 97%

Number of invoicesPercentage of target achieved cumulatively

93% 98% 97% 97%

Value of invoicesPercentage of target achieved cumulatively

98% 98% 98% 98%

Nov-19

Page 1 of 6

Please refer to further guidance here N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201920\Current versions for front sheet reference when completing this front sheet. Title Communications and Engagement Report Agenda item 11 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging




Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Juliet Rodgers, Associate Director of Communications and Engagement.

Juliet Rodgers, Associate Director of Communications and Engagement.


This paper summarises key communications and engagement activities since the last board meeting in public.

Recommendation(s) The Board/Committee is being asked to: To note communications and engagement activities for the period.


This paper summarises key communications and engagement activities since the last board meeting in public.


☒


☐


☒


☐

Board Assurance Framework Refer to latest BAF report here for current and target risk scores: N:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201920\Current versions for front sheet reference Ref. Risk


score and movement

Target risk score

*Assurance Level

Example: *Refer to assurance levels table below. 1.1 JR Risk that we do not engage effectively with a range

of our patients, population and stakeholders. 16 ↓ 8 Medium

1.2 LD/JR Risk that member practices and other partners do not see the potential positive impact of their engagement with HVCCG

16↓ 8 Medium

1.3 JR Risk that we have an unengaged staff body 4→ 4 High New strategic risks identified by this report Other significant risks related to this report (from the Corporate Risk Register) Resource Within existing resources. CFO Signature


Board Meeting Date of Meeting: 30 January 2020

Page 2 of 6

implications


None we are aware of.


Our engagement work seeks to include our diverse communities. An equality analysis was carried out on the participation strategy.


Does your paper provide supporting evidence for HVCCG’s EDS2 portfolio? Please refer to EDS2 guidance here: https://www.england.nhs.uk/wp-content/uploads/2013/11/eds-nov131.pdf and indicate which goal your proposal/paper supports by clicking the appropriate box(es) Better Health Outcomes ☒ Improved Patient Access and Experience ☒ A Representative and Supported Workforce ☒ Inclusive Leadership ☒


N/A

Report history

None.

Appendices None.






https://www.england.nhs.uk/wp-content/uploads/2013/11/eds-nov131.pdf

https://www.england.nhs.uk/wp-content/uploads/2013/11/eds-nov131.pdf

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1. Introduction and purpose of paper This paper summarises the communications and engagement activity for the previous period. Members will note that the assurance levels are indicated as mostly amber; this report outlines the activities being undertaken to address risks associated with any shortfalls in engagement with our audiences. 2. Patient and public participation

2.1 Community health and wellbeing ambassadors We have recently added ambassadors from the local National Childbirth Trust and West Herts College to make our current total 36.

2.2 NHS England (NHSE) participation assessment The assessment for 2020 focusses on the criteria which were not met in 2019; this is to encourage CCGs to concentrate on areas of improvement and for Herts Valleys this means the evidence will focus on criteria within the annual reporting section and some around feedback and evaluation and also the equalities and health inequalities domains. We are gathering evidence to support compliance and will make our submission to NHSE by the deadline of 10 February. Moderation is undertaken by NHSE and NHS Improvement prior to confirmation of final results which will be received in summer 2020 and presented to the board in September.

2.3 Developing GP practice patient groups (PPG) The PPG incentive scheme has now been approved by the Primary Care Commissioning Committee (PPIC), with a few minor amendments. The document will be discussed again at the practice managers forum before the self- assessment criteria are finally agreed and we will share the scheme with practices and their patient groups in February, with implementation of the scheme in April.

2.4 Patient stories Our next patient story session is planned for Thursday 20 February 2020. An invitation has been sent out to board and PPIC members. The focus of the two patient stories will be on the transgender patient journey with two members of that community sharing their experience of health services.

2.5 Patients involved in CCG groups We have recently recruited two patients to be part of the falls project task and finish group. One is a carer for her frail husband and the other has first- hand experience of falls services. We had four expressions of interest for this role. We are holding a session for patients and staff, on Tuesday 28 January to review how the CCG recruits and supports patient representatives on various groups, committees and projects and to consider the effectiveness of this element of our participation work. Following the session, we will make any changes that are identified to help us make improvements.

2.6 Patient engagement network

A schedule of engagement meetings has been organised for 2020, these include patient engagement sessions and two ‘let’s get connected’ events on death and dying and memory loss. 2.7 Reader panel

Page 4 of 6

The 22 reader panel members have recently reviewed ‘support to lose weight and quit smoking before surgery’ leaflets that are being distributed to surgeries. Members of the panel made a number of valid points and have resulted in a range of quite significant changes – to wording and also the visuals. 3. Print and broadcast media activity • Considerable coverage leading up to the general election, throughout December and continuing

into January, has been about local parliamentary candidates talking about how to get the best for patients with the planned £400 million announced by the government for the improvement of West Hertfordshire hospitals.

• Local newspapers and the BBC online reported on the New Hospital Campaign (NHC) raising £20,000 to contribute to legal fees for their judicial review claim relating to the decision-making process on hospital redevelopment.

• The Hemel Gazette reported that from December and continuing for six months, GP practices in west Hertfordshire are offering additional same day appointments for children of four years old and under.

• BBC Three Counties Radio interviewed Angelina and Gary Murphy about their circumstances one year on from the Nascot Lawn respite centre closing.

• There was coverage for Kathryn Magson cutting the ribbon at the ceremony to open the updated site for Manor View Practice in Watford. Manor View Practice was formed in February after the merger of Manor View in Bushey and Callowland Surgery in Watford.

• The Hemel Gazette & Express and Herts Advertiser shared examples of schools all over Hertfordshire taking part in the conversation run by #JustTalk, as well as hosting assemblies and holding PE lessons or art classes that were themed around mental health.

4. Digital and social media We continue to use social media platforms to promote our public health messages and news to partners, residents and other stakeholders.

In December our key messages were around staying well during the winter, including awareness of the NHS111 service and receiving the flu jab if you have a health condition. The ‘keep antibiotics working’ campaign and the ‘help us help you – Catch it, bin it, kill it’ campaign have also featured on our social media channels.

For January our key messages have been about Dry January (giving up alcohol for the month) and the same day GP appointments for children four years and under were promoted as well.

Social media posts that were most prominent on Facebook were the mental health messages for ‘every mind matters’, ahead of the FA cup football games. Our most engaged with tweets were related to the organ donation law in England changing in the spring.

Campaigns We continue to deliver winter pressure awareness campaigns. As previously mentioned, particular areas for this year’s campaign are: promotion of NHS111; encouraging promotion of flu jabs for

Page 5 of 6

eligible patients (particularly pregnant women who are not in an ‘at risk’ group); encouraging people to seek advice from local pharmacists; and promotion of children’s GP extended access appointments. Delivery is via CCG communications channels including social media, e-bulletins and information on the CCG website. Working with East and North Herts CCG we have created and distributed nearly 57,000 flyers for west Herts, which have been placed in primary school children’s’ book bags to take home to their parents and carers in December. Around 160 primary schools around Watford, Borehamwood, St Albans, Hemel Hempstead, Stevenage, Waltham Cross and Welwyn Hatfield were given enough leaflets to distribute to every single pupil. We have also produced stickers for health visitors to place on children’s red health record books. Both the stickers and flyers are being targeted at schools and health visitors situated in and working around GP practices whose patients make have higher avoidable visits to A&E, than their peers. We are also working with partners, such as the early years family commissioning team at Herts County Council, to send information to parents and patients through their networks. We have asked all our key partners to share our messages around staying well during the winter. A flyer and poster promoting children’s GP extended access appointments is being distributed to practices during February. Fitness for surgery An awareness- raising campaign is supporting new fitness for surgery arrangements that are being implemented from January 2020. Communications have been developed jointly with ENH CCG including leaflets for patients that have been delivered to GP surgeries. The leaflets, together with an explanation of the policy and a question and answer sheet for patients, are on the CCG website. WaitLess App A communications campaign has been developed ready to support the roll-out of the WaitLess App which has been procured by the STP technology workstream. Communications will be rolled out to health professionals initially to help with signposting patients to urgent treatment centres. Communications roll out is planned to happen simultaneously with Hertfordshire and West Essex information appearing on the app for local patients. NHS app We have continued to promote this to staff and GP surgeries in line with NHS Digital’s plan to familiarise staff with the app before promoting widely to patients. This included our chief executive emailing all staff to encourage them to download the app and contacting the other chief executives within the west Herts area encouraging them to do the same. NHS Digital are launching a national public-facing communications campaign shortly which we will use to promote the app locally to west Hertfordshire residents. 5. Staff communications and engagement The final response rate from Herts Valleys CCG staff to the national NHS staff survey was nearly 90% - a very pleasing outcome which is both higher than average and higher than previous years for

Page 6 of 6

Herts Valleys. The executive team has received the results which are currently under embargo nationally and will be released in mid- February. We have been carrying out some engagement with staff around our organisational values, and sessions have helped develop a series of refreshed draft behaviours that will be discussed at our next staff involvement group. 6. Member practice communications and engagement We continue to engage with our GP practices through the weekly GP bulletin, which disseminates messages from other local organisations, outlines relevant local training sessions and provides promotional material for surgeries on current health campaigns. The December GP forum meeting talked about the funding and other support that the CCG is providing to help the development of primary care networks. It also outlined investment and new projects in mental health as well as plans for primary care IT and a wider technology strategy. Feedback on the presentations was positive. As part of our work to improve information and signposting for patients accessing community-based health services we have developed communications for GP practices as key referrers into these services. This information, including provider contact details and information about clinics in each locality will help practice staff to signpost patients more efficiently. We are also providing a write-up about each service to go on GP websites. This is being sent to practices in January.

1 | P a g e

Please refer to further guidance here Z:\Nursing & Quality\8 Risk Management System\2. Board Assurance Framework\BAF 201920\Current versions for front sheet reference when completing this front sheet. Title Audit Committee Report to HVCCG Board Agenda item 12 NHS Official Sensitive: Commercial ☐ Check the box if paper contains commercial information which may be damaging



Decision ☐ Approval ☐ Discussion ☐ Assurance ☒ Information only ☐

Author and job title Responsible director and job title Director signature The director is signing to indicate their approval of the paper and to confirm that any EQIA, QIA or DPIA has been approved. Paul Smith Board Lay Member



The Committee discussed matters relating to conflicts of interest and reiterated the need for a proactive stance in declaring new interests. It also was noted that Board members needed to lead by example including having completed COI mandated training. Four internal audits had been received, Financial Feeder Systems & Payroll (substantial), Equality Delivery System, Primary Care Delegated Commissioning and Business Continuity (all reasonable). The one high priority action on the primary care audit had been completed.

Recommendation(s) The Board is being asked to: Discuss and note this report and to confirm assurance received.


State briefly any engagement activities and the relevant outcomes of that engagement. N/A


☒


☒


☒


☒



score and movement

Target risk score

*Assurance Level

The audit committee is seeking assurance across the BAF risks. New strategic risks identified by this report None

Other significant risks related to this report (from the Corporate Risk Register)


Board Meeting 30 January 2020

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None Resource implications

None CFO Signature


None identified


N/A


N/A

Better Health Outcomes ☐ Improved Patient Access and Experience ☐ A Representative and Supported Workforce ☐ Inclusive Leadership ☐


N/A

Report history This is a new report.

Appendices






Audit Committee Report to HVCCG Board

Short Summary of Paper

The Committee discussed matters relating to conflicts of interest and reiterated the need for a proactive stance in declaring new interests. It also was noted that Board members needed to lead by example including having completed COI mandated training. Four internal audits had been received, Financial Feeder Systems & Payroll (substantial), Equality Delivery System, Primary Care Delegated Commissioning and Business Continuity (all reasonable). The one high priority action on the primary care audit had been completed.

The Committee was updated on information governance and cyber security and requested further assurance around mapping of information/cyber risks to lines of defence, with particular reference to third parties.

There were two overdue audit actions relating to the moderate assurance audit of STP work streams, which were now due for completion in the next month. It was noted that with changing structures, these actions needed to be completed and transferred.

Financial Authorisation limits had been clarified and amended to reflect latest management arrangements. The Committee also reviewed the updated Standards of Business Conduct Policy.

External audit presented the 19/20 audit plan and commended finance on their paper identifying policies, areas of estimate and judgement as good practice.

Risk updates were received on ACS mobilisation & Public Participation.

Recommendation

The Board is asked to discuss and note this report and to confirm assurance received.

Engagement

N/A

BAF

The audit committee is seeking assurance across the BAF risks.

Audit Committee Report

January 23, 2020

The Committee discussed the decision register and was assured that conflicts were generally being well recorded and managed without an excess of bureaucracy. It was noted that there was, however, a continuing need for members and employees to be proactive in declaring new interests and not wait to be asked. However, it also was noted that while the decision register appeared complete, there were generally nil returns identified by decision makers. Given the added conflicts likely in new NHS structures it was agreed that a simple, though not exhaustive, checklist of COI examples would be prepared and shared with GP practices. In addition, there was some discussion of the need for Board members to set a good example on COI including having up to date training metrics. The need for GPs to declare interests more generally also was noted, not least because non-compliance could impact on their funding from the CCG.

The Committee reviewed the gift and hospitality register and noted that this seemed both complete and was generally low level and of minimal concern.

The Committee was briefed on Information Governance and cyber security. At its previous meeting, the Committee had asked Management to consider whether the on-going cyber compliance of 3rd parties was adequately assured. It was fairly clear that assurance was received as part of the contracting process and the question related to how assurance was received of compliance with contractual commitments once the contract was in operation. In discussion, it was noted that the lines of defence in these areas needed to be better evidenced and that the information flows and associated risks needed to be demonstrated.

The Committee noted both the updates Standards of Business Conduct policy that had been updated to incorporate some internal audit points and to better match the NHS policies on COI, and also Financial Authorisation levels that had been amended to provide greater clarity as well as to reflect the existing management arrangements

External Audit updated the Committee on the work-plan to get to a May 28 sign-off which was agreed with Finance. The auditors identified the areas that they had identified as significant from an audit perspective. These included risk of management override of controls (a mandated risk for all organisations by audit standards), and financial sustainability (reflecting the on going challenging financial environment of the NHS and the Hertfordshire health economy.

The Finance team briefed the committee on major accounting standard changes (primarily IFRS16 affecting reporting of leases – minor impact on CCG), and

areas of estimate & judgement that could affect the year end accounts. The auditors commended the team on the inclusion of this as good practice not always followed by other CCGs.

Internal Audit reported that four audits had been completed:

• Financial Feeder Systems & payroll – substantial (0 recommendations) • Equality Delivery System – reasonable (3M, 3L recommendations) • Primary Care Delegated Commissioning – reasonable (1 High, 1 Low

recommendations) • Business Continuity Plan – reasonable (1M, 1L recommendation).

The Committee noted that both recommendations on the Primary Care audit had been completed.

The Draft 20/21 internal audit plan was discussed. The Committee suggested that the MIG could be included later in the year and were assured that the governance audit would include the transitioning to committees in common.

The BAF was noted. The Committee were assured that the Board committees were giving due consideration to the risks affecting their areas of business.

The BAF risk relating to public engagement was discussed. It was noted that NHSE were recommending that the annual report more explicitly include a “you said, we did” format to highlight areas where public engagement had fed back into actions taken. There was some discussion as to the sense/benefit of this given the embedded nature of patient participation in our processes but there was resigned acceptance that an attempt to do this was required. Overall the Committee suggested that the Annual Report would better reflect engagement and the wider performance of the CCG by being streamlined and avoiding repetition. The external auditors, who are required to confirm that the data and major claims made in the report can be substantiated, endorsed this.

An ACS mobilisation update was provided. The Committee agreed that this had been handled effectively both by the CCG and the new Provider. Key points from the discussion were:

• Appropriate & adequate resource is needed for major changes like this • We need to be sceptical of all provider plans based on recruitment of

scarce healthcare professionals and factor “optimism bias” into our plans • We need to recognise that the outgoing Provider may be less co-operative

that we would like and that a do minimum approach should probably be expected and factored into plans.

Date of next meeting March 19.

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Meeting : Quality Committee Date : 03 October 2019 Time : 09.00 – 11.30 Venue : The Forum, Conference Room 2

Present:

Stuart Bloom (SB) Lay Board Member (Chair of meeting)

Kathryn Magson (KM) Chief Executive Officer

Diane Curbishley (DC) Director of Nursing and Quality & Deputy CEO

Trevor Fernandes (TF) GP board member - Dacorum Alison Gardner (AG) Lay board member and lead on PPI

Kate Page (KPa) GP board member and Locality Chair for Hertsmere In attendance:

Jill Ainsworth Beardmore (JA-B) Patient representative to the Board Susie Barker (SBa) Deputy Director of Nursing and Quality (Interim)

Jane Brown (JB) Healthwatch Hertfordshire

Shazia Butt (SBu) Head of Quality Assurance Kate Chand (KC) Associate Director of Performance & Quality Improvement

Toby Holder (TH) Head of CHC and CYPCC

Lynn Stewart (LS) Head of Infection, Prevention and Control Sarah Mantle (SM) Senior Infection Prevention & Control Nurse

James Hughes (JH) Senior Quality Assurance Manager

Antonia Hyde (AH) Senior Quality Assurance Manager

Mary Emson (ME) Designated Nurse Safeguarding Children, Looked after Children & Care Leavers

Rami Eliad Locality Chair for Watford and Three Rivers Joan Plant (JP) Associate Director of Resilience & Quality Improvement

Alison Pointu (AP) Mobilisation Clinical Quality Lead

Stephenie Evis (SE) Named Nurse for Adult Safeguarding

Miranda Sutters (MS) Public Health Consultant James Slater (JS) CHC Project Manager

Sandra Birch (SB) Minute taker

Attendees for deep dive only From HVCCG

Nicolas Small Chair, HVCCG

Paul Smith Lay board member David Evans Director of Commissioning

Avni Shah Programme Director Planned and Primary Care

From WHHT Jane Shentell Director of Performance (WHHT) Clare Hearnshaw Head of Cancer Services and Palliative Care

Ross Cheetham Colorectal Surgeon and Clinical Director for Surgery QC/144/19 Welcome, introductions and apologies for absence (Chair)

SB welcomed everyone to the meeting and introductions were made. Apologies for absence were received from Juliet Rodgers.

QC/145/19 Declarations of Interests No specific declarations had been received in relation to agenda items.

QC/146/19 Minutes of the previous meeting

FINAL

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The minutes of the meeting held on 5 September 2019 were reviewed and agreed as an accurate record of the meeting.

QC/147/19 Matters arising and action log QC/110.2/19 Quality Alert System

The trusts discharge summaries was discussed at a recent Quality Review meeting as part of their improvement plan. The admission summaries are not always being received by GP surgeries, WHHT are reviewing this and providing an update and the CCG will be building into the contract for 2020 and an update will come to the committee in Q2 Quality Report. Action to remain open. QC/124/19 ACS mobilisation plan – detailed plan for 14-15 week waits. The CCG is not satisfied with the process for 18 week waits, this is part of the handover which is happening now and the CCG will look to resolve the problem post mobilisation.

QC/148/19 Nursing, Quality and System Resilience Risk Report JH informed the meeting of the current local risk register and requested that the meeting

review and agree the reduction of risk score NQ9 and NQ44. NQ9 – Learning from Serious Incidents The CCG has provided support to HPFT resulting in a reduction in outstanding serious incident reports. Currently there are 15 overdue reports of which 10 are in the final approval stage, which is a much improved position. NQ44 – Adult community services (ACS) quality risk This risk highlights the potential impact on quality and safety of service provision and currently there are no gaps in controls owing to a number of milestones being reached during September. The risk score has been reduced to 8 leaving a risk gap score of 0.

The committee reviewed and agreed the reduction of risk scores for NQ9 and NQ44. QC/148.1/19 Q2 Board Assurance Framework (BAF)Report

DC informed the committee that Q2 BAF was the latest version which had been approved by the September Board and asked whether the committee had any questions and how assured they were of the progression.

The committee felt assured of the current controls, actions and progress described. QC/149/19 Adult Community Services Transition/Mobilisation AP informed the committee that on 1 October 2019 Adult Community Health Service went

live, there were some minor hitches but to ensure the delivery of a safe service, CLCH had floor walkers in place responding to issues and all had been resolvable. These were:

IT issues - most seemed to be in relation to staff not understanding logging on and passwords, although a lot of staff was able to access existing HCT passwords.

SystmOne should have come across in its entirety but one gateway did not; this has now been resolved.

Staffing issues at Langley ward where there seemed to be gaps in cover on the ward, this was addressed by using agency staff although CLCH were not aware of the extent of the issue prior to 1 October. There is a quality issue regarding the lack of staff and this will be addressed. Jane Skippen, CLCH Director of Nursing visited all bedded wards to ensure all was well in the first week.

One access number for podiatry and a number of patients were unable to get through before 9a.m. as the line was dead, no further patient complaints regarding this.

Potters Bar fire door was broken which meant that patients could access outside onto a flight of stairs, a person was placed outside of the fire door 24.7 to deny access until the door was fixed; this is now resolved.

Post 1 October 2019 the following will take place:

During the first 2 weeks AP will have daily phone calls with Jane Skippen; the frequency

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of these calls will be reviewed. During week one quality assurance visits will take place, these will be ongoing.

A HVCCG Transition group will be held weekly. Quality oversight will be built into business as usual for the N&Q Team.

The Quality Committee and Board oversight group will provide scrutiny of quality and safety via reports prepared by AP.

SB felt that the handover had been well planned and executed and thanked AP.

The committee felt assured of the plans and processes currently in place.

QC/150/19 Safeguarding Adult Annual Report SE informed the committee of the progress made in delivering the CCGs safeguarding adult

responsibilities. The main achievements from last year are:

Safety and Improvement process – this continues to provide an overarching framework ensuring a coordinated response, especially the work with care homes for example the work undertaken with Forest Care Village.

Domestic Homicide Review - during 2019 there have been 5 DHRs and the Head of Adult Safeguarding is a DHR panel member and monitors progress to ensure recommendations and actions are achievable for health organisations.

Annual adult safeguarding assurance visits to provider services are undertaken and for all organisations there has been significant improvement in all areas of adult safeguarding.

Consolidation of training compliance for all providers but specifically HPFT who have shown consistent improvement in training compliance for Level 1 and 2 adult safeguarding and achieved the 95% target for Level 2 in Q4.

The Chair thanked the team for a good report and positive improvements. The committee noted the report

QC/151/19 Q1 Quality Alert System Report JH provided an update on the quality alerts (QAs)received from General Practices:

During Q1 a total of 186 quality alerts were received, the largest number of QAS were raised by Watford and Three Rivers GPs at 68. QAS were received in relation to 6 provider organisations with WHHT receiving the highest number and Connect the highest for a community provider. The team will be looking to improve the feedback mechanism from providers especially the lack of responses received from the Royal Free and Connect which are being formally raised with them via the CQRM process. The number of reports has been dropping off largely from not being actively promoted recently and therefore the QAS process is being reviewed to ensure stakeholders are given clear guidance and timelines for responses.

The following questions/comments were made in discussion: RE regularly makes requests via the QAS system and receives no response, not even an acknowledgement. If practices receive no response they will not continue to provide the information? QAS is not designed for dealing with individual issues moreover for collating themes and trends, but agreed an acknowledgement should be received first from the QAS system with a request to the provider for further information. SBu to ensure a full review to strengthen process and communication.

The committee noted the report and requested an update on the refresh of QAS for November meeting.

QC/151.1/19 ACTION Update on refresh of QAS to November meeting

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JS joined the meeting QC/152/19 Provider Cancer Patient Experience Survey JH provided the meeting with information regarding the recently published National Cancer

Patient Experience survey report and explained that for a lot of the areas WHHT are scoring outside of expected ranges, although there is still room for improvement. The survey will be raised at the next WHHT CQRM at the end of October to address results.

The following questions/comments were made in discussion: Were there differences between specialities? The CCG will be receiving an action plan from WHHT and will confirm a timeline for this and then we will have a better idea of where the hot spots are. What is WHHT achievement against limit range as all will need an improvement plan? Will provide a report to the committee November/December. The response rates against these are useful to understand where figures come from? Will provide detail once received. What is the question of GP support, what is the expectation? Will provide detail once known.

The committee noted the report QC/152.1/19 QC/152.2/19 QC/152.3/19

ACTIONS

Confirm timeline for action plan from WHHT Confirm percentage response rate

Provide detail of GP support required QC/153/19 National Friends and Family Test (FFT) update SBu informed the meeting that the Friends and Family Test guidance has been refreshed

nationally and will come into effect from 1 April 2020. The most significant change is to move away from measuring response rates to understanding how the feedback has been used to improve the quality of services locally and drive up quality improvements. The CCG will work with all commissioned providers via their Contract Quality Review Meetings (CQRMs) to ensure providers are prepared for and implement the necessary changes between now and April 2020.

ME joined the meeting The following questions/comments were made in discussion:

Will the focus remain on bringing as much information as possible to improve services? Yes the focus will remain. DC informed the meeting that at the recent WHHT CQRM, WHHT advised that a call is made to every discharged patient to see how the discharge had gone and the question was asked why they were not asking the FFT questions at that time as well. DC will follow up with Tracey Carter, Chief Nurse, WHHT. If they don’t get an answer from the patient do they stop trying? Yes, the call is to confirm how the discharge has gone, not a welfare call. It was agreed to focus on discharge going forward.

The committee noted the report

QC/153.1/19 ACTION

Gather more detail regarding the call to the discharged patients by WHHT – how do they record/learn from these

QC/154/19 Section 11 update ME provided an update on Section 11 visits and the agreed action plans for WHHT, HCT,

HUC and HPFT. It is expected that each organisation carries out a self-assessment on the action plans which are discussed at the annual Section 11 visits. HPFT have amber around not having a Named Doctor and ME has been asked to source information from other professionals to see whether this post can be covered in a different way.

The following questions/comments were made in discussion:

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Are GPs aware of contact details? HCT to ensure that all GPs are aware of contact details for school health teams. Why does it take to January 2020 to ensure that this action has been completed could it not happen sooner? Yes it can be done sooner, will take back to ensure updated for next report. There does not seem to be mention of child deaths within the serious incident section of HPFT action plan? Suicide is looked at from a multi-agency partnership forum. There is a multi-agency suicide report which can come to this meeting, it was agreed to invite Sue Matthews to November meeting.

The committee noted the report QC/154.1/19 QC/154.2/19

ACTIONS

Review completion date for ensuring GPs are aware of contact details for school health teams.

Multi-agency suicide report to come to the November committee ME left the meeting

QC/155/19 CHC and PHB monthly Report TH presented the key highlights regarding Continuing Healthcare and Personal Health

Budgets: The CHC admin team trained two summer placements who contributed greatly to the admin team, one of which was successful at interview and is now the Appeals Coordinator. The team also continue to utilise Apprenticeships; one admin member recently completed their apprenticeship in Business Administration and were awarded a distinction and were nominated for ‘Learner of the Year’. The placements team continues to face challenges with bed capacity due to a restriction on placements at two nursing homes who have embargos in place; although staff have managed to achieve high success rates in placing patients out of WHHT including those requiring 1:1 care. The team continue to meet the Quality Premium targets for CHC. There are currently no outstanding disputes which need to be reported to NHSE. The team has a new appeals manager driving things forward and a lot of local authority disputes not agreed continue to be resolved at Multi-disciplinary team meetings. The PHBHub is being rolled out in a staged manner which starts with HVCCG.

The following questions/comments were raised in discussion: Is there positive support from other CCGs? Yes, TH confirmed the team are currently working with two other CCGs looking at where and how to work together more effectively. HVCCG is the lead across the STP for PHB.

The committee noted the report QC/156/19 CYPCC monthly Report

JS informed the meeting that the report provides assurance of next steps being taken to mitigate the risk of 20 for NQ38. The mobilisation project is on track to achieve its objectives. Actions outlined in paper completed:

Eight children are now under the care of another provider and being commissioned directly by HVCCG; five children are accessing care through direct payments and four children remain under the care of HCT.

Currently working on an options appraisal paper. Have met with neighbouring CCGs in E&NHerts and West Essex.

The following questions/comments were raised in discussion: In terms of liaising with the other CCGs how is this taking place as approaches may differ? An intention business case outline of options going forward will be written; level of detail

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will be in the next steps. DC requested that given the CCG expects that future models for CHC will be led by the ICP this needs to be taken into account in the options appraisal. It was agreed that the intention business case will come back to the Quality Committee to make a recommendation before making the decision and then it will go to Executive Committee.

The committee noted the report and agreed that NQ38 will be reviewed at the November committee

QC/156.1/19

ACTIONS

Options paper to come to November Quality Committee. JS left the meeting QC/157/19 Monthly Care Home and Home Care Providers Risk Report

JP informed the meeting of the key points to note from the monthly care home and home care providers risk report:

Turning Point – Follybridge is showing an improvement although remains as ‘Requires Improvement’ for the time being. CQC have also noted the improvement.

Concept Care has been added to the report due to an embargo being placed on new admissions by both HCC and HVCCG. The CCG has no assurance of quality; there are currently no managers in post.

Two care homes have been added, Lyndon House and Thorpdale following a ‘Requires Improvement’ outcome on HCC’s Provider Assessment and Market Management Solution (PAMMs) report.

Manor Road care home has given notice to HCC to cease trading, closure date will be confirmed once all residents have an alternative placement.

Quince House care home has also given notice to close which is a concern as it focuses on Learning Disability patients.

The following questions/comments were made in discussion: River Court has been on the radar since 2015 are there still issues there? HC1 have embraced the CHIT nurse and the quality of care in baseline is fine, will look at rating for next report. Is there a concern with Shenleybury as the Manager has limited experience? There is no patient risk; the staff at the home are supporting the manager who is attending a leadership course to enhance their knowledge.

LS and SM joined the meeting Do you look at day centres?

Not learning disability day centres, currently focussing on three of the bigger centres attached to large residential homes. It was agreed to seek assurance from Simon Pattison’s team to ascertain whether they can provide us with that assurance.

The committee noted the report QC/157.1/19 ACTION

Seek assurance from HCC Learning Disability team via Simon Pattison Learning Disability commissioning team as to whether Learning Disability day centres are visited.

QC/158/19 Infection, Prevention and Control Annual Report LS introduced Sarah Mantle who joined the team recently as Senior Infection Prevention &

Control Nurse. LS presented the key highlights from the 2018/19 Infection, Prevention and Control Annual Report. Clostridium difficile (C.difficile) cases within west Hertfordshire fell by almost 20% when

compared to the previous year. The number of WHHT C.difficile cases reduced by almost 50% compared to the previous year, overall WHHT ranked as second lowest

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amongst the 17 trusts within East of England which reflects achievements of antibiot ic prescribing and repeat samples.

A dedicated service (Commisceo) for management of respiratory outbreaks in care homes was commissioned. During 2018/19, a total of 29 respiratory outbreaks were managed by this service within west Herts, 10 were confirmed as caused by influenza which is less than last year. A contract review meeting is due to be held in the comings weeks in preparation for the 2019/20 winter season.

There was a significant increase in the number of MRSA blood stream infections, a total of 13 were reported against a target of zero, this was the highest number reported since 2010.

The number of E coli BSIs reported in 2018/19 increased by approximately 5%, however in HVCCG the increase was higher at 18% and by the end of the year, this meant that the CCG was 64% above ceiling for the year.

44 cases of Carbapenemase producing Enterobacteriacae (CPE) were reported at WHHT since the implementation of CPE screening and the actions undertaken included enhanced cleaning of areas including sink and drain decontamination, and training for ward staff.

Have been successful in building an STP IPC team to focus on proactive approach to IPC, with Sarah Mantle just starting and 2 band 7 nurses joining the team in January 2020, plus an extra admin team band 4 member has recently joined the team supporting the band 5 already in post.

Will start to phase in a service from West Essex to provide a service they are funding. The following questions/comments were made in discussion:

Who and how was the funding for the STP wide service approved and has a Memorandum of Understanding (MoU) between the three CCGs been drafted? It was agreed that a MoU for shared IPC service is to be written and shared for sign off including the percentage split of staff time.

AP left the meeting

How is the team dealing with the rise in MRSA cases? The team will continue to do post infection reviews for each case of MRSA, a number of the cases were patients with chronic skin or wounds and there is little that can be done to prevent those.

The committee noted the contents of the Annual Report QC/158.1/19 LS will write a MoU for shared IPC service and shared for sign off including the percentage

split of staff time. QC/158.1/19 Outbreak LS informed the meeting of an Invasive Group A Strep (iGAS) outbreak. Mid Essex CCG have

had 38 cases with 14 deaths which have a clear link to community nursing services and wound care has been looked at as part of the investigation. Public Health England have investigated the bacteria causing these infections and it has highlighted that 10 cases in Hertfordshire have the same strain known as emm89, although were not related to mid Essex. Four of the patients were identified as having had contact with HCT community teams and East & North Herts CCG and HCT are working with PHE to identify the possible causes of the outbreak and prevent any further cases. There has been no link to social care and transport and the Herts Equipment service has also been looked at. PHE recommended the screening of community nurses which took place on the 30 September and are still awaiting the results. HCT have carried out a deep clean of equipment and carry cases/boxes, car boots etc. of the community nursing services. It was noted that these cases span a period of 18 months.

The following questions/comments were made in discussion: Has a conversation with CLCH taken place?

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Yes LS is in contact with them and the Infection control nurse from HCT has been transferred to CLCH as part of TUPE arrangements.

The committee thanked LS for the verbal update LS and SM left the meeting. QC/159/19 Review of how COI were managed

There were no other Conflicts of interest declared during the meeting that had not been mentioned at the beginning of the meeting.

QC/160/19 Risks identified during the meeting A question was raised as to whether the iGAS outbreak should be on the Nursing and

Quality Risk Register and it was felt that something more generic could cover this on the risk register. A question was raised regarding the flu season, primarily the situation with flu vaccinations in primary care. The GPs present raised a concern regarding the delay in receiving the flu vaccines for the (under 65s) and DC agreed to speak to Michelle Campbell to confirm when they will be received and a message will be cascaded to primary care.

QC/160.1/19 ACTION DC to speak to Michelle Campbell regarding the delay practices are experiencing in receiving the flu vaccines.

QC/161/19 Reflection on Equality/Diversity in relation to decisions made

Equality and Diversity was dealt with in an appropriate manner. QC/162/19 Committee Work Plan Invite Connect for December Deep Dive

Cancel January committee, January items to be moved to February/March

QC/163/19 Items to cascade to localities Cascade information regarding the delay in flu vaccines once known

QC/164/19 WHHT Cancer improvement plan deep dive The Chair welcomed Jane Shentall, Clare Hearnshaw and Ross Cheetham to the meeting.

JS presented the key headlines from the presentation: WHHT performance is ahead of the national and regional position for 2 week waits and

62 day performance.

For July saw an increase in 2 week wait referrals up 21% with over 300 more referrals than June. The trust undertook its own referral deep dive to see whether there was any particular theme but none identified. Conversion rates are consistent right referrals, not seeing people abusing the pathway, seeing appropriate referrals in a significant volume.

62 day performance slide not complacent with the figures, know there is more to do. July was a difficult month, notably pressures were in urology, lower GI and lung. August figures are currently 82.1% ahead of plan.

The trust has looked at areas which required attention to make a difference and these are:

Consistently achieve the national CWT standards. Build on a way in which can be compliant at all times to move polling range so when a

patient is referred in right at the beginning of the pathway, they are referred in first week rather than second.

Reduce percentage of breaches incurred due to a patient cancelling appointment as they will be able to be seen in the second week.

The trust has developed improvement plans and actions to improve performance.

Specific services were targeted and KPIs for monitoring their performance were identified.

Support from PMO

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A work shop took place in July 2019 where programme and information leads looked at principles and processes in place to support delivery and tracking and general ideas have evolved which have metrics attached. Trajectory for 2ww was down for August, but back on track for September. One of the successes for improvement is the polling range reduction and booking people in first window. All patients treated over 62 days from referral are reviewed for clinical harm. Governance structure and performance framework. The Performance Committee Chair is satisfied with progress and plans in place; these are supported by external challenge from external regulators NHSi who have agreed to reduce frequency of performance review meetings to bi-monthly.

The following questions/comments were made in discussion: Have clinicians any thoughts of how things can be improved? Quality wise there is still work to be done, question regarding general practice, poor around multi-disciplinary working, there doesn’t seem to be anything better to tell practices. Breaches are quite small numbers with wide variations. A lot of the breaches are classified as ‘outpatient inadequate, health care provider delay, patient choice and admin delays’ are these looked at by a clinician on a Monday? The department works on a referral basis, it will also be patients who will breach and it is hard to provide clinics on an ad hoc demand. What assurance can you give us around delivery and how you manage the spikes for example lung and gastro what do we need to do to ensure rigour in those pathways? Have resilience in system. Not all services struggle with capacity, in this department unable to model with any assurance for fluctuation. How does the board receive assurance around trajectory? WHHT can share the modelling with the CCG; the key factor going forward is to find the most appropriate pathway for patients to free up capacity. MDT meetings play a big part of that. What is the requirements/assurance to deliver joint targets? Will take learning from elsewhere who has a sustained position. Would also welcome support as well in managing issues around patient choice where the percentage of breaches is quite significant. What are the escalation points, what triggers this? WHHT noted that this is a whole holistic approach with a number of trigger points. Can you elaborate on breaches around capacity and ambulance delays? For outpatient and admin delay there are national breach labels which cover a broad list; for all diagnostics and you have to choose one. Are admin delays really unavoidable? Admin support is spread wide across the whole trust and delays could be around sick leave and no handover problems with MDT tracking. What is the main cause? Tracking What can you do to fix that? Triangulate all contributory reasons for a breach and dig beneath each one. As a GP I have not been contacted once about a patient who has not been willing to attend a 2ww referral, do you inform GPs when a patient refuses an appointment? Yes by law the trust will inform the GP, if a patient DNAs twice then a letter is sent to the GP and the patient.

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How can primary care help with patients who do not attend appointments? The trust is open to find better ways to engage with all services. This is where the data is key, need to know numbers. It was agreed that KC and Jane Shentell will go through the detail to provide joint assurance. AG offered support for patients and how to talk to them at point of referral.

QC/164.1/19 QC/164.2/19 QC/164.3/19

Action arising from deep dive

WHHT to share detailed action plans in relation to cancer improvement. KC to link with JS regarding setting up an MDT approach to review all constitutional

target improvement plans including cancer.

WHHT to confirm if AG offer to work with WHHT and CCG if additional support is needed regarding communication to patients with suspected cancer.

1 | P a g e

Meeting : Performance Committee Date : 3rd October 2019 Time : 11.30-12.30pm Venue Quorum

: :

Conference Room 2, The Forum, Hemel Hempstead One voting board member, one clinician, one lay member of the board

Committee Members

Alison Gardner (AG) Lay Board Member Catherine (Kate) Page (KP) GP Board member and Locality Chair – Hertsmere Diane Curbishley (DC) Director of Nursing & Quality and Deputy CEO

Paul Smith (PS) Lay Board Member (Chair of meeting) Rami Eliad (RE) GP Board Member – Watford & Three Rivers

Stuart Bloom (SB) Lay Board Member Trevor Fernandes (TF) Deputy Clinical Chair and GP Board Member – Dacorum

Attendees Adrian Manning (AM) Patient Transport Contract Manager Avni Shah (AS) Programme Manager, Planned and Primary Care

David Evans (DE) Director of Commissioning Iram Khan (IK) Corporate Governance Support Manager

James Hughes (JH) Senior Quality Assurance Manager Joan Plant (JP) Associate Director, Resilience and Quality Improvement Kate Chand (KC) Head of Quality & Performance Improvement

Kathryn Magson (KM) Chief Executive Officer Kosar Parveen (KP)

Miranda Sutters (MS) Public Health Consultant Nicholas Small (NS) Chair Shazia Butt (SB) Senior Contracts Manager

Simon Pattison (SP) Head of Service, Integrated Health and Care Commissioning Team Sue Barker (SB) Interim Deputy Director, Nursing & Quality

Tracey Brown (TB) Deputy Director, Operational Delivery Tracy Pooley (TP) Head of System Resilience

Apologies Caroline Hall (CH) Chief Finance Officer Richard Pile (RP) GP Board member – St Albans and Harpenden

PC/190/19 Welcome, introductions and apologies for absence (Chair) 190.1 Introductions were made and apologies for absence were received from CH and RP.

PC/191/19 Declarations of interests (Chair) 191.1 There were no new declarations of interests.

PC/192/19 Minutes of previous meeting (Chair) 192.1 The minutes of the meeting held on 5th September 2019 were reviewed. 192.2 The committee agreed the minutes as an accurate record of the meeting.

PC/193/19

193.1 PC/180.21/19: DC will provide a further update at the next meeting. - Open.

Draft - subject to approval Agenda item 3

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PC/188.3/19: This item will be covered on the agenda for this meeting- Closed. PC/188.10/19: AS confirmed that this will be brought to the next meeting- Open.

PC/194/19 Committee Work Plan (DC)

194.1 The committee noted the work plan. PC/195/19 Governance Items

195.1 BAF Report 195.2 The committee noted the BAF report.

PC/196/19 Performance Report (KC)

196.1 A&E 4-hour standard Although West Herts performance remains non-compliant for June 2019 (82.1%)

improvement have been since May 2019 and July and August 2019 is now in-line with trajectory figures.

The Trust has developed a A&E improvement plan and trajectory was submitted to NHSi on 19th September 2019. The CCG has made contact with NHSi and have agreed to provide joint feedback to WHHT. The improvement plans will be monitored through the CQRM.

196.2 Referral to Treatment (RTT)

Herts Valleys CCG did not meet the target for RTT in June 2019 at 86.9% against a target of 92%.

Improvements are required at WHHT regarding their capacity plans in order to achieve the 2019/20 targets. The Trust has developed an improvement plan and associated trajectories setting out how they will achieve the target by March 2020. The CCG will have sight of them once feedback has been provided by NHS Improvement.

HVCCG has recruited an interim RTT Programme Manager to develop and implement a plan in order to achieve the overall CCG target.

A decrease is expected in Luton and Dunstable performance in July and August 2019 due to issues in cardiology. A full recovery is expected by September-October 2019. A more detailed plan will be brought to the next committee meeting.

RTT Improvement Plans (KP)

The joint NHSE and NHSi planning guidance for 2018/19, stipulates that ‘the number of patients waiting on an incomplete pathway at the end of March 2019, will be no higher than that reported at the end of March 2018 and that the number of 52-week waits should be halved.

AS a commissioner the CCG are doing all they can to support those specialities who are under pressure, and activity is being reviewed in order to support with backlogs.

The initial focus has been to understand from other local providers whether they are experiencing challenge and if so, within which specialties and whether they are open to work together. From discussion with a number of local acute trusts the 2 following providers have expressed an interest in working with HVCCG: Luton and Dunstable Hospitals NHS Trust – specialities identified are ophthalmology, urology and Laparoscopic Cholecystectomy (Gall bladder removal), and Buckinghamshire Healthcare NHS Trust – specialities identified also relate to ophthalmology, urology and Laparoscopic Cholecystectomy. Discussions are also occurring with Spire Harpenden and a number of BMI sites.

Exact numbers are expected within 7-8 weeks. KP will be working very closely with the contracts and finance team to ensure a smooth process is carried out. A more robust report will be provided at the next meeting.

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It was confirmed that the CCG are beginning to receive data from Royal Free London (RFL), and Barnet and a meeting will be taking place next week in order for the CCG to have sight of their numbers and specialities. West Herts have their plan, which they are working towards and exceeding.

196.3 Cancer Cancer will now be reported on at every third meeting.

196.4 HUC Performance There is a 2-part matrix where performance in HUC dips. HUC have stated that this is

due to the summer holiday period. Each breach is being investigated and the contract manager will provide feedback from a quality point of view.

Performance against the target for urgent visits within 2 hours was not met in June at 92.8% (target 95%) however, a 1% increase in performance when compared against May performance is noted. Urgent consultations within two hours in June performance shows a drop to 83.1%. This was due to limited rota fill in June.

Concerns around calls will be brought to the next committee meeting.

RE advised that a lot of patients are sitting in the triage pool, are the committee confident that these patients are being dealt with in a timely manner? How can the committee be assured that this is not a structural issue rather than a busy period i.e. school holidays? This information will be provided to committee in future reports.

KM confirmed that performance in HUC is validated on a weekly basis by monitoring calls.

The committee noted that overall Herts Valley performance has improved. 196.5 Connect

A performance plan has been developed and a revised set of KPIs have been agreed. Reporting will be available from December 2019.

There has been some improvement in performance for June 2019, but this is not consistent for July or August 2019, however performance is expected to improve.

196.6 Millbrook

A revised set of KPI’s are being presented to the Commissioning Executive. The new LPR’s will be reported against and this will be shared with the committee

once they are known.

AS informed the committee that the contract is coming to an end and the market is being explored.

196.7 Mental Health (DE)

Performance relating to ‘adult routine 28-day referral’ target remains non-compliant in June 2019; however July’s performance saw a significant increase at 83.58% and 91% for August 2019.

CAMHS routine 28 days performance saw an improvement from June’s performance of 22.7% to July at 27.55%, an increase each month since April 2019.

HPFT provide a weekly CAMHS activity report to the commissioners for review, the waiting list has gone down from over 500 people to 172 countywide and 81 in Herts Valley (week ending 13th September 2019). HPFT have developed an internal recovery plan for 2019/20, and there is a system wide demand and capacity assessment to agree the overall level of capacity required across all CAMHS services. The contract conditions included a requirement that HPFT’s performance will improve consistently from the current level to meet the 95% target by March 2020. A deep dive into this issue was held at the September Quality/Performance Committees with more detail provided.

DE confirmed that this data is accurate. 196.8 Non-Emergency Patient Transport Service (NEPTS) (AM)

Since April 2019, when EEAST took over the activity which the CCGs were outsourcing to private providers, their performance across all KPIs saw a decline. EEAST have started to address this and July’s performance has seen good

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improvements, with every KPI indicator seeing the highest achievement of performance for the year to date.

With the acknowledgement that the current contractual KPI thresholds and targets are not deliverable or viable, HVCCG held a meeting with the consortium commissioners and EEAST on 12th September 2019 to propose a set of achievable KPIs and thresholds which ensures patient experience remains a high priority – These have been based on West Essex CCG’s KPIs who have developed a set of realistic but robust set of KPIs with EEAST. In proposing these KPIs, detailed exception reports from EEAST will be required of any journey that fails the agreed threshold levels.

The 2019/20 CEO/CFO contract discussions and negotiations with EEAST have been concluded, which takes the contract up to 31st December 2019. The contract has an optional one-year extension and EEAST have provided a financial proposal to extend this for 15 months (from 1st January 2020 to 31st March 2021) thereby avoiding the potential destabilising of the service in middle of winter and potentially putting patients at risk. HVCCG have produced a board report recommending the extension of the contract to 31st March 2021 which has been agreed by the board.

A task and finish group has been agreed so that expectations are very clear.

AM advised the committee that currently patients should be picked up within 90 minutes, which sometimes exceeds to 2+ hours. The CCG are now suggesting that 75% of patients are collected within that time window. It would then be expected that 85% of patients are collected within 105 minutes and 95% of patients within 2 hours. The message to patients is that they can expect to be collected within 90 minutes, meaning patients will receive a better service then they are receiving at present.

196.9 Sustainability

No questions were raised by the committee. 196.10 Quality Premium

The yearend position has been provided to the committee.

No questions were raised by the committee. 196.11 Individual Funding Requests (MS)

MS introduced the report and the following was highlighted: The paper summaries the activity of quarter 1 this year.

The issues around the ultrasounds have been actioned. 196.12 The committee noted that paper and felt assured by the report. PC/197/19 Closing Items (Chair)

197.1 Review management of conflicts of interest during the meeting: There were no new specific conflicts declared at this meeting.

197.2 Reflection on equality and diversity in relation to decisions made: There were no issues raised.

197.3 Risks identified during the meeting: None.

197.4 Items for cascade to localities and organisations: None. Date and time of next meeting: 7th November 2019, 11.30am

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Meeting : Audit Committee Date : Thursday 17 October 2019 Time : 09.30 – 10.55am Venue

: Conference Room 2, The Forum, Marlowes, Hemel Hempstead HP1 1DN

Present: Paul Smith (PS) Audit Chair & Board Lay Member (Chair of meeting) Stuart Bloom (SB) Board Lay Member Alison Gardner (AG) Board Lay Member In attendance: Ruth Boughton (RB) Information Governance Manager (AC/106/19 only) Clive Makombera (CM) Risk Assurance Director, RSM Katy Patrick (KP) Deputy Head of Corporate Governance (Minutes) Natashia Smith (NS) HR Business Partner (AC/110/19 only) Elke Taylor (ET) Acting Chief Finance Officer Lucy Trevett (LT) Audit Manager, BDO Rod While (RW) Head of Corporate Governance (by telephone) AC/98/19 Welcome, introductions & apologies for absence (PS) 98.1 • Apologies for absence were received from Kate Page and Rami Eliad who were both on

annual leave. • Rod While apologised for being unable to attend in person but joined the meeting by

telephone. AC/99/19 Declarations of interest (PS) 99.1 • There were no specific interests declared in relation to the agenda items.

AC/100/19 Minutes of previous meeting (PS) 100.1 The minutes of 18 July 2019 were agreed as an accurate record of the meeting.

AC/101/19 Matters arising (PS) 101.1 The action log was reviewed and the following was noted:

• AC/115.4/18 A response to the partial assurance audit on STP work streams was on the agenda. The risk management strategy and procedure is due for annual review but has not been amended in 2019 since changes will be necessary in the move to the proposed 3-CCG merger and establishment of an Integrated Care System (ICS). This action to be closed.

• AC/86.4/19 The signed declaration on LCFS Annual Report was submitted on 10 October 2019. This action to be closed.

• AC/86.5/19 LCFS were asked to provide further information about the areas identified as fraud risks in the internal survey at the next meeting.

• AC/86.6/19 Fraud risk deep dive on HR to be added to the work plan for January and maintained as a standing item for future meetings. This action to be closed.

• AC/92.4/19 Paper on third party data security risks at STP and ICS/ICP level to be added to the work plan for the next meeting. This action to be closed.

• AC/93.4/19 No action is being taken by East & North Herts CCG or West Essex CCG to review federation governance. This action to be closed.

Final Minutes

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• AC/86.5/19 RW has met with Sarah Howe, RSM and a report with recommendation about further actions in relation to the governance review has been received. This action to be closed.

• AC/86.5/19 Committee self-assessment was on the agenda for this meeting. This action to be closed.

• AC/86.5/19 There is a process in place for Executive review of audit actions. This action to be closed.

• AC/86.5/19 The emergency planning audit has been completed. This action to be closed. 101.2 The committee noted the action log updates and further actions requested. 101.3 The committee noted the fraud self-review tool submitted on 10 October 2019. AC/102/19 Committee work plan (PS) 102.1 The committee noted the work plan for 2019/20. AC/103/19 Decision Register Q2 2019/20 (RW) 103.1 • The decision register had been updated for the remainder of Q2.

• Those entries in red indicate items not for publication, either because they are commercially sensitive and therefore confidential, or where meeting minutes have not yet been approved.

103.2 • PS noted that there is a good process in place and there have been some improvements in the way that declarations of interests are made.

103.3 The committee noted the report. AC/104/19 Gifts and Hospitality Register (RW) 104.1 • RW noted that the committee should refer to the revised version of this report that he

circulated as there were some inaccuracies in the report in the pack. • The committee was asked whether future quarterly reports should include the whole

register or just recent additions. 104.2 • The committee agreed that a full report should be produced at year end for assurance,

with the intervening reports just reporting on recent additions. • CM asked whether declarations were made when hospitality had been declined. It was

confirmed that this is what is required in the policy but a reminder should be sent out to that effect.

104.3 The committee noted the Gifts and Hospitality Register. 104.4 ACTION: Remind localities, board members and staff that they are required to report

hospitality that has been declined (RW) AC/105/19 Conflicts of Interest self certification 105.1 • Brought to the committee for noting as the Q2 report has already been signed by the CEO

and Audit Chair and submitted to NHSE as part of the quarterly assurance process. 105.2 The committee noted the Conflicts of Interest self-certification submission. AC/106/19 SIRO Report 106.1 RB presented the report and noted some key points:

• Freedom of Information (FOI) requests are now included in the report and HVCCG is fully compliant with deadlines.

• It is proposed that IG policies are amalgamated and made more user-friendly in line with the approach in West Essex CCG (WECCG). East and North Herts CCG (ENHCCG) are conducting a similar exercise. The new document will be reviewed by both the virtual IG group and Executive team before being brought to the board for approval.

• The new IG toolkit was submitted for the first time in March 2019 and has since been expanded in June 2019. There are a number of new standards requiring compliance but guidance is not yet complete. A baseline assessment (not for publication) will need to be submitted to NHS Digital by end of October 2019. Discussions with other CCGs have

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concluded that the initial submission should state that not all of the standards have been met, alongside an action plan. A summary of this plan is included in the report. HVCCG is working with HBLICT colleagues where both have elements to address.

• A table-top exercise is being planned to test preparedness and implications of a potential incident where there is no access to the N drive.

• ET is the new SIRO and the necessary actions are being put in place alongside training as appropriate for her and colleagues.

106.2 The following points were raised in discussion: • RB explained that the virtual IG group comprises the SIRO, Caldicott Guardian, RW, RB and

Trudi Mount. The group works well with virtual approval, discussion and comments taking place as required by email so that delays are minimised.

• Work is underway to establish how we manage secondary use of data. Data sharing with the STP is particularly complicated since the STP is not an organisation and therefore cannot be a data controller.

• Further assurance is required in relation to third parties and cyber compliance, particularly as proposed system changes take place. Some spot checks are currently undertaken The committee asked that the virtual group discuss risk stratification and the programme of assurance needed and report back to the next committee on: which parties are implicated; what the risks are; and what the CCG can do to improve assurance*.

• NHS Digital has offered free cyber security training for board and Executive members and this will be set up in the next few months.

• All data breaches should be reported to RB, including information incorrectly sent to individuals from providers.

106.3 The committee noted the report. 106.4 ACTION: Discuss assurance requirements for third party cyber compliance as noted above*

and bring a report to the next committee. (RB) 106.5 ACTION: Reminder to be sent to staff that all data breaches should be reported to RB,

including provider incidents (RB). AC/107/19 Committee effectiveness self-assessment (PS) 107.1 • Responses were mainly positive, but the need to re-establish a more structured

mechanism for committee reports to the board was noted. 107.2 • The committee agreed that there should be an Audit Committee Chair’s report to each

public board meeting to both aid understanding of the committee’s work and provide the board with an opportunity to provide its own challenge.

• PS confirmed that there are two GP members of the committee but they are not required for a quorum.

107.3 The committee noted the self-assessment. 107.4 ACTION: Add Audit Committee Chair’s report as a standing item on the agenda for board

meetings in public (RW) AC/108/19 Review of detailed financial policies (ET) 108.1 • A more comprehensive review of financial policies was conducted in 2018/19 following a

number of regulatory changes. There have been no changes in regulations or authority so far this year: the review is therefore light touch, aimed at improving understanding.

108.2 • ET was not aware that funding for the STP or other organisations is reflected in these policies: to be checked.

108.3 The committee approved the changes to detailed financial policies and authorised the revised version to be uploaded to the CCG’s intranet.

108.4 ACTION: Reference to the ‘Finance and Performance Committee’ on page 40 requires correction (ET)

108.5 ACTION: Check whether policies cover funding for outside bodies (ET)

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AC/109/19 Self-assessment of financial control, planning and governance processes and systems (ET) 109.1 • Where results were not 100% explanations were given:

- The QIPP financial trajectory is currently 95% against a 100% requirement although this is being reviewed to ensure that all mitigations have been taken into account.

- Greater awareness in the team means that cash management has now improved and no further supplementary drawdowns are expected.

- Training was delivered to the board in Q1. A paper to the Executive Committee will set out information about HFMA online courses and who should undertake them. This will address training requirements more adequately.

- Capacity and capability requires less than 5% turnover to meet the requirement and HVCCG’s turnover was just above 5%. There are, however, no concerns about the capacity and capability of the finance team with only one band 4 vacancy at present. There will potentially be increased turnover associated with significant organisational change, but ET is confident that HVCCG has both a very capable and experienced senior management team who are able to minimise any risks and also the ability to attract high calibre staff.

109.2 • AG noted that she has worked with the finance team and agrees that they are very high performing and committed.

109.3 The committee noted the contents of this assessment. AC/110/19 Raising concerns (whistleblowing) update (NS) 110.1 • No reports have been received in the last six months.

• Actions requested by the committee in March 2019 have been undertaken: - Awareness has been raised in primary care through the practice managers’ forum. An

article has been shared supporting policy development. - There is no wider comparative data available for CCGs but comparison with ENHCCG

and WECCG shows that no concerns have been raised there either. 110.2 The following points were raised in discussion:

• Further assurance will be sought from the NHS staff survey which has gone live in October and the CCG is encouraging as much uptake as possible.

• Additional mini staff surveys are unlikely to get a good response, but there will be follow up surveys to pick up locally on any concerns raised in the national survey.

• HVCCG’s policy reflects the national policy and NS is not aware of any new guidance in relation to the Freedom to Speak Up Guardian: to be checked.

• Information to Practice Managers to be clarified to avoid confusion. • Future reports to include some softer intelligence in relation to raising concerns.

110.3 The committee noted the report and that some assurance can be taken from the NHS staff survey but asked for future reports to include additional forms of assurance.

110.4 ACTION: Check whether there has been any new guidance issued in relation to the Freedom to Speak Up Guardian (NS)

110.5 ACTION: Send clarification to Practice Managers about their Freedom to Speak Up Champion (NS)

110.6 ACTION: Consider what additional forms of assurance might be gathered and include these in the next report (NS)

AC/111/19 External audit update (LT) 111.1 LT provided a verbal update:

• Assurance work around the mental health standard was deferred but has now commenced. There remains a lack of guidance about what is required in terms of calculations. The revised deadline is end of October 2019 and the findings of BDO’s technical lead will be discussed with Nicola Peters. Compliance is to be assessed as: complete; no material issues; or not enough information. More information will be shared at the next committee.

• Planning work for the 2019/20 audit starts in December 2019 with the physical audit plan

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to be presented to the spring committee meeting. 111.2 The committee noted the update. AC/112/19 Internal audit progress report and other updates 112.1 • CM noted that several papers had been shared with the committee, but his comments

would be focused on section 1 of the progress report. • The planning process is in place with the majority of review dates agreed. A number of

audits have already taken place and two final reports are included in section 1: medicines management (substantial assurance) and conflicts of interest (reasonable assurance).

• A benchmarking paper assesses the CCG’s progress since 2017/18 and 2018/19 and compares HVCCG performance with the RSM CCG client base.

• There are no overdue management actions to report and RSM will continue to follow up actions raised in the new audits.

112.2 The following points were raised in discussion: • More regular reminders about COI are required to board, members and staff: this will be

raised in the Chair’s reports to board. • The timeliness of management updates has improved. • The benchmarking shows that HVCCG is not an outlier. • Internal audit advice and support in developing governance processes will be helpful in

ensuring a consistent approach to reporting across all three CCGs in advance of the establishment of committees in common: there is learning to be brought from RSM’s experience in London.

• RSM conduct searches of Companies House and other publically available information when checking declarations of interest.

112.3 The committee noted the reports. AC/113/19 BAF report Q2 2019/20 (RW) 113.1 The committee noted the Q2 report which was reviewed and approved by the board on 26

September 2019. AC/114/19 Risk deep dive: Update on STP risk processes in response to partial assurance audit (PS) 114.1 • STP PMO lead was unable to attend the meeting due to the change in timing. Internal audit

will be conducting a follow up exercise on this partial assurance audit when the progress reported can be confirmed.

114.2 The committee noted the update. AC/115/19 Review of how conflicts of interest were managed in the meeting (PS) 115.1 • No specific conflicts of interest were raised. AC/116/19 Review of how equality and diversity issues were dealt with in the meeting (PS) 116.1 • Softer intelligence is to be considered in relation to raising concerns (whistleblowing). AC/117/19 New risks identified in the meeting (PS) 117.1 • It was noted the third party cyber risks require more assurance. AC/118/19 Items for cascade to localities and staff (PS) 118.1 • Reminder that hospitality declined needs to be declared. AC/119/19 Date and time of next meeting (PS) 119.1 23 January 2020, 10.00am, Conference Room 2, The Forum

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Meeting : Finance Committee Date : Thursday 7th November 2019 Time : 1.00pm Venue Quorum

: :

Conference Room 2, The Forum, Hemel Hempstead One voting board member, one clinician, one lay member of the board

Committee members Trevor Fernandes (TF) Deputy Clinical Chair and GP Board Member – Dacorum Paul Smith (Chair of Committee) Board Lay Member Stuart Bloom (SB) Lay Board Member Richard Pile (RP) GP Board member – St Albans and Harpenden Corina Ciobanu (CC) GP Board Member and Locality Chair – Dacorum Kathryn Magson (KM) Chief Executive Officer Attendees Avni Shah (AS) Programme Director, Planned and Primary Care James Olweny (JO) Deputy Director of Contracting Elke Taylor (ET) Chief Finance Officer Maria Kyriacou (MK) Associate Director of Transformation Nicola Peters (NP) Acting Deputy Chief Finance Officer Apologies Lynn Dalton (LD) Director of Primary Care Diane Curbishley (DC) Director of Nursing & Quality and Deputy CEO Rami Eliad (RE) GP Board Member – Watford & Three Rivers FC/280/19 Welcome, introductions and apologies for absence (Chair) 280.1 • Introductions were made and apologies for absence were received from LD, DC, and

RE. FC/281/19 Declarations of interests (Chair) 281.1 • TF declared that his wife, although not mainly working at Hospice of St Francis, still

carries out some teaching there. • No specific conflicts of interests were declared in relation to the agenda items.

FC/282/19 Minutes of previous meeting (Chair) 282.1 • The minutes of the meeting held on 5th October 2019 were reviewed and agreed as

an accurate record of the meeting.

283.1 FC/275.2/19- ET advised that this action is currently being reviewed- Open. FC/284/19 Committee Work Plan 284.1 • It was confirmed that there have been no changes to the work plan. FC/285/19 Assurance Items (JO) 285.1 Acute Contracting and Finance Report

JO introduced the report with the following points: • Overall the position remains the same as the previous month with West Herts, East

and North Herts and Luton and Dunstable continuing to underperform. • The main points to note at the point of delivery level are:

- A&E: This remains above plan for all the main contracts. - Critical Care: This is still above plan but the variance to plan compared to Month 4 has reduced.

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- Elective: The over performance is mainly driven by an increase of Elective Births at RFL, Day case activity at both WHHT, and ENHT. - Non-Elective: The two main drivers for the over performance are Emergency spells at WHHT the Same Day Emergency Care (SDEC) POD at RFL. - Other: As previously reported, the underperformance within this PoDis mainly attributed the reduction in the price change for Adalimumab. Outpatients: Activity is above plan at WHHT, L&D and RFL.

• Potential Mitigations: Mobilisation of the UTC at WHHT. Agreement of WHHT 2019/20 contract form (MIC). Application of appropriate contract challenges and ensuring correct coding and charging/contractual rules applied. Agreement of a local price for Same Day Emergency Care activity at RFL. Yearend reconciliation with RFL.

• Further Risks: Elective over performance (where activity increases further to clear the RTT backlog). Increasing NEL and A&E over performance during winter. Volatile critical care activity.

• The 2018/19 outstanding claims for main the provider contracts are all closed. • The 2018/19 outstanding claims for smaller provider contracts form part of the year

end reconciliation process. The year reconciliation for these contracts is expected to be completed by the middle of November 2019.

285.2 Finance Report (NP) • At month 6 the CCG is reporting a surplus on programme budgets of £0.534m

(expenditure less than available resources). The current forecast is that the CCG will deliver to plan at the end of the financial year.

• Within programme budgets, there is a year to date overspend against the acute contracts, although the performance by individual providers varies. All other programme service lines, including Mental Health, Community and Primary Care, are showing an underspend year to date.

• Running costs are reporting to plan. • Most areas are currently reporting to plan at year end, with the exception of

Prescribing, where there is an anticipated pressure of £1.32m, which will need to be met by the use of contingency reserves.

• KM assured the committee members that the prescription budget is being closely monitored and advised that there is minimal prescribing taking place over the counter.

• ET confirmed that this year the budget is satisfactory for prescribing, however it has been recognised that Brexit may impact the prices of drugs and this will be monitored accordingly.

• The main risks identified at month 6 relate to activity pressures, including the high level of emergency activity, and non-delivery of QIPP on the acute contracts.

• The risks are assessed as being fully mitigated by non-recurrent and prior year benefits.

• The committee noted and felt reassured by the report. 285.3 QIPP Report (MK)

• The QIPP value for 19/20 is £15.4m. The reported value year to date at month 6 is £6m, which is 95.8% against the original plan.

• Details of the red schemes can be seen in the papers which was shared prior to the meeting.

• The criteria on the finance RAG status are Green greater than 90% delivery on savings target, amber 70 to 89% delivery on savings target, red less than 70% delivery on savings target.

• The delivery leads select the RAG statuses for dependencies, resource and capacity and scope / progress against plan.

• I have asked each director to identify the savings so that all departments are

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comfortable with the QIPP in place. • MK confirmed that great improvement can be seen in comparison to the previous

year. • ET advised the committee that the whole concept of QIPP will be reviewed as a

priority to ensure that both schemes can deliver on both sides. • A meeting will take place next week with the internal director to discuss what QIPP

will look like going forward. Reducing demand and reducing patients attending Watford will be discussed to begin with.

• AS confirmed that there are clinicians in all the areas, and it is about joining this up with Watford.

• We are working with the Primary Care team to look at interventions which could be put in place to discourage people from attending A & E.

• MK confirmed that there are no risks in delivering the plan in terms of staff capacity. • TF asked what part of QIPP is being looked at for the UTC in Watford and MK advised

that the overall value for the acute work is around £5m, half of which is non-elective. FC/286/19 Investment Items 286.1 wAMD service provision by Community Health & Eye Care Lt

• This paper outlines the proposal for the community ophthalmology provider Community Health Eye Clinic (CHEC) to provide a service for the diagnosis, treatment, follow-up & ongoing assessment of patients with wet Age-related Macular Degeneration (wAMD), delivered from an accessible local setting. This service will be available to patients registered with a GP practice within Herts Valleys CCG who are identified and deemed suitable for wAMD treatment by medical retina specialists within the community ophthalmology service.

• The Committee is asked to approve the financial envelope for a 3-year provision of the wAMD pathway as a part of the community ophthalmology service provision by CHEC.

• It was confirmed that there are around 364 patients who are seen each year. Current patients will not be moved, the new contract will be in place for new patients.

• The pathway delivered will be in-line with NICE guidance and a tariff has been agreed for each of the pathways which will be followed.

• KM confirmed that this can be funded if the activity comes out of the acute trust. • The committee confirmed that they are clear that the case has been clinically

reviewed and asked that the affordability is reviewed outside of the meeting. • The committee agreed that they are satisfied with the proposal if assurance can be

provided by management. FC/286.2/19 NEW ACTION: The committee agreed that practices will be reviewed outside of the

meeting and then presented to Watford as there have been contractual changes with Watford and so these need to be incorporated. The contractual implications will be taken away and discussed between MK and AS outside of the meeting.

FC/287/19 Other Items 287.1 Mobilisation Risks

• The new Arden & GEM contract is due to go-live on 12 December 2019. This was approved as the preferred bidder back in September 2019.

• This was a procurement under the health services framework and the contract is close to being signed.

• The committee are asked to review the mobilisation plan, raise any questions and endorse the recommendation on funding of NEL CSU to enable a parallel running period of a maximum of one month at a cost of £53,000.

• The Risk Stratification element and a range of enhancements to the products and outputs of the main specification will be delivered as part of a phase 2 to go live on 1st April 2020.

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• The paper identifies a range of risks and includes details of how these are planned to be mitigated as part of the CSU services mobilisation plan. These risks are: - Contract finalisation may hit major obstacles which the parties cannot resolve. - The minimum deliverables required for the Service Commencement date of 12 December as per the agreed mobilisation plan may be missed by Arden & GEM CSU. - NEL CSU may try to levy additional costs to assist the migration to the new provider. - NEL CSU may be slow to transfer data and services and miss agreed deadlines. - The CCGs BI staff may not be able to cope with the additional workload of the mobilisation and maintain all business and usual BI deliverables. - Although a formal acceptance test has been planned for before Service Commencement, issues may arise in the immediate period after going live. - PCN Directors may not support the GEMIMA roll-out on the basis of workload. - There may be a general push back on GEMIMA, based on a poor perception of the effectiveness and functionality of NELIE, and the assertion that key staff (Practice Managers and admins) are too busy to engage in mobilisation. - GEMIMA may fail to deliver the capabilities required for PCNs, EERM, Frailty etc. - The STP PHM programme and the “wave 2” offer from NHSE for PHM pilot site is not sufficiently joined up with GEMIMA. - GEMINA training is not effective.

• As of 30th October 2019, the overall plan is rated to be on track – RAG green – however, the above risks do need to be fully mitigated as described in the main paper.

• The most important risks relate to primary care roll-out. The mobilisation plan includes a full primary communication and engagement plan, which has been fully consulted on in advance with LDP clinical leaders, Locality Chairs and other key stakeholders.

• The committee are concerned that practices will be annoyed that there another change is being implemented.

• The committee requested assurance with regards to mobilisation and KM informed the committee that it has been requested, for assurance, that a ‘double run’ is carried out in the interim and the committee endorsed the double running in order for reassurance.

FC/287.2/19 NEW ACTION: ET will provide an update on Mobilisation Risks to the committee at the next meeting.

FC/288/19 Closing Items 288.1 Review management of conflicts of interest during the meeting

• TF declared that his wife, although not mainly working at Hospice of St Francis, still carried out some teaching there however, this was deemed not relevant during today’s meeting.

• No specific conflicts of interests were declared in relation to the agenda items. 288.2 Reflection on equality and diversity in relation to decisions made

• There were no issues raised. 288.3 Risks identified during the meeting

• No new risks were identified in the meeting. 288.4 Items for cascade to localities and organisation

• None recorded. Date and time of next meeting: 5th December 2019, 1.00pm

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Meeting : Commissioning Executive Committee Date : Thursday 10th October 2019 Time : 10am – 1pm Venue

: Conference Room 2, The Forum

Present: (Committee members) Daniel Carlton-Conway (DCC) Board GP Member Diane Curbishley (DC) Director of Nursing and Quality and Deputy Chief Executive Officer David Evans (DE) Director of Commissioning Rami Eliad (RE) Board GP Member (Watford and Three Rivers) Asif Faizy (AF) Locality Chair (Watford and Three Rivers) Trevor Fernandes (TF) Board GP Member (Dacorum) (Chair) Corina Ciobanu (CC) GP Board Member and Locality Chair (Dacorum) Kathryn Magson (KM) Chief Executive Officer Catherine Page (CP) Board GP Member and Locality Chair (Hertsmere) Simon Pattison (SP) Head of Service, Integrated Health and Care Commissioning Team Richard Pile (RP) Board GP Member (St Albans and Harpenden) In attendance: Elizabeth Babatunde (EB) Clinical Lead for Primary Care Jill Ainsworth-Beardmore (JAB) Patient Representative Lynn Dalton Director of Primary Care Avni Shah (AS) Programme Director Planned and Primary Care Miranda Sutters (MS) Consultant in Public Health Tracey Norris Herts for Learning Governance (minutes) CE/300/19 Welcome and apologies (Chair) The Chair welcomed everyone to the meeting, apologies had been received from Stuart Bloom

and Nicolas Small.

CE/301/19 Declarations of interest (Chair) There were no new conflicts of interest to declare.

CE/302/19 Minutes of previous meeting (Chair) The minutes of the meeting held on 12 September 2019 were approved as an accurate record

of the meeting

CE /303/19 Matters arising (Chair) The following update was provided for items not already on the agenda:

CE/286.2/19: Review and evaluation against the contract and then consider role out to PCNs, to be commissioned through the mental health team. A paper would be brought to the November PCC.

CE/288.2/19: Update would be provided to the next Commissioning Executive meeting.

CE /304/19 QIPP update (Kathryn Magson) The committee noted the report on pages 13-17 of the document pack. KM summarised the

report:

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QIPP Value for 2019/20 is £15.4million. Month 5 YTD reported value is £5million which is 95.1% against the original plan. 2020/21 value of £16million is expected to be signed off by the regulator. Main issue was reporting rather than performance, a qualitative view was taken when it

was clear that the monitoring mechanism in place was not appropriate. For example, there was no reduction in ENT activity despite a reduction in referrals

because of the high waiting lists. LTPT: a deep dive would be arranged shortly (this was currently running behind schedule). Urgent care: the run rate was improving but was over plan. A&E attendance: overall 6/7% over plan (type 3 was 26% over plan but admissions only

0.6% over plan). There was a pipeline of schemes being drawn up for next year which would be submitted

in November/December (paediatrics, cardiology and respiratory). There were no financial issues to raise and KM assured the committee that the urgent

care and A&E rates would continue to be monitored closely. CE /304.1/19 The committee noted the report

CE /305/19 BAF Update (Chair) TF referred to the report update at pages 20-26 of the document pack and confirmed that DE

would update the report to reflect the change in risk to Harpenden Memorial SOC since ACS mobilisation. There would be no change to 32.b primary care.

CE/305.1/19 The committee noted the report CE/305.2/19 ACTION: DE to update Harpenden Memorial BAF to reflect changes in risk following ACS

mobilisation CE /306/19 Mental Health: AQP (Simon Pattison & Adam Solomon) See report at pages 27-35 of the document pack: Any Qualified Provider (AQP) Counselling

update and recommendations for procurement. SP and AS gave the following update: The recommendation is to continue with a mixed model led by HCC. Current contracts run until March 2020. The current capacity issues would be addressed by increasing the hourly rate to £47.50.

Questions and clarifications were raised by the committee: DE recommended that the rate be increased to £50 per hour. There had been no uplift

for a long time and this would ensure the drive to IAPS was achieved. This contributed to the national target and was affordable.

Existing providers had already been consulted with, hourly rates varied from £50 - £60. Q was £50 enough to build capacity? Yes it was hoped so, 4 organisation had attended

the pre-procurement meeting which was a positive sign. GP members concurred that this service was valued and should be invested in. Each session was an hour (50mins consultation, 10mins of note writing). Q what was the average number of sessions a patient needed and were DNA rates

tracked? Typically patients (suffering from depression) had between 8-16 sessions. The average was 7.5. DNA rates were at their highest during the early stages (ie after 2 or 3 sessions) and were tracked. DNA were not paid for.

Q was there time for the procurement process to take place before March? April was achievable but would be tight, it might be necessary to extend the existing contracts for one month.

CE /306.1/19 The committee noted the report and approved the recommendations for procurement based on a mixed model and the increase in the hourly rate to £50.

CE /306.2/19 ACTION: SP/AS to commence procurement process CE /307/19 Mental Health: Dementia strategy consultation (Simon Pattison & Adam Solomon) See report at pages 36-41 of the document pack which sets out the proposals for developing a

Hertfordshire joint dementia strategy for 2020-2025 to build on the existing joint strategy which would be coming to an end (2015-2019). The Commissioning Executive were asked to: Approve a 12 week consultation process

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Provide feedback on identified stakeholders. The following points were raised in discussion: Consideration should be given to the need for flexibility/creatively to enable carers’

engagement. For example some group sessions/1:1 meetings should be offered at weekends and be local to the carer’s place of residence (they often did not have time to travel large distances).

The feedback from carers/other stakeholders would determine the priorities. It was clear from patient feedback that there were many patients who were not yet

benefiting from the support that was already available, they could be targeted through practice patient groups or locality patient groups.

Suggestion that a priority should be on dementia prevention (as much as support). This could be achieved through the healthy living agenda.

Dementia strategy was not yet reflective of the move to ICS/ICG provision which would be in place by April 2020.

The collaborating parties included HCC, HVCCG and East and West Herts CCG. The strategy would need to be able to offer parity of footprint locally.

CE /307.1/19 The committee noted the report and agreed that the consultation should go ahead once the objectives had been agreed and shared with the executive team.

CE /307.2/19 ACTION: SP/AS to finalise objectives of consultation with executive team CE /308/19 Mental Health funding update (Simon Pattison) SP referred the committee to the reports at pages 42-54 of the document pack which

summarised the mental health transformation funding that has been successfully secure as part of the Herts and West Essex STP and also the steps taken to improve the CAMHS service (in terms of reducing waiting lists and increasing capacity). The following questions were raised: Other forums have heard about the challenges at A&E and how there was not an

adequate response to acute mental health (47 presentations a week). SP reported that the crisis funding would improve this offering, eg crisis café model

providing an alternative destination to A&S. Concern was raised that there were only 4 suites available at the Kingfisher unit. 28 day referral aim was too slow, this should really be happening within a week. The eating disorder referrals were made through triage but urgent referrals would be

made more quickly as the patients would be well known to the service. Personality disorder referrals would be made through SPARKS and would be 28 days. One of the key aims was to achieve quicker access for all mental health disorders and

there were clear KPIs around access. A new pilot for access and intervention for CAMHS (jointly provided by HTFT and Step2)

would identify the gaps in the service. Transformation and performance management review conversations were taking place

every two weeks. A more effective service was anticipated by the end of October now that triaging was

happening in one pace. CE/308.1/19 The committee noted the update CE/309/19 HVCCG/PH collaboration (Miranda Sutters)

MS reported the following: A meeting had been held in August and a list of options to work together on had been

drawn up (gambling pathway and prescribed drugs pathway). This would be joint work across Hertfordshire with shared learning from West Essex. The business case on Children’s Weight Management would be received later today. Did the committee agree that these should be the priorities for HVCCG/PH to be working

on? The following comments were made: KM reported that HVCCG was comfortable as long as there was a link to PCN prescribing. Papers were shared with board members and PH representatives went to locality

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meetings. GP members felt that it was good to have a joint strategy, in the past discussions had

always been about money first and health impact second. Reports of the currently difficulty to access contraception were noted. The waiting time

for LARK was up to 3 months. The Hub approach was welcomed. The target list would be shared with delivery boards (some issues were specific to

different localities). Difference specialist clinics would be offered in different areas depending on workforce. MS referred to the interactive map which shows where to go for coils (for example). Members felt the capacity issues (eg 6-8week wait for coil) was a public health issue and

should not rely on the locality to provide. Not all young people would want to go to their surgery for contraceptive advice. Training opportunities for practitioners were scare (for coil). One practice had offered 8 hours per week for this but had received no referrals. This was

a comms issue, as clearly there was demand for this service. MS would re-issue the interactive map. GP members felt that they were being bombarded

with comms and it was apparent that some key messages were getting lost. All members were agreed that the single point of access model would work best. MS

would take this message back. CE/309.1/19 The committee noted the update CE/309.2/19 ACTION: MS to share feedback re single point of access model (Hub System) to PH and

reissue the interactive map CE /310/19 Weight management options (Miranda Sutters and Sue Matthews) The proposed business case was to offer intensive support for families and improve coverage

via £350,000 investment pa into the service and £30,000 for mobilisation. Questions were invited: KM confirmed that she had signed off the proposal. GP members were supportive of anything that would increase the reach of this service. Currently PH invested £270,000 and this was a good example of PH listening to WHCCG

concerns and addressing them. KPI should be around inequalities, target sessions in certain areas and identify patients

through Children’s Centres and deprivation areas. Even localities colour coded “green” would still have small pockets of deprivation (eg

St Albans and Berkhamsted). The committee approved option 3, subject to East and North Herts CCG agreement. Consideration was given to what would happen if East and North Herts CCG did not agree

to the proposal. If no agreement was forthcoming it would be offered to WHCCG only and if this was the case, agreement would be sought with DE/KM on the funding levels.

Q Did this service link in with Children’s Services and Education? They did not contribute to the funding pot but offered advice on healthy eating which complemented Option 3.

Referrals should and could be made by school nurse/health visitors. The paediatric dietetics service was not yet live, but this was already being commissioned

from HCT. Q were pathways clear enough for Tier 2 rejections? A deep dive into dietetics showed they were only at 40% - a full audit was required and

this would take place within 10 days. The committee asked for assurances that if HCT expanded the service the CCG were not

paying twice for the same service. CE /310.1/19 The committee approved option 3 subject to East and North Herts CCG agreeing to the

proposal and the audit outcomes being incorporated into the proposal as needed. CE/310.2/19 ACTION: Obtain assurances re potential double payments to HCT

CE /311/19 Early Intervention Vehicle Service (EIVS) (Dr Clair Moring and Roshina Kahn) See report at pages 55-80 of document pack. The committee were invited to discuss and

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approve the specification of the early intervention vehicle service which was based on the model that East and North Herts CCG had in place and builds on what is offered in a care home The service provider would be the East of England Ambulance Service and the steps would be: Fall > call 999 > triage > EEAST clinical navigator will agree category > dispatch EIVS

instead of ambulance Proposed start date: 1 April 2020 As part of the specification, the team had reviewed data from East and North Herts re

conversion rates. The following was raised in discussion: Had the skill set of the EIVS personnel been established? Prescribing/suturing/OH

assessment? As part of the specification process, CM and RK has looked at what actually happens in

the East and North Herts CCG model to identify the skill set. The EIVS provide very little prescribing but to be independent and autonomous there was clearly a minimum skill set required.

If the EIVS decide that an ambulance is required, they will remain with the patient until the ambulance arrives.

This should not add any additional layers of responsibility onto the GP. GP members pointed out that there was less flexibility in GP surgeries in this area to

provide assessments in the afternoon (as compared to East and North Herts). GP members suggested that EIVS should be an ECP - Band 6 was not good enough. EB reported that the banding for an advanced nurse practitioner was being reviewed. Links with CLCH would be explored. The next steps would be to take this proposal to the board as there needed to be a

discussion with the East on paying for services twice due to under delivery (despite recent arbitration outcome).

RK would make the agreed changes to the specification and circulate to the Executive Board as early as possible.

CE /311.1/19 The committee approved the proposal subject to the desired changes to the specification. CE /311.2/19 ACTION: CP and RK would make changes to the specification and circulate to the board.

CE /312/19 Wet Age Related Macular Degeneration Pathway Delivery Business Case (Meelan Trivedy/Avni Shah/Aparna Garg)

See report at pages 81-128 of the document pack. MT and AG summarised the outline proposal as follows: WaMD service is proposed to be provided in the community by CHCE in from January

2020. The proposed clinical model was in line with NICE guidelines. The current system of

multiply appointments in hospitals would be replaced by a one stop shop in Watford. Retinal specialist would offer image reviews, nurses would provide injection service and

dedicated practitioner would coordinate activities/follow up appointments. Eye care liaison officer (if there was sufficient demand) would provide emotional support

and direct patients to voluntary care services. Advanced electronic management system would improve communications between

hospital providers, enable efficient reporting, audit tool. KPIs would focus on waiting times, time line for treatment and DNA/cancellations. The infrastructure was in place, the specification needed to be agreed for new patients

(existing patients would continue to go to their existing provider). The following was raised in discussion: How was the current community provider (CHEC) performing against its KPIs? The finance

committee had performed a deep dive and felt it was performing well against its KPIs, It has taken on a backlog of c1000 patients from elsewhere, and it has the capability and the capacity.

How accessible is the “one stop shop”? It was based in a shopping centre which had good

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access/transportation links. The biggest issue will be for patients from the Hertsmere location – there was no public

transport from Hertsmere to Watford. They currently use Potters Bar. Moorfields have confirmed that they will not be leaving Potters Bar Community Hospital. KM suggested that the specification mandate another site or offer Moorfield the

opportunity to provide this service in Potters Bar for the Hertsmere locality. EQIA should show that the access issues were considered as part of this discussion.

The specification was approved on the basis that the Finance Committee were dealing with the contract issues.

CE/312.1/19 The committee approved the specification. CE /313/19 GP direct access diagnostics suspected cancer (Phil Sawyer/Gemma Thomas) See report at pages 129-136 of document pack which commented on the pilot giving GP’s

direct access to head MRI and CT Abdomen and Pelvis to rule out pancreatic and brain and CNS cancer. This addressed the following three objectives: Compliance with NICE requirements to offer direct access diagnostics Support the delivery of the Quality Premium Deliver the NHS long term plan of having early diagnostics at Stage 1 and Stage 2. The following was raised in discussion: Currently direct access was available at West Herts Hospital, if it was rolled out,

discussions would be held with L&D and the Royal Free. GP members felt that this was a great scheme and began to address the fact that

diagnostics was often too late in the UK. 21 days was ambitious and due to manpower issues in radiology the wait was often up to

6 weeks. There was a shared aim to create a rapid diagnostics centre across SDP. Was the 3% detection rate value for money? This service was not considered expensive

and it was a national requirement. The committee agreed that this proposal was right for patient care, as well as being in the MIG.

CE /313.1/19 The committee approved the proposal to commission GP direct access to MRI for brain and CNS cancer and CT scan for pancreatic cancer.

CE/314/19 Dermatology (James Sinclair) See report at pages 137-185 of the document pack which has assessed the first six months of

data from the Community Dermatology Service (CDS) which went live in January 2019. The main findings were: GP referrals have increased in line with procurement. Conversion rates to community have increased by c75% (expected at 40-50%). Over-performance on first attendances. Waiting times was an issue for the service; 85% were seen within 6 weeks. Admin provision had not been sufficient to make follow up phone calls etc. Secondary care activity was in line with non-pilot activity. GP feedback survey was not very positive: 45% said service was low/poor quality vs 17%

who said it was high quality. As a result, the provider will now spend more time speaking to practice managers to get

direct feedback. Other issues included the responsiveness of Health Harmony prescriptions, clinical

concerns about speciality doctors, concerns about management plans. A CCG inspection will take place imminently. The service is overseen by a consultant dermatologist.

The following was raised in discussion: Confusion over CDS advising patients to ask their GP to prescribe medication that

can/should be purchased over the counter eg emoluments. Cases where patients were referred back to secondary care after being seen by CDS. Issue with CDS not being resourced properly because it was just a pilot – if this is

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extended to a permanent contact then the provider would be expected to do better. Despite the evidence to the contrary, the services feels better to the GP. The service was cost neutral at this point – the CDS was seeing a higher number of

patients in the community at a lower price. The location of sites should be revisited – were they in the right places? Watford Hospital have consultant availability and might consider delivering this service in

other localities. The underlying strategy was to delivery this service in the community and close down any

clinics operating within a Trust. Health Harmony currently provide service in two localities. Once other localities are identified, Watford could be invited to delivery this community service whilst using the DXS pathway forms.

Watford would need to understand that the number of onward referrals to their own consultants would not be increased.

The committee were keen for Health Harmony and Watford to start working together delivering this service.

CE/314.1/19 The committee noted the report. CE/314.2/19 ACTION: JS to speak to Watford about providing service in identified localities.

CE/315/19 Priorities Forum Policies (Miranda Sutters) Cough Assist Devices: minor updates which were approved.

Circumcision: this had been reviewed by the urologists and medical directors. Approved. CE/294.1/19 The committee approved the policies

CE/316/19 Children’s Transformation (Kate Healy, Elizabeth Kendrick, Naomi Mason) See report at pages 186-241 of the document pack. KH presented a summary of the HCT

Children’s community services transformation: The vision had been co-developed with partners in Hertfordshire, families and providers. Transformation had achieved improved access, reduced bounce and reduced waiting

times. There was now a single point of access (telephone and email) through Hub. Created capacity through streamlining processes, increased the role of admin staff,

creation of new templates, improved consistency of documentation. 10% increase in patients being seen within 18 weeks. 150 patients have been taken off the waiting list. Creation of multi-disciplinary team meetings to agree who takes a patient on – eliminating

ability to bounce patient back to another team. Pilot in January 2020 will see admin staff coordinating appointments for a cohort of

identified patient. HCC will put in resource to join up health and social care. Admission avoidance activity: WHHT data shows upper respiratory infection is the single

biggest issued. Community nursing service will pilot the Wheezy pathway. ASD assessment has been a challenge in Hertfordshire with this taking too long. A

supported 18 week pathway has been created and will be achievable by next year. The following was raised in discussion:

Whilst the main services have been transformed, the management of the backlog still needs addressing. The GP still sees long waiting lists, anxious parents and children’s community nurses who are not that accessible to primary care.

How has the partnership with WHHT been developed? WHHT sit on the admissions avoidance group, joint data is being analysed.

Community paediatrics are working closely with hospital paediatrics. The next phase of the integrated care partnership needs to be carefully designed. The

service has become more efficient and is in a better place to transform further. The Wheezy Pilot is too small and should be bigger. Aim for paediatrics to work up and down the pathways appropriately – this was not

evident in outpatients. There were 11 consultant paediatricians.

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There was greater integration between community and hospital consultants and sharing of information with hospital paediatrics – this avoided parents having to repeat themselves.

As the sector moved towards ICP there needed to be more cooperation between services. Eg hosting out-patient clinics in children’s centres, pulling paediatrics into primary care settings. The conversations should be about the service not hospital vs community staff.

The co-location of staff in clinics creates training opportunity and identifies ways to work together.

Clinical decisions should drive the use of the estates. This has been a big change to the working pattern of community paediatrics (previously

they had been working in three separate units). Clair Moring had been invited to present to the directors meeting. DE would help prepare a framework to support an agreed way of working (for paediatrics

on the ground) using a single pathway. Ultimately, the CCG should be able to commission a pathway not based on providers.

The following was agreed: A review/stocktake would take place in March 2020. Pilots would be expanded, being mindful of the fact that the current pilot in Hertsmere

was the smallest locality and had a small cohort of high intensity users. CE/316.1/19 The committee noted the report. CE/316.2/19 Review of Children’s transformation to take place in March 2020 CE/316.3/19 DE to help create framework to support an agreed way of working on the ground

CE/317/19 Funding voluntary sector via PCN (David Evans) See report at pages 242-284 of the document pack which recommended:

The approval of a one-off funding commitment of £200,000 or less in the current financial year to support a new grants process, via PCNs, to support PCN Social Prescribing Link Workers to build on existing voluntary and community assets and address gaps in community resources which will produce non-clinical interventions which are evidenced to improve health and well-being.

The finances had been agreed and ensured parity of investment in mental health issues. The following was raised in discussion:

It was suggested that an investment in CAB (particularly in the Watford area) could reduce the number of referrals.

PCNs could link up and offer a combined solution. These should be presented to the November PCC meeting.

A template process will have to be followed. There were no preferred providers. The PCNs would have to sponsor what they wanted in each locality.

It was agreed that this should be discussed in locality meetings. CE/317.1/19 The committee approved the recommendation. CE/317.2/19 ACTION: take to locality meeting

CE/318/19 ACS mobilisation The following was reported:

Since launch day, only minor IT issues had been reported. There had only been one complaint following the Dacorum practice managers meeting. CLCH have (inevitably) been finding issues that had been swept under the carpet, eg bed

based practice, ability in nurse based workforce, but these were being addressed. KM asked board member to refrain from citing anecdotal reports of minor issues in public

meetings as this could potentially generate unhelpful press/media coverage. Any questions from board members should be directed to AS or SC. The committee congratulated DE and his team for such a smooth transition.

CE /319/19 Review of how conflicts of interest were managed in the meeting (Chair) No conflicts of interest had been raised. CE /320/19 Reflection on equality and diversity in relation to decisions made (Chair) Nothing raised.

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CE /321/19 Risks identified during the meeting (Chair) HCT

Sexual health CE /322/19 Any other business (Chair) Since her update at agenda item CE/309/19 , MS had been able to liaise with Sue Matthews

regarding contraceptive and sexual health clinics and the community gynaecology services would be used as a hub base.

Date and time of next meeting: Thursday 10th October 2019 at 10am

Meeting closed at 1.15pm

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Meeting : Public Involvement Committee Meeting Date : 20th November 2019 Time : 10.00am-1.00pm Venue

: Lower ground floor room The Forum

Present: Alison Gardner (AG) Board Lay Member & Committee Chair Brian Gunson (BG) Health Watch Herts Colin Barry (CB) Patient Rep Watford & Three Rivers Daniel Carlton-Conway (DCC) GP Board Member Diane Eaton (DE) Patient Rep Watford & Three Rivers Gavin Ross Patient Rep St Albans & Harpenden Janice Neal (JN) Patient Rep Hertsmere Jill Ainsworth (JA) Patient Rep Dacorum John Wigley (JW) Patient Rep St Albans & Harpenden Kevin Minier (KM) Patient Rep Dacorum Madeleine Donohue (MD) Patient Rep Dacorum Robert Hillyard (RH) Patient Rep Hertsmere Juliet Rodgers (JR) Associate Director Communications & Engagement In attendance: Sundera Kumara- Moorthy (SKM) Health Watch Herts Gemma Thomas (GT) Head of Planned and Primary Care Ian Armitage (IA) Programme Director Jamie Sinclair (JS) Commissioning Manager Planned Care Kayleigh Kingsland Herts for Learning (minutes) Renate Scheffer (RS) Project Support Officer Rod While (RW) Head of Corporate Governance Trudi Mount (TM) Head of IM&T and Estates PPI/82/19 Welcome and apologies 82.1 • The Chair welcomed everyone to the meeting; apologies had been received from Alex

Hickinbotham and Heather Aylward. • JR reminded the committee that we are currently in Purdah

o The pre-election period describes the period immediately before elections or referendums when specific restrictions on activity are in place for public bodies including the NHS. This is often referred to as ‘purdah’ and it is designed to ensure we remain impartial during this politically sensitive time.

o We have a general election coming on 12 December and purdah formally came into force on Wednesday 6 November.

o The general principles are: o We do need to keep our normal activity running; it is important that the NHS

continues to function as normal; o We shouldn’t make any new decisions or announcements of policy or

strategy; o We shouldn’t take decisions on large and/or contentious procurement

contracts;

Item 03

FINAL MINUTES

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o Herts Valleys CCG staff, board members or other representatives are not allowed to participate in debates or events, in their professional capacity, that may be politically controversial, whether at national or local level;

o We must preserve our political neutrality as an organisation. PPI/83/19 Declarations of interest 83.1 • There were no new conflicts of interest to declare. PPI/84/19 Minutes of previous meeting 84.1 • The minutes of the meeting held on 15th September 2019 were approved as an

accurate record of the meeting by the committee. PPI/85/19 Matters arising 85.1 PPI/38.4/19: Ongoing.

PPI/40.2/19: Ongoing.

PPI/42.3/19: RW has been working on this and the Chair requested that this information is ready for the event taking place 28th January 2020- Ongoing.

PPI/74.4/19: Action not due until January 2020- Ongoing.

PPI/77.5/19: Ongoing. PPI/86/19 Committee work plan 86.1 • The work plan was noted. The Chair invited committee members to make suggestions

for agenda items going forward as required. 86.2 The committee noted the work plan. PPI/87/19 Cancer Performance Review 87.1 • GT and RS delivered a presentation to the committee based on cancer performance

for 2018-2019 and welcomed any questions - circulated at the meeting. 87.2 Questions raised:

Is there any sense of what the problems are at the RFL? • They now have NHS England and NHSI monitoring their improvement plan. In terms

of particular problems, there have issues with performance and reporting due to the merging of reports and it is taking them some time to get back on track. Patients have been lost in the system when the merger took place. RFL are aware of all their issues and have plans in place to ensure that they are on track by April 2020.

If the providers are not meeting the specification, what can you do to get an improvement? • We can impose financial penalties with RFL. • We can work with other providers lead commissioner if we aren’t able to impose a

penalty.

Do we have a friends and family test? • We do and there is also a national patient survey and the Trust is preparing an action

plan around this. • Patients are also being supported to ensure that any guidance and support is made

available for them.

With regards to finding a solution to the delays, what is the most important? • When there is a breach the Trust always carry out a breach analysis. The most

significant delay area is outpatients. 87.3 The committee noted the cancer performance update PPI/88/19 Urgent Care Strategy

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88.1 IA provided an update to the committee based on the urgent care strategy and welcomed any questions.

88.2 Questions raised: Why has it taken so long to get an urgent care centre in Watford?

• It takes time to make sure the right service is being put in place. A procurement process had to be put in place, which takes time.

The data I have seen shows that Watford is better than any other localities, has extended access made a difference in Watford and is the urgent treatment centre still urgently required?

• People would say that it has been beneficial. In terms of performance, Watford has been sitting in the bottom quartile, but there has been a huge increase in activity. There has been a rise in people attending A & E.

We have been told that there will not be an urgent care centre in Hertsmere, it would be very helpful to know what could be put in place in other establishments in order to reduce the pressure on other urgent care facilities?

• For Hertsmere one of their recent developments is that national urgent treatment centres have been seen as the way forward.

• Hertsmere has been reliant on Chase Farm, but there are now developments in Barnet, Edgeware and Finchley which will have urgent care centres.

It would be useful for us to have some ideas of possibilities which we can share with our PCN’s?

• IA will feed this to the relevant group.

How do you think we are going to cope with the winter demand this year? • We must consider the level of activity and how we can plan ahead. • We have been through what did and did not work last year, however there is always

an element of the unknown. • There is a lot of work that goes into forward planning.

88.3 The committee noted the update. PPI/89/19 Herts Wheelchair Service: Results of Market Engagement and Next Steps 89.1 JS provided an update to the committee based on the results of the Herts wheelchair service

market engagement and the next steps: • A market engagement event took place for potential providers and service user

complexity and service user demand was discussed. • There will be lots more engagement in terms of going to market with this. • It was suggested that carer groups are targeted, and JS advised that there is good

engagement and representation at but attendance at these meetings has dwindled. 89.2 Questions raised:

Do you have any other links to non-NHS groups who may have view on this? • We have not yet but we are planning to engage with Hertfordshire County Council on

this, and the charity sectors.

Has the concept of wasted wheelchairs been considered? • We do have concerns that the service is not as on top of this as it should be.

If there is a risk that the carer groups are dwindling, is there not a gap where wheelchair users can be approached in order to gather a group?

• This is what I would like to do, without a formal decision being made it is quite difficult to do.

What are we doing about West Essex? • I have discussed this with them, and they have confirmed that they are happy with

their service at present.

4

PPI/90/19 Patient Participation and Engagement Report 90.1 JR provided an update to the committee on the patient participation and engagement report:

• The CCG was asked by NHSE to take part in a good practice webinar around the CCG reader panel.

• The CCG is awaiting the next assessment, and in the meantime, feedback has been received on the CCG’s own assessment which has been reviewed as a team. This exercise has helped the team review processes and activity to ensure best practice.

• West Herts Hospitals Trust is very keen to improve public involvement. • An event is being arranged for 28 January 2020 or order to join those together who

are involved in various involvement activity to share best practice and help give us feedback on what works well and what could be better.

90.2 Questions raised: Have CLCH said that they will have an involvement?

• Our feeling is that they are very willing, but in terms of the work that they do in this area, they need to build that up.

The list of all the committees that everyone is on is great to see. Other involvements that people have which are not CCG related but they would welcome input from the community would be beneficial, is there a scope for this? This is a good idea, ways in which we can work more closely with others should be explored. The team will look at this.

Can the event on 28 January 2020 provide what is meant by pro-production? • The event must have a focus on getting people’s feedback.

It is great that we have 200 people, how would I then make contact with one of the health ambassadors?

• We can provide info about which organisations are represented.

In the groups I am attending, can we think about how patients can be involved? • This is something that we have thought about. PCNs are finding their feet, we do not

want to say that involvement can only by on a PCN level. PPI/90.4/19 Action: HA will consider further how links with others can be made.

90.5 The committee noted the report PPI/91/19 Hospital Redevelopment and Funding 91.1 JR provided an update to the committee on the hospital redevelopment and funding:

• There has been an announcement from the government to state that they will be investing in the West Herts Hospital Trust.

• Boris Johnson visited Watford General hospital and a figure of £400 million has been discussed.

• The detail is unknown at present and a meeting will be taking place where we expect further information will be provided

• This is very good news for the redevelopment of the estate that West Herts runs. • Although this has not been received in writing the CCG are confident that it will be

agreed. 91.2 Questions raised:

There is some confusion around the figures and people think that the £400 million is in addition to the £350 million.

• This is £400 million in total.

How solid is this promise of the £400 million, could It be withdrawn following the election? • It cannot be an absolute commitment, it is a commitment from the current

government, however this announcement came from the government.

Is £400 million enough to do what we want? • We have always been very clear that we will not be able to do everything we would

5

like to do in an ideal world, but it will deliver very significant change and improvement.

We still have 3 different campaigns for a green field site, and we are not sure what is happening with this?

• We don’t know all the detail necessarily about the campaign groups. We do know that one of them has made a claim for judicial review.

91.3 The committee noted the report PPI/92/19 Cyber Security 92.1 TM delivered a presentation to the committee on cyber security:

• Following the cyber-attack which took place a few years ago a fake email test was carried out recently and sent to all NHS staff and the results of this have been reviewed.

• TM presented the email which was sent to NHS email accounts and identified the key elements of the email which we would expect people to notice as fake

• These emails are usually from organisations which have no reason to email you. • Account holders should delete the emails, if they are in any doubt users should not

click on any links within these emails. • The test email exercise will be repeated in six months’ time. • All IT will be updated to Windows 10.

PPI/93/19 Local Reports 93.1 Dacorum

• Additional paediatric appointments and extended access seems to be making slow progress.

• There have been no issues around the booking system, but there has been an issue with appointments not being fulfilled.

• Parents must be made aware of the extended access for children which is available to them at the time of making an appointment.

• Patient groups are being encouraged to attend the Dacorum group meeting taking place on 26th November 2019.

• MD is concerned that there may be a potential loss of data during the Berkhamsted merger.

• The non-emergency transport service- this has been extended to 2021. PPI/93.2/19 Action: JW and AG will be attending the Primary Care Commissioning Committee meeting

and will raise extended access for children at the meeting. 93.3 Hertsmere

• Since the Hertsmere network meeting took place on 6 November 2019 it has come to light that HCT has transferred its Parkinson’s nurse to East & North Herts and CLCH has been unable to recruit a successor, meaning that patients in West Herts have no support between their consultant visits which occur at about 7 month intervals. It appears that practices are unaware of the situation. This has been passed to Hertsmere’s LCC and to the CCG for clarification and, if correct, for advice on what alternative arrangements are being put in place.

• The AGM and a health talk will take place on 25 November 2019. • A dementia awareness session will be taking place on 21 November 2019 and 28

people are signed up to attend. PPI/93.4/19 Action: Lynn Dalton will confirm that a mechanism in place for communicating important

service gaps or issues to GP practices. 93.5 St Albans & Harpenden

• Due the general election St Albans & Harpenden are not able to hold their meeting on 27 November 2019 and the next meeting will take place on 29 January 2020.

• There are still concerns about the lack of progress at the Harpenden Memorial Centre

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and no further updates have been issued. The Chair advised this has been noted by the committee and this matter is included in the committee work plan.

93.6 Watford & Three Rivers • CB attended an event that was run by Connect at Wolsey House, Hemel Hempstead –

entitled “Fit for Living, Fit for Life” which led CB to consider the relationships between Connect and some of the other organisations.

• In addition CB and DE are attending other locality meetings. • DE had a recent Connect experience and welcomed discussion from committee

members outside of the meeting. • DE requested that when meetings are cancelled that this is communicated promptly. • The committee thanked DE and CB for the work that they have carried out as patient

representatives. 93.7 The committee noted the reports PPI/94/19 Any other business 94.1 Elections

• The CCG is working around election restrictions which apply to any conversations that are controversial or sensitive.

• There may be items on the agenda today which may not be able to be covered as there are restrictions in place and this will be monitored throughout the meeting today.

• It was confirmed that there are no restrictions on NHS member of staff, and they can take part in political activity and therefore the members of the PPI committeecan also take part as individuals.

Management Leads

• It was requested that details of locality management leads are shared with committee members.

PPI/94.2/19 Action: RW to recirculate management leads to committee members. Closing Items PPI/95/19 Review of how conflicts of interest were managed in the meeting 95.1 • There were no new conflicts of interest declared at the meeting. Risks identified during the meeting 95.2 • The big risk to the committee is Purdah as discussed under item 94.1. Items for cascade to the organisation 95.3 • To ensure that practices are kept up to date and GP’s are kept up to date with local

developments. Date and time of next meeting: 22nd January 2020

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Meeting

:

Primary Care Commissioning Committee (PCCC) Part 2 held in public

Date : 10 December 2019 Time : 10.30am Venue

: Maylands Business Park, Hemel Hempstead, HP2 7ES

Present: Dr Elizabeth Eyitayo (EE) Executive Lead for Primary Care Development Dr Rami Eliad (RE) GP Board Member and Locality Chair – Watford and Three Rivers Dr Asif Faizy (AF) GP Board Member and Locality Chair – Watford and Three Rivers Alison Gardner (AG) Board Lay Member Kathryn Magson (KM) Chief Executive Officer Simon Pattison (SP) Head of Service, Integration Care and Commissioning Team Thelma Stober (TS) Board Lay Member (Chair of meeting) Nicholas Small (NS) GP Member (Hertsmere) and CCG Chair In attendance: Susie Barker (SB) Deputy Director of Nursing and Quality Michelle Campbell (MC) Assistant Director of Primary Care and Localities, HVCCG Lynn Dalton (LD) Director of Primary Care, HVCCG Tracey Norris HfL Governance team (minutes) Observers (Members of the public): None present PART 2: MATTERS TO BE CONSIDERED WITH THE PUBLIC AND PRESS PRESENT PC/158/19 Chair’s introduction and apologies for absence 158.1 Thelma Stober welcomed everyone to the meeting, in particular, Karen Livingstone to her

first meeting as CEO of the LMC. Apologies for absence had been received from Trevor Fernandez, Andrew Anderson,

Daniel Carlton-Conway and Diane Curbishley. Alison Gardner was feeling unwell and left the meeting (she had been present for the Part 1 section).

Nicholas Small and Simon Pattison were running late and would join the meeting at agenda item PCC/148/19

The meeting was quorate with 1 x lay member, 2 x executive voting members and 1 x non-conflicted clinician voting member.

There were no members of the public present. PC/159/19 Interests to declare 159.1 A schedule of interests declared in advance of the meeting was discussed and is attached

to the minutes as appendix 1. All Herts Valleys GPs were potentially conflicted for items PC/166/19 through to

PC/170/19 on the agenda and would take part in the discussion only. PC/160/19 Minutes of previous meeting (Chair) 160.1 The minutes of the meeting held on 21 November 2019 were reviewed and agreed as an

accurate record. The action log would be updated at the next meeting in January (today’s extraordinary

meeting had been put in the diary at short notice and only two weeks had passed since the

Final approved Minutes

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last meeting). 160.2 The Committee accepted the minutes as a true record of the meeting PC/161/19 Matters arising 161.1 Any matters arising from the previous meeting would be carried forward to the next meeting. PC/162/19 STP Primary Care Strategy Delivery Plan (Michelle Campbell) 162.1 MC referred the committee to the report at pages 12-27 of the document pack. This paper

was for information only and summarised the five pillars that created the STP PC strategy: An implementation plan would be brought to the next meeting for consideration. The team at CCG were trialling a new project management software and this would be

used to track milestones, KPIs and other deliverables. There was a narrative underpinning each of the five pillars which would enable STP

colleague to work collaboratively together. Progress of the delivery plan would be regularly reported to the PCC. In addition, NHS

England would expect to see evidence of implementation and delivery. 162.2 The committee noted the contents of the report. PC/163/19 GP Extended Access – proposed contract extension 163.1 In the absence of Sarah Ayub, Michelle Campbell presented this item and referred the

committee to the proposal at pages 28-52 of the document pack: Extended access was up and running in the Watford locality. The other three areas

(Dacorum, Hertsmere and St Albans and Harpenden) were in year two of a pilot. It was proposed that these three pilots be extended for another year to 31 March 2021 to

align with the implementation of commission extended access for Primary Care Networks from April 2021.

QA visits were made to each federation which included a review of policies and implementation procedures.

The QA visit report was attached as an appendix to the report (page 36 of the document pack).

Some actions had been identified from the QA visits and these had been worked up into an action plan with timelines.

Return visits were planned for January to ensure compliance (on target or completed). A risk matrix model would be completed by each team (items that were currently Amber

would be expected to move to Green). There had been pressure from NHS England for Watford to go out to competitive tender

again, but this approach had not been consistently applied by NHS England as other areas had extended existing contracts.

It was considered to be counterproductive to re-tender just a year before the PCN might take on responsibility for this service.

163.2 The following points were raised in discussion: Protected paediatric appointments had been agreed at the last meeting. Initial difficulties in Watford had been linked policy matters and it was suggested that the

policies now in place in Watford could be used as template for other areas. All present recognised that compliance to new policies was the hardest part – it was a new way of working for many.

IT governance was an issues and there was a general need for better support of the IT infrastructure.

Lessons learnt from the Watford experience should be applied to the other three areas. It was clarified at the meeting that there were options in each of the contracts to extend

by 12 months. The Committee wanted more assurances around the delivery of the service and

recommended that Ruth undertake a IG review. (This had already been completed but was

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not reflected in the paper). CQC compliance was a requirement in the contract but has not yet been achieved. The option of moving to an “uber-PCN” was considered, a cross-PCN provision. It was

acknowledged that dialogue was needed between PCN, CDs and federation prior to April 2021.

This programme should be linked to EERM to ensure that federations were maximising their resources. These work programmes complemented each other.

Need for improved signposting by GP receptionist. Delivery of extended access in the St Albans area was discussed. St Albans did not follow

the hub format although KM felt that the provision in St Albans was improving. Hertsmere divided the 52 hours between the seven practices (based on 30 minutes per

1000 patients). Q was there a minimum standard/expectation for cross-fertilization (patients being seen

at different surgeries)? Should the CCG demand that a Hub system or at the very least a rota system be part of the

contract specification? Not all patients were prepared to travel to another surgery for an appointment. Contracted hours varied depending on population size. Education of receptionist/admin staff was critical, there was a need for change

management support. Patients needed clear message/directions to the Hub. In Watford, practices rotated the location of the Hub. In Hemel there was a fixed Hub. Q Had enough QA been undertaken? Only one Hub visit had taken place in St Albans by

the QA team. NW suggested that all sites should be visited. LD confirmed that a rotating QA visit programme had been planned for. It was agreed that a fixed Hub model worked best and also complemented the 111 service. A clear strategy was needed for when the PCN started to delivery this. This was a

conversation to start now. GP members did not need to leave the room as they were both from the Watford area and

were therefore not conflicted.

163.3 The committee approved the expansion of the pilots by one year subject to the following: New KPIs in place re cross-fertilization (based on the Watford model). Share Watford extended access policies across other areas. Arrange QA visits in the first quarter, rotating around different Hubs. Achieve CQC Minimum delivery (by middle of 2020) should be at PCN footprint level.

163.4 The committee approved the contract extension of GP extended access subject to the recommendations in PCC/147.3/19 above.

PCC/164/19 Evaluation of Harpenden Anxiety Service for Young Children Pilot Project (Lynn Talbot) 164.1 Lynn Talbot joined the meeting and referred the committee to her report at pages 53-60 of

the document pack: A variety of practices had been able to propose pilot schemes last year and this report

evaluated the pilot of the Harpenden Anxiety Service for Teenagers and the Young (HASTY).

It was a 6 month pilot. The GP practice employed two private psychologists to treat patients.

It was felt that more appropriate triage could have filtered patients to different levels of mental health support.

The report did not recommend the roll out of this pilot. 164.2 The following points were raised in discussion:

Had the finding of the evaluation been shared with the GP who devised the pilot? Not yet. There was a lack of detailed information in the evaluation report – how much did it cost,

how many patients were seen, how many were referred to CAMHS?

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LT explained that the GP was unable to provide all the necessary data figures. The pilot cost £56,000 for 6 months. Patients were seen more quickly than through CAMHS which had waiting list of up to a

year for a psychologist appointment. Some quantitative data had been made available to LT (but had not been included in the

report). (Nicholas Small and Simon Pattison joined the meeting)

Appointments had been filled up quickly but psychologist did not undertake group sessions.

LT believed that better value for money could be provided by Thrive. TS wanted to know how patient need would be addressed if the pilot was not extended. EE asked if there had been clinical evaluation of the patient profile. Under the transformation plan it was hoped that the CAMHs service would be improved

and become more equitable. It was unclear from the evaluation report whether or not the aims of the pilot had been

achieved: Reduce A&E attendance and admissions Reduce crisis situations Reduce referrals to CAMHS Avoid long wait times Support a local and national strategy for managing mental health in children/young

people 164.3 The committee did not feel they had enough facts to make a decision to halt or roll out the

pilot and requested that: LT refresh the evaluation report including more data to address the KPIs Hold the GP to account to provide any missing data Defer the decision until January Share the evaluation findings with the GP

164.4 The committee agreed to defer the decision on the HASTY pilot until January 164.5 LT to re-visit evaluation report and re-submit to January meeting

PCC/165/19 Thrive Project Proposals 165.1 LT presented an evaluation of the Thrive project which had been running in St Albans from

April 2019. See pages 51-90 of the document pack: The recommendation was for a 6 month roll out across the CCG with a further evaluation

after 6 months. There was a low DNA rate and longer appointments were provided. This provided a more integrated service and gave GPs additional specialist training on

mental health conditions (eg suicide, anxiety and depression). It was making use of the extended access appointments based on a Hub model located in

one practice in St Albans (one session per week at Parkbury House). 165.2 The following points were raised in discussion:

EE confirmed that 70% of appointments were filled with a 6% DNA rate. The sessions were offered from 4-7pm and the practice had used £1.50 from the CCG to implement it.

There was confusion over why the practice was charging £1.50 if this was part of the extended access slots.

(ADDENDUM: Daniel Carlton Conway provided clarification around the £1.50 payment at the next PCC meeting held on 23 January; the £1.50 was transformation funding and due process had been carried out by the PCC in previous meetings to approve/sign off the payments). The THRIVE project had not been presented to the CCG as part of the extended access

discussion. It appeared as if the provider did this without informing the commissioner. The committee were confused about the funding, did the £1.50 come from

transformation money from last year? It became apparent during the discussion that this proposal needed to be deferred to

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allow time to clarify the funding positon and set up clear budget boundaries and project specification.

165.3 The committee agreed to defer the proposal until January. 165.4 LT would clarify funding and project specification and re-submit to January meeting PCC/166/19 Phlebotomy and Anti-Coagulation Service (Lynn Talbot) 166.1 EE summarised the phlebotomy and anti-coagulation service and referred the committee to

the report at pages 69-99 of the document pack which set out how the HVCCG would like to commission phlebotomy and anti-coagulation level 4 services at PCN level from July 2020 as detailed in the enhanced Commission Framework. This would be subject to: Finalising the approach and finances with WHHT by mid-January for a go-live date in July. The proposed tariff per contract was £1.70.

166.2 There following points were raised in discussion: Phlebotomy GP members felt that there was appetite to do this. The main issue was over collection

times of phlebotomy. The option of GP storing bloods overnight in centrifuges was not considered realistic due

to the onerous QA issue. The last pick up of 2pm was too early. There needed to be more flexibility. Ideally a lunchtime and 5pm pick up time was required.

The logistics of two pick-ups from 16 PCNs was considered. It was felt that this would be achievable as the current system serviced 2 pick-ups from 58 practices.

Was the blocker to this a collection issue or a reduced workforce in pathology after 6pm? It was expected that the pathology procurement service would likely result in a new

provider being selected. Would some practices hit the ceiling? This was unlikely. No one was near the cap

(Watford had the highest level at 38% - see table on page 5 of the report) WHHT want this service to be delivered at PC level. KM confirmed that there would be additional support and funding to enable PCNs to

delivery this service. Payments would be for the PCN to deliver the service (admin and minimal premises costs)

and would not be passed on to practices. TS recommended that the phrase “direction of travel” on the front page of the report be

changed to “intention”. Anti-Coagulation There was overlap between level 1 and level 4. Comments from the last clinical directors meeting had been taken on board. There had been a discussion around the delivery of service at PCN level if Warfarin levels

fall. See page 8 for numbers by practice and locality. 166.3 GP members (RE/AF/NS) left the meeting whilst the remaining committee members made

the following decision: There was variable appetite from PCNs to delivery this (most were positive, Dacorum was

delivering it already, St Albans did not support it). It was agreed that it should be pursued and the CCG would work with the practices that

delivery it to agree a pricing structure. Change should not be held back because some localities did not want to participate. The costs would have to come out of the Trust. This provision was part of the SOC and

should not be paid for twice. A formal proposal (with finalised costings) would be brought to the January meeting.

166.4 The committee approved the phlebotomy and anti-coagulation proposals subject to the conditions stated above in PCC/150.3 /19

166.5 The formal proposal would be brought back to the January meeting (RE/AF/NS re-joined the meeting )

PCC/167/19 GP Forward View – PCN development Programme

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167.1 MC referred the committee to the report at pages 100-106 of the document pack and summarised the proposal: Additional national funding had been received from NHS England in June 2019. The allocation process had been transparent and had been taken to clinical directors who

had supported the funding proposals: Each PCN would be allocated £15,000 (up from £8,500 in 2018/19) for practice-

wide events. This funding information should be shared with practices as well as PCNs.

167.2 The following points were raised in discussion: Bringing members of PCNs together was very important. Clinical directors might share information with GP leads but this did not always flow on to

staff. There was lots of barriers to information cascading to all staff. The GP bulletin was sent out weekly to GP practices but it was recognised that there was

a need to agree a better method of cascading information to staff with the LMC. It was suggested that the comms team could create an area on the intranet for PCN

information. 167.3 GP members (RE/AF/NS) left the meeting whilst the remaining committee members made the

following decision: The GP forward view was approved.

167.4 The committee approved the GP Forward View proposal (RE/AF/NS re-joined the meeting )

PCC/168/19 PCN – CCG Transformation Support Programme 168.1 MC referred the committee to the report at pages 107-115 of the document pack which

outlined the creation of a programme to support PCN development of CDs and practice managers to promote future succession planning: The funding for the programme would come from the CCG budget (it was a non-recurrent

spend). Additional project management support would be available to help the implementation

of the phlebotomy and anti-coagulation services. Funding would go to PCNs that were committing to delivering services.

168.2 The following points were raised in discussion: THRIVE would be taken out of the proposal (see decision to defer at agenda item

PC/165/19) A discussion followed on how the project management service should be divided

between phlebotomy and anti-coagulation services and it was agreed the project management service should support set up and mobilisation not admin.

A clear job description would be needed. The delivery mechanism of services could be specified at this point.

168.3 GP members (RE/AF/NS) left the meeting whilst the remaining committee members made the following decision: The OD development programme of £154,806 was approved. THRIVE would be deferred. The proposed allocation of £11,000 on venue and refreshments was not approved.

Spending on these items should be in line with CCG rules and guidelines. The 10% inflationary uplift would be removed. The repayment of training costs (if individual left the PCN) would be written into

contracts. The training budget was for existing clinical directors as well as for identifying/developing

potential successors. Project management time would be allocated as follows:

One day a week for phlebotomy One day a week for anti-coagulation

168.2 The committee approved the CCG transformation support programme subject to the conditions set out in 152.3 above.

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(RE/AF/NS re-joined the meeting ) PCC/169/19 Safeguarding Funding Options 169.1 MC referred the committee to the report at pages 116-123 of the document pack which sets

out a proposal for reimbursing GPs for completing Section 17 and Section 47 requests: The CCGs have been working with the LMC to agree a reasonable rate. Work was put on hold in September as it was understood that the East of England Region

wanted to roll this out at a regional level. This failed to happen. West Essex recommended a rate of £90 per hour in November. Discussions between HVCCG, East and North Herts and the LMC concluded that this was

an appropriate rate. Typically there were 400 Section 17 requested each month with 45 progressing on to

become a Section 47. The length of time it took to complete a Section 17 varied from 15 minutes to over 3

hours depending on the complexity of the individual and the amount of information requested.

This would be a pilot for 6 months and an audit would be made of completion times – the Local Authority would collect and share this data.

A pre-populated template was being developed. 169.2 The following was discussed:

Would this create a precedent for an hourly rate for a GP? The rate would be broken down into a rate of £15 per 10 minutes. GPs were required to complete and return a Section 17 in 24 hours - collecting data from

different sources (A&E attendance, prescribing, consultations etc). There was an opportunity for GPs to overstate the time it had taken them to complete

the forms. There would have to be an element of trust. 169.3 GP members (RE/AF/NS) left the meeting whilst the remaining committee members made the

following decision: The CCG would prefer the Region to take the lead on this and it was expected that they

would release guidance on a reasonable hourly rate later this month. The payment should have been in place from 1 November – but it was agreed that

payment would not be backdated. A rate of £15 per 10 minutes was agreed. Effective date would be when the comms were prepared (probably before Christmas).

169.4 The committee approve the rate of £15 per 10 minutes for GP to complete Section 17 and 47 forms

(RE/AF/NS re-joined the meeting ) PCC/170/19 Primary Care Mental Health Pilot Extension 170.1 Simon Pattison referred the committee to the report at pages 124-131 of the document pack

which requested the extension by a further 12 months to the mental health pilots in operation. This was required because the pilots had taken longer to staff and set up than originally planned: The pilots had been identified as part of last year’s mental health investment strategy. Evaluation of the pilots was not yet possible. There had been significant recruitment issues.

170.2 The following was discussed: GP members found the service to be good in parts but there was little flexibility to adapt

to the needs of the patients. The upper age limit on the 18-65 service was a barrier – it should be open-ended. The 6 month delay (due to recruitment issues) had been expected.

170.3 GP members (RE/AF/NS) left the meeting whilst the remaining committee members made the following decision: The proposed pilot extensions were agreed.

170.4 The committee approve the 12 month extensions to the pilots. (RE/AF/NS re-joined the meeting )

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PC/171/19 Review of how conflicts of interest were managed in the meeting (Chair) 171.1 The chair confirmed that conflicts had been managed when required. GP members had left

the meeting for the decision making process at items: PCC/166/19 PCC/167/19 PCC/168/19 PCC/169/19 PCC/170/19

PC/172/19 New risks identified (Chair) 172.1 Risk for mobilisation for anti-coagulation and phlebotomy PC/173/19 Items for cascade to localities and the organisation (Chair) 173.1 Phlebotomy

Anti-coagulation PC/174/19 Reflection on equality and diversity discussions in the meeting (Chair) 174.1 None raised.

Meeting ended at 5.45pm Date and time of next meeting (Chair) Thursday 23 January 2020, 1.30 – 5pm, Conference Room 2, The Forum

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Documents

Herts Valleys Clinical Commissioning Group...To ensure transparency and openness, individuals should notify the Chair of any potential conflicts of interest in relation to agenda items,