NHS Darlington Clinical Commissioning Group Governing Body ... · NHS Darlington Clinical Commissioning Group . Governing Body Meeting . 1. st December 2015 . Hackworth Room, Community

NHS Darlington Clinical Commissioning Group Governing Body Meeting

1st December 2015 Hackworth Room, Community Safety Centre, Park Place,

Darlington DL1 5LR

Time Item No. Item Attached or Verbal

Presented By

12:00 Welcome, Introductions and Apologies for absence

Verbal All

12:00 GB/15/57 Declaration of Interests

Verbal All

Pre–critique of the Governing Body Meeting to include identification of any other business items and to hear relevant representation from Members on items on this agenda and

commissioning responsibilities

12:00 GB/15/58 Minutes of the NHS Darlington Clinical Commissioning Group (CCG) Governing Body held on 15 September 2015 and GB Development Session on 13th October 2015

Attached Chair

12:05 GB/15/59 Matters Arising and Action Log

Attached Chair

12:10 GB/15/60 Chief Officer and Chair Report – September 2015

Attached Chair

12.20 GB/15/61 Patient and Public Involvement Verbal Michelle Thompson

Performance/Operational 12:25 GB/15/62 Finance Report – Month 7

Attached Lisa Tempest

12:35 GB/15/63 Clinical Quality Update

Attached Diane Murphy

12:45 GB/15/64 Performance Report – November 2015


Strategy and Planning 12.55 GB/15/65 Planning Round 2016/17


13.05 GB/15/66 Co-Commissioning of Primary Medical Services Attached Jackie Kay

13.15 GB/15/67 Approach to Planning and Development of Commissioning Intentions for 2016/17

Attached Jackie Kay

13.25 GB/15/68 Learning Disability Fast Track Update

Attached Diane Murphy

13.30 GB/15/69 Urgent Care Strategy 2015 - 20

Attached Jackie Kay

Governance/Assurance 13.40 GB/15/70 Securing Quality in Health Services

Attached Ali Wilson

13.50 GB/15/71 Risk Management December 2015


Items to note without discussion 13:55 GB/15/72 Confirmed Committee Minutes:

Formal Executive Committee – 8 September, 15 September, October Quality, Performance and Innovation Committee – August, September

Attached All

Finance Committee – August, September Governance, Audit and Risk Committee – July Community Council of Patients, Public and Carers – August

Questions from the Public – Members of the public may raise issues of general interest which relate to the Agenda

Post –critique of the Governing Body Meeting

Date and Time of Next Meeting: 1st March 2016 commencing at 12noon in Hackworth Room,

The Community Safety Centre, Park Place, Darlington DL1 5LR

“Representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity in which

would be prejudicial to the public interest (Section 1(2) of the Public Bodies Admissions to Meetings Act 1960)”

DARLINGTON CLINICAL COMMISSIONING GROUP GOVERNING BODY

Tuesday 15th September 2015

12noon – 2pm

The Pease Room, Community Safety Centre, Park Place, Darlington DL1 5LR

UNCONFIRMED MINUTES

Present: Andrea Jones (AJ) Clinical Chair Ali Wilson (AW) Interim Accountable Officer Lisa Tempest (LT) Interim Chief Finance/Operating Officer Richard Harker (RH) Clinical Quality Lead Michelle Thompson (MT) Lay Member – Patient and Public Involvement John Flook (JF) Lay Member – Governance Andie McKay (AM) Lay Member – Finance Angela Galloway (AG) Secondary Care Clinician Alison MacNaughton-Jones GP Representative In attendance: Jackie Kay (JK) Assistant Chief Officer Murray Rose (MR) Director of Commissioning, DBC Miriam Davidson (MD) Director of Public Health, DBC Ann Greenley (AG) Head of Clinical Quality, NECS Jenna McGuiness (JMc) HR Manager, NECS (Item No. 54) Glenda Lynn (GL) PA/Minute Taker

Action Welcome, Introductions and Apologies for Absence

The Chair of the Governing Body explained to those present that Martin Phillips, Chief Officer, Darlington CCG continues to be on sick leave and welcomed Ali Wilson, Chief Officer, Hartlepool and Stockton-on-Tees CCG who is acting as Interim Accountable Officer for Darlington CCG in Martin’s absence. In addition to her role as Chief Finance Officer, Lisa Tempest is also acting up into the role of Chief Operating Officer. The Chair and members of the Governing Body sent Martin Phillips their best wishes. Welcome was also extended to Alison MacNaughton-Jones.

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During the work of the Task and Finish Group, the need for additional clinical input into Governing Body had been identified. Alison, as Chair of Members Assembly had kindly agreed to fulfil the role. Angela Galloway, who has on an interim basis, been the Secondary Care Clinician representative on the Governing Body, for some time, has now been appointed into the role for a period of three years. Diane Murphy, though unable to attend the Governing Body meeting today, was welcomed into the role of Interim Chief Nurse for the CCG. Apologies for the meeting were received from Diane Murphy.

GB/15/39 Declarations of Interest/Register of Interests There were no declarations of interest for agenda items. For information, AW advised the Governing Body of a number of her interests,

• public sector directorship with Community Ventures (The LIFT company)

• Academic Health Science Network – Director • Ad Astra Academy (Member)

The Register of Interests will be updated to reflect this information. The Register of Interests can be seen on Darlington CCG website.

Pre-critique of the Governing Body meeting to include identification of any other business items and to hear relevant representation from Members on items on the agenda and commissioning responsibilities Governing Body was informed of the new layout of the agenda for the Governing Body meetings which will include this item in future.

GB/15/40 Minutes of the NHS Darlington Clinical Commissioning

Group (CCG) Governing Body held on 2 June 2015 The minutes of the meeting held on 2 June 2015 were accepted as a true record.

GB/15/41 Matters arising from the minutes of the Darlington CCG Governing Body held on 2 June 2015 and Action Log There were no matters arising from the minutes of the Governing Body meeting held on 2 June 2015. The action log was discussed and updated accordingly.

GB/15/42 Chair and Chief Officer Report – September 2015 The Governing Body considered a report that provided an

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update from the Chief Officer and the Chair. AW highlighted some of the areas within the report and provided updates since the production of the written report: 7.0 Contract Update – County Durham and Darlington NHS Foundation Trust Contract agreement and signature now completed. 8.1 Children and Young People’s Mental Health Transformation Programme

NHS England is developing a major service transformation programme to significantly reshape the way services for children and young people with mental health needs are commissioned and delivered across all agencies over the next five years. To take this piece of work forward, Christine Scollen, Senior Commissioning Support Officer, NECS has been signposted to Healthwatch for advice on making contact with children and young people who access these services in an attempt to collate information and identify any gaps in the service provision.

8.3 Vanguard Applications NHS England has announced eight new vanguards to

transform urgent and emergency care. The vanguards will change the way organisations work together to provide care in a more joined up way. A collaborative proposal had been submitted for the North East and was successful.

The Governing Body:

i) received the report ii) noted the updates and considered the issues

highlighted

GB/15/43 Community Council Governing Body considered this report, intended to update the Governing Body on the Community Council meetings since June 2015. The meeting in June included Jackie Kay, Darlington CCG Assistant Chief Officer introducing Ali Wilson, explaining to the Community Council the interim arrangements in place due to the extended sickness absence of Martin Phillips. JK explained that the membership of the Community Council is being reviewed , including the feedback mechanism.

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Following the cancellation of the July meeting, due to apologies received during the holiday season, the Community Council members received a presentation in August from Greg Burke regarding Community Pharmacies and the services they provide to complement GP services. Lisa Tempest presented the County Durham and Darlington Urgent Care Strategy 2015-2020 and members were asked to provide feedback on the strategy. Community Council Members were informed of the proposal to refresh the Community Council. Colleagues from NECS are working to produce a recruitment pack and a volunteer agreement pack. It is anticipated that this process will be concluded by January 2016. The Governing Body noted the report.

GB/15/44 Securing Quality in Health Services (SeQiHS) Governing Body was reminded that the SeQiHS programme was established to address the challenges health services face in ensuring that the best possible care is provided for local people by the application of evidence based clinical standards. SeQiHS is a multi-organisational programme of large-scale change. The vision is, to deliver in the region of 700 key clinical standards consistently across County Durham and the Tees Valley, so that the 1.2million population receive the highest standards of care and best possible outcomes within the resources available. Over the last two years work has taken place with clinical staff and independent experts to understand the challenges in detail and to deliver several pieces of preparatory work. The scope of the services include:

• Acute Surgery • Acute Medicine • Intensive Care • Acute Paediatrics, maternity and neonatology • A&E, minor injury, urgent care centres etc

North of England Commissioning Support (NECS) will provide the next phase of the programme support which will be delivered by a core dedicated programme support team. A Programme Director (Jon Tomlinson) has been appointed and began working on the programme on 7th September. The next phase of the programme will have dedicated support to deliver a number of outputs. A critical element will be the engagement of patients, the public

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and other stakeholders, including clinicians, in how the services will be shaped. It is expected that the first Stakeholder meeting will take place towards the end of September. The Governing body received the update.

GB/15/45 Finance Report – Month 4 Governing Body was asked to consider the report of the CCG’s financial position for the four months to 31 July 2015. At the end of July 2015, Darlington CCG reported a year-to-date surplus of £589k. This is in line with the forecast for the year which requires the CCG to deliver a surplus of £1.767m. The CCG is currently reporting a pressure of £714k on its mental health budget due to a number of high cost packages for care not provided as part of our existing contracts, having been put in place in recent months due to an increasing number of patients requiring specialist care. The CCG has a risk share arrangements in place with Tees, Esk and Wear Valley NHS Foundation Trust in respect of the overall mental health budget, plans are being developed to bring the spend back in line with the budget. As the CCG approaches year end it will be possible to evaluate how successful these plans have been. When asked by Governing Body about the financial risks detailed in the report, in particular the cost of void space LT explained that the CCG is responsible for the cost of void space and subsidy arrangements relating to NHS premises in Darlington which the CCG is currently required to fund under current NHS rules. Governing Body was made aware of the inclusion of an overview of QIPP schemes within the status report and informed that all schemes are currently on track to deliver planned savings. The Governing Body received the report.

GB/15/46 Clinical Quality Report – July 2015 The Governing Body considered a quality and performance report that provided an in depth review of the acute and community services providers. AG highlighted the following key points:

• The most recent data release of the NHS England Quality Dashboard for July 2015 shows that County Durham and Darlington Foundation Trust (CDDFT) are showing as a statistical outlier for Central Alerts and Diagnostics over 6 week waits and is below standard for A&E 4 hour waits,

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referral to treatment admitted and MRSA • South Tees Hospital Foundation Trust (STHFT) remains

a negative outlier for HSMR with a rate of 112.8 (previously 112.5). It is a negative outlier for weekend HSMR at 119.8, year to March 2015. NECS Business Intelligence team has identified issues with the accuracy of the Trust’s mortality data and has referred concerns to the Hospital Evaluation Data Team and the University of Birmingham for investigation.

• STHFT are also showing as a negative outlier for Clostridium Difficile, reporting four cases in July 2015, which brings them to 22/50 actual cases this year.

• STHFT continue to hold a Monitor risk rating score of 1 due to financial sustainability and a governance risk rating of red.

Nurse Revalidation Nurse revalidation comes into effect on 1st April 2016. All registered nurses are required to provide evidence they meet revalidation requirements. The CCG is on target and meeting its obligation in this regard. The Governing Body received the report and agreed that necessary actions were being taken forward to improve quality and experience for patients.

GB/15/47 Performance Report – Month 4 The Governing Body was informed of the CCG’s performance in respect of NHS Constitutional Standards. On a year to date basis Darlington CCG is currently achieving the following constitutional standards:

• Referral to Treatment within 18 weeks • No patient to wait for over 52 weeks for treatment • Ambulance category A response times (8 minutes) • No mixed sex accommodation breaches • Incidence of MRSA • Incidence of C-Diff • % of people followed up within 7 days of discharge from

inpatient psychiatric care. The Governing Body was informed that a number of standards are currently not being achieved:

• The CCG’s main provider of diagnostic tests, CDDFT have failed to achieve the target of 1% or less patients waiting for more than 6 weeks for 15 consecutive months. A number of measures have been put in place by the

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Trust to increase capacity, which has resulted in a reduction in the volume of delays and had been expected to report it has achieved the 1% target in August, however due to pressures in Endoscopy this was not the case.

• CDDFT have failed to achieve the target 95% of patients should spend no more than 4 hours waiting in A&E Unit. Planning is currently underway for winter to ensure that the Trust is able to manage activity surges.

• Ambulance handovers at A&E should not exceed 30 minutes. CDDFT are a regional outlier, though performance has improved during 2015.

• Although overall performance for North East Ambulance Service is above target for 19 minute response times, performance for Darlington is slightly below 95% on a year to date basis. The Trust continues to implement action plans to improve response times.

Governing Body was assured that the CCG continues to monitor the performance standards and receives weekly data from the Trust. The Governing Body received the report.

GB/15/48 Winter Debrief and Forward View Event Outcomes, Evaluation and Action Plan The Governing Body was informed that CCGs across the North East had requested that North of England Commissioning Support (NECS) organise the winter debrief and forward view event for 2015/16. The purpose of the event being to look back and learn lessons from the winter monitoring period of 2014/15 and identify areas of best practice and innovation to be progressed throughout coming months in readiness for winter 2015/16. The report and the event were used to inform local SRG planning for 2015/16. The Governing Body discussed some of the issues raised at the event and highlighted in the report. Delays in the discharge process causes significant pressures in the system. At the present time patients are free to choose the nursing home they are discharged into, causing delays if no beds are available. A number of suggestions were recorded, amongst which was a regional standard process, removing the patient/family choice initially should their choice require a delayed discharge, with a move possible when a bed in the home of choice becomes available. LT explained that much of what was discussed at the event is still to be confirmed. The Governing Body acknowledged receipt of the report.

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GB/15/49 Urgent Care Strategy 2015 – 2020

The Governing Body was informed that the Urgent Care Strategy has been developed by the County Durham and Darlington System Resilience Group, shaped by the standards encompassed within NHS England’s Planning Guidance, Everyone Counts 2015/16 to 2019/20, key national and local review of urgent and emergency care services, NHS England’s Five Year Forward View and the recently introduced Eight High Impact Interventions for urgent and emergency care. The Strategy sets out a joint vision and patient centred principles, together with whole systems solutions to achieving them. JK explained that this Strategy is brought to Governing Body in a near final format, having been to a recent Formal Executive meeting and also to Community Council. Though acknowledging that the Strategy does not specifically give detail of what the services will look like in Darlington, it is flexible enough to adapt. The Governing Body approved the Strategy in principle with devolved responsibility for future minor changes to the CCG Executive and colleagues in NECS.

GB/15/50 Director of Public Health – Annual Report The Director of Public Health presented to the Governing Body detail of the Director of Public Health Annual Report 2014/15. This is the second annual report since the transfer of public health to the local authority and has a theme of ‘Public Health a Shared Agenda. In the production of the report, MD explained that she had accessed a wide range of reports, in particular reports to the Scrutiny Committee. Key points within the presentation were:

• Life Expectancy – across the Borough there is a life expectancy gap of 12.4 year for men and 8.1 years for women

• Common Causes of Death and Health Inequalities – cancer, heart disease/stroke and lung and liver disease

• Highlights from Health Profiles - 20.4% of pregnant women smoking at the time of delivery

- 62.9% breast feeding initiation

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- reducing under 18 conception rates • Key Challenges

- Creating the environment and opportunities for people to live healthier lives

- Improving early detention of cancer through increased awareness and access and update of screening programmes

- Public sector financial challenges The Governing Body, thanked MD and noted the content of the presentation.

GB/15/51 Safeguarding Adults – Annual Report The Governing Body was advised of information highlights and key aspects of the strategic and development work undertaken by the Adult Safeguarding team on behalf of Darlington CCG, offering assurance to the Governing Body in relation to adult safeguarding, working within Darlington Local Authority multi-agency policy and procedures, and continues to develop safeguarding adult knowledge and awareness across staff and member practices. Over the past 12 months, the safeguarding adult team has followed a programme of work that has sort to strengthen a number of areas of business, discussed in more detail in the report:

• The lessons learnt from safeguarding concerns • Governance and assurance arrangements • Leadership and accountability • Effective systems and processes • Workforce knowledge and capability • Primary care engagement

In addition, the CCG has, in line with national recommendations, stipulated that all staff undertake mandatory adult safeguarding eLearning. 100% of CCG staff have completed the appropriate level of training. The Governing Body received the report and acknowledged the work undertaken by the safeguarding adults team.

GB/15/52 Safeguarding Vulnerable People in the NHS The Governing Body was informed that the purpose of this briefing was to provide an update on the key requirements of the CCG in relation to safeguarding, as outlined in the refreshed Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework (July 2015). A number of the key requirements within the compliance

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document were highlighted and considered by Governing Body:

• Leadership and Accountability – a clear line of accountability for safeguarding properly reflected in the CCG governance arrangements. Specific Action: The CCG is aware of the absence of a Named GP/Professional and have a plan to respond.

• Policies and Training – Safeguarding Children, Adults, Mental Capacity Act 2005 Policy is currently being updated via NECS and CCG

• Policies and Training – The CCG does not have a specific Managing Safeguarding allegations against CCG staff policy and procedure. Developmental NECS and HR action

• Prevention – Working with the local authority to enable access to community resources that can reduce social and physical isolation for adults. Specific Action: To monitor activity, both in relation to the SAB and CCG/LA commissioning discussions and decisions in order to respond as appropriately determined.

• Co-commissioning arrangements are being introduced from April 2015 and provide a number of different models for involving CCGs in the commissioning of primary care services. Specific Action – The CCG will implement co-commissioning arrangements in relation to safeguarding and Primary Care in accordance with an agreed MOU between the CCGs and NHSE.

The Governing Body noted the briefing document and endorsed the specific or developmental actions required.

GB/15/53 Risk Management The Governing Body was advised that the purpose of this paper was to provide an overview of the Darlington CCG risk register as of August 2015 and provide assurance to the Governing Body. Management of risk is a continual activity, which must be performed throughout the organisation. Without on-going and effective risk management processes it is not possible to give confidence that the organisation will meet its objectives. Two risks have been escalated to red since the last Governing Body meeting: Risk 1354 – Quality of Care in Care Homes – concerns identified by the Care Quality Commission and Safeguarding team relating to the quality of care provided to patients in a care home in

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Darlington Risk 845 – A&E Handovers. The CCGs main provider continues to be a regional outlier in respect of A&E handover delays causing delay in clinical assessment and treatment of patients. Risk 1101 – Premises Costs and Risk 1023 – Diagnostic Tests remain on the risk register as a red risk. On 1 September a new risk was identified following a fire at Carmel Medical practice which has left the practice unable to provide services from this location for up to six months. The CCG is working with the practice to identify alternative premises, who are at the moment working out of Doctor Piper House. Consideration is being given to the possibility of moving staff to Hundens Lane. AJ extended the thanks of the Governing Body to LT for the work she and NECS colleagues, particularly IT staff, had input to help Carmel staff at this difficult time. The Governing Body noted the content of the report and the progress made in terms of managing the risks rated as extreme.

GB/15/54 HR Annual Report HR provided the Governing Body with a report in relation to HR activity during the course of the financial year. Governing Body discussed the content of the report, referring to the need for consistency on the reporting of contract arrangements and being mindful of the organisational development work recently undertaken and the impact should a member of the organisation leave. The Governing Body noted the report was for information only.

GB/15/55 Summary of Complaints Activity 1 April 2014 – 31 March 2015 The Governing Body was informed that this report provides a summary of service improvements identified as a result of complaint investigations and of the continuous improvement developments within the complaints handling process, along with a summary of complaints and concerns handled by the NECS Complaints team on behalf of the CCG during the period 1 April 2014 to 31 March 2015. The NECS Complaints Team handled a total of 546 cases during the reporting period, 20 of which were from Darlington CCG residents. In 13 cases, the investigation/response was led by the CCG, the remainder were passed to provider organisations for action. Four of the CCG cases were handled

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under the NHS complaints procedure as formal complaints, 8 were resolved as informal concerns/advice/MP enquiries. All cases were acknowledged by the NECS Complaints Team within the target timescale of three working days. Ten of the thirteen cases, led by the CCG related to the commissioning of musculo-skeletal and physiotherapy services. MT asked about the collating of soft intelligence, a significant amount of which goes to Healthwatch. AG acknowledged the usefulness of local information. The Governing Body noted the content of the report.

GB/15/56 Confirmed Committee Minutes The Governing Body received minutes from its Committees • Formal Executive Committee – May, June 2015

• Quality and Performance Innovation Committee – May, June,

July 2015 • Finance Committee – April, June, July 2015

• Governance, Audit and Risk Committee – May 2015

• Community Council of Patients, Public and Carers – May,

June 2015

GB/15/57 Any Other Business No other business was discussed.

Questions from the Public – Members of the public may raise issues of general interest which relate to the agenda

No members of the public attended the Governing Body meeting. Post-critique of the Governing Body Meeting AW thanked those attending the meeting. The level of informality and provided a platform for debate and challenge. Date and time of next meeting

The next meeting will be held on Tuesday 1 December 2015 in Pease, Community Safety Centre, Park Place, Darlington DL1 5LR commencing at 12noon.

Signed………………. Chair.………………….

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Date……………………

DARLINGTON CLINICAL COMMISSIONING GROUP GOVERNING BODY DEVELOPMENT SESSION

Tuesday 13 October 2015

12noon – 2pm

Board Room, Doctor Piper House

UNCONFIRMED MINUTES

Present: Andrea Jones (AJ) Clinical Chair Ali Wilson (AW) Interim Accountable Officer Lisa Tempest (LT) Interim Chief Finance/Operating Officer Richard Harker (RH) Clinical Quality Lead Michelle Thompson (MT) Lay Member – Patient and Public Involvement John Flook (JF) Lay Member – Governance Andy Mackay Lay Member - Finance Alison MacNaughton-Jones GP Representative Diane Murphy Interim Chief Nurse In attendance: Miriam Davidson (MD) Director of Public Health, DBC Andrew Stainer (AS) Head of Transformation (Item 2) Julie Young (JL) Snr Commissioning Support Officer (Item 2) Glenda Lynn (GL) PA/Minute Taker

Item No. Action 1. Apologies for Absence

Jackie Kay

2. Children and Young People Mental Health and Wellbeing Plan The Governing Body was informed of the development of the plan in line with the national ambition and principles set out in Future in Mind – Promoting, protecting and improving our children and young people’s mental health and wellbeing (2015). The report establishes a clear consensus about how to make it easier for children and young people to access high quality mental health care when they need it. As Darlington CCG is the lead commissioner, the Governing Body is required to support the ongoing development plan and assign delegated authority for CCG endorsement prior to submission to

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NHS England. The Darlington Transformation plan sets out the Five-year Children and Young Peoples Mental Health and Wellbeing Plan for Darlington, in line with the national ambition and principles set out in Future in Mind – Promoting, protecting and improving our children and young people’s mental health and wellbeing.

A requirement of Future in Mind is for areas to develop a local plan focused on improving access to help and support when needed and improve how children and young people’s mental health services are organised, commissioned and provided.

In response, the Darlington Children and Young People’s Mental Health and Wellbeing Plan 2015-20 has been developed; building on the foundations of the previous work.

The plan is based on local interpretation of the themes and principles within Future in Mind. Specific objectives are detailed below:

• Prevention, resilience and early identification • Improving access – system with no tears • Care for the most vulnerable • Accountability and transparency • Workforce

A communication and engagement strategy will be developed to support implementation of this plan, which will include children and young people. The Governing Body considered the detail of the report and action plan. Governing Body was reminded that this is a five year plan. Though there are some ‘must does’ for the first year there are a number of phases across the five year period. The Governing Body:

• noted the content of the report; • acknowledged that the Transformation Plan is a living

document, • and granted delegated authority to Darlington CCG Chief

Officer / Finance Officer to endorse the plan and propose spend against the funding allocation to enable submission to progress.

3. Primary Care Commissioning Level 3 Delegation

The Governing Body was informed that NHS England has now invited CCGs who do not have delegated arrangements for the commissioning of primary medical services to apply for delegated

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responsibilities. The deadline for this application being 6 November 2015. On 1 April 2015 the CCG assumed joint responsibility with NHS England for the commissioning of primary care and a Joint Committee was established along with a Joint Operational Group. Governing Body was reminded of the differences between the current joint commissioning arrangements and those to be considered when agreeing to delegated responsibilities along with the benefits and opportunities open to the CCG. Delegated commissioning devolves control from the centre via NHS England to the local CCG level. It will essentially give the CCG and member practices an opportunity to shape the vision for, and develop the future of primary care as part of the wider Darlington 2020 vision and plans for transforming pathways of care. The CCG Executive have previously considered this at a meeting on 6 October and concluded that it was timely and appropriate for the CCG to submit for level 3 delegation. Governing Body was informed that this would also be discussed at Members Assembly on Thursday 15 October. Governing Body noted the issues and benefits, together with the potential risks. Subject to a majority agreement from Members Assembly on 15 October, Governing Body agreed the recommendation to apply for delegated commissioning to commence on 1 April 2016 with delegated authority to be given to the CCG Interim Accountable Officer and Assistant Chief Officer to prepare and submit the necessary application to NHS England by 6 November 2015.

Date and time of next meeting The next meeting public Governing Body meeting will be held on Tuesday 1 December 2015 in The Hackworth Room, Community Safety Centre, Park Place, Darlington DL1 5LR commencing at 12noon.

Signed………………. Chair: Andrea Jones Date……………………

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Governing Body

1st December 2015 Action Log

No Date of

meeting agreed

Action Responsible officer

Agreed completion

date

Progress Outcome

1. 02.06.15 CCG Assurance Quarter 3 14/15 Governing Body was advised of a change of methodology to assurance assessments. LT agreed to enquire and circulate information to Governing Body members regarding the position nationally.

LT Following the meeting

LT had discussed with NHS England and has assurance of consistency across all CCGs. AW advised she is aware that NHS England are considering the involvement of lay members for each CCG, again for a consistent approach.

2. 15.09.15 Safeguarding and Looked After Children Annual Report 2014-2015 Governing Body expressed concern at the poor achievement of initial health assessments timescales, recognising that this is a multi-agency issue which needs to be addressed by all concerned. AJ agreed that a letter be sent to the Safeguarding

AJ A letter of concern had been sent to the Safeguarding Board. No reply has yet been received though it is recognised that the Board has not met again since the letter was sent.

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No Date of meeting agreed

Action Responsible officer

Agreed completion

date

Progress Outcome

Board on behalf of the Governing Body to formally record the concerns raised.

NHS Darlington Clinical Commissioning Group

Governing Body

Agenda Item: 60

1st December 2015

Title Chief Officer and Chair Report

Purpose Approval ☐ Discussion ☒ Information ☒

Category

Strategy &

Planning ☒

Performance &

Operational ☒

Governance &

Assurance ☒

Responsible Portfolio Lead

Ali Wilson and Andrea Jones

Clinical Sponsor

Andrea Jones

Author of Report Jackie Kay

Recommendation(s) The NHS Darlington Clinical Commissioning Governing Body is

asked to:

• receive the report • note the updates and consider the issues highlighted

Executive Summary

This report provides a brief update for the Governing Body of NHS Darlington Clinical Commissioning Group (CCG) covering the period from the last report to Governing Body in September 2015 to date. The report covers a breath of business from key assurance and governance items; clinical pathway initiatives and engagement activities as well as key National developments.

Clinical Engagement

N/A

Does this report provide evidence of assurance for the Assurance Framework and / or mitigate risk included on the CCG’s Risk Register?

Yes- It is essential that the Governing Body is kept up to date with local and national initiatives. The report covers a wide range of business of the organisation some of which is identified as part of the CCG’s risk and assurance framework and areas contained within the risk register.

Has an Equality Analysis been

N/A

completed?

Attachments Appendix One- NHS England Clinical Commissioning Group Annual Assurance 2014/15 Appendix Two – NHS England Assurance Letter CAMHS transformational plan

CCG strategic objectives supported by this report

Objective Domain Tick

1. Well-led Organisation To be well-led and governed ensuring continuous development of the CCG

☒

2.

Delegated Functions Delivery of the CCG’s delegated functions including joint commissioning of primary care and GPIT, whilst exploring and preparing for further opportunities

☒

3.

Financial Management Delivery of financial balance including the 1% surplus, value for money and efficiencies to enable the CCG to reinvest to deliver our strategic plans

☒

4. Performance Ensuring measurable improvement of the quality and safety of the services that we commission

☒

5.

Planning Identify commissioning opportunities and working in collaboration with partners, including Local Health and care providers and the voluntary sector to improve the health and wellbeing of patients and communities and to reduce health inequalities.

Delivery of innovative and new models of care

To demonstrate system leadership across the health and social care economy

☒

Other Committees/Meetings where this report has been presented

N/A

Does this need to be reported to another Committee/Meeting?

N/A

NHS DARLINGTON CLINICAL COMMISSIONING GROUP GOVERNING BODY CHAIR/CHIEF OFFICERS REPORT – December 2015

1.0 Governance Issues 1.1 CCG Assurance Summary 2014/15

Formal written feedback has now been received from NHS England for 2014/2015 assurance. The overall assurance category for the CCG following the local Quarter 4 review and completion of the regional/national moderation process is assured with support. In the letter NHS England congratulate the CCG on the progress and achievements made over the last year and formally thanked the team for the “open and constructive dialogue”. Assessment against the individual domains is noted below with the full letter from NHS England attached in Appendix One

In accordance with the CCG’s accountabilities to our members and the public the assurance letter has been published on the CCG website and noted as part of the Governing Body meeting on 01 December 2015.

1.2 CCG Assurance Framework 2015/16

The new assurance framework introduces a continuous assurance process that aims to provide confidence that CCGs are operating effectively. This replaces the previous requirement for an assurance meeting to be held each quarter whereby contact with the CCGs should be proportionate and add value. The Q1 assurance meeting was held between NHS England and the CCG in June 2015 in order to determine (new) domain baselines. The outcome of the assessment is currently going through the national consistency check and written feedback is awaited, once received this will be shared with the Governing Body at the earliest opportunity.

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1.3 Financial Control Environment Assessment

In November 2015, the CCG received feedback on the financial control environment assessment submitted by all CCGs. Nationally; there are four areas that require attention for the majority of CCGs - long term planning, in-year financial performance, level of net risk and commissioning support service provision. The CCG assessed itself as good or excellent for all of these areas.

NHS England, as part of the ongoing work on financial resilience we will be making these areas of specific focus. They will be looking for those CCGs that demonstrate a high level of control in these areas to act as exemplars for others. The assessments have also been used alongside other financial metrics and local intelligence to identify CCGs that are potentially at risk of failing to meet their financial plan for the year.

There will be follow up action that, having undertaken the assessment and identified actions to improve financial processes and controls, these actions are followed up. Audit Chairs are asked to ensure that this happens with oversight by the Audit Committee. Also regional teams are to put in place appropriate monitoring arrangements and will be required to provide regular progress updates. CCGs are encouraged to undertake another self-assessment in the next few months to gauge progress and NHS England are developing plans for future follow-up on a national basis.

2.0 Stakeholder Engagement 2.1 Darlington 2020 Vision – Shaping the priority deliverables

Recent progress and engagement has included a well-attended event held on 3 November 2015 for clinicians and practitioners from a range of organisations alongside voluntary and community sector colleagues to further shape and design the first six priority areas (Self-Management, Social prescribing, Frail Elderly MDT, Long Term Conditions, High Impact Users and Care Hubs) in the Vision 2020 programme. The detail captured from the event has been built into deliverable summaries, which are now becoming full descriptions of what each priority area looks like, how it’s going to delivered, by whom and at what risk. The next key stage of input will be from corporate enablers – finance, workforce, estates – to establish the degree to which existing plans and fixed points can be aligned with Vision 2020 or where they need to be taken account of in scheduling.

3.0 Delivery Plan including Clinical Pathway work and Planning Round 2016/17

One of the recommendations from the task group of the Members Assembly was to complete a refresh of priorities within the current CCG delivery plan. This has now been concluded by the operations and delivery group reducing the number of schemes from over eighty plus down to thirty seven schemes. These priority schemes will now feed into the planning round and development of commissioning intentions for 2016/2017. Updates will be provided to the Governing Body over the coming months as the work progresses.

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On 19 November the early work in developing commissioning intentions and refresh of priorities was shared with a wide range of lead clinicians from the CCG. The aim of the session was to reconnect the group with the CCG’s clinical priorities and plans and seek approval for the arrangement of priorities into 4 key work streams namely:-

• Children and young people and families; • Mental Health and Wellbeing; • Hospital care; • Outside of Hospital Care;

Clinicians have now been asked for expressions of interest for workstream clinical lead roles in order to take this forward at pace. In order to make best use of clinical expertise and release capacity for clinicians to lead pathway development work, it was also proposed to restructure the membership of three of the formal committees whereby one GP and one practice manager will form part of both the Finance Committee and the Quality, Performance and Innovation Committee. It was also proposed that one additional GP joins the Governance, Auditand Risk Committee. These proposals were supported by the group and expressions of interest requested. It is anticipated that the new arrangements and workstreams will “go live” by February 2016.

4.0 Focus on Cancer Services in Darlington

The CCG have been able to secure support and funding for two posts in order to ensure there is a clear focus on cancer strategy and cancer performance for Darlington. MacMillan have provided fundiing for two year’s funding for a cancer project manager. We look forward to Dave Chapman joining the CCG team on 4 January 2016. As project manager he will be working closely with Dr James Carlton who has recently redefined his role with the CCG working 2 sessions per week as GP lead for cancer and also covering adult safeguarding responsibilities. We appreciate the ongoing positive relationship with MacMillan and look forward to future developments from these two key appointments.

5.0 Darlington Children and Young People’s Mental Health and Wellbeing Plan

The Governing Body agreed the final transformation plan at its meeting in October in time for submission to NHS England on 16 October 2015. There were three possible outcomes of the assurance process: “Assured”, “Assured with recommendations” and “Resubmission required”. The CCG has now received confirmation that the plan is Assured (see Appendix Two). This assurance rating means that the funding to support transformation will be released in line with national guidance and directly invested in to Children and Young People Mental Health Services in Darlington. Furthermore the Review Panel commented that the Darlington plan was a very strong submission standing out over and above other plans across Cumbria and the North East. As such the Darlington

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plan was identified as an “exemplar plan” and with CCG agreement will be shared with the national NHS England team. The CCG wish to extend thanks to all those who contributed to developing what is a complex, multiagency transformational plan and securing this very positive outcome under such immense pressure on timescales.

6.0 Commissioning Standards Integrated Urgent Care

In July 2015 the CCG received a letter regarding the commissioning of a functionally integrated 24/7 urgent clinical assessment, advice and treatment service. In October the Commissioning Standards were published. The standards bring together NHS 111, GP out-of-hours and clinical advice under a single commissioning framework. They are intended to support commissioners to deliver the transformation of urgent care services as set out in Sir Bruce Keogh’s Urgent and Emergency Care Review and more recently the Five Year Forward View.

The Standards have been developed following widespread engagement through a variety of routes with a range of stakeholders, which have included the Urgent and Emergency Care Review roadshow events undertaken over the summer months with commissioners and providers. The standards are built on evidence and what is known to be best practice. Elements of the standards will be aspirational at present; however it is envisaged that as Integrated Urgent Care services evolve and become established then the standards will be further enhanced and revised on an annual basis.

To access the Commissioning Standards please click on the following link http://www.england.nhs.uk/wp-content/uploads/2015/10/integrtd-urgnt-care-comms-standrds-oct15.pdf.

The CCG will use these standards to assure that our local plans for urgent care meet these standards and are captured in the planning round together with assuring the areas the CCGs are responsible for are managed and achieved.

7.0 Quality and Safeguarding 7.1 Named GP for Childrens Safeguarding

Currently the CCG has a recognised gap in the role of a named GP for Safeguarding Children. The Chief Nurse and GP Quality Lead are exploring ways to cover the responsibilities. The named nurse for safeguarding children is mitigating any potential risk in the interim.

7.2 Designated Medical Officer for Special Educational Needs

Work is underway to appoint a designated medical officer (DMO) for children with special educational needs. The national guidance describes a skills set consistent with those of a consultant paediatrician. This newly described role is in the context

http://www.england.nhs.uk/wp-content/uploads/2015/10/integrtd-urgnt-care-comms-standrds-oct15.pdf

http://www.england.nhs.uk/wp-content/uploads/2015/10/integrtd-urgnt-care-comms-standrds-oct15.pdf

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of the SEN standards and a recommendation of Ofsted. The DMO role is to be followed up via NECS provider management team to secure the post across County Durham and Darlington.

8.0 NHS Commissioning Leaders 2015

On 12 November 2015, the Interim Accountable Officer and Chair attended the NHS commissioning leaders event. The event was for commissioning system leaders to work in partnership on current challenges and priorities, through: • roundtable discussions, led by CCGs/NHS England covering key areas such

as transforming specialised services, the commissioning strategy 2020 and finance

• opportunities to influence the development of new and emerging areas of work, including implementing the cancer strategy and transforming urgent and emergency care

• question and answer sessions with key speakers, including Simon Stevens, Chief Executive of NHS England

• the chance to network, learn from others and share experiences

The event was well attended by CCG colleagues across the country and provided an opportunity to learn from others and also share our CCG’s priorities and experiences.

9.0 Local Digital Roadmap

Each CCG had to complete a template to inform NHS England what the footprint will be for the Local Digital Roadmap and the Governance that will support it by 30 October 2015. For Darlington CCG the agreed footprint includes Durham Dales, Sedgefield and Easington CCG, North Durham CCG, Darlington Borough Council and Durham County Council, County Durham and Darlington NHS Foundation Trust, Tees, Esk & Wear Valley NHS Foundation Trust, North of England Commissioning Support and the 11 GP Practices within Darlington CCG. The footprint and partners are considered appropriate as all organisations are currently working together to support the Better Care Fund implementation. The CCG’s objective is an integrated approach to enable the sharing of information digitally across both Health and Social Care. It has been agreed that during implementation further discussions will be undertaken to ensure collaboration, sharing information and best practice to develop a wider scale plan with the eventuality of a large scale roadmap. The Darlington Unit of Planning will develop and implement the digital roadmap with the CCG Governing Body approving the final submission. The Darlington Health and Wellbeing Board will receive the Local Digital Roadmap prior to submission in April 2016.

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10.0 National Developments 10.1 Consultation on the Government's mandate to NHS England to 2020

The mandate to NHS England sets the government’s objectives for NHS England, as well as its budget. In doing so, the mandate sets direction for the NHS, and helps ensure the NHS is accountable to Parliament and the public. A new mandate to NHS England is due to be published following the completion of the Spending Review, to take effect from April 2016. The consultation document sets out how the government proposes to set the mandate to NHS England for this Parliament. The final mandate will be subject to the outcome of the government’s Spending Review, due to be published on 25 November 2015.

10.2 Building the Right Support

Building the right support: A national implementation plan to develop community services and close inpatient facilities was published on Friday 30 October by NHS England, the Local Government Association (LGA), and the Association of Directors of Adult Social Services (ADASS). The plans it contains have been developed with significant contribution and constructive challenge from people with learning disabilities and/or autism, their families and carers, and a range of commissioners, providers, voluntary sector and representative groups.

It represents a key milestone in the ongoing cross-system Transforming Care programme, which has seen a number of reforms including the roll out of Care and Treatment Reviews and an upcoming consultation response on strengthening the rights of individuals.

While local areas will be able to design bespoke services with those who use them, the plan sets out the need for:

• local housing that meets the specific needs of this group of people, such as schemes where people have their own home but ready access to on-site support staff;

• a rapid and ambitious expansion of the use of personal budgets, enabling people and their families to plan their own care, beyond those who already have a legal right to them;

• people to have access to a local care and support navigator or key worker, and;

• investment in advocacy services run by local charities and voluntary organisations so that people and their families can access independent support and advice

10.3 Evaluation highlights areas for improvement in long term conditions care

An ethnographic evaluation carried out by the Ipsos Ethnography Centre of Excellence (ECE) – part of Ipsos MORI – has found that older people living with multiple long term conditions are generally happy with the NHS but often find the health and care system is not set up for their needs. The ethnographic evaluation is

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an in depth approach to understanding people and their behaviours over a period of time.

The key findings include:

• People greatly value the care and support they receive from the NHS and the wider health and care sector, and in the main feel the care they receive is good.

• People are trying hard to manage their long term conditions to the best of their abilities, but often feel the system is not set up to cope with their multiple and complex needs.

• People with more than one long term condition struggle to coordinate them all. They can feel there is no support linking all of their conditions and focusing on them personally and holistically.

• People with long term conditions want to have everyday achievable goals and support that fit realistically within their everyday lives.

• People can feel that they are a burden within their home as well as within the health and care system, which can prevent them seeking the help and support they need.

• Too often, there is an absence of discussion about care and care needs, within the home and within the health care system.

Similar issues have been highlighted during consultation work locally and the 2020 Vision implementation plans will seek to address these concerns.

10.4 Planning, assuring and delivering service change for patients

Published by NHS England on 01 November 2015, this guidance sets out the required assurance process commissioners follow when conducting service reconfiguration. Its purpose is to provide support and assurance to ensure reconfiguration can progress, with due consideration for the four tests of service change which the government mandate requires NHS England to test against. It also covers the agreed levels of assurance and decision making required for significant service change which the NHS England board ratified in May 2015; key themes of service reconfiguration; and the assurance process.

There is no change to any of the detail supplied in this guidance’s predecessor ‘Planning and delivering service change for patients’. This revision is designed to clarify the assurance process required and introduce the new assurance and decision making levels. Some service changes may not be the result of a location specific reconfiguration, but may consider a single service or inter-dependent range of services across a wide geography. Service change such as those will fulfil the principles set out in this guide, through there will be slightly different processes affecting the sequence and timing of consultations, to comply with legal regulations which apply to these types of changes. Service changes may also be whole system based and work across social and health care. Consideration must be given to additional processes and assurances required within partner organisations. The guidance is designed for and

8

applicable to service change and reconfiguration occurring within the NHS environment. 62 day referral to treatment standard at a National level was consistently below the required 85% at national level. Waiting times have a very direct link with the quality of service provided. It is expected that the remit of System Resilience Group (SRG) will be explicitly expanded to cover the 62 day cancer standard given the need to drive better and sustained performance. This document is a helpful reminder of the required processes to achieve the system transformation currently underway as part of the Darlington 2020 Vision and the Better Health Services (SeQiHS) programme.

Ali Wilson Interim Accountable Officer Andrea Jones Chair Date: 20 November 2015

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7 October 2015

Dear Ali

Clinical Commissioning Group Annual Assurance 2014/15

Many thanks for meeting with us on 29th June 2015 to discuss the annual assessment of Darlington Clinical Commissioning Group (CCG), and establish the actions and development priorities for the coming year. This letter is a summary of the assurance meetings that we have held over the last year and provides a synopsis of the improvements and ambitions for future development laid out against the assurance domains. This is the final review using the six domains. Subsequent assurance meetings will be held on the basis of the new assurance framework with its five components: well led organisation, delegated functions, performance & outcomes, financial management and planning.

I am grateful to you and your team for the work you had done to prepare for the meeting and the open and transparent nature of our dialogue which has led to productive discussions. This letter sets out the key points we covered in the discussion outlined above.

Key Areas of Strength / Areas of Good Practice We would like to acknowledge the overall progress the CCG has made to date with the ongoing establishment of the organisation and in addressing local issues and challenges. The work in relation to major strategic and service transformation is complex and challenging. We recognise the progress made by the CCG which has resulted in some very tangible outcomes for patients. These achievements include a 1.9% reduction in non-elective activity, the delivery of a discharge target of 50% for patients with learning disabilities without a discharge plan and the delivery of a new eye service.

You have detailed the support that you have been receiving from the North of England Commissioning Support Unit (NECS) including progress through quarter 4 and into quarter 1 2015/16 on the commissioning of support services for 2016/17 and potential use of the Lead Provider Framework.

Alison Wilson Chief Officer (Interim) Darlington Clinical Commissioning Group Dr Piper House King Street Darlington DL3 6JL

NHS England - Cumbria and North East

Waterfront 4 Newburn Riverside

Newcastle upon Tyne NE15 8NY

Email address – [email protected]

Telephone Number – 0113 825 1507

mailto:[email protected]

2

The CCG has made good progress during 2014/15 for example with the evolving strategic partnership with Darlington Borough Council, the implementation of the Better Care Fund schemes; and the work linked to the Regional Back Pain Pathway. Positive references were also made to the ‘Primary Healthcare Darlington’ work undertaken as a result of the Prime Minister’s Challenge Fund, as well as continuation of positive patient and public engagement.

The CCG has, clear emphasis on organisational development demonstrated in the recent refresh of Darlington Clinical Commissioning Group’s (CCG) organisation development plan and associated action plan for identified priorities.

Action: CCG to maintain progress with initiatives for the community.

NHS Constitution Standards Key indicators within the NHS England delivery dashboard have shown some improvements throughout the year, for example in ambulance response times. However there are still ongoing challenges in delivery of some NHS Constitutional Standards notably accident and emergency waiting times, diagnostics, and cancer waits (including 2 week breast, 31 day surgery and 62 day waits).

Some quality issues continue to prove a challenge locally e.g. 12 hour breaches and healthcare associated infections (HCAI).

A framework is needed to focus on quality and performance issues and activity management; this should also include financial control.

Action: CCG to focus on key performance and quality priorities and meet constitutional standards.

Action: Framework to be developed and shared with NHS England by the end August.

Five Year Forward View During the year we have discussed the CCG’s vision for primary and out-of hospital care along with geographic and patient flow. The CCG needs to adapt its local strategy to incorporate the Five Year Forward View into a clear long term plan and we are expecting to see timescales by which this will be shared for discussion. We acknowledge the development within primary care though there is a need to bring this together into a collective sense of overall direction.

Action: CCG to translate local strategy into a clear long term plan.

Action: CCG to develop a vision for primary care by December 2015.

NHS Statutory Duties We have received your annual report and accounts and through these reports are assured that the CCG is meeting all of its statutory duties.

Discussions throughout the year have demonstrated the focus and action taken within the CCG on addressing parity of esteem, which has seen significant improvements for the local population.

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The CCG has demonstrated a financial commitment to mental health and learning disabilities. The approach is evidenced in the range of commissioned mental health liaison services working in acute hospitals, community services and care homes to ensure that people with concurrent mental health problems are able to access services appropriately. In addition Darlington CCG is currently undertaking a benchmarking exercise to understand how the level of investment in mental health compares to other areas.

Significant time and effort has been invested into collaboration to develop partnership arrangements, notably with Darlington Borough Council and good progress has been made.

Action: CCG to maintain and enhance relationships with partners.

Emergency Preparedness, Resilience and Response (EPRR) I would like to take this opportunity to thank you for your commitment to the work of the Local Health Resilience Partnership in the past year and in particular the undertaking of the on-call provision, a major component of your role as a Category 2 Responder as defined in the Civil Contingencies Act.

You may recall in her letter of the 20th May 2015, the NHS England National Director of NHS Operations and Delivery, set out the expectations for the 2015-16 EPRR assurance process which NHS England will use in order to be assured that NHS England and the NHS in England are prepared to respond to an emergency and has resilience in relation to continuing to provide safe patient care. As in the 2014 – 15 assurance process, this year’s self-assessment against the NHS England core-standards is a fundamental element of how your CCG is prepared to respond to an emergency and I would wish to thank you in advance of the October submission date for your support in undertaking this vital piece of work.

Key Areas of Challenge The CCG has outlined key areas of challenge for the year ahead, including delivering the necessary efficiencies and maintaining the constitutional standards given competing pressures. A more productive relationship with County Durham and Darlington NHS Foundation Trust (CDDFT) is required to deliver the constitutional standards and better outcomes for patients. It was agreed that NHS England would convene a joint meeting with CCGs to discuss a joint approach to CDDFT.

The current healthcare system is unsustainable and collectively there is a need to focus on the reconfiguration required. There is potential for an Acute Collaboration Vanguard bid submission, as well as a requirement to fully engage in the Securing Quality in Hospital Services (SeQiHS) work programme.

We acknowledge that all of these challenges are fully recognised with appropriate risk mitigation plans in place.

Action: CCG to monitor activity closely during 2015/16.

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Key Interdependencies and Associated Issues You explained the vision that you have for transforming services over the next five years and described the progress outlined for primary care in order to support this. We commend the formation of Primary Healthcare Darlington, a federation of Darlington practices. The CCG has a close working relationship with the local authority that has been strengthened through the work around Better Care Fund. The CCG won ‘Best Integration Project of the Year Award’ at the inaugural North East and Cumbria Commissioning Awards, for the work done by the CCG and partner organisations in Darlington, who have come together to establish older people multi-disciplinary teams.

Action: CCG to maintain positive work with partners.

CCG Transformational Programmes NHS England acknowledges the work the CCG has started to transform out-of-hospital care and your work to strengthen primary care provision. We are now looking for CCGs to clarify their intentions and commit to hospital sector transformation to ensure that patients have access to high quality and clinically sustainable services in the medium- to long-term. For Darlington CCG, you described the vehicle for transformational change for your patients as the Securing Quality in Health Services programme (SeQiHS) programme.

To ensure that NHS England in Cumbria and the North East is best placed to support CCGs as they develop and implement their transformational plans and that our approach to assurance is proportionate and value-adding, I am aligning a named NHS England Director to be each CCG’s first point of contact. In this instance, Alison Slater, Director of Delivery will be your link-director.

Action: CCG to work with the other CCGs in the Durham, Darlington and Tees area to ensure the SeQiHS Programme has proposals ready to consult on from April 2016.

Development Needs and Agreed Actions The overall assurance category for the CCG following the local Quarter 4 review and completion of the regional/national moderation process is assured with support. Assessment against the individual domains is noted below. Domain Assurance rating 1. Are patients receiving clinically commissioned, high quality services?

Assured

2. Are patients and the public actively engaged and involved? Assured 3. Are CCG plans delivering better outcomes for patients? Assured with support 4. Does the CCG have robust governance arrangements? Assured 5. Are CCGs working in partnership with others? Assured 6. Does the CCG have strong and robust leadership? Assured

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The CCG has made good progress particularly around joint working with Darlington Borough Council towards your strategic aims; we indicated a key message around system sustainability and delivery of key constitutional targets.

The six domains of the outgoing assurance framework still provide a platform for continuing organisational development of the CCG and they also will inform the well led organisation component of the new assurance framework.

Action: Guidance for new assurance framework to be shared with CCG as soon as published.

Overall we would like to congratulate you on the progress you have made over the last year and the achievements you have made.

Thank you again to you and your team for meeting with us and for the open and constructive dialogue. I hope this letter provides an accurate summary of our discussions and notes the areas for ongoing development going forward. We look forward to continuing to work with you to improve the health and wellbeing of the residents of Darlington.

Yours sincerely

Tim Rideout Director of Commissioning Operations

Appendix Two

NHS England: North (Cumbria and the North East)

Waterfront 4 Goldcrest Way

Newcastle Upon Tyne NE15 8NY

By email: [email protected] 17th November 2015 Dear Dr Jones Re: Assurance of CAMHS Transformation Plans Firstly, thank you for submitting your CAMHS Transformation Plan by the national deadline and in accordance with the published guidance. We appreciate that this is an incredibly busy time for CCGs and your partners and recognise the significant amount of work that has gone into the production of this plans. Your plan was reviewed by a multi-disciplinary panel in accordance with the national guidance. The panel was convened by the Medical Directorate of NHS England Director of Commissioning Operations (DCO): Cumbria and the North East (CNE) and consisted of representatives from:

• NHS England Specialised Commissioning • CYP IAPT National Programme • Public Health England • Northern England Maternity and Children’s Strategic Clinical Network • Northern England Mental Health Strategic Clinical Network • NHS England DCO: Finance Team • NHS England: Health and Justice Commissioning

There were three possible outcomes of the assurance process: “Assured”, “Assured with recommendations” and “Resubmission required”. Based on the content of your plan and supporting appendices, guided by the information you highlighted in your self-assessment and using the key lines of enquiry we shared with you prior to submission, your plan has been Assured.

mailto:[email protected]

Appendix Two

This assurance rating means that the funding to support transformation will be released as outlined in the national guidance. You will be asked to submit your updated finance tracker, detailing how you have spent the money issued in quarters 3 and 4 on 31 January 2016 and 30 April 2016 respectively for assurance purposes and for the funding allocation for 2016/17. It is important to ensure that this funding is used for the purpose that it is intended and invested in to Children & Young People Mental Health Services. Should a situation arise where, either due to insufficient capacity or other difficulties with service implementation, financial slippage against notional allocations may materialise, that this is declared to the DCO Team. Thank you again for all the time and hard work invested by members of your CCG and those in your partners organisations in the production of this plan. Following this effort, the implementation stage of the plan will see children, young people and their families in your area enjoy real benefits in terms of outcomes whilst helping them reach their full potential. Regards

Ben Clark Caris Vardy Assistant Director: Clinical Strategy Head of Specialised Mental Health NHS England: North (CNE) and Learning Disability Commissioning NHS England: North CC Andrew Stainer NHS Darlington CCG


Governing Body

Agenda Item: 62

1 December 2015

Title Finance Report Month 7


Category

Strategy &

Planning ☐

Performance &

Operational ☒

Governance &

Assurance ☐


Lisa Tempest, Chief Finance Officer

Clinical Sponsor

Andrea Jones, Chair and Lead Clinician

Author of Report Lisa Tempest

Recommendation(s) The Governing Body is asked to:

• Receive and consider the CCGs financial position

Executive Summary

This report is to inform the Governing Body of the CCG’s financial position for the seven months to 31st October 2015. At the end of October 2015 (month 7) Darlington CCG reported a year-to-date surplus of £1.031m. This is in line with the forecast for the year which requires the CCG to deliver a surplus of £1.767m. To mitigate the significant financial pressures impacting most areas of spend the CCG will need to utilise all remaining reserves to maintain a balanced position. Further deterioration of the position will lead to a risk of the CCG being unable to deliver its planned surplus. Detailed work has been undertaken to identify the underlying causes of the financial pressures and an action plan is in place to address issues identified. Performance against this plan will be monitored by the Finance Committee. Details of key financial recovery actions being undertaken in other CCGs have been obtained and will be discussed at the Finance Committee meeting in December. Acute Services Spend on acute hospital services is forecast to be £878k higher

than planned however this is net of the reversal of accruals from 2014/15 which are no longer required and the actual overspend against plan is £2.063m. The contract with our lead provider County Durham and Darlington NHS Foundation Trust is forecast to exceed plan by £1.981m (796k net of the benefit of the accrual reversal) for the year. Elective/day case activity has increased as the provider continues to reduce waiting list size in order to address performance issues with waiting times, particularly for diagnostics. Despite the Better Care Fund successfully reducing the number of non-elective admissions the cost of admissions is significantly higher than planned as admitted patients have more complications and co-morbidities. A cost pressure has also been identified for A&E where the case mix continues to be more complex. Other key acute contracts have lower levels of variance against cost and activity plans. The overspend on Non NHS Acute relates primarily to BMI Healthcare due to high levels of activity for ophthalmology and orthopaedic services. Mental Health Services The CCG is currently reporting a pressure of £713k on its mental health budget due to a number of high cost packages for care not provided as part of our existing contracts having been put in place in recent months due to an increasing number pf patients requiring specialist care. The CCG has a risk share arrangement in place with Tees, Esk and Wear Valleys NHS Foundation Trust in respect of the overall mental health budget and plans are being developed to bring spend back into line with budget. Once plans are agreed and in place the forecast will be adjusted to reflect this. Community Health Services The financial pressure on Community Health services is due to an expected increase in the cost of Urgent Care centre attendances during the course of the year and admissions to the Richardson Community Hospital. The opening of the Darlington ‘community ward’ at Ventress Care Home in November 2015 will significantly reduce usage of community hospital beds. Continuing Health Care Continuing Health Care costs are higher than planned due to an increase in the number packages put in place for children during recent months, partially offset by a reduction in the number of ‘fast track’ packages for adults expected. The reported position is net of the reversal of an accrual from 2014/15 of £500k therefore the actual variance from plan is

£551k Running Costs The CCG is currently managing within its Running Cost Allowance for 2015/16 however costs increased as a result of the interim arrangements that have been put in place during the extended sickness absence of the CCGs Chief Officer. Further detail is included in the Finance Report provided in Appendix A.

Clinical Engagement

Not appliccable


Key financial risks relating to the current financial position have been identified and are monitored by the Finance Committee.

Has an Equality Analysis been completed?

Not appliccable

Attachments Appendix 1 – Finance Report M7




☐

2.


☐

3.


☒


☐

5.




☐


Finance Committee 9th November 2015 Executive 17th November 2015


No

Finance Report for the seven months ended 31st October 2015

£1,031k(F) £1,767k(F)

£1k(F) £0k

£85,371k £143,602k

£0k £0k

98.49%

99.99%

99.15%

99.64%

YTD Forecast Executive Summary Commissioning spend The CCG is reporting a YTD surplus of £1,031k and forecast surplus of £1,767k. This is in line with the plan submitted to NHS England. Running Costs The CCG is reporting a surplus of £1k YTD and a break-even forecast outturn. Cash The forecast cash drawdown is in line with the cash limit for the year.

Capital There is £10k of capital included in the plan submitted to NHS England for IT equipment, as yet there has been no business case submitted. Better Payment Practice Code (BPPC) 95% of invoices to be paid in 30 days The CCG is exceeding the 95% target for both NHS and Non NHS Invoices.

Invoices Value

Non NHS

NHS

1

Overview

This report provides an update on the financial performance of NHS Darlington CCG for 2015/16 financial year.

The CCG’s financial position is under continual review and the current position shows the

organisation to be on track to achieve its key financial targets. However, it should be highlighted there are significant pressures within the system in all areas and the current position has been met by the CCG releasing a benefit from the 2014/15 accruals into its year to date and forecast outturn. These pressures, if not addressed over the remainder of the year, will potentially impact on the delivery of the planned surplus position.

The current position shows a year to date underspend of £1,032k on an allocation of

£145,768k. The CCG received recurrent allocations of £198k for Neurology and £163k for Wheelchairs and non recurrent allocations of £25k Liaison Psychiatry and £23k UEC Vanguard during the month.

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Summary of Financial Position 31st October 2015

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Darlington CCG Revenue Expenditure 2015-16 YTD Budget YTD Actual

YTD Variance (Under)/

Overspend 2015-16 Budget Forecast Outturn

Forecast Variance (Under)/

Overspend£000's £000's £000's £000's £000's £000's

Commissioned Services

Acute Services 43,732 44,547 816 74,742 75,620 878Mental Health Services 9,421 9,884 463 16,150 16,863 713Community Health Services 9,038 9,412 374 15,468 16,313 845Continuing Care Services 6,106 6,136 30 9,827 9,878 51Primary Care Services 10,850 11,089 238 18,363 18,646 283Other 2,138 2,137 (1) 3,582 3,579 (4)

Reserves (Includes Surplus) 2,951 0 (2,951) 5,307 774 (4,533)

Total Commissioned Services 84,236 83,205 (1,031) 143,439 141,672 (1,767)

Running Costs

Corporate Costs and Services 1,353 1,352 (1) 2,319 2,327 8

General Reserve - Admin 0 0 0 10 2 (8)

Total Running Costs 1,353 1,352 (1) 2,329 2,329 (0)

Total Revenue Expenditure 85,589 84,557 (1,032) 145,768 144,001 (1,767)

Acute Services

4

CDDFT contract is currently showing a forecast overspend position of £796k after the benefit of the 2014/15 accrual which totalled £1,185k. The reported forecast overspend before the release of the 2014/15 accrual was £1,981k . The position includes the application of penalties of £430k plus 50% reinvestment of £215k. CQUIN, drugs and devices, emergency readmissions and an estimate for stroke best practice are based on 2014/15. There still remains a high level of uncoded activity within the data which could affect the reported financial position. The forecast has been adjusted to take into account reductions in diagnostic procedures through Q3 and Q4 now performance targets associated with this activity are being met. Newcastle Hospitals NHS FT over-performance has been projected to the end of the year and is driven by electives, ITU and high cost drugs. For electives the main areas where this is occurring are HB orthopaedic non-trauma procedures, SA haematological disorders and QZ vascular procedures. Non NHS Acute mainly comprises BMI Woodlands Hospital with an annual budget of £4,234k. The contract value has been estimated using 2014/15 outturn data, this is causing over-performance of £495k and activity management processes have now begun to understand this and plan for a reduction in activity. Early pressures can be found in day Case and elective activity, which is mainly due to trauma and orthopaedics and pain management.

Budget Actuals Variance Budget Forecast Variance£000 £000 £000 £000 £000 £000

County Durham and Darlington FT 33,390 34,150 759 57,045 57,841 796South Tees Hospitals NHS FT 3,276 3,087 (189) 5,585 5,360 (224)Newcastle Hospitals NHS FT 825 984 159 1,414 1,735 322North Tees and Hartlepool NHS FT 711 547 (164) 1,219 936 (283)Collaborative Commissioning 0 0 0 0 0 0NHS Acute NCA 719 680 (39) 1,233 1,238 5Non NHS Acute 2,645 2,959 314 4,534 4,814 280NEAS 1,728 1,704 (25) 2,963 2,945 (18)NHS Networks 7 7 0 12 12 0Ambulance Services 0 0 0 0 0 0Winter Resilience 430 430 0 737 737 0

Total Acute Services 43,732 44,547 816 74,742 75,620 878

YTD Annual

Mental Health Services

5

TEWV – the forecast underspend of £153k is due to a discharge from Fulmar Ward in May 2015. NTW – Based on the month 5 finance and activity data the forecast outturn for the contract is £101k underspent which includes an over-activity budget of £152k . The underlying contract, before the over-activity budget, is showing a £36k overspend year to date assuming no new admissions. Notice has been given on the contract for 2015/16. Other NHS – This now shows a balanced position as the costs relating to a placement in the 5 Boroughs Partnership NHS FT are being redirected to St Helens CCG based on information received from North West Commissioning Support Unit. Independent / Voluntary Sector – the forecast overspend is consistent with the figures reported at month 6. A package of care with The Priory had originally been notified as being a Darlington CCG patient but through the monitoring work being carried out it was found to be a DDES CCG patient so the costs have been taken out. This cost reduction has been offset by charges in relation to a package of care with Danshell which is subject to a responsible commissioner dispute with Northumberland CCG. The Who Pays guidance places the financial responsibility on the initial CCG until the dispute is settled. The CCG has entered into a risk share agreement with TEWV to manage the overall Mental Health and Learning Disabilities budget to ensure breakeven at the end of the financial year, review work will be carried out in conjunction with TEWV to manage the financial position particularly in relation to NTW and Individual Packages of Care.


TEWV 8,043 7,964 (79) 13,787 13,634 (153)NTW 206 157 (49) 352 252 (101)Other NHS 9 9 0 16 16 0Other NHS Mental Health 0 0 0 0 0 0Independent / Voluntary Sector 915 1,504 589 1,568 2,531 963Mental Health Services - Winter Resilience 0 0 0 0 0 0Local Authority Agreements 248 251 3 425 430 4Total Mental Health 9,421 9,884 463 16,150 16,863 713

YTD Annual

Community Health Services

6

NHS Contracts have been assumed to perform in line with plan. The exception to this is a charge for urgent care over-performance with CDDFT which is outside of the contract and is calculated each month based on activity figures resulting in an overspend of £270k. Also included, is the recharge of activity for the Richardson Hospital, for which there is no funding in place totalling £474k. Other community - £101k overspend in the main relates to Virgin MSK of £65k, Minor Ops – opthamology of £23k and £11k for Intra-Health anti –coagulation services .


NHS Contracts 7,590 7,918 328 13,011 13,755 744Hospice 455 455 0 781 781 0Other Community 993 1,038 45 1,676 1,777 101

Total Community Health Services 9,038 9,412 374 15,468 16,313 845

YTD Annual

Continuing Care Services

7

Continuing Healthcare (CHC) costs are based on the annual cost of individual packages included in the finance database. This is the most up to date information available at the time of publishing this report. Continuing Healthcare Services are showing a year to date overspend of £30k and forecast outturn overspend of £51k. Included within the forecast outturn position is the benefit of an unutilised accrual from 2014/15 of £500k. The main area of overspend is within Children’s services due to an increase in the number of children eligible for Continuing Care. The annual cost of CHC Risk Pool is included in line with NHS England guidance. The change in package numbers within month 7 for each benchmarking category are shown below :- CHC Fast Track - 21 new or changed packages and 27 ended Joint Packages - 6 new or changed and 4 ended Section 117 – 16 new or changed and 9 ended Continuing Health Care – 37 new or changed packages and 30 ended Personal Health Budgets 0 New Funded Nursing Care – 7 new packages and 21 ended


CHC Risk Pool 898 898 0 898 898 0CHC - Management costs 99 99 0 169 169 0CHC Fast Track 427 276 (151) 731 468 (263)Continuing Care - Joint Packages 695 704 9 1,191 1,207 16Continuing Care - Section 117 820 787 (33) 1,406 1,350 (56)Continuing Health Care 2,719 2,735 16 4,661 4,689 28Personal Health Budget 0 31 31 0 53 53Funded Nursing Care 387 387 0 663 665 2Children 62 220 158 106 378 272Total Continuing Care Services 6,106 6,136 30 9,827 9,878 51

YTD Annual

Primary Care Services

8

Prescribing - The forecast outturn overspend of £443k has been based on information received from the PPD in October based on April to August actual data and two months accrual. This is offset by £90k forecast underspend relating to the prescribing rebates scheme and £91k relating to DCC LARC recharges based on quarter 1 information. Enhanced Services - is showing a £25k underspend and is based on the claims received for April to September. Other Primary Care includes the Oxygen contract. To date five months actual data has been received and two month accrued.


Prescribing 10,123 10,374 251 17,354 17,655 301Enhanced Services 58 44 (14) 100 75 (25)Commissioning Schemes 96 96 0 165 165 0Out of Hours 0 0 0 0 0 0Other Primary Care 573 574 2 745 751 7Total Other 10,850 11,089 238 18,363 18,646 283

YTD Annual

Other

9

The forecast outturn underspend on Patient Transport Services of £37k relates to County Durham EMS. Programme Projects is currently forecasting a £26k overspend and relates to adhoc invoices received with budget to be identified. Reablement relates to the payment to Darlington Borough Council for BCF.


Patient Transport Services 374 359 (15) 641 604 (37)Programme Projects 123 147 25 127 153 26NHS 111 181 177 (4) 310 306 (4)Exceptions & Prior Approvals 26 19 (7) 44 55 11Safeguarding 36 36 0 62 62 0Reablement 1,399 1,399 0 2,399 2,399 0Total Other 2,138 2,137 (1) 3,582 3,579 (4)

YTD Annual

Running Costs

10

Non pay costs include the costs of commissioning support services, accommodation, audit fees and other corporate costs. The CCG is currently showing a £1k favourable year to date position and a balanced forecast outturn position against a total running cost allocation of £2,329k. The month 7 position includes accruals totalling £130k mainly in relation to salary recharges, property costs, audit and clinical leads. A total of £34k accruals remain from 2014/15 for telephone costs.


Pay 283 273 (10) 485 480 (5)Non Pay 1,070 1,079 10 1,834 1,847 14Reserves 0 0 0 10 2 (8)Total Running Costs 1,353 1,352 (1) 2,329 2,329 0

YTD Annual

QIPP The table below summarises the forecast savings by key programme area as at 31st October 2015, compared to the QIPP plan for the year:

11

QIPP Programme Total QIPP

Plan 2015/16

£'000

YTD QIPP Plan

£'000

YTD Actual

Savings£'000

Variance£'000

Latest Forecast Savings

£'000

Variance to full

year QIPP plan

£'000

Notes

Acute services 1,964 1,058 1,058 0 1,964 0 No Issued Identified to date

Mental Health Services 145 84 84 0 145 0 No Issued Identified to date

Community Health Services 300 30 30 0 300 0 Redesign expected to realise savings September onwards.

Continuing Care Services 250 140 140 0 250 0 No Issued Identified to date

Primary Care services 150 50 50 0 150 0 Prescribing expected to realise benefits from Q2 onwards.

Running Costs 268 156 156 0 268 0 No Issued Identified to date

Total QIPP savings (allocative) 3,077 1,518 1,518 0 3,077 0

Provider (technical) efficiencies 3,942 2,300 2,300 0 3,942 0 Required national tariff efficiencies incorporated into contracts

Total QIPP 7,019 3,818 3,818 0 7,019 0

Better Payment Practice Code (BPPC) – cumulative to 31st October 2015

Note: Credit notes, CHC and Non Contracted Activity invoices have been adjusted from the above figures

12

The BPPC (Better Payment Practice Code) requires NHS organisations to pay all invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later.

Better Payment Practice Code - 30 Days NUMBER £000's

Non-NHSTotal Non-NHS Trade Invoices Paid in the Year 3,709 12,754Total Non-NHS Trade Invoices Paid Within 30 Day Target 3,653 12,645Percentage of Non-NHS Trade Invoices Paid Within 30 Day Target 98.49% 99.15%

NHS Total NHS Trade Invoices Paid in the Year 835 62,078Total NHS Trade Invoices Paid Within 30 Day Target 832 62,072Percentage of NHS Trade Invoices Paid Within 30 Day Target 99.64% 99.99%


Governing Body

Agenda Item: 63

1 December 2015

Title Clinical Quality Update


Category

Strategy &

Planning ☐

Performance &

Operational ☒

Governance &

Assurance ☐


Diane Murphy

Clinical Sponsor

Diane Murphy

Author of Report Diane Murphy/Rob Milner

Recommendation(s) The Governing Body is asked to note the content of the report

and advise of any additional actions required.

Executive Summary

The purpose of the report is to appriase the governing body of quality issues in our providers by exception. The period covered is Q2. The key issues are identified clearly in the body of the report and relate to:- NEAS - poor and deterioraing performance TEWV - compliance with level 3 safeguarding traning The findings and recommendation from the RCA report re South Park Care Centre. Continued gap in Named GP cover for safeguarding children The gap in a designated medical offcer for SEND.

Clinical Engagement

The issues highlighted are discussed at CQRG and QPI and have clinical input.


The report addresses some of the risks identified within the CCG risk register.


n/A

Attachments Clinical Quality Update




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2.


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3.


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5.




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The report has not been to any other committee although the information contained within it has been presented to a number of different meetings (CQRGS/QPI)


No

Clinical Quality Summary Report

1. Background The purpose of this report is to provide Darlington Clinical Commissioning Group (CCG) with a monthly update of issues relating to the quality of services and their impact on patient experience. It also includes information relating to compliance against national and local standards and matters raised about professional performance and safeguarding. The information provided about primary care relates to information received by the Clinical Quality Team at NHS North of England Commissioning Support (NECS) via the Safeguarding and Risk Management System (SIRMS). The CCG is still yet to receive a regular information flow relating to serious incidents, complaints, NICE compliance, CAS alerts or professional performance concerns within primary care. The CCG received assurance at the primary care Quality Surveillance Group (QSG) from the Area Team that this will be in place shortly. This information will be included in this report when it becomes available. Where key issues, risks and areas of concern are identified these are challenged through the respective Clinical Quality Review Groups (CQRG). A summary of the discussions which have taken place at the CQRGs is also included within the report to provide assurance of the actions being taken forward. 2. Discussion, implications and risks The primary areas of interest, concern or risk for Darlington CCG are as follows: 2.1 Patient Experience - Formal CCG complaints Received In October, two formal complaints were received by Darlington CCG. One complaint related to a retrospective CHC funding decision and the other concerning the outcome of an individual funding request. 2.2 Acute & Community Services This section provides, where known, the quality intelligence for CDDFT and STHFT. It is pertinent to highlight that the providers only provide quality reports on a quarterly basis, therefore the monthly reports focus on the information owned and monitored by NECS. 2.2.1 County Durham and Darlington Foundation Trust (CDDFT) Care Quality Commission (CQC) Inspection Report The results of the CQC inspection were published on the 29th September 2015 the overall rating for the Trust is “requires improvement”. The Trust were rated good for Caring and Responsive services however require improvement in the delivery of safe, effective and well led services.

2

Key actions: CDDFTs action plan was shared at the October CQRG and a summary report has been shared with the CCG Chief Nurse. The Trust is aiming towards the achievement of an ‘Outstanding’ rating once all actions have been taken. NHS England - North Region Quality Dashboard The NHS England Quality dashboard for October indicates CDDFT are statistically worse for RTT 52 plus week waits and CQC. CDDFT are showing as an outlier for Monitor while a decision is made as to next steps following deterioration in the Trust’s financial position. Key actions: The above exceptions will continue to be challenged via the CQRG and contract management group. Healthcare Associated Infections (HCAI) The Trust is showing good performance for Clostridium difficile with 10 cases reported against an annual target of 19 (53% of years’ objective). Safeguarding Children’s / Adults Training There are ongoing concerns in respect of numbers of staff receiving /accessing training. Remedial action plan received following a performance notice although this still fails to provide sufficient assurance. In response a further performance notification is to be issued. Coroner’s Report The Coroner has issued a Regulation 28 to both CHSFT and CDDFT for a patient that died in their care. The regulation was issued as the Coroner felt that there was no policy in place between the two Trusts clarifying areas of responsibility and channels of communication when patients are referred. Poor levels of communication both directly and indirectly between each Trusts medical professionals and poor understanding of each other’s differing practices and procedures were possible factors in the case. 2.2.2 South Tees Hospitals NHS Foundation Trust (STHFT) NHS England Quality Dashboard The NHS England Quality dashboard shows STHFT is below standard for Cancer 62 day wait (urgent GP referral). The Trust remains statistically worse for SHMI, HSMR, weekend HSMR, Monitor, CQC and RTT 52+ week waiters. Health Care Associated Infections (HCAI) Clostridium Difficile - The Trust’s current position is 37/50 (32 validated) YTD actual. This continues to be monitored by South Tees CCG as Lead commissioner and the CQC with regular monitoring of the HCAI action plan. Never Events STHFT reported in October a Never Event relating to wrong site surgery (despite standard procedure, L4/5 disc level was fenestrated and incised in error). The investigation report into this incident is being monitored by South Tees CCG as Lead Commissioner. Mortality Summary Hospital Mortality Index (SHMI) figures have been released for August 2014 to July 2015. The Trust now reports a SHMI of 114.8 which is again calculated as

3

significantly higher than expected. The Trust also remains a negative outlier for Hospital Summary Mortality Rate (HSMR) with an increased rate of 117.2 for August 2014 to July 2015. Key actions: Capacity of the Specialist Palliative Care Team has been expanded. Additional nursing time is being used to actively seek out patients who are dying, rather than waiting for referral, using the electronic Early Warning Score system the Trust has in place (this system was not previously available). The Mortality Group perform weekly mortality reviews. Prominent themes from reviews relate to problems with documentation (implementation of electronic Clinical Noting will help with the inherent problems of paper recording systems), use of Do Not Attempt (DNACPR) forms and problems in co-ordination of care/senior input/advance decision making in complex patients with multiple problems. The problem of admission of dying patients, particularly from nursing homes, remains a recurrent theme. 2.3 Mental Health Services 2.3.1 Tees, Esk and Wear Valleys NHS Foundation Trust (TEWVFT) Safety thermometer – September 2015 shows TEWVFT continue to be a negative outlier for falls with harm. The Trust has done a deep dive and the outcome is monitored via their CQUINN scheme with annual audits built into the audit cycle. Serious Incident reporting Q2 has seen a decline in reporting of SIs within 2 working days and submission of 24/72 hour reports. This is managed via CQRG and is being picked up in the trust via the learning lessons project. Early reporting and review of incidents is indicative of a safety culture that not only identifies and reports but seeks to learn lessons and implement actions promptly. CQC intelligent monitoring TEWV were identified (as at June 2015) as having two elevated risk for safety namely:-

• Patients that die following injury or self-harm within 3 days of being admitted to acute hospital beds

• Number of deaths in patients detained under mental health Act

No priority has been assigned due to the recent CQC assessment of “good” . Patient-Led assessment of the care environment (PLACE) As at Sept 2015 TEWVFT scored above national average with the exception of Condition, appearance and maintenance of premises and organisation food. Information provided at the November CQRG meeting provided assurance that this has improved. Safeguarding Children training compliance Although the trust has a significant amount of training available there has been a decrease in compliance for training at level 3. The trust executive is focusing on this gap in compliance and the safeguarding team are working with services to improve attendance. Of particular note and concern is that compliance in the CAMHS service is currently 49.9%. The trust re working to validate this data and the issue has been formally escalated tot eh contract group for further discussion and action. The issue has also been flagged at

4

Quality Surveillance group and will be a single agenda item at the January meeting. Darling, DDEs and NDCCG and HAST have been requested to prepare s full position paper on this item. 2.4 North East Ambulance Service and 111 Service Performance at a Darlington CCG level for RED 1 Red 2, and Red1 &2 all exceed the 75% target. Cat A response times however are at 92.9% wh8hcis below the 95% target. It is however important to note that overall NEAS performance against these indicators is poor and is a deteriorating picture as set out below with failure of the target at Q2.

Indicator Target /

local trajectory

Qtr 2 2015/16 YTD July-15 Aug-15 Sept-15

Red 1 75% 75.24% 72.25% 72.58% 74.51%

73.32%

Red 2 75% 75.08% 70.78% 72.58% 74.53%

72.88%

Red 19 95% 95.07% 94.17% 93.29% 94.82%

94.19% There are system pressures, as measured by handover delays which reduced but are increasing again but not yet at previous levels and a steady increase in NHS111 Referrals to 999. In the absence of satisfactory assurance of a recovery plan at CQRG and against a backdrop of deteriorating performance and increasing pressure san extraordinary meeting has been convened for 27 November 2015 between NEAS executives and lead commissioners (Executive Nurses and contracting teams). Workforce There continues to be a shortfall of paramedics but from December 2015 lead clinician posts will be filled by advanced technicians to improve use and optimization of skills. NEAS are still progressing recruitment with 3 starting during October, a further 16 qualifying in January 2016 and overseas recruitment in Poland commencing. The Trust reported a deteriorating in sickness and absence rate from 6.46% to 6.49% in August 2015. They are developing a plan to review all policies to enable improved sickness and absence rates. Central Alerting System It was previously reported that the NRLS suggest that some ambulance satellite navigation systems may not be up to date with new locations resulting in delays to the ambulance reaching its destination. The Trust has advised that actions are in place to address the recommendations by the end of December 2015.

5

2.5 Children’s safeguarding There continues to be a gap in the role of a Named GP for safeguarding children. Despite informal efforts no one has been identified as willing to take on this important role that is well described in inter-collegiate standards. Work is now underway to describe the role and to set out how any post holder would be supported to manage the perceived risk associated with it. This will then be shared with GPs and we will proactively seek to recruit a post holder. 2.6 Special Educational Needs (SEND) A designated Doctor role is required to support meeting standards of care for SEND. SEND will be subject to OFSTED inspection in 2016 and it is imperative we achieve resolution on this. In conjunction with DDES and NDCCG Darlington CCG are looking to identify the resource required (time and cost) and determine whether this is additional to current contract with CDDFT. The contracting team are working on this with a view to early resolution.

2.7 South Park Care Centre Darlington CCG currently funds nursing residents in this home. Many of these patients transferred to South Park following the decommissioning of St Johns Nursing home in October 2014. Since October 2014 concerns had been noted in relation to the home. In January 2015 the home has been subject to executive strategy for intervention and monitoring. Following a CQC inspection in May 2015 a notice of proposal to remove registration for provision of nursing care was issued on 10

July 2015.

Strategy meetings continue and progress has been sustained despite ongoing staffing pressures in the home. The Local Authority has reinstated admissions to the residential care element of the home in response but continue to actively monitor standards. Feedback is that the agreed action plans are being addressed and improvements are being made across all areas of care. There remains a risk however in regard to sustainability due to the homes difficulty in recruiting and retaining qualified staff. A Multi agency RCA review has been held and shared at joint management team. Recommendations made are:

• A review of the current assurance systems for nursing homes adherence to nurse registration checks should be undertaken.

• All Care Home recruitment policies must include the requirement to check professional qualifications prior to any offer of employment.

• Care Home training records (anonymised) should be requested as part of an assurance process.

• Use of agency staffing or gaps within rotas within a care provider should be monitored to identify prolonged, higher than expected levels impacting on the quality and continuity of care.

• When concerns are raised regarding staffing levels these must be acted upon in an appropriate and timely manner to gain assurance that the safety of residents and

6

quality of care is maintained. An information sharing discussion with partner agencies should take place as a minimum.

• An agreed mechanism must be in place for sharing concerns and soft intelligence with partner agencies.

The priority must be preventing Providers from reaching the Executive Strategy stage. Trigger points to look out for are;

• Management changes • High turnover of staff • High levels of agency staffing • Prolonged gaps in staffing rotas • Poor uptake of training • Number and frequency of voluntary suspensions in place • Complaints being received • Safeguarding referrals • Number, or type, of medication errors reported (where a Home is responsible) • If a Provider escalates to the Executive Strategy stage the partner agencies must

be mobilised quickly in a coordinated manner with a clear lead from each organisation identified.

Further work will now be put into place to develop an action plan to take forward the recommendations. 3. Recommendations The Governing Body is asked to:

• receive and consider the report, • agree that necessary actions are being taken forward with the respective

organisations to improve quality and experience for patients. Authors: Diane Murphy, Interim Chief Nurse, NHS Darlington CCG

Rob Milner, Senior Clinical Quality Officer, NECS Sponsor and Executive lead: Diane Murphy, Interim Chief Nurse, NHS Darlington CCG Date: 24 November 2015


Governing Body

Agenda Item: 64

1 December 2015

Title Performance Report November 2015


Category

Strategy &

Planning ☐

Performance &

Operational ☒

Governance &

Assurance ☐


Lisa Tempest, Chief Finance Officer

Clinical Sponsor

Andrea Jones, Chair and Lead Clinician



Receive and consider the report

Executive Summary

This report is to inform the Governing Body of the CCG’s performance in respect of NHS Constitutional Standards using the most up to date performance information for each indicator. On a year to date basis Darlington CCG is currently achieving the following constitutional standards:

Referral to Treatment within 18 weeks Ambulance category A response times (8 minutes) No mixed sex accommodation breaches 95% of patients should spend 4 hours or less in and A&E

Unit % of people followed up within 7 days of discharge from

inpatient psychiatric care Patients waiting for diagnostic tests should not wait more

than 6 weeks from referral (although two providers are currently failing to meet the 1% target)

The below standards are currently not being achieved:

No patients to wait for over 52 weeks for treatment: One Darlington patient has been waiting for over 52 weeks for surgical treatment with Country Durham and Darlington NHS Foundation Trust. The Trust has been asked to

undertake a root cause analysis and provided details to the CCG.

At least 85% of patients should be treated within 62 days of an urgent GP referral for suspected cancer: The CCG is currently failing to meet this target with YTD performance of 82.4% as at the end of September 2015. Breach and root cause analyses are shared on a regular basis between providers and with commissioners and the Cancer Network has held a workshop to review the cancer strategy and identify issues and recommendations to be taken forward. All Trusts, with the support of their local cancer network partners, are expected to recover the standard as soon as possible and in any event by the end of the 2015/16 financial year.

Incidence of MRSA and C-Diff: As at 15th October Darlington CCG reported one case of MRSA and a total of 14 cases of C-diff against an annual trajectory of 17 therefore the CCG is currently above the planned trajectory. All breaches are discussed through monthly Clinical Quality Review Group meetings. The post infection review process has been followed for all identified cases with relevant lessons learnt identified and actions implemented as appropriate.

Handover between ambulance and A&E should not

exceed 30 minutes: County Durham and Darlington NHS Foundation Trust are a regional outlier. In September 2015 a total of 81 delays were reported however performance has improved month on month since January 2015 and in September 2015 the number of delays was at its lowest level since 2013/14

Ambulance category A response times (19 minutes): Overall performance for the North East Ambulance Service has deteriorated during quarter 2 and is below the target for 19 minute response time. Performance for Darlington has deteriorated to below 95% on a year to date basis. Norther East Ambulance Services continue to experience significant staffing pressures and other issues which are impacting performance. The Trust is currently developing a revised action plan which is to be shared with commissioners in November 2015.

A detailed overview of Darlington CCG performance in respect of NHS Constitution Standards with exception reports is included in Appendix 1.

Clinical Engagement

Not appliccable

Does this report provide evidence of assurance for the

Key financial risks relating to the current financial position have been identified and are monitored by the Finance Committee.

Assurance Framework and / or mitigate risk included on the CCG’s Risk Register? Has an Equality Analysis been completed?

Not appliccable

Attachments Appendix 1 – Performance Report




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3.


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5.




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Quality Performance and Innovation Committee, 24th November 2015.


Darlington CCG - NHS Constitution Performance Summary

1

Latest Reporting Data Period

Operational Standard National Average Exception Report

Referral to treatment access times

% patients waiting for initial treatment on incomplete pathways within 18 weeks 92.0% 92.6% 94.9% 94.5% 94.1% 96.7%Number patients waiting more than 52 weeks for treatment 0 1 3 6 0Diagnostic waits

% patients waiting less than 6 weeks for the 15 diagnostics tests (including audiology)Sep-15

1.00%1.70% 0.23% 1.01% 1.96% 0.89%

CDDFT ER02STHFT ER01

A&E waits

% patients spending 4 hrs. or less in A&E or minor injury unit YTD Sep-15 95.0% 94.1% 95.6% 95.9% 96.0%

Handover between ambulance and A&E over 30 minutes 0 938 238 11 2099

Handover between ambulance and A&E over 60 minutes 0 206 44 0 366

Trolley waits in A&E not longer than 12 hours YTD Sep-15 0 0 0 0Ambulance response times

RED 1 response in 8 mins 76.5%RED 2 response in 8 mins 77.3%RED 1&2 response in 8 mins 77.2%Cat A Response within 19 mins 95.0% 93.2% 92.9% 94.8%

Number of crew clear delays over 30 mins 0 1551Number of crew clear delays over 60 mins 0 70Mixed Sex accommodation

Mixed Sex accommodation - number of unjustified breaches YTD Oct-15 0 0 0 0 0HCAI

Incidence of MRSA 0 1 1 2 0Incidence of C Diff CCG 74 14 10 32 19Cancelled Operations

All patients who have operations cancelled to be offered another binding date within 28 days YTD Sep-15 0 0 7 0Mental Health

% people followed up within 7 days of discharge from psychiatric in patient care YTD Sep-15 95.0% 100.00%Cancer

% of patients seen within 2 weeks of an urgent GP referral for suspected cancer 93.0% 93.6% 93.9% 94.1% 94.2% 92.4%

% of patients seen within 2 weeks of an urgent referral for breast symptoms 93.0% 92.9% 94.8% 91.7% 93.9% 93.8%

% of patients treated within 31 days of a cancer diagnosis 96.0% 97.6% 98.8% 99.8% 97.4% 99.1%% of patients receiving subsequent treatment for cancer within 31 days - drugs 98.0% 99.6% 100.0% 100.0% 100.0% 100.0%% of patients receiving subsequent treatment for cancer within 31 days - surgery 94.0% 95.4% 100.0% 98.9% 95.3% 98.0%% of patients receiving subsequent treatment for cancer within 31 days - radiotherapy 94.0% 97.6% 100.0% 99.2%% of patients treated within 62 days of an urgent GP referral for suspected cancer 85.0% 82.0% 82.4% 86.9% 80.4% 84.4%% of patients treated within 62 days of an urgent GP referral from an NHS Cancer Screening Service 90.0% 93.5% 100.0% 95.7% 96.4% 97.9%% of patients treated for cancer within 62 days of consultant decision to upgrade status N/A 89.0% 100.0% 100.0% 84.8% 89.5%

Darlington CCG NTHFTSTHFTCDDFT NEAS

NEAS ER01

YTD Sep-15

YTD Sep-15 CDDFT ER01

CDDFT ER03/04STHFT ER02

YTD Oct-1575.0% 74.3%

YTD Sep-15

69.1%

YTD Sep-15DCCG ER01STHFT ER03NTHFT ER02

To 15th Oct-15 HCAI 01

YTD Sep-15DCCG ER01CDDFT ER05NTHFT ER01

YTD Sep-15

2

NHS Constitutional Indicators by month – Darlington CCG 2015/16

Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Q1 Q2 Q3 Q4 Year End Q1 Q2 Q3 YTD

pts treated < 18 wks 4,860 4,166 4,156 4,107 3,998 3,983 4,165 4,485 4,244 4,468 4,634 4,656 4,543 4,596 13,727 13,801 12,261 12,633 52,422 13,346 13,795 0 27,141total pts 5,085 4,372 4,357 4,334 4,264 4,220 4,412 4,749 4,469 4,698 4,869 4,906 4,793 4,861 14,416 14,444 12,955 13,381 55,196 14,036 14,560 0 28,596% Compliance 95.6% 95.3% 95.4% 94.8% 93.8% 94.4% 94.4% 94.4% 95.0% 95.1% 94.1% 94.9% 94.8% 94.5% #DIV/0! 95.2% 95.5% 94.6% 94.4% 95.0% 95.1% 94.7% #DIV/0! 94.9%

Number patients waiting more than 52 weeks for treatment (Incomplete pathways only)

0 Total Number 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 1 CDDFT ER01

pts waiting > 6 wks 65 87 130 292 161 221 213 202 146 101 50 10 2 4total pts 1,569 1,609 1,895 2,694 1,833 1,907 1,986 2,074 1,959 1,779 1,684 1,568 1,672 1,756% Compliance 4.14% 5.41% 6.86% 10.84% 8.78% 11.59% 10.73% 9.74% 7.45% 5.68% 2.97% 0.64% 0.12% 0.23% #DIV/0!

Response < 8 min 21 16 35 38 30 43 27 34 31 32 24 25 31 19 30 36 44 103 104 287 87 75 30 192Total Responses 26 19 40 50 48 51 35 41 40 40 33 30 42 23 43 51 54 138 127 370 113 95 43 251% Compliance 80.8% 84.2% 87.5% 76.0% 62.5% 84.3% 77.1% 82.9% 77.5% 80.0% 72.7% 83.3% 73.8% 82.6% 69.8% 70.6% 81.5% 74.6% 81.9% 77.6% 77.0% 78.9% 69.8% 76.5%Response < 8 min 384 419 407 367 431 442 382 386 421 438 404 385 386 341 418 1,340 1,287 1,205 1,210 5,042 1,263 1,112 418 2,793Total Responses 477 523 521 489 615 573 490 480 521 527 505 483 503 473 602 1,642 1,623 1,625 1,543 6,433 1,553 1,459 602 3,614% Compliance 80.5% 80.1% 78.1% 75.1% 70.1% 77.1% 78.0% 80.4% 80.8% 83.1% 80.0% 79.7% 76.7% 72.1% 69.4% 81.6% 79.3% 74.2% 78.4% 78.4% 81.3% 76.2% 69.4% 77.3%Response < 8 min 405 435 442 405 461 485 409 420 452 470 428 410 417 360 448 1,376 1,331 1,308 1,314 5,329 1,350 1,187 448 2,985Total Responses 503 542 561 539 663 624 525 521 561 567 538 513 545 496 645 1,693 1,677 1,763 1,670 6,803 1,666 1,554 645 3,865% Compliance 80.5% 80.3% 78.8% 75.1% 69.5% 77.7% 77.9% 80.6% 80.6% 82.9% 79.6% 79.9% 76.5% 72.6% 69.5% 81.3% 79.4% 74.2% 78.7% 78.3% 81.0% 76.4% 69.5% 77.2%Response < 19 min 477 520 508 499 603 582 492 495 534 537 503 487 509 457 553 1,599 1,586 1,610 1,569 6,364 1,574 1,453 553 3,580Total Responses 503 542 561 538 662 624 523 519 561 566 536 513 541 495 643 1,678 1,676 1,761 1,666 6,781 1,663 1,549 643 3,855% Compliance 94.8% 95.9% 90.6% 92.8% 91.1% 93.3% 94.1% 95.4% 95.2% 94.9% 93.8% 94.9% 94.1% 92.3% 86.0% 95.3% 94.6% 91.4% 94.2% 93.9% 94.6% 93.8% 86.0% 92.9%

Mixed Sex accommodation - number of unjustified breaches 0 Total Number 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Incidence of MRSA up to 15th October 2015 0 Total Number 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 1 0 1 0 1Actual 3 4 2 2 1 2 2 2 2 1 3 2 1 4 1 2 10 5 6 23 6 7 1 14Target 2 1 2 2 2 1 1 1 2 2 1 2 1 1 2 6 5 6 3 20 5 4 4 17Variance -1 -3 0 0 1 -1 -1 -1 0 1 -2 0 0 -3 1 4 -5 1 -3 -3 -1 -3 3 3

% of people followed up within 7 days of discharge from phychiatric in-patient care

95.0% % Compliance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 93.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0%

pts seen < 2 wks 208.0 216.0 227.0 203.0 228.0 183.0 225.0 268.0 242.0 231.0 241.0 254.0 229.0 259.0 661.0 705.0 658.0 676.0 2,700.0 714.0 742.0 0.0 1,456.0total pts 215.0 225.0 239.0 211.0 239.0 194.0 231.0 282.0 254.0 243.0 260.0 274.0 249.0 271.0 683.0 736.0 689.0 707.0 2,815.0 757.0 794.0 0.0 1,551.0% Compliance 96.7% 96.0% 95.0% 96.2% 95.4% 94.3% 97.4% 95.0% 95.3% 95.1% 92.7% 92.7% 92.0% 95.6% #DIV/0! 96.8% 95.8% 95.5% 95.6% 95.9% 94.3% 93.5% #DIV/0! 93.9%pts seen < 2 wks 30.0 26.0 36.0 36.0 31.0 24.0 38.0 50.0 33.0 48.0 54.0 36.0 42.0 44.0 128.0 103.0 103.0 112.0 446.0 135.0 122.0 0.0 257.0total pts 31.0 29.0 37.0 37.0 31.0 27.0 42.0 56.0 35.0 50.0 59.0 39.0 43.0 45.0 135.0 109.0 105.0 125.0 474.0 144.0 127.0 0.0 271.0% Compliance 96.8% 89.7% 97.3% 97.3% 100.0% 88.9% 90.5% 89.3% 94.3% 96.0% 91.5% 92.3% 97.7% 97.8% #DIV/0! 94.8% 94.5% 98.1% 89.6% 94.1% 93.8% 96.1% #DIV/0! 94.8%pts treated < 31 days 43.0 54.0 46.0 45.0 58.0 35.0 38.0 47.0 36.0 32.0 43.0 55.0 50.0 34.0 143.0 144.0 149.0 120.0 556.0 111.0 139.0 0.0 250.0total pts 43.0 54.0 46.0 45.0 58.0 35.0 38.0 48.0 36.0 32.0 43.0 56.0 51.0 35.0 146.0 145.0 149.0 121.0 561.0 111.0 142.0 0.0 253.0% Compliance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.9% 100.0% 100.0% 100.0% 98.2% 98.0% 97.1% #DIV/0! 97.9% 99.3% 100.0% 99.2% 99.1% 100.0% 97.9% #DIV/0! 98.8%pts treated < 31 days 15.0 19.0 26.0 14.0 24.0 12.0 12.0 8.0 11.0 18.0 7.0 3.0 12.0 10.0 36.0 46.0 64.0 32.0 178.0 36.0 25.0 0.0 61.0total pts 15.0 19.0 26.0 14.0 24.0 12.0 12.0 8.0 11.0 18.0 7.0 3.0 12.0 10.0 36.0 46.0 64.0 32.0 178.0 36.0 25.0 0.0 61.0% Compliance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% #DIV/0! 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% #DIV/0! 100.0%pts treated < 31 days 8.0 10.0 3.0 14.0 3.0 5.0 11.0 12.0 8.0 7.0 10.0 2.0 12.0 5.0 32.0 28.0 20.0 28.0 108.0 25.0 19.0 0.0 44.0total pts 8.0 10.0 3.0 15.0 3.0 6.0 12.0 12.0 8.0 7.0 10.0 2.0 12.0 5.0 32.0 28.0 21.0 30.0 111.0 25.0 19.0 0.0 44.0% Compliance 100.0% 100.0% 100.0% 93.3% 100.0% 83.3% 91.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% #DIV/0! 100.0% 100.0% 95.2% 93.3% 97.3% 100.0% 100.0% #DIV/0! 100.0%pts treated < 31 days 12.0 14.0 11.0 16.0 20.0 16.0 20.0 17.0 9.0 20.0 11.0 11.0 10.0 13.0 42.0 37.0 47.0 53.0 179.0 40.0 34.0 0.0 74.0total pts 12.0 14.0 11.0 16.0 20.0 16.0 20.0 17.0 9.0 20.0 11.0 11.0 10.0 13.0 42.0 37.0 47.0 53.0 179.0 40.0 34.0 0.0 74.0% Compliance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% #DIV/0! 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% #DIV/0! 100.0%pts treated < 62 days 13.0 15.0 16.0 10.0 17.0 17.0 19.0 21.0 9.0 13.0 16.0 27.0 23.0 10.0 57.0 52.0 43.0 57.0 209.0 38.0 60.0 0.0 98.0total pts 17.0 19.0 18.0 14.0 22.0 20.0 23.0 23.0 12.0 15.0 23.0 31.0 26.0 12.0 66.0 62.0 54.0 66.0 248.0 50.0 69.0 0.0 119.0% Compliance 76.5% 78.9% 88.9% 71.4% 77.3% 85.0% 82.6% 91.3% 75.0% 86.7% 69.6% 87.1% 88.5% 83.3% #DIV/0! 86.4% 83.9% 79.6% 86.4% 84.3% 76.0% 87.0% #DIV/0! 82.4%pts treated < 62 days 5.0 9.0 9.0 8.0 10.0 1.0 0.0 0.0 3.0 1.0 0.0 0.0 1.0 1.0 16.0 17.0 27.0 1.0 61.0 4.0 2.0 0.0 6.0total pts 5.0 9.0 9.0 8.0 10.0 2.0 0.0 0.0 3.0 1.0 0.0 0.0 1.0 1.0 16.0 17.0 27.0 2.0 62.0 4.0 2.0 0.0 6.0% Compliance 100.0% 100.0% 100.0% 100.0% 100.0% 50.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% #DIV/0! 100.0% 100.0% 100.0% 50.5% 98.4% 100.0% 100.0% #DIV/0! 100.0%pts treated < 62 days 1.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 2.0 2.0 0.0 0.0 4.0 0.0 2.0 0.0 2.0total pts 1.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 3.0 2.0 0.0 0.0 5.0 0.0 2.0 0.0 2.0% Compliance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% #DIV/0! 66.8% 100.0% 100.0% 100.0% 80.1% 100.0% 100.0% #DIV/0! 100.0%

RTT

2015/16 2014/15 2015/16

Exception ReportIndicator Threshold

2014/15

% patients waiting for initial treatment on incomplete pathways within 18 weeks

92.0%

93.0%

Cat A Red 2 8 min 75.0%

DiagnosticsPatients waiting for a diagnostic test should have been waiting less than 6 weeks from referral

1.00%

Ambulance Response Times

Cat A Red 1&2 8 min 75.0%

Cat A 19 min

Cat A Red 1 8 min 75.0%

95.0%

% of patients treated for cancer within 62 days of consultant decision to upgrade status

N/A

MSA

HCAI

HCAI 01Incidence of CDIFF up to 15th October 2015

% of patients receiving subsequent treatment for cancer within 31 days - surgery

94.0%

% of patients receiving subsequent treatment for cancer within 31 days - radiotherapy

94.0%

% of patients treated within 31 days of a cancer diagnosis

96.0%

% of patients treated within 62 days of an urgent GP referral for suspected cancer

85.0% DCCG ER01

Mental Health

% of patients treated within 62 days of an urgent GP referral from an NHS Cancer Screening Service

90.0%

% of patients receiving subsequent treatment for cancer within 31 days - drugs

98.0%

Cancer

% of patients seen within 2 weeks of an urgent referral for breast symptoms

93.0%

% of patients seen within 2 weeks of an urgent GP referral for suspected cancer

NEAS ER01

Performance Issue

Darlington CCG were non compliant against the 62 day standard in Sep-15 reporting 83.3% against the 85% target. YTD the CCG reporting 82.4%.

A total of 12 treatments were recorded under this standard of which 2 failed to be treated within the 62 day target.

Both breaches in Sep-15 were reported in Upper GI.

Exception Report D’ton CCG ER01

Actions Taken

• Copy of responses to second Tripartite letter have been requested but not yet received from all Trusts.

• Trusts are sharing copies of their breach analysis reports (RCA’s) at patient level (anonymised). The RCA’s for July treatments have been distributed to the relevant CCG for information with a summary of the reasons behind the breaches. All RCA’s for August have not yet been received but will be analysed and shared as soon as possible .

• Feedback from NT&H re some reasons why Trusts can achieve and CCGs don’t achieve the 62 day standard – a) CCGS always allocated a full breach where Trusts can share breaches when pathway shared across more than one Trust b) Exeter system doesn’t always have CCG recorded on every record. If a Trust doesn’t go into system to update at the end of the month/qtr, then the CCG total referrals will be understated resulting in breaches more likely causing target not to be achieved. CDDFT and South Tees to look into this in their own Trusts to scope size of issue

• Cancer Network workshop to review elements of Cancer Strategy and contribute to how some of the recommendations need to be taken forward. A lot of the discussions were around capacity of diagnostic services and the major problem that qualified personnel in diagnostics is in short supply and this is a national problem

• Cancer Network is preparing some detailed reports in respect of pathways which will be signed off by the Network Site Specific Groups and then circulated to a wider audience.

Indicator Threshold Trend Line

Apr-15 – Sep-15 D’ton CCG

Sep-15 D’ton CCG YTD Sep-15

% of patients treated within 62 days of an urgent GP referral for suspected cancer 85.0% 83.3% 82.4%

3

Timescale for performance improvement

All Trusts, with the support of their local cancer network partners, are expected to recover the standard as soon as possible and in any event by the end of the 2015/16 financial year.

Other Intelligence Where there is evidence that poor performance is significantly driven by network wide issues, Trusts will be expected to work with local commissioners and other providers involved to develop a pathway based improvement plan.

4

NHS Darlington CCG – Sep-15 Cancer Analysis

% %2 WEEK WAIT 93.0% 259 271 95.6% 1456 1551 93.9%2 WEEK BREAST SYMP 93.0% 44 45 97.8% 257 271 94.8%31 DAY WAIT 96.0% 34 35 97.1% 250 253 98.8%31 DAY SUBS RADIO 94.0% 13 13 100.0% 74 74 100.0%31 DAY SUBS SURG 94.0% 5 5 100.0% 44 44 100.0%31 DAY SUBS DRUGS 98.0% 10 10 100.0% 61 61 100.0%62 DAY WAIT 85.0% 10 12 83.3% 98 119 82.4%62 DAY CNSLTNT UP N/A 0 0 100.0% 2 2 100.0%62 DAY SCREENING 90.0% 1 1 100.0% 6 6 100.0%

62 Day Wait GP Referral

% %Total 85.0% 10 12 83.3% 98 119 82.4%Brain/CNS 85.0% 0 0 100.0% 0 0 100.0%Breast 85.0% 0 0 100.0% 20 21 95.2%Children's 85.0% 0 0 100.0% 0 0 100.0%Gynae 85.0% 3 3 100.0% 12 12 100.0%Haem (exc AL) 85.0% 1 1 100.0% 4 4 100.0%Head & Neck 85.0% 0 0 100.0% 2 3 66.7%Lower GI 85.0% 0 0 100.0% 5 7 71.4%Lung 85.0% 1 1 100.0% 8 11 72.7%Other 85.0% 0 0 100.0% 1 2 50.0%Sarcoma 85.0% 0 0 100.0% 1 1 100.0%Skin 85.0% 2 2 100.0% 21 21 100.0%Testicular 85.0% 0 0 100.0% 0 0 100.0%Upper GI 85.0% 0 2 0.0% 2 5 40.0%Uro (exc testes) 85.0% 3 3 100.0% 22 32 68.8%

Cancer Type Target %Sep-15 Sep-15 Cumulative Position

ACTUAL ACTUAL

Target Type Target %Sep-15 Sep-15 Cumulative Position

ACTUAL ACTUAL

Performance Issue Unadjusted figures for CDDFT show the Trust reporting 2 over 52 week waits in Sep-15 against the Incomplete RTT standard. One of the patients has been identified in the speciality of Ophthalmology and is attributable to NDCCG. One of the patients has been identified in the specialty of General Surgery and is attributable to Darlington CCG. Commissioners have requested an update from the Provider but this has not been received to date.

Exception Report CDDFT ER01

Actions Taken Commissioners are awaiting actions RCA and resulting actions from the provider.

Timescale for performance improvement Following RCA actions will be implemented to ensure no further breaches.

Other Intelligence

NHSE guidance released on 24th June 2015 informed of changes to RTT operational standards. RTT Admitted and Non-Admitted operational standards are being abolished and RTT incomplete will remain as the sole RTT measure. Performance will continue to be reported in 2015/16 but Commissioners can no longer penalise Providers for failure of these target.

5


Apr-15 – Sep-15 STHFT Sep-15

Number of patients waiting more than 52 weeks for treatment (incomplete pathways)

0 2

Performance Issue

In Sep-15 CDDFT reported a position of 1.01% with 86 patients breaching the target. This was a disappointment to the Trust following achievement in Sep-15.

Echocardiography is now the only area where issues remain and mainly at the North Durham Hospital site.

Actions Taken

In relation to the pressures at the North Durham Hospital site:

• Backlog relates solely to Cardiology Echoes

• One member of staff now back from Maternity leave which has alleviated some capacity issues and locum weekend sessions progressing where required

• Shortage of kit and rooms is being addressed by subsequent kit being purchased allowing the transfer of a machine to UHND

• Longer term plans in place by appointing additional Echo staff to deal with increasing demand, this capacity will not come into place until next Summer though due to the training lead in time


Backlog clearance at North Durham Hospital is predicted to be October/November.

Other Intelligence

The financial penalty of £200.00 per breach will be applied, this is a consequence for failure to meet the operation standard. This is in line with the NHS Standard Contract terms and conditions.

6


Apr-15 – Sep-15 CDDFT Sep-15

Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral 1.00% 1.01%


Provider Diagnostic Analysis

7

CDDF

T

CHSF

T

NTHF

T

STHF

T

GHFT

CDDF

T

CHSF

T

NTHF

T

STHF

T

GHFT

CDDF

T

CHSF

T

NTHF

T

STHF

T

GHFT

AUDIOLOGY ASSESSMENT 239 135 364 409 183 0 7 0 41 9 0.00% 5.19% 0.00% 10.02% 4.92%

BARIUM ENEMA 7 2 0 4 45 0 0 0 0 0 0.00% 0.00% 0.00% 0.00% 0.00%

COLONOSCOPY 276 185 182 349 286 1 3 1 48 10 0.36% 1.62% 0.55% 13.75% 3.50%

CT 1221 210 627 792 291 0 2 0 0 0 0.00% 0.95% 0.00% 0.00% 0.00%

CYSTOSCOPY 53 390 92 90 114 0 10 24 0 3 0.00% 2.56% 26.09% 0.00% 2.63%

DEXA SCAN 309 84 229 281 211 0 0 0 0 0 0.00% 0.00% 0.00% 0.00% 0.00%

ECHOCARDIOGRAPHY 860 786 393 89 364 82 0 23 1 43 9.53% 0.00% 5.85% 1.12% 11.81%

ELECTROPHYSIOLOGY 0 0 0 0 0 0 0 0 0 0 0.00% 0.00% 0.00% 0.00% 0.00%

FLEXI SIGMOIDOSCOPY 256 0 68 120 87 1 0 0 10 4 0.39% 0.00% 0.00% 8.33% 4.60%

GASTROSCOPY 391 266 184 262 265 1 0 0 19 9 0.26% 0.00% 0.00% 7.25% 3.40%

MRI 794 285 700 1284 417 0 0 0 0 0 0.00% 0.00% 0.00% 0.00% 0.00%

Non Obstetric ULTRASOUND 3958 795 2524 2045 1720 0 0 0 0 72 0.00% 0.00% 0.00% 0.00% 4.19%

PERIPHEAL NEUROPHYS 80 167 0 304 32 0 0 0 0 3 0.00% 0.00% 0.00% 0.00% 9.38%

SLEEP STUDIES 24 47 0 108 0 0 0 0 2 0 0.00% 0.00% 0.00% 1.85% 0.00%

URODYNAMICS 16 78 19 27 31 1 36 0 0 0 6.25% 46.15% 0.00% 0.00% 0.00%

TOTAL 8,484 3,430 5,382 6,164 4,046 86 58 48 121 153 1.01% 1.69% 0.89% 1.96% 3.78%

Diagnostic Analysis (Site Specific) - Sep-15

DIAGNOSTIC TYPE

No of patients waiting No of patients waiting > 6 weeks % waiting > 6 weeks

Performance Issue

CDDFT breached the performance target each month from April to June 2015. YTD to 9th Nov-15 the provider was reporting 95.6% against the 95.0% target. The Trust performance has increased in each month from Feb-15 through to Sep-15 but here has been a drop in October. This is reflective of pressures across the region.

Actions Taken

A number of proactive steps have been put in place to help prepare for surges, and ensure robust arrangements for reviewing and challenging performance. This includes:

• The national ECIST Team have been supporting CDDFT in recent months including in the development of their Unscheduled Care Improvement Plan. The Programme will be led by the Director of Operations

• Project Groups have been established to plan for the co-location of A&E and Urgent Care at DMH and the expansion of ED/Medical Assessment at UHND. Final decisions will be made in the context of forthcoming SeQiHS recommendations for the Durham and Tees Valley health economy

• CDDFT have submitted and now had approved their winter resilience schemes with funding contribution from CD&D SRG. Schemes are in line with the 8 High Impact Interventions. The SRG has recently agreed in late October to fund another scheme around discharge although details are still being worked through

• The North East Care Vanguard for Urgent and Emergency care has now been approved and is being managed through the regional Urgent and Emergency Care Network. Locally all acute trusts included CDDFT will benefit from this work. Current key priorities include the new payment model to improve how urgent and emergency care services work together and the flight deck which has been re-established from 1st Oct 2015.

• A weekly SRG phonecall is now in diaries to address any immediate local pressures • CDDFT now have in place their Winter Plan and NEEP escalation framework for 2015/16. A regional event took place on 8th Oct to provide assurance to

NHS England • A tripartite meeting took place with CCG’s, Monitor, NHS England and CDDFT in August. Following this meeting it was requested that the SRG provide an

action plan with the top 3 priorities for improvement. This has been done and is monitored monthly via SRG • A business case to move most elective Orthopaedics from Acute sites to BAH is close to completion. It is intended the move will take place before the

end of 2015/16 • The Trust is undertaking the ‘perfect week’. This will take place at UHND 11-18 November and at DMH 9-16 November


The Trust is now achieving this target YTD.

Other Intelligence

Although published weekly A&E data had previously been available, national guidance has resulted in A&E performance data now only being reported monthly. Local arrangements have been made with CDDFT to provide daily unvalidated information.


May-15 – Oct-15 CDDFT Oct-15

CDDFT YTD 9th Nov-15

% patients spending 4 hrs. or less in A&E minor injury unit 95.0% 95.0% 95.6%


8

Performance Issue

CDDFT continue to remain an outlier across the region. In September 2015 a total of 81 delays were reported. However performance has improved month on month since January 2015 and in September 2015 the number of delays was at it’s lowest level since 2013/14.

Issues within A&E (CDDFT ER03) impact on achievement of this target.

Actions Taken

The actions set out in CDDFT ER03 aim to help assist with decreasing the number of delays being reported. Further actions include: • Length of stay has reduced by 10% following the implementation of the ‘Perform’ Project

• Resilience monies have been allocated to provide additional Emergency Department (ED) staffing and bed capacity

• Expansion of the UHND (MAU) Acute Admissions Department


As this indicator carries a zero tolerance target, the Trust will continue to report a breach against both of these targets.

Other Intelligence

Q1 Ambulance diverts data recorded a total of 91 diverts (Penalties, £182,000) with 70 diverts from other providers being accepted into CDDFT (incentives, £105,000). A large number of diverts are being recorded from UHND to DMH.

9



CDDFT YTD Sep-15

Handover between ambulance and A&E over 30 minutes 0 81 938

Handover between ambulance and A&E over 60 minutes or more 0 6 206


Performance Issue

CDDFT reported 90.5% in Sep-15 against the 93% operational standard.

Under performance of the operational standard reported in April, June, July & September has impacted negatively on the Q1, 2 and YTD position.

Urgent 2WW Breast Symptomatic referrals rose by 25% in Q1 in comparison to the same period in 2014/15. The closure of the Breast service at City Hospitals Sunderland has resulted in a flow of patients being diverted to CDDFT. CDDFT provide additional clinics but patient choice prevents target always being achieved.

Actions Taken

CDDFT continue to implement a number of actions to address overall cancer performance, other key specific actions include: • Cancer services are working closely with Care Groups to ensure capacity is increased if necessary • The new mammography machine is due to ne installed in DMH to commence the new out-patient service. The first breast clinic to go-live

using the new machine will take place on Monday 17th August • The Trusts are looking to secure an additional 15 slots per week although this will not come into place until the new year


CDDFT are aiming to achieve this indicator going forward to bring the YTD position back in line.

Other Intelligence

Cancer Research UK launched the latest Be Clear on Cancer Breast Campaign which aims to target women over 70. The campaign will run from the 13th July to 6th September the message will focus on “1 in 3 women who get Breast Cancer are over 70, so don’t assume you’re past it”.

10



CDDFT YTD Sep-15

% of patients seen within 2 weeks of an urgent referral for breast symptoms 93.0% 93.0% 91.7%


Performance Issue

The trust reported 121 breaches of the 6 week diagnostic target in Sep-15. The breaches for September were 48 colonoscopy, 41 audiology, 19 gastroscopy, 10 flexi sigmoidoscopy, 2 sleep studies and 1 cardiology (echo). Gastroenterology has developed an action plan to address their capacity issues.

Actions Taken Audiology is as short term resource issue due to a member of staff leaving, the service are undertaking the recruitment process to appoint a replacement and are exploring the possibility of a locum to support capacity in the interim.

Timescale for performance improvement Provisional data for Oct-15 shows that performance continues to be off-track. This is due to a Cardio Scanner breaking down. The scanner does routinely receive maintenance and when taken off-line a mobile scanner is used. As this was an unplanned break down it has resulted in delays in obtaining the mobile scanner and therefore impacting of capacity. Nov-15 performance is also at risk if a mobile scanner is not in place.

Other Intelligence

11

Indicator Threshold Trend Line Apr-Sep-15

STHFT Sep-15

Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral

1.0%

1.96%

Trend Line Apr-14 – Mar-15

STHFT Sep-14

1.03%

Exception Report STHFT ER01

Performance Issue

South Tees NHS Foundation Trust (STHFT) have historically experienced significant pressures within their A&E department and this has resulted in some patients waiting an excessive amount of time to be handed over by the ambulance crew. As a result of improved performance within the emergency department, South Tees FT continues to report a decline in ambulance handover numbers. The Trust understands that this indicator carries a zero tolerance however continue to work hard to reduce the numbers being reported.


Actions Taken The Actions taken to address increasing pressures within A&E (STHFT ER02) provide detail on the actions being taken by the Trust to address this issue. It is anticipated that the Action plan will positively impact on trying to minimise handover delays being experienced within the Trust.

Timescale for performance improvement Although never acceptable, instances of handover delays remain due to the increasing demand and pressures being faced within A&E. Commissioners will continue to monitor STHFT and apply the appropriate contractual penalties.

Other Intelligence


Apr-15 – Sep-15 YTD

Sep-15

Handover between ambulance and A&E over 30 minutes 0 238

Handover between ambulance and A&E over 60 minutes or more 0 44

12

Quality Indicator Operational Standard

Period Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD

2015/16 68 38 28 53 25 26 238

2014/15 39 73 42 60 40 105 102 113 102 157 101 103 1037

2015/16 15 6 3 11 4 5 44

2014/15 2 6 4 21 7 27 12 35 31 46 22 34 247

Handover between ambulance and A&E 30 minutes or more 0

Handover between ambulance and A&E 60 minutes or more 0

Performance Issue Performance of the 62 Day Urgent GP standard remains an area of concern for the Trust. Figures for Sep-15 report the Trust non-compliant for the 6th consecutive month in a row with performance at 76.9% against the 85% operational standard. Indicative figures for Oct-15 show that the Trust are likely to fail the target again. The Trust has failed to achieve compliance in Q2. The Trust were aware that failure of Q2 may possibly instigate a MONITOR review due to on-going underperformance however the Trust have discussed with MONITOR who have informed they have until Q3 to improve performance before any review will be instigated. There is still a risk around Q3 performance against this indicator.


Actions Taken • Urology continues to be the main area of concern. Lists have been taken from other specialties and given to Urology to increase elective capacity. To

increase capacity the Trust is looking to implement additional weekend sessions (now available Sat & Sun rather one or the other).

• Endoscopy – capacity issues. An action plan has been developed and performance is expected to improve in Oct/Nov-15. A Gastroenterologist has been appointed and commences in Dec-15.

• The Trust has indicated that they are now compliant with the 8 key priorities. 1 of the priorities relates to a Demand & Capacity Tool which the Trust are looking to implement. The tool requires training which STHFT were willing to host.

• The Trust confirmed that individual Tumour Site Specific Action Plans have been developed with those tumour sites failing to achieve the 85% operational standard. The Deputy Director of Performance (Sarah Danieli) will be presenting these action plans to Commissioners at the SRG on 18th Nov-15. Quarter 2 performance indicated an additional failing tumour site of Lower GI. Sarah Danieli will share action plan.

• The Trust was aware of the new guidance issued from Monitor/NHSE/TDA in relation to improving and sustaining cancer performance. Sarah Danieli confirmed that RCA’s are carried out on all breaches and confirmed work was underway on a process to assess clinical harm on patients waiting over 104 days.

• Workforce Risks – The Trust are actively looking at overseas recruitment to fill Consultant Vacancies. In terms of Urology a new locum is scheduled to start in Dec-15.

Timescale for performance improvement The Trust anticipates achievement of this indicator in Quarter 3.

Other Intelligence

The Trust continue to challenge the current policy on late referrals and are in discussions with NHSE regarding this. The Trust have indicated that if changes

were made regarding late referrals then performance would significantly improve. 13


Apr-15 – Sep-15 Quarter 2 2015/16

Sep-15 STHFT YTD

Sep-15

% of patients treated within 62 days of an urgent GP referral for suspected cancer 85.0%

79.0% 76.9% 80.4%

Trend Line Apr-14 – Mar-15

Quarter 2 2014/15

Sep-14 STHFT Year End 2014/15

84.2% 79.1% 84.9%

Performance Issue North Tees FT reported achievement of the 2 Week Wait standard in Sep-15 reporting 94.1% against the 93% operational threshold. A total of 765 referrals were received in Sep-15 of which 45 failed to be treated within target.

Exception Report NTHFT ER01

Actions Taken The Trust’s Cancer Improvement Recovery Plan has been developed to support the improvement of cancer targets. The plan is expected to deliver improvements in the following key areas: • Pathway Management – reviewing previous task and finish action plans to ensure full implementation • Governance Processes – reviewing accountability, escalation processes and waiting list monitoring procedures • Management of Patient Tracking – review the current overall tracking procedures and the associated workload management North Tees FT provide assurance that all patients are offered an initial first seen out-patient appointment within 14 days from receipt of referral however there are patients who choose to wait and this creates a delay in being seen. The Trust previously requested for further GP engagement to ensure patients are aware of the importance of their referral and are looking to secure attendance at the next and future CCG time-out events to progress this via clinician to clinician discussions. The Trust has secured attendance for two of their cancer leads at the Nov-15 time out session to progress the clinician to clinician discussions regarding the importance of ensuring that patients are aware of the importance of their referral. They will also take this opportunity to discuss the new national 2ww guidance with the GPs. Timescale for performance improvement The Trust continues to monitor Cancer performance through internal governance processes with robust escalation frameworks in place, however the delivery of Cancer standards requires a system wide approach. The Trust recognises that close working with external stakeholders is a key element to ensuring patients are fully informed at point of referral, therefore reducing unnecessary waits due to patient choice. The Trust has advised that they aim to recover performance for all Cancer Targets by the end of quarter 3 2015/16 with an acknowledgement that this is still subject to some influencing factors outside of their control. They are open to discussions with both the CCGs and neighbouring organisations to look at any system wide pathway changes that could be developed to improve cancer pathways and consistent performance against the standard.

Other Intelligence

14


Apr-15 – Sep-15 Quarter 2 2015/16

Sep-15 NTHFT YTD

Sep-15

% of patients seen within 2 weeks of an urgent referral for suspected cancer 93.00%

91.8% 94.1% 92.4%

Trend Line Apr’14 – Mar’15

Quarter 2 2014/15

Sep-14 NTHFT Year End 2014/15

92.6% 94.0% 93.9%

Performance Issue North Tees FT reported non compliance of the 62 day urgent GP standard in Sep-15 reporting 80.0%. In Sep-15 a total of 45 treatments were recorded for this standard of which 9 failed to be treated within 62 days.

Exception Report NTHFT ER02

Actions Taken The Trust’s Cancer Improvement Recovery Plan has been developed to support the improvement of cancer targets. The plan is expected to deliver improvements in the following key areas: • Pathway Management – reviewing previous task and finish action plans to ensure full implementation • Governance Processes – reviewing accountability, escalation processes and waiting list monitoring procedures • Management of Patient Tracking – review the current overall tracking procedures and the associated workload management The Trust review the weekly Cancer PTL’s and actions are highlighted and shared with appropriate teams. Minutes from the PTL review group are shared with the Cancer Delivery Group. Monthly breach meetings have been re-instated for Commissioners to discuss breaches with Provider. The Trust’s action plan update has been received and approved by the commissioner and has subsequently been shared with Monitor and NHS England. Timescale for performance improvement North Tees FT achieved Q1 and are compliant for the YTD position. . The Trust has advised that they aim to recover performance for all Cancer Targets by the end of quarter 3 2015/16 with an acknowledgement that this is still subject to some influencing factors outside of their control. They are open to discussions with both the CCGs and neighbouring organisations to look at any system wide pathway changes that could be developed to improve cancer pathways and consistent performance against the standard. Other Intelligence

The trust has set up a lung task & finish group to focus work for this tumour group.

Following the national requirement regarding subsequent PTL management whereby any breaches >104 days will have a RCA undertaken, it has been agreed

that the details of these will be shared with the CQRG group for comment / action as appropriate and will also be discussed at the regional commissioner

network meeting.

15


Apr-15 – Sep-15 Quarter 2 2015/16

Sep-15 NTHFT YTD

Sep-15

% of patients treated within 62 days of an urgent GP referral for suspected cancer 85.0%

83.2% 80.0% 84.4%

Trend Line Apr’14 – Mar’15

Quarter 2 2014/15

Sep-14 NTHFT Year End 2014/15

85.9% 91.7% 83.9%

Performance Issue North East Ambulance Service are commissioned to provide the operational standards at a service level. At a Trust level NEAS performance throughout August, September & October reported a decline in the provider failing to achieve the operational standard for both 8 minute response times and 19 minute response times. NEAS are now reporting a YTD position to Oct-15 below standard for both indicators. In Oct-15, NEAS reported 67.3% for 8 minute response times against the 75% threshold and 91.8% for 19 minute response times against the 95% threshold. D’ton CCG reported under achievement in October against both indicators in month and are currently failing the 19 min indicator at a YTD position.

The last financial year and this year, to date, have been challenging for NEAS. Though there has been an overall decrease in absolute incident numbers, influenced by an increase in the Hear and Treat rate, Red performance has been below the three national standards. Influences over NEAS’ performance include:

• Vacancies – NEAS is carrying a large number of paramedic vacancies. The national shortage of trained paramedics has impacted on recruitment plans.

• Due to the pressure from Monitor to reduce our deficit from its current £4.7 m to £3.5m NEAS have had to take the steps of:

– reducing our 3rd party support from September 2015 – the pattern of demand has been reviewed and those 3rd party resources available to NEAS have been targeted to meet the peaks.

– not being able to continue to support our Community First Responder scheme to the same level further to the ending of the BHF funding of £350k – NEAS still has an expansive list of CFRs, but does not now have the infrastructure in place to support them as closely as in previous years.

• National change to Red 1 categorisation (October 2014) – for the past year, NEAS has seen a trebling of the Red 1 demand following a national change to include peri-arrest patients in this category. This increase in demand for Red 1 incidents has increased pressure on NEAS response times.

• Red incident demand – NEAS has seen an increase in Red incident demand in October 2015, with 8%, or 40, more per day than in September 2015. An increase in Red demand was also seen in August 2015, which saw an increase of 5% over August 2014. From the latest national benchmarking ambulance data, NEAS is the third highest responding ambulance service in the country (as at August 2015), which, in light of current performance, reflects pressure being felt nationally for ambulance responses. The increased Red demand this month is reflected in our current performance. Month to date, as at 16th October 2015, is; Red 1 at 70.04%, Red 2 at 69.13% and Red 19 at 91.94%.

• Hospital delays – NEAS continues to experience a high number of hospital delays and is also starting to see hospital diverts increase. In September 2015, there were 40 diverts in total and for the period 9th to 15th October 2015 there have been 15 diverts in place.

• Increase in alternative dispositions – NEAS has maintained a high level of See & Treat outcomes for patients, with over 40,000 patients not conveyed to hospital in April to September this year, which is in line with 2014/15. NEAS has seen an increase of 11% in Hear & Treat cases this financial year.

• Ambulance Response Programme - the pilot began for NEAS week commencing 5h October 2015 and will run until 31st March 2016. This pilot programme is not designed to target direct increases in Red performance, but rather to improve on the accuracy of triage and target the right response for the patients’ needs.

Indicator Threshold CCG

YTD Oct-15 CCG Trend Line May-15 – Oct-15

NEAS YTD Oct-15

NEAS Trend Line May-15 – Oct-15

8 minute response 75.0% 77.2% 73.4%

19 minute response 95.0% 92.9% 94.4%

Exception Report NEAS ER01

16

Timescale for performance improvement Performance activity is being monitored daily with several actions coming into effect however NEAS have provided no assurances that performance will be achieved in the coming months.

The target date to achieve full establishment in terms of recruitment is planned for September 2016.

Other Intelligence Recruitment activity is underway to achieve full establishment across the service lines. The target date is still September 2016 to achieve full establishment. Third party providers are continuing to be used in the interim. More work needs to be done to understand the impact of sickness absence has on safe staffing levels and the reasons for attrition. Paramedic recruitment continues to be challenging with the numbers leaving being greater than those being recruited. Whilst NEAS acknowledge there is a national shortfall, the Trust has successfully recruited 21 qualified paramedics since October to date.

Exception Report NEAS ER01 continued

17



NEAS YTD Oct-15


8 minute response 75.0% 73.4%

19 minute response 95.0% 94.4%

Actions Taken To address the current performance situation, NEAS is looking to the following actions over the course of this year:

• Deep dive into the Red rate – NEAS understands that some of the pressure from Red incidents is created internally and is implementing a root cause analysis into the rate of Red incidents triaged. This will look to address and issues system related as well as process and staff related.

• HALOs – NEAS is introducing HALOs at two hospital sites – NSECH and QEH Gateshead. The HALOs will help to reduce handover issues over the winter period.

• End of Life vehicles – NEAS has introduced three ring fenced EoL vehicles. The provision of this as a standalone service relieves some of the pressure on our core resources.

• Clinical Hub – NEAS has been through two rounds of recruitment for Clinical Hub clinicians and is looking to recruit an additional 19 clinicians in total.

• Co-responding with Fire and Rescue Services – NEAS is working closely with the four Fire and Rescue Services in our area on an agreement for responding to incidents. Discussions are currently focussing on identifying potential FRS stations for a pilot scheme.

• REAP Level 3 – in reaction to the current demand, sickness and performance levels, the Trust has increase the REAP level to 3. This means that some patient transport service vehicles will move onto emergency care front line services; paramedic trainers and other clinical staff working in support services will return to front line duties; and clinically qualified managers will be made available for front line duties.

NEAS is currently reviewing and consolidating previous action plans, with the view to sharing a new action plan with commissioners in Nov-15.



NEAS YTD Oct-15


8 minute response 75.0% 77.2% 73.4%

19 minute response 95.0% 92.9% 94.4%

Analysis of Ambulance Response Times – All Providers 2015/16

18

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Trend Line

Org Code

Provider Organisation Name Apr-15 to Sep-15

Numerator 714 699 639 666 638 622

Denominator 975 904 833 887 883 857

North East Ambulance Service 73.2% 77.3% 76.7% 75.1% 72.3% 72.6%

Numerator 1,160 1,099 1,037 1,172 1,132 1,098

Denominator 1,548 1,491 1,494 1,655 1,647 1,567

Yorkshire Ambulance Service 74.9% 73.7% 69.4% 70.8% 68.7% 70.1%

Numerator 830 811 730 796 744 729

Denominator 1,106 1,048 990 1,061 1,046 1,033

East Midlands Ambulance Service 75.0% 77.4% 73.7% 75.0% 71.1% 70.6%

Numerator 1,036 1,057 960 1,049 1,042 977

Denominator 1,297 1,310 1,272 1,405 1,418 1,378

East of England Ambulance Service 79.9% 80.7% 75.5% 74.7% 73.5% 70.9%

Numerator 24 37 20 39 35 33

Denominator 32 48 30 56 51 42

Isle of Wight NHS Trust 75.0% 77.1% 66.7% 69.6% 68.6% 78.6%

Numerator 772 724 835 776 809 682

Denominator 1,111 1,079 1,254 1,155 1,229 1,097

London Ambulance Service NHS Trust 69.5% 67.1% 66.6% 67.2% 65.8% 62.2%

Numerator 1,717 2,015 1,819 1,830 1,781 1,681

Denominator 2,411 2,471 2,279 2,308 2,291 2,144

North West Ambulance Service 71.2% 81.5% 79.8% 79.3% 77.7% 78.4%

Numerator 828 768 631 645 631 651

Denominator 1,080 1,016 868 952 886 947

South Central Ambulance Service 76.7% 75.6% 72.7% 67.8% 71.2% 68.7%

Numerator 864 861 814 809 789 818

Denominator 1,139 1,157 1,124 1,104 1,090 1,125

South East Coast Ambulance Service 75.9% 74.4% 72.4% 73.3% 72.4% 72.7%

Numerator 1,043 1,063 1,021 1,087 1,135 1,001

Denominator 1,322 1,415 1,356 1,443 1,490 1,334

South Western Ambulance Service 78.9% 75.1% 75.3% 75.3% 76.2% 75.0%

Numerator 1,513 1,474 1,516 1,534 1,437 1,503

Denominator 1,864 1,888 1,901 1,933 1,782 1,913

West Midlands Ambulance Service 81.2% 78.1% 79.7% 79.4% 80.6% 78.6%10,501 10,608 10,022 10,403 10,173 9,795

13,885 13,827 13,401 13,959 13,813 13,437

75.6% 76.7% 74.8% 74.5% 73.6% 72.9%

RYD

RYF

RYA

England Total

% of Red 1 Calls responded to within 8 minutes

England Tota l Numerator

England Tota l Denominator

RX6

RX8

RX9

RYC

R1F

RRU

RX7

RYE


Org Code


Numerator 10,511 10,734 9,898 10,980 10,163 10,614

Denominator 13,622 13,745 13,457 14,593 14,361 14,624


Numerator 15,809 16,599 15,743 16,468 16,697 16,431

Denominator 21,759 22,580 22,357 23,489 23,844 23,326


Numerator 15,138 15,670 14,930 14,859 14,185 14,125

Denominator 20,287 21,109 20,461 21,128 21,689 21,349


Numerator 16,696 16,954 15,845 15,781 15,595 14,534

Denominator 23,341 24,349 23,988 25,232 25,232 24,759


Numerator 459 463 432 473 423 416

Denominator 617 612 564 628 618 549


Numerator 24,283 25,724 25,274 26,457 25,711 24,457

Denominator 37,525 38,670 38,743 39,965 39,572 39,382


Numerator 24,058 26,907 27,005 26,433 26,144 25,761

Denominator 33,355 33,884 34,548 34,799 34,659 34,408


Numerator 9,983 10,499 10,060 9,892 10,298 9,893

Denominator 13,043 13,789 13,497 13,958 14,375 13,955


Numerator 16,378 16,692 15,588 16,150 16,142 15,488

Denominator 21,178 21,951 21,017 22,024 22,412 21,166


Numerator 15,812 16,623 15,942 16,780 18,025 16,571

Denominator 23,181 25,091 24,191 25,177 26,123 24,333


Numerator 23,060 24,212 22,837 23,957 24,102 22,962

Denominator 30,019 31,523 30,339 31,513 31,639 30,589


237,927 247,303 243,162 252,506 254,524 248,440

72.4% 73.2% 71.4% 70.6% 69.7% 68.9%

RX6

RX8

RX9

RYC

R1F

RRU

RX7

RYE

RYD

RYF

RYA



England Total

% of Red 2 Calls responded to within 8 minutes


Org Code


Numerator 13,965 14,101 13,440 14,695 14,325 13,665

Denominator 14,573 14,634 14,265 15,457 15,213 14,648


Numerator 22,360 23,079 22,619 23,794 24,095 23,571

Denominator 23,244 23,978 23,744 24,961 25,356 24,740


Numerator 20,068 20,782 20,028 20,325 20,169 19,995

Denominator 21,349 22,113 21,414 22,140 22,672 22,316


Numerator 23,474 24,267 23,282 24,047 24,004 23,095

Denominator 24,570 25,587 25,153 26,498 26,509 25,985


Numerator 532 602 498 610 607 537

Denominator 554 631 552 643 641 564


Numerator 36,181 37,384 37,075 38,230 37,793 37,080

Denominator 38,418 39,543 39,718 40,870 40,535 40,208


Numerator 33,172 34,865 35,222 35,018 35,081 34,508

Denominator 35,561 36,175 36,740 37,033 36,884 36,478


Numerator 13,371 13,934 13,435 13,887 14,208 13,934

Denominator 13,977 14,634 14,228 14,828 15,136 14,876


Numerator 21,511 22,169 21,037 21,817 22,123 21,122

Denominator 22,317 23,108 22,141 23,128 23,502 22,291


Numerator 22,679 24,283 23,209 24,040 24,900 23,391

Denominator 24,471 26,464 25,486 26,558 27,218 25,573


Numerator 31,131 32,601 31,415 32,582 32,543 31,501

Denominator 31,883 33,411 32,240 33,446 33,421 32,502


250,917 260,279 255,681 265,562 267,087 260,181

95.0% 95.3% 94.4% 93.8% 93.5% 93.2%


RX6

England Total

R1F

RRU

RX7

RYE

RYD

RYF

RYA

RX8

RX9

RYC

% of Cat A Calls responded to within 19 minutes


Performance Issue MRSA 2015/16 up to 15th October 2015 CCG have a confirmed case of MRSA reported in Aug-15 CDDFT have a confirmed MRSA case reported in May-15. STHFT have a confirmed MRSA case reported in Apr-15 and an unconfirmed case reported in Oct-15 C.Diff 2015/16 up to 15th October 2015 Darlington CCG – A total of 14 cases against an annual trajectory of 17 (CCG is currently over planned trajectory) CDDFT – A total of 10 cases reported against an annual trajectory of 19. STHFT – A total of 32 cases reported against an annual trajectory of 50 (Provider is currently over planned trajectory). NTHFT – A total of 19 cases reported against an annual trajectory of 13. (Provider has now breached the target set for 2015/16)

Exception Report HCAI01

Actions Taken All breaches are discussed through monthly Clinical Quality Review Group meetings. The post infection review process has been followed for all identified cases with relevant lessons learnt identified and actions implemented as appropriate.

Timescale for performance improvement There is a zero tolerance of MRSA which means that all commissioner and provider targets are zero and therefore any breaches will remain for the whole of 2015/16.

Other Intelligence

19

Indicator Threshold CCG CDDFT STHFT NTHFT

Incidence of MRSA 0 1 1 2 0

Incidence of C.Diff Various 14 10 32 19

Quality Premium 2014/15

The 'quality premium’ is intended to reward CCGs for improvements in the quality of the services that they commission and the associated improvements in health outcomes and reducing inequalities. The quality premium paid to CCGs in 2015/16 will reflect the quality of the health services commissioned by them in 2014/15 and will be based on five national measures and one local measure. The total payment for a CCG based on performance against the four national measures and the three local measures will be reduced if providers do not meet the NHS Constitutional rights or pledges for patients (RTT 18 week, A&E 4 hour, Cancer 2 week waits & 8 min Cat A ambulance calls). The total amount possible for CCGS to receive in achievement of the Quality Premium will be £5 per patient in the CCG, according to the same formula as the payment of the running cost allowance. For Darlington CCG this amounted to £522K for 2014/15. The 2014/15 quality premium position is summarised on the following page, highlighting the indicators against which the quality premium will be determined, together with the relevant financial value attributed to each indicator and the latest assessment of performance. This summary now includes a ‘best, worst and likely’ scenario as due to the timing of published data it is uncertain at this stage whether a number of the indicators will be achieved or not. The 2013/14 Quality Premium was finalised during 2014/15, with a total amount of £163,417 but this was reduced to £0 following an adjustment due to financial performance.. It is anticipated that similar timescales will apply for the award of the 2014/15 quality premium, with the final amount confirmed during 2015/16 and any relevant funding received by Q4.

20

National and Local Quality Premium Indicators 2014/15

21

Population 104,587 Potential Fund £522,935

MeasurePercentage of

Quality PremiumValue for

CCG's ThresholdOutcome and data

publishedMeasure Achieved/Forecast

Best Worst

Preventing people from dying prematurely 15.00% 78,4403.2 % reduction 2014 from 2014

from 2013Summer 2015

2013 Rate - 2,229.22014 Rate - 2,487.6

Indicator not achieved£0 £0

IAPT 15.00% 78,440 15% by 31.03.15 Monthly updates14/15 year end position was

12.6% which is below target of 12.8% and QP Indicator is 15%

£0 £0

Avoidable emergency admission 25.00% 130,734Composite measure for 2014/15 is

less than or equal to 2013/14Summer 2015

Failed - reported 2,621.48 to Mar-15 YTD

£0 £0

F&F Test 15.00% 78,440Action plan, assurance on actions &

roll outMonthly updates

Average ED score in 14/15 greater than 13/14

£78,440 £0

Improved reporting of medication safety incidents

15.00% 78,440Agreed increase in reporting from Q4

2013/14 to Q4 2014/156 mthly updates

Data released in October for previous year so not expecting this data until October 2015.

£78,440 £0

Percentage of Quality Premium

Value for CCG's

ThresholdOutcome and data

publishedMeasure Achieved/Forecast Best Worst

D'ton CCG Local Indicator

Emergency admissions within 30 days of discharge

15.00% 78,440 13.79% Quarterly updates Mar-15 YTD 12.97% £0 £0

100.00% 522,935 £156,881 £0Exception

Report

-£39,220 £0

-£39,220 £0

-£78,440 £0£78,440 £0Revised Total

Category A Red 1 ambulance calls - 75% target 73.63% Mar-15 25%

Total Adjustment

A&E waits - 95% target 94.34% to 31st Mar 15 25%

Cancer 2 ww - 93% target 95.90% Mar-15 0%

Referral to treatment times (18 weeks - Incomplete) - 92% target 94.44% Mar-15 0%

National Indicators

Indicator

Value Measure Achievement

Total

NHS Consitutional rights and pledges Measures Achieved/Forecast Adjustment to funding Quality Premium Funding Adjustment

Exception Report

NHS D'ton CCG - Quality Premium 2014/15

Indicator

D'tonAchievement Exception

ReportValue

Quality Premium 2015/16

For 2015/16, the quality premium will be based on four national measures and two local measures, with any achievement subsequently paid to the CCG in 2016/17. The total payment for a CCG based on performance against the four national measures and the two local measures will be reduced if providers do not meet the NHS Constitutional rights or pledges for patients. The total amount possible for CCGs to receive in achievement of the Quality Premium will be £5 per patient in the CCG, according to the same formula as the payment of the running cost allowance. For Darlington CCG this amounted to £522K in 2014/15 and the 2015/16 figure is expected to be a similar amount. The following page includes the 2015/16 quality premium and highlights the indicators against which the quality premium will be determined, together with the relevant financial value attributed to each indicator.

22

National and Local Quality Premium Indicators 2015/16

23

Population 104,587 Potential Fund £522,935

Measure

Percentage of Quality Premium

Value for CCG's Threshold Data Source Published Data Measure Achieved/Forecast Best Worst

10.00% 52,294

average trend percentage reduction in the potential years of life lost (standardised for sex and age) from amenable mortality for the CCG

population to be achieved over the period between the 2012 and 2015 calendar years. This should be no less than 1.2%

HSCICBaseline data for 2014 will be available in summer 2015. Outcome data for 2015 will

be available in summer 2016

Data will not be published until Oct-16

£52,294 £0

Avoidable emergency admissions 15.00% 78,440a reduction, or a zero per cent change, in the annualised trended change in the Indirectly Standardised Rate of emergency admissions for these

conditions over the 4 years 2012/13 to 2015/16HES

Baseline data for 2014/15 will be available in summer 2015. Outcome data for

2015/16 will be available in summer 2016No data available at this stage £78,440 £0

Delayed transfers of care which are an NHS responsibility

15.00% 78,440The total number of delayed days caused by delayed transfers of care in

2015/16 should be less than the number in 2014/15Delayed Transfers of Care (NHS England)

MonthlyRate of 537 to Aug-15 - less than

14/15 equivalent period.£78,440 £0

Reduction in the number of people with severe mental illness who are currently smokers

20.00% 104,587A reduction in the percentage of people with severe mental illness

who are current smokersGP data extracted by

GPES.Quarterly

42.3% to Aug-15 - baseline is still being calculated

£104,587 £0

Improvement in the health related quality of life for people with a long term mental health condition

10.00% 52,294A reduction in the difference between the health related quality oflife for people with any long term conditions compared to those

with a mental health long term condition

Data source: GP Patient Survey, CCG

OIS

Data availability:2014/15-September 20152015/16-September 2016

Data will not be published until Sep-16

£52,294 £0

10.00% 52,294

Part a) reduction in the number of antibiotics prescribed in primary care by 1% or greater.

Individual practice reduction to be decided by the CCG.Part b) number of co-amoxiclav, cephalosporins and quinolones as a percentage of the total number of selected antibiotics prescribed in primary care to be reduced by 10% from each CCG’s 2013/14 value,

Part c) Secondary care providers validating their total antibiotic prescription data

PHE gov.uk website. 6 monthly

To Jul-15Achieving co-amoxiclav element

Close to achieving antibiotic element with downward trend and

9 months left

£52,294 £0

Local Measure 1Emergnecy re-admissions within 30 days of discharge from hospital

10.00% 52,294 Reduction from 14-15 to 15-16 HES Monthly No data available at this stage £52,294 £0

Local Measure 2An increase in the % of patients on a palliative care register to 0.7%

10.00% 52,294 Increase to 0.7% Trust Quarterly No data available at this stage £52,294 £0

100.00% 522,935 £522,935 £0

Percentage Value of Quality Premium

Value for CCGQuality Premium

Funding AdjustmentQuality Premium

Funding AdjustmentException

Report

RTT Incomplete 30% 156,881 94.9% YTD Sep-15

A&E A&E 4 hour target 30% 156,881 95.6% YTD Sep-15

Cancer Cancer 2WW First seen OPA within 14 days of referral 20% 104,587 93.9% YTD Sep-15

NEAS Category A Red 1 ambulance calls 20% 104,587 74.3% YTD Oct-15 -£104,587 £0 NEAS ER01

100% 522,935 -£104,587 £0

£418,348 £0Other Adjustments (adverse variance against planned financial position)Revised Total

Local Indicators

D'ton CCG Local Indicator

Total

NHS Consitutional rights and pledges

Indicator Operational Standard Achievement/Current Performance

Total Constitutional Adjustment

92%

95%

93%

75%

National Indicators

National Indicators

Reducing potential years of life lost

Urgent and emergency care

Improving Antibiotic Prescribing

Mental Health

NHS D'ton CCG - Quality Premium 2015/16

Indicator

D'ton CCG

Exception Report

Value Achievement


Governing Body

Agenda Item: 65

1 December 2015

Title Planning Round 2016/17


Category

Strategy &

Planning ☒

Performance &

Operational ☐

Governance &

Assurance ☐


Jackie Kay, Assistant Chief Officer

Clinical Sponsor

Andrea Jones

Author of Report Andrew Copland – Commissioning and Delivery Manager Hartlepool and Stockton on Tees CCG

Recommendation(s) Governing Body is asked to:

• note the briefing provided • consider the key issues identified for the CCG • agree that a further report comes to Governing Body in

January to provide an update once formal guidance has been received

Executive Summary

The purpose of this report is to provide the Governing Body with a summary of the requirements of the Planning Round for 2016/17 and the key issues to be addressed by NHS Darlington Clinical Commissioning Group (CCG). Whilst formal Planning Guidance has yet to be released a WebEx was held by NHSE on the 21st October 2015 and the key national planning messages were:

• CCGs should start their planning now and look to refresh as guidance is published in late December,

• Start now within local systems to develop the direction of travel to 2020, and the translation of these into deliverables for the service,

• The need for transformational change was reiterated to meet the £22bn challenge identified in the Five Year Forward View (FYFV),

• Develop and confirm Units of Planning (UoP) for longer term transformational plans, with joint work by commissioners and providers in the units of planning,

• Consideration to be given to increasing the footprint of existing UoP,

• CCGs should develop their operational plan for 2016/17 as a subset of plans developed at new UoP level.

To support the above the Spending Review will be announced on 25th November, and is likely to be accompanied by multi-year allocations to commissioners Early messages are for the development of a health care system wide sustainability and transformation plan between commissioners and providers, working with local authorities, to deliver the required transformation. Plans will need to be place based, multi-year and set out the changes needed to close the three gaps (quality, prevention and finance) between now and 2020. There is a clear need for system leadership and CCGs will have a key role in shaping the response to the Transformation challenge, developing clear plans and making their contribution to closing the financial gap as set out in Five Year Forward View. One early and key consideration for the CCG will be the refresh of the Unit of Planning (UoP). This review of the UoP should be regarded as part of a move towards place based planning. This will mean the expansion of the UoP for the CCG to mirror the Durham Tees Valley footprint that aligns with the existing arrangements for Better Health Services/Securing Quality in Health Services (SEQiHS) Other key messages are:

• The contracting round will have to be completed by April 2016

• There is a potential 3 year allocation with a further two year indicative allocation being considered to aide financial stability

Further guidance is anticipated in late December Clinical Engagement

Ongoing during the planning process


Not appliccable


Not appliccable

Attachments




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2.


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3.


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5.




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Not required


Not required

Planning Round 2016/17

1. Purpose of the Report 1.1 The purpose of this report is to provide the Governing Body with a summary of the

requirements of the Planning Round for 2016/17 and the key issues to be addressed by NHS Darlington Clinical Commissioning Group (CCG).

2. Background

2.1 Whilst formal Planning Guidance has yet to be released a WebEx was held by NHSE

on the 21st October 2015 and the key national planning messages were: • CCGs should start their planning now and look to refresh as guidance is

published in late December, • Start now within local systems to develop the direction of travel to 2020, and the

translation of these into deliverables for the service, • The need for transformational change was reiterated to meet the £22bn

challenge identified in the Five Year Forward View (FYFV), • Develop and confirm Units of Planning (UoP) for longer term transformational

plans, with joint work by commissioners and providers in the units of planning, • Consideration to be given to increasing the footprint of existing UoP, • CCGs should develop their operational plan for 2016/17 as a subset of plans

developed at new UoP level.

To support the above the Spending Review will be announced on 25th November, and is likely to be accompanied by multi-year allocations to commissioners.

3. Reflections on the 2015/16 Planning Round 3.1 NHSE recognise that the 15/16 planning round had been very challenging for all the

agencies involved, and are committed to providing CCGs in the North, support through thus process as expectations are high for this year, especially with regards to timely contract agreement.

4. Key Issues 2015/16 Planning Round

4.1 Five Year Forward View and Transformation 4.1.1 Early messages are for the development of a health care system wide sustainability

and transformation plan between commissioners and providers, working with local authorities, to deliver the required transformation. Plans will need to be place based, multi-year and set out the changes needed to close the three gaps (quality, prevention and finance) between now and 2020. All organisations will still need to produce an operational plan; setting out ambitions to improve quality and outcomes as well as reconciling activity and finance in 2016/17. This plan should be agreed across all commissioners and providers. Organisational plans therefore remain statutory requirements but the objectives of the system wide transformation plan will be at the top of planning hierarchy as part of this planning round and should drive and connect the organisational plans below it.

4.2 System Leadership

4.2.1 There is a clear need for system leadership and CCGs will have a key role in shaping the response to the Transformation challenge, developing clear plans and making their contribution to closing the financial gap as set out in Five Year Forward View. There should be action on the three key fronts taking into account local needs and circumstances. Nationally these are:

4.2.2 The Health and Wellbeing Gap. Failing to get serious about prevention will mean

then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded-out by the need to spend at a national level billions of pounds on wholly avoidable illness.

4.2.3 The Care Quality Gap. Unless we reshape care delivery, harness technology, and

drive down variations in quality and safety of care, then patients’ changing needs will go unmet, people will be harmed who should have been cured, and unacceptable variations in outcomes will persist.

4.2.4 The Funding and Efficiency Gap. If we fail to match reasonable funding levels

with wide-ranging and sometimes controversial system efficiencies, the result will be some combination of worse services, fewer staff, deficits, and restrictions on new treatments.

4.2.5 This last element must been seen in the context of a much greater health need in

the North with 20% more non elective activity than the average for the UK. The emphasis is very much on the transformation of care and local vanguards (of which 22 of 50 are in the North) will be seen as the main mechanism to spread ideas and learning.

4.3 Units of Planning 4.3.1 One early and key consideration for the CCG will be the refresh of the Unit of

Planning (UoP). This was agreed in 2014/2015 and is currently aligned to Darlington Borough Council and our two main local health providers, County Durham and Darlington NHS Foundation Trust (CDDFT) and Tees Esk and Wear Valley NHS Foundation Trust (TEWV).

4.3.2 Currently there are 58 UoP in the North covering 66 CCGs whilst there are only 122

nationwide within 211 CCGs; this represents a clear opportunity to revisit the UoP to improve efficiency and effectiveness.

4.3.3 This review of the UoP should be regarded as part of a move towards place based

planning and any change should be based upon current arrangements for specialised commissioning, urgent and emergency care networks, Health and Wellbeing Strategies, digital road maps, reconfiguration programmes and devolution. In practical terms this will mean that the natural expansion of the UoP for the CCG will be to mirror the Durham Tees Valley footprint that aligns with the existing arrangements for Better Health Services/Securing Quality in Health Services (SEQiHS). This reconfiguration will mean that governance and programme arrangements for transformation plans and connection to organisational plans will be easier to agree. The expectation is that CCGs will be asked to confirm new UoP before the start of the formal planning round in January.

4.4 Digital Road Map

4.4.1 At the end of October the CCG submitted to NHSE a completed template confirming its footprint for the Digital Road Map (DRM), which has been configured to incorporate the Darlington and Durham Units of Planning. However these clashes have been anticipated and as the DRM is a subset of the wider Transformational planning process and heavily dependent on provider structures i.e. Trusts cannot have different IT arrangements for each CCG, it is not expected to flag any particular issues going forward though the size of the footprint could expand in future years.

4.5 Assurance 4.5.1 NHS England is working with the National Trust Development Agency (TDA) and

Monitor (as they move together to form NHS Improvement) on an approach to assurance. Their aim is to share details of templates and timetable ahead of planning guidance in December. However as mentioned earlier the expectations are that:

• organisational plans, based on shared system assumptions, will be completed by early April,

• that the contracting round will be completed by April 2016, • that the system wide transformation plans will be prepared by mid-2016 • that there will be a read across between activity and finance assumptions

in the organisational and transformational plans with shared assumptions about years 1, 2 and 3.

4.6 Other Key Messages 4.6.1 Better Care Fund. The Better Care Fund will continue into 2016-17 with no

expectations of changes to the minimum contribution or a mandated increase in the sum invested. Whilst BCF plans still require Health and Wellbeing Board sign off there is a continued commitment to align BCF planning with CCG processes.

4.6.2 Mental Health. Parity of Esteem remains a key concern and financial investment in

Mental Health should be in line with growth. There will be new access standard and specific funding for; Early Intervention in Psychosis (EIP), Improving Access to Psychological Therapies (IAPT) and Liaison Mental Health.

In addition there will be for:

• Child and Adolescent Mental Health a new eating disorder waiting time

standard with treatment starting within a maximum of 4 weeks from first contact with a designated healthcare professional for routine cases and within 1 week for urgent cases.

• Perinatal - Plans for perinatal mental health and objectives that align to funding soon to be provided

• Crisis care concordat - Details to confirm that commissioned services for people with urgent or emergency mental health needs are delivered in line with mental health Crisis Care Concordat principles and include all ages (CYP)

4.6.3 Transforming Care (Learning Disabilities). Future plans should include the CCGs ambition to commission the full pathway and recognise the need to engage with partners and service users. This in line with plans developed by the Tees Integrated Commissioning Group. Commissioners working with their partners should have

effective engagement arrangements with patients and their families to better understand the needs and experience of care (both hospital and community).

Plans should also allow for delivering effective case management and discharge planning - preventing inappropriate admissions to inpatient services, as per the recent locally appointed inpatient nurse coordinator role. All patients should have a case manager who works with the clinical team and other professionals to ensure the development of a pathway to discharge In addition commissioners should work with relevant local authorities and community providers to assess patients’ progress for at least six months after discharge assuring community multi-disciplinary professionals are in place to strengthen community placements and support reduction in admissions. This builds on local work to transition long stay patients and staff to the community and the development of a “time out” facility as an alternative to inpatient admission.

4.6.4 Finance. There is a potential 3 year allocation with a further two year indicative allocation being considered to aide financial stability. At present the draft business rules are similar to the current year. There will be a clear trajectory for financial balance in 16/17 as a minimum and cumulative surplus of 1% achieved by 2018/19, exceptions will need to be agreed with the Treasury.

5. Next Steps 5.1 Further guidance is anticipated in late December and a follow up WebEx will be held

in January 2016. Ahead of that period it is anticipated that the CCG works with NHSE and partners to develop the approach to be taken in the North. This is in addition to continuing engagement with providers to develop system wide transformational plans.

6. Recommendations 6.1 Governing Body are asked to:

• note the briefing provided • consider the key issues identified for the CCG • agree that a further report comes to Governing Body in January to provide an

update once formal guidance has been received 7. Contact Officer

Name: Jackie Kay Job Title: Assistant Chief Officer


Governing Body

Agenda Item: 66

1 December 2015

Title Co-Commissioning of Primary Medical Services

Purpose Approval ☒ Discussion ☐ Information ☐

Category

Strategy &

Planning ☒

Performance &

Operational ☐

Governance &

Assurance ☐


Jackie Kay

Clinical Sponsor

Andrea Jones

Author of Report Jackie Kay

Recommendation(s) The Governing Body is asked to

• Receive the final submission document submitted to NHS

England

Executive Summary

As of April 2015 Darlington CCG has a joint commissioning arrangement in place for commissioning of primary medical services in conjunction with NHS England. In October 2015 NHS England invited CCGs to apply for full delegated responsibilities by a deadline 06 November 2015. The purpose of this paper is to:- • update on feedback from Members Practices and NHS

England leading up to the submission • outline the anticipated timelines for decision from NHS

England Feedback from member practices At the Members Assembly in October 2015 member representatives were asked to consider the paper presented and have further dialogue in their practices and respond with support or otherwise for the proposal for full delegation from April 2016. Subject to a majority agreement from the Members Assembly the Assistant Chief Officer was to prepare and submit the

necessary application to NHS England by 06 November 2015. By the time of the submission date the following responses were received

• 10 practices responded: • 9 practices confirmed support for full delegation • 1 practice indicated they had ‘no strong feelings either

way’ and were happy to ‘go with the majority’ • 1 practice not yet responded ( delayed response owing to

postponement of practice meetings) NHS England Support and Next Steps The submission document was completed in conjunction with Cumbria and North East NHS England who have given their support for the application. The application will be discussed by a regional panel on 16 November. Discussions will be by exception, no issues with the CCG’s application are anticipated at this stage. Relevant sections in the Constitution have been reviewed with some minor changes to be made as well as amendments to the terms of reference for the Joint Commissioning Committee. The Constitution amendments will need to be submitted and approval received ahead of the April 2016 deadline.

Clinical Engagement

From November 2014 through to February 2015, a range of meetings were held with the extended clinical leadership group and also the Members Assembly in order to reach agreement on the most appropriate level at which to progress with the co-commissioning of primary care. The Governing Body met in February 2015 and agreed to go ahead with a level 2 (joint commissioning) application with an aspiration to move to level 3 (delegated Commissioning) at a future date. The Members Assembly have been re engaged in the discussion at the meeting on 15 October 2015 where it was proposed that the CCG extend their responsibilities to full delegation of commissioning primary medical services.


Yes- New CCG assurance framework requires assurances on delegated functions from April 2015. CCG Risk Register to be updated to include risks associated with agreed model of co-commissioning


N/A

Attachments Appendix One – Final sub mission document attached.



1. Well led organisation ☒

2. Delegated functions ☒

3. Finance ☒

4. Performance ☒

5. Planning ☒

6. Transformation ☒


Informal Executive 06 October 2015 Members Assembly 15 October 2015 Formal Executive 17 November 2015



Governing Body

Agenda Item: 67

1st December 2015

Title Approach to planning and development of commissioning intentions for 2016/17


Category

Strategy &

Planning ☒

Performance &

Operational ☐

Governance &

Assurance ☐


Jackie Kay

Clinical Sponsor

Andrea Jones

Author of Report Jackie kay

Recommendation(s) Governing Body is asked to note the contents of the report.

Executive Summary

This report provides an update on progress to date on the approach to planning and development of commissioning intentions for 2016/2017. Robust, ambitious yet affordable and achievable commissioning plans are critical for the CCG as a successful commissioning organisation. It is recognised that we are coming to the end of the two-year plan that was developed in 2013/14; This is the opportunity to refresh plans and ensure they are in line with local strategic direction and the Five Year Forward View. The key focus is to develop initiatives that have a stronger focus on outcomes and measurable targets as well as demonstrating system leadership and transformation. At the process moves forward it will be important to test out any plans and assumptions across organisations and identify any risks and mitigations associated with delivery. The mechanism for this is in Darlington is primarily though the unit of planning as well as via the formal contract review meetings and contract negotiation discussions with our main providers.

Early dialogue with providers and key partners is crucial to enable effective and efficient service models to be put in place, through joint understanding, ownership and development aligned to shared priorities. Performance monitoring of the delivery of commissioning plans against targets set is an integral part of the CCG assurance process with NHS England. Darlington CCG has an operations and delivery group in place which meets weekly and will take forward implementation, tracking and reporting of agreed commissioning plans. This group will also oversee a change management control process for any new schemes of work or requests in year to be sense checked and a recommendation made from specified work stream leads to the CCG Executive/Joint Management Team and Unit of Planning.

Clinical Engagement

• The initial workshop for development of commissioning intentions on 4 November included an invitation to the clinicians involved in the members assembly task group.

• The outputs from the session on 4 November will be taken for further discussion with clinical leads on 19 November.

• Initial priorities and outputs from the refresh work and workshop are to be shared with the Members Assembly on 18 November.

• Further clinical engagment will follow through until the commissioning intentions are finalised.


Yes- evidence for the components of the framework- specifically well led organisation; financial management; performance and planning. Yes- a robust commissioning plan helps to mitigate a number of potential areas of risk for the organisation.


This will be completed as the commissioning plan and intentions are finalised.

Attachments Full paper attached




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Darlington Unit of Planning - 05 November 2015 Informal briefing /Informal Executive – TBC Members Assembly – 18 November 2015


1. Introduction and Strategic Context This report provides an update on progress to date on the approach to planning and development of commissioning intentions for 2016/2017.

The development and publishing of commissioning intentions is carried out annually as part of the planning round and is seen as a key mechanism to notify a wide range of stakeholders of the CCG’s commissioning plans. As we approach the end of the two-year operational plan developed in 2013\14 there is the opportunity to refresh the plans and ensure they are in line with the local strategic direction and the Five Year Forward View.

Learning from previous planning processes has identified that a more structured approach to planning is required with a stronger focus on identifying issues and challenging areas for Darlington which need priority attention from the CCG and its partner commissioning organisations. Identified commissioning intentions need a stronger focus on outcomes and measurable targets with a move away from a list of projects (that are not always joined up) with a mix of clear evidence based initiatives and policy driven changes that will best support the CCG to achieve improved outcomes for the local population as well as deliver its responsibilities in the NHS Constitutional Standards including financial balance.

The strategic partnership between Darlington Clinical Commissioning Group (DCCG) and Darlington Borough Council (DBC) allows for commissioning intentions across both organisations to be shared or aligned. Furthermore the Unit of Planning and the Darlington Chief Officers Group have developed a shared vision for 2020 with a commitment from the range of health and social care organisations to develop programmes of work which deliver the following vision:

By 2020 there will be a sustainable health and social care economy in Darlington that places citizens at the centre of the model and which builds strategies and services around them. Personal responsibility, prevention of harm, self-management of conditions, prompt access to primary care and easy access to general acute services will form a continuum of provision in Darlington, with some specialist services being provided elsewhere.

The “Better Care” (BCF) programme together with exciting opportunities presented by the extension of the co-commissioning model for primary care services and local developments of New Models of Care will enable the CCG and its partners to stretch our ambition further with regards to care outside of hospital. Over the same timeframe as the 2020 vision, Securing Quality in Hospital Services (SEQIHS) will move ahead in parallel to deliver high quality, sustainable acute care services across Durham and Tees Valley.

On 21 October NHS England held a national planning launch. The key messages from the launch were :- • Spending Review will report on 25 November, likely be accompanied by multi-year

allocations to commissioners:

• Start now within local systems to develop the direction of travel to 2020, and the translation of these into deliverables:

• Transformational change needed to meet the £22bn challenge identified in the Five Year Forward View:

• Develop and confirm units of planning for longer term transformational plans, with joint work by commissioners and providers in the units of planning:

• Operational plan for 2016/17 for each organisation that can read across to strategies developed at unit of planning level:

• BCF process aligned to overall planning process:

• Maintain the work to link activity and finance:

• Complete the transition to SUS.

Consistent with other years, planning guidance from NHS England will be published in December 2015: Figure 1 shows the overall context and factors that will shape the planning guidance.

2. Implications and risks Robust, ambitious yet affordable and achievable commissioning plans are critical for the CCG as a successful commissioning organisation. The plans should articulate a clear and consistent narrative as to the key priorities and ambitions of the organisation. The key focus is to develop initiatives that have a stronger focus on outcomes and measurable targets with a particular emphasis on system leadership and larger scale transformation.

During the process of developing plans it is important to test out any assumptions across organisations and identify any risks and mitigations associated with delivery. The mechanism for this is in Darlington is primarily though the unit of planning ( ongoing) as well as via the formal contract review meetings and contract negotiation discussions with our main providers (December through to March).

Performance monitoring of the delivery of plans against targets set is an integral part of the assurance process with NHS England area team. 3. Next Steps Review and redrafting of commissioning intentions will follow on over the coming months to ensure commissioning plans: • are recognised, owned and lead by Darlington clinicians • describe the ambition with a focus on outcomes and measurable targets linked to key

issues and challenges for the CCG in improving the health outcomes for the people of Darlington

• demonstrate delivery towards the 2020 vision Timelines- Initial Commissioning Intentions workshop high level analysis

Early November 2015

Discussion with Members Assembly and clinical leads

Mid November 2015

Stakeholder engagement November 2015 – January 2016 Contracting round commences December 2015 NHS England planning guidance published December 2015 CCG Executive sign off Early-mid December 2015 CCG Governing Body January 2016 Health and Wellbeing Board January 2016 4. Recommendations Governing Body is asked to:-

• Receive the progress update paper • Note the key areas of focus for 2016\17 planning • Note the high level timeframe for further development of the commissioning

intentions and plans.

5. Author, Clinical Sponsor and Executive Lead Author: Jackie Kay Title: Assistant Chief Officer Clinical Sponsor: Andrea Jones Title: CCG Chair Executive Lead: Jackie Kay Title: Assistant Chief Officer Date: 03 November 2015


Governing Body

Agenda Item: 68

1st December 2015

Title Learning Disability Fast Track Update

Purpose Approval ☒ Discussion ☒ Information ☒

Category

Strategy &

Planning ☒

Performance &

Operational ☐

Governance &

Assurance ☒


Diane Murphy

Clinical Sponsor

Diane Murphy

Author of Report Donna Owens

Recommendation(s) Governing Body is asked to note the progress against the

National Transformation Programme and the Delivery of Fast Track.

Executive Summary

On 12th June 2015 NHS England announced that the North East and Cumbria would be one of five national Fast Track areas for Transforming Care for people with a learning disability. A Regional Plan that is underpinned by local proposals to deliver community based alternatives to inpatient care, alongside the reduction in commissioned beds has been developed and supported through the Regional Transformation Board

Clinical Engagement

The development of the Fast Track Plan has included the involvement of people with a learning disability, families and carers and clinicians through the Regional Trasformation Board.


The ability to deliver the required reduction in beds will require a sufficiently resourced and robust community response. Failure to develop this area will result in continued demand for beds, which may result in an increase of out of area placements and higher financial impact.

Has an Equality Analysis been

Not as a result of this report

completed? Attachments 1. Update Paper

2. Regional Plan CCG strategic objectives supported by this report



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2.


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3.


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5.




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N/A


Darlington HWBB- January 2016

NHS Confidential

Learning Disabilities- Fast Track- Governing Body

Update

Darlington CCG November 2015

NHS Confidential

Page 2 of 5

Fast Track- Transforming Care

November 2015

1. Introduction and Background The purpose of this briefing is to provide the CCG Governing Body with an update in relation to the Learning Disability Transformation Fast Track Programme. During the 1990s and 2000s there were many resettlement programmes for people with learning disabilities. However, there is still an over reliance on hospital settings for the care of people with learning disabilities and/or autism. Following the Winterbourne View scandal and the Sir Stephen Bubb report, the Transformation Programme was developed.

By improving community infrastructure, supporting the workforce, avoiding crisis, earlier intervention and prevention we will be able to support people in the community so avoiding the need for hospital admission. This will result in systematic closure of learning disability in-patient hospital beds over the next 3 years across the North East and Cumbria.

The Transforming Care guidance highlights the importance of local partnership working between commissioners from local government and the NHS with an emphasis on the oversight and support of Health and Wellbeing Boards.

The focus for the North East and Cumbria has been on reducing reliance on in-patient beds, and increasing community based capabilities, to meet the recommendations of the Sir Stephen Bubb report, the aims being: • Less reliance on in-patient admissions • Developing community alternatives • Prevention and support to avoid crisis • Better management of crisis when it happens • Better, more fulfilled lives

Prior to the announcement of the National Fast Track Programme, the Northern CCG Forum had identified learning disabilities as a ‘large scale’ transformational change programme. The Northern CCG Forum also agreed the Terms of Reference and governance arrangements to oversee this programme of work with the North East and Cumbria Learning Disability Transformation Board being established to oversee and manage the development and delivery of the learning disability transformation programme. NHSE have recently published a national plan to develop community services and close inpatient facilities for people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health conditions - ‘Building the Right Support’ which builds upon the work being undertaken across the country and in particular the fast track site progress.

NHS Confidential

Page 3 of 5

2. Regional Planning Process

Through the Transformation Board, CCGs, Local Authorities and other key stakeholders have been working together to develop the overarching regional transformation plan. This has included detailed mapping of services and gap analysis. A baseline assessment of needs and services has been completed and there has been further analysis of the data with specific quantification of how many people are in various community settings. The reduction in inpatient beds across the North East and Cumbria has been of significant focus nationally. A trajectory produced for the Region will bring the current bed base of 146 down to 70, For NHSE this is projected to be from 109 to 62 across low and medium secure beds. For Tees Esk and Wear Valley this represents a reduction of 55% of their commissioned beds. More detailed discussion as to where and how this can be achieved is currently taking place. Some units are already small and the reduction of too many beds on one site could challenge the service viability.

3. Local Update A joint proposal has been developed across Durham and Darlington with the two Local Authorities and three CCGs. The proposals have been completed through joint working with partners, actively gathering and assessing local intelligence from front line support staff, inpatient services, CTRs and safeguarding alerts, to inform future models of care that can prevent avoidable admissions and support effective discharges. There are three elements to the proposal, ; Proposal 1: Community based accommodation – Workforce Development and Time Out Facility The Joint Planning Group in place for Durham and Darlington has been using local intelligence to consider community based solutions. A model has been developed by the group which will support 6 people with high support needs in the community and maximize their independence, by delivering social care and health services in an integrated and flexible way. The development is proposed as the first of three schemes which would provide up to 30 units of accommodation in the community, located across Durham and Darlington. In order to underpin the new services for 30 patients identified for hospital

NHS Confidential

Page 4 of 5

discharge in the next 2-3 years there needs to be some development in the workforce, to achieve consistent, best practice in relation to Positive Behaviour Support. A training model is proposed, to pilot training tools and develop practice standards for the region. Proposal 2: Transitions planning Two patients who have been in inpatient settings for over 10 years are currently being supported to transition to a bespoke community based provision. The development has been overseen by a project group of all key stakeholders and has also included a detailed transition plan that will enable inpatient staff to work into the new environment and support new staff in delivering consistent responsive care. The costed plan to support this discharge will require up to £196,000 of non-recurring investment from the CCGs. This approach will build in sustainability; promote the greater likelihood of long-term success and prevention of re-admission. Proposal 3: Enhanced Community Support The discharge of these two patients will free up a five bed inpatient unit with an indicative release of £135,000 per bed. It is proposed to utilise the match funding allocation of this to deliver an enhanced community support service, offering increased access and specialised support. Assurance meetings have been established within secure services in relation to patients progressing to rehabilitation and are being used to inform future planning. It is likely that the flow of patients will increase in pace, especially in relation to patients requiring complex rehabilitative services, given the trajectory for bed reductions across the secure services also. Supporting the reduction in admissions will be the implementation of the Care and Treatment Review (CTR) process. A CTR is triggered at the point when a person is identified as “at risk” of being admitted to a specialist learning disability or mental health inpatient setting, and should facilitate a process of seeking alternatives to admission if possible and, if not, follows them through any subsequent admission, period of assessment/treatment and towards discharge.

4. Finance: Transformation Funding for Learning Disability Services The funding requested across the region to deliver the Fast Track Plan was £2,710,900 and was a level which the Chief Finance officers from across the region believe is prudent and would support deliverable and cost effective approaches to successfully moving the projects forward.

The Durham Darlington proposals have requested match funding against investment of the transition packages of care and the shift of investment from inpatient beds to the community.

Notification was received from NHS England on 5th October that the North East and Cumbria had been successful in securing £1,432M from an available pot of £8.2 million. A further £623K has been allocated following review of patient level business

NHS Confidential

Page 5 of 5

cases to assist in the double running/ transition where required to ensure safe transition of service from in-patient care to community based provision and to maintain patient safety. It should be noted that the existing funding is not adequate in relation to covering the cost of the overarching plan and additional locality plans. The Transformation Board has therefore developed a prioritisation process and will consider the proposals against others form the region for a share of the allocation

5. Conclusion and Recommendations The Governing Body is asked to note the progress against the Transformation Agenda and accept the proposals to delivery sustained community infrastructure. Locality proposals are dependent on the award of fast track funding and the successful negotiation of bed closures with release of investment with TEWV. There are risks in relation to the pace and number of bed closures for the CCG. Workforce requirements are significant and achievement of the proposed trajectories will require transformation of the workforce across the region Author: Donna Owens Joint Commissioning Manager (Learning Disabilities) Head of Customer Programme: Mike Brierley

1 Supported by: NHS North of England Commissioning Support

North East and Cumbria Fast Track Learning Disability Transformation Plan


Contents 1. Executive Summary ..................................................................................................................... 4

1.1 The Collective Ambition ....................................................................................................... 4

1.2 How the future will be different ........................................................................................... 4

1.3 The collaborative approach ................................................................................................ 5

2. Mobilise the area .......................................................................................................................... 9

2.1 Governance and planning arrangements ............................................................................. 9

2.1.1 The patient base / population we are commissioning for ........................................... 10

2.1.2 What is the provider base? ............................................................................................. 10

2.1.3 What are the commissioning arrangements with providers? Are there collaborative commissioning arrangements that can support this work? .................................................. 12

2.1.4 How do flows work, and are there other complications / geographical / organisational considerations? ................................................................................................. 13

2.1.5 Who are the key partners to this plan and do they endorse it? ................................. 14

3. Understanding where you are .................................................................................................. 15

3.1 Baseline assessment of needs and services ..................................................................... 15

3.1.1 Population / demographics ....................................................................................... 15

3.1.2. What is the case for change? ........................................................................................ 17

4. Develop your vision .................................................................................................................... 19

4.1 Vision, Strategy and outcomes ........................................................................................ 19

4.1.1 What are your aspirations for Learning Disability services and outcomes? ...... 19

4.1.2 What principles are you adopting and how will you know if you have succeeded? ................................................................................................................................. 22

4.1.3 What outcomes will change and what will the change be?.................................. 23

5. Define your model of care ......................................................................................................... 26

5.1 Proposed service changes ............................................................................................... 26

5.1.1 What will your future system look like? ......................................................................... 26

5.1.2 How will this be different for people with a learning disability and their families .... 34

5.1.3 How will this be different for staff and providers .................................................... 36

5.2 Strategic alignment ............................................................................................................ 36

5.2.1 How does this fit with other plans and models to form a collective system response? .................................................................................................................................... 36

5.2.2 What will these changes depend on from other strategies / plans? ................... 38

6 Plan for success ......................................................................................................................... 41


6.1 Workforce, Education and Training Considerations .......................................................... 41

6.1.1 What are the programmes of change to deliver this new model? ............................ 41

6.1.2 Who is leading the delivery of each of these programmes, and what is the supporting team and governance to deliver it? ...................................................................... 43

6.1.3 What are the risks, assumptions, issues and dependencies? .................................. 43

6.2 Workforce, Education and Training Considerations ..................................................... 46

6.2.1 Question A ......................................................................................................................... 46

6.2.2 Question B ......................................................................................................................... 48

6.2.3 Question C ......................................................................................................................... 48

6.2.4 Stakeholder Engagement................................................................................................ 49

7 Financials..................................................................................................................................... 54

7.1 What investment is required and what are the programme costs of delivery? .......... 54


1. Executive Summary

1.1 The Collective Ambition Our ambition is for the North East and Cumbria to be as good as anywhere in the world to live for people with a learning disability and / or autism and a mental illness or behaviour that challenges. This vision was developed by all stakeholders, including people with a learning disability, before Winterbourne View, the Bubb report or Fast Track transformation programmes. However, we have not moved far enough or fast enough in achieving this vision.

The transformation programme aims include: • Less reliance on in-patient admissions, delivering a 50% reduction in

admissions to inpatient learning disability services by 2020 • Developing community support and alternatives to inpatient admission • Prevention, early identification and early intervention • Avoidance of crisis and better management of crisis when it happens • Better more fulfilled lives.

1.2 How the future will be different By developing our community infrastructure, supporting our workforce, avoiding crisis, earlier intervention and prevention we will be able to support people in the community so avoiding the need for hospital admission. This will result in the systematic closure of learning disability inpatient hospital beds over the next 5 years across the North East and Cumbria.


We will ensure that, everyone has a chance to live as a valuable member of their community; close to the important people in their lives and supported by those who understand and care for them. We will do this by meeting the agreed assessed needs of individuals and their carers through effective commissioning. While the focus of our fast track plan is on reducing the number of unnecessary hospital admissions and ensuring that where these do occur they are for as short a time as possible, this should be seen in the context of our much broader system changes.

1.3 The collaborative approach We will achieve this vision by continuing to work collaboratively with partners across health, social care and the third sector to significantly strengthen support in the community for individuals and their families. We will also develop a highly skilled, confident and values-driven workforce who support people with learning disabilities. We will use the learning from successful resettlement programmes that supported people to move into a range of community based care options during the 1990’s and 2000’s. This learning and the commitment from all stakeholders and our understanding of what it takes to deliver large scale transformational change will help us to deliver this plan. As a result of the changes described in this plan:

• choice and control will be at the heart of ALL service planning and provision • people will be identified and supported much earlier to improve their quality of

life and outcomes • care and support services will always be well coordinated, planned jointly and

appropriately resourced • people will be supported to avoid crisis and if were to occur, crisis situations

will be well managed • people will be helped to stay out of trouble and receive appropriate support if

they do enter the Criminal Justice System • there will be a highly skilled, confident and value driven workforce who

support people with learning disabilities • people will always receive high quality, evidence based care in the most

appropriate setting.

Throughout our transformation programme we are committed to robust evaluation and helping to develop the evidence base to inform future commissioning cycles and non-fast track areas.

Mobilise the area Across the North East and Cumbria, it is estimated that the prevalence of learning disabilities is 0.6% but if we include those with mild disability the prevalence may be as high as 2.5% equating to around 65,000 people.


Our plan encompasses the complex provider landscape across the North East and Cumbria. Well-established and strong NHS, local authority and independent sector provider forums in localities enable social care and voluntary sector community providers to work collaboratively.

We have mapped the current system provision across the North East and Cumbria including the local variation of different configurations of care, the wide mix of rural and urban areas of affluence alongside deprived communities, the use of services from people outside of the area and the impact of and alignment to Vanguards and Integrated Care Pilots. A North East and Cumbria Learning Disabilities Transformation Board was already established and has been used to develop the regional plan and guide the development and implementation of locality plans. The Board is accountable to the Northern CCG Forum, North East ADASS, NHS England, carers and people with a learning disability. Local Implementation Groups will lead delivery and the Transformation Board will receive any escalated risks and issues.

There are 10 task and finish groups which will take forward the key work needed to deliver the key priorities within the plan, these include pathway development, market engagement, communication and engagement and workforce development. An implementation plan will be used to oversee the programme and track progress over the next 5 years.

The key partners who have endorsed the plan and are represented at the North East and Cumbria Learning Disabilities Transformation Board are:

- 11 Clinical Commissioning Groups in the North East and Cumbria - North East Association of Directors of Adult Social Services representing the

12 Local Authorities in the North East - Cumbria County Council - NHS England Specialised Commissioning - Provider organisations (NTW, TEWV, Cumbria Partnership, Danshell Group,

social care providers) - North East and Cumbria Learning Disability Network - Confirm and Challenge Group (supported by Sunderland People First) - Inclusion North - NHS Health Education North East

Understanding where you are A baseline assessment of needs and services has been completed and we will conduct further analysis of the data with specific quantification of how many people are in various community settings.


The system is currently performing well against national outcome measures and has surpassed the Transforming Care Discharge Ambitions discharging 61.25% of Inpatients into community settings. The Care and Treatment Review target has also been achieved.

However, the case for change lies within the current health care experience for people with learning disabilities being varied and fragmented. This will be transformed and standardised through delivery of this plan, with the highest levels of care delivered and fragmentation in the system reduced. There are a number of challenges including a lack of robust outcome measures, the length of time required to develop sustainable community-based alternatives to admission and a lack of systems to identify people at risk of poor outcomes.

Develop your vision

We have worked with all partners and stakeholders across the North East and Cumbria to identify clear aspirations for learning disability services and better outcomes for people. The North East and Cumbria will ensure that people with learning disabilities have services and support to live in their own homes and stay within them in the long term if they choose to do so. Our plan details outcomes in the areas of clinical outcomes, patient experience and sustainability.

11 principles and core standards have been developed in conjunction with all partners across health and social care in the region. This work included people with learning disabilities, their families and carers. These principles are aligned to the national model of care and provide a helpful framework to help monitor progress against our objectives.

The North East and Cumbria Transformation Board has made a commitment that people with learning disabilities, their families and carers will be truly involved in helping to develop and achieve the transformational changes.

The main outcomes for change include enhanced community based support leading to a significant reduction of people needing to be in an in-patient hospital setting. Placement breakdown will be avoided increasing stability for the person living in the home of their choice. Quality of care will be dramatically improved and individual outcomes and quality of life improved.

Define your model of care The proposed model is based on the principles described in the national service model and is developed across the life span taking into consideration the changing needs and requirements of people with learning disabilities.

The model of care focuses on 7 key strands:

• Choice and control at the heart of ALL service provision and planning • Systematic, early identification and intervention • Planned, proactive and coordinated care in the community • Effective prevention and management of Crisis • Helping people to stay out of trouble and supporting people who enter the

Criminal Justice System


• A consistently highly skilled, confident and value driven workforce • Equitable service provision and high quality evidence based care

Early intervention and effective crisis support delivered through enhanced home intensive support teams will be a fundamental part of the service offer within all localities across the North East and Cumbria. These integrated teams will include Specialist Learning Disability clinical capacity as part of comprehensive and well-integrated community support service.

Plan for success A programme level implementation plan has been developed that is underpinned by locality implementation plans to ensure the agreed standards and principles are embedded throughout the North East and Cumbria. Planned changes will also be considered at a provider level, with clusters of commissioners working collaboratively to ensure optimal service configurations are achieved. Across the North East and Cumbria there are a number of different commissioning arrangements that are being reviewed with the aim of establishing further pooled budget arrangements, joint contracts and alternative commissioning models to support delivery of this transformation plan. A communication and engagement strategy has been developed to ensure all stakeholders are informed and engaged throughout the development of plans and the delivery of the programme. This includes establishing a platform for knowledge and information exchange and a social network to keep stakeholders engaged and share actions, learning and best practice. In North East and Cumbria, there are already strong relationships between stakeholders, including people with learning disabilities, their families and carers. This has resulted in meaningful engagements resulting in excellent examples of joint working across health and social care. We will build upon this, strengthening engagement with a wider range of stakeholders including the third sector and embracing our commitment to co-production. Workforce development is identified as a major priority for the North East and Cumbria and will ensure we have the right people with the right skills and knowledge and behaviours to deliver personalised, preventative and safe support.

Transformation Funding for Learning Disability Services The North East and Cumbria Fast Track project plan is predicated on key financial investment from the Transformation funding being in place. The funding being requested is at a level which the Chief Finance Officers from across the region believe is prudent and will support deliverable and cost effective approaches to successfully moving the project forward. Our submission has been produced with input from all local CCGs, local authorities and other key stakeholders across the area. The approach taken to compile the Funding Requirement has been assured through existing governance arrangements and as such has been approved by the North East and Cumbria Learning Disability Transformation Board. The Funding requirement reflects both Regional and Locality based priorities and has been scrutinised to ensure that duplication is minimised, cross working is encouraged and


that the overall plan results in resources being targeted in the most appropriate way to maximise impact and best support successful project delivery.

The approval of Transitional funding will be reported back to the Transformation Board and they will receive regular monitoring reports on progress, slippage and outcomes in relation to the funding on a regular basis once it is awarded.

Our ambition across the North East and Cumbria is to reduce current beds by 52% by the end of March 2020.

2. Mobilise the area

2.1 Governance and planning arrangements The North East and Cumbria Learning Disabilities Transformation Board brings together the North east and Cumbria unit of planning and has been established to oversee and support transformation of Learning Disability services to help ensure the North East and Cumbria is the best place to live for people with a learning disability. The Board is accountable to the Northern CCG Forum, North East Association of Directors of Adult Social Services, NHS England, carers and people with a learning disability. It develops and monitors compliance with a regional programme plan which incorporates a detailed transition plan in line with NHS England’s fast track programme and provides appropriate links to other groups and organisations across the region. The Board identifies and communicates any impacts of service changes to the health and social care economy such as the financial impact to a commissioner or provider organisation and also identifies and shares best practice across the North East & Cumbria and the wider system. The terms of reference for the Board further details regarding programme governance are embedded below. The diagram below shows the accountability structure and workload flow for the programme.

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NE&C Learning Disability Network

NE ADASS Northern CCG Forum

ANEC NHS England

NHS England Fast Track

NE&C Learning Disability Transformation Board

Task & finish groups / Work streams

Local Implementation Groups

Local Authority

CCGS

LGA

Specialised Commissioning

Provider Services


2.1.1 The patient base / population we are commissioning for The North East and Cumbria Fast Track is taking a population based approach to its transformation programme. We recognise that improving the lives and outcomes of people with learning disabilities requires a life course approach which supports the changing needs of individuals throughout their life. Stakeholders across the North East and Cumbria have agreed an ambitious and broad vision which requires focused improvement and transformation across the wider determinants of health. This transformation plan is focused on some specific areas within this broader portfolio of work which will contribute to ensuring people receive high quality, evidence based care in the most appropriate setting and increasing the number of people cared for in the community. The North East and Cumbria has a good understanding of the current numbers of people with learning disabilities who are being supported by health or social care, including detailed information on the numbers of people currently receiving treatment and care in a learning disability inpatient setting. The specific services described within this transformation plan are to be commissioned for people with a learning disability and / or autism who also have, or are at risk of developing, a mental health condition or behaviours described as challenging, or whose behaviour can lead to contact with the criminal justice system. Across the North East and Cumbria, it is estimated that the prevalence of learning disabilities is 0.6%, however this is likely to be a significant underestimate. Including those with mild disability the prevalence may be as high as 2.5% equating to around 65,000 people. Using the published Quality Outcome Framework prevalence (0.6%) applied to each local authority population; we can project the number of people with a learning disability for the next five years (assuming an increase of about 3% each year).

2.1.2 What is the provider base? This table provides and overview of the provider landscape and the types of services provided across the North East and Cumbria: Learning Disability Service Providers

CCG commissioned inpatient learning disability services - Including acute

assessment and treatment

Northumberland Tyne & Wear NHS Foundation Trust (NTW) Tees Esk & Wear Valleys NHS Foundation Trust (TEWV) Cumbria Partnership NHS Foundation Trust

Independent sector: Danshell Group There are very few out of area placements


Services commissioned by NHS England Specialised Commissioning - Learning disability

secure services - CAMHs Tier 4 - Forensic community

outreach - Complex

neurodevelopmental community service

NTW & TEWV NTW & TEWV - medium and low secure services for people with a learning disability. TEWV - forensic community outreach service & contract leads for prison health (includes prison health, custody diversion). Both organisations provide services as part of the Ministry of Justice (MOJ)/NHS partnership, offender personality disorder pathway. NTW Provide CAMHs into Kyloe House and Aycliffe secure children’s home. NTW - provide CAMHs Tier 4 learning disability services (acute assessment unit, low and medium secure services, inpatient assessment & treatment service for children and young people with a mild to moderate learning disability and /or challenging behaviour and a complex neurodevelopmental community service CNDS).

Community Learning Disability Services

NTW (Sunderland & Newcastle) TEWV (Durham, Darlington, Hartlepool & Stockton) Integrated teams existing in Durham in partnership with LA Cumbria Partnership (Cumbria) South Tyneside NHS Foundation Trust (South Tyneside & Gateshead) Northumbria Healthcare NHS Foundation Trust (Northumberland & North Tyneside)

Social Care Providers A wide range of independent and 3rd sector providers are commissioned across the North East & Cumbria to provide supported living, accommodation, day care, respite and residential care. Mainstream Health Service Providers Primary Care Services

Approximately 470 GP practices Pharmacies Dental practices Optometrists

Community Services Secondary Care services Mental Health Services Acute Hospital Services Ambulance Services

NHS Acute Hospital services: - City Hospitals Sunderland NHS Foundation Trust - County Durham and Darlington NHS Foundation Trust - Cumbria Partnership NHS Foundation Trust - Gateshead Health NHS Foundation Trust - Newcastle upon Tyne Hospitals NHS Foundation Trust - North Cumbria University Hospital Trust - North Tees and Hartlepool NHS Foundation Trust - Northumberland, Tyne and Wear NHS Foundation Trust - Northumbria Healthcare NHS Foundation Trust - South Tees Hospitals NHS Foundation Trust - South Tyneside NHS Foundation Trust Acute Learning Disability Liaison Nurses are located within acute trusts across the region NHS Mental Health service providers: - NTW - TEWV - Cumbria Partnership NHS Ambulance services: - North East Ambulance Service NHS Foundation Trust - North West Ambulance Service NHS Foundation Trust

http://www.sunderland.nhs.uk/chs

http://www.cddft.nhs.uk/

https://www.cumbriapartnership.nhs.uk/

http://www.gatesheadhealth.nhs.uk/

http://www.newcastle-hospitals.org.uk/

http://www.ncuh.nhs.uk/index.aspx

http://www.nth.nhs.uk/

http://www.ntw.nhs.uk/

http://www.northumbria.nhs.uk/

http://www.southtees.nhs.uk/

http://www.sthct.nhs.uk/


2.1.3 What are the commissioning arrangements with providers? Are there collaborative commissioning arrangements that can support this work?

A wide range of service options are available across the North East and Cumbria. Many of these are currently based on single commissioner contracts (including block, cost per case and individualised budget arrangements) and there are a small number of localities with pooled budgets. Establishing further pooled budget arrangements, joint contracts and alternative commissioning models will be explored to support delivery of this transformation plan. Clinical Commissioning Groups – The attached document provides some examples of the current commissioning arrangements in place across the North East and Cumbria and also describes some of the future plans that are in place.

4. Collaborative arrangements.docx NHS England Specialised Commissioning – Services such as Child and Adolescent Mental Health services (CAMHs) and Adults are commissioned for patients from England. These services meet the four factors for specialised services as described in the prescribed services manual. (NHSCB 2013).The services are commissioned and contracted for using the NHS standard contract. Services are contracted on a block basis with an all-inclusive price. Currency for payment is usually by occupied bed day for impatient services and by activity for community services. CQUIN schemes are in place for all services and monthly contract monitoring meetings are held to manage performance against the contract. Continued close collaboration is required with partners in Health and Justice commissioning and providers of custody diversion schemes as well as prison in-reach teams, the commissioners and providers of the offender personality disorder pathway which is a joint initiative between the Ministry of Justice (MoJ) and NHS England and the five police authorities across North East and Cumbria. Local Authorities – A range of local commissioning arrangements exist:

• All local authorities use Direct Payments and Individual or Virtual Budget arrangements to offer people personal choice and flexibility. In most authorities such options are supported by approved provider lists or a system for accrediting providers. Many of these are now featuring joint care and health budget elements.

• Regarding provision of supported living services, accommodation and day care, most authorities have a Framework or Approved Provider mechanism in place covering provisions for different levels or types of need. Provision of highly specialised services or tailored individual packages may involve traditional tenders outside of those arrangements.

• For respite provisions, authorities use a mixture of block and spot-purchase contracts.

• Residential care is usually on a block or spot-contract basis.


Increasingly, local authorities are looking to develop collaborative agreements or strategic partnerships with providers in order to achieve more enhanced partnership working. This includes flexible services with swifter response and better value for money. A number of providers are now able to offer capital for new developments as result of backing from social investors. Provider geography, natural alignments and collaborative arrangements – There are natural clusters of CCGs / Local Authorities around providers and the detailed implementation plans will address the impact and plan service changes at a provider level. System and Market Engagement - Strong provider forums already exist within localities and these bring a range of social care and voluntary sector community providers together. In addition the North East and Cumbria Learning Disability Network have put the region in a strong position with well established relationships across commissioners, providers and other stakeholders. There are effective mechanisms to share best practice with strong collaborative approaches that deliver system wide change. There are also opportunities to introduce new providers and new innovative ways of working to deliver improved outcomes for people with learning disabilities. A market review as part of a wider provider review would benefit the whole system approach as there are a high number of a wide range of services.

2.1.4 How do flows work, and are there other complications / geographical / organisational considerations? The diagram below shows the flows across the system and how cohorts of people with learning disabilities move around the system.


Considerations

• Local variation • Geography and deprivation • Legacy of large intuitional care facilities • Determining ordinary residence • People from out of area • Commissioning of specialised services • Distinct pathways • Transition from children to adult services • Data and information • Contracts • Vanguards and Integrated Care Pilots • Fully considering the needs of all cohorts.

Further detail about these considerations is attached in the embedded document.

5. Considerations.docx

2.1.5 Who are the key partners to this plan and do they endorse it? There are strong partnerships in place across the North East and Cumbria and these have enabled many of the key partners to be brought together and engaged in the


development of this plan. NHS and Local Authority commissioners and a wide range of other stakeholders have committed to delivering the new models of care and support for people with learning disabilities. This will be achieved with people with learning disabilities, their families and advocates and will be provided through more detailed co-produced plans. The North East and Cumbria Learning Disabilities Transformation Board was recently established to oversee the development and delivery of the transformation programme across the region. This Board has endorsed the plan and during September and October formal endorsement will be sought from Health and Wellbeing Boards across the fast track area. Partners represented at the North East and Cumbria Learning Disabilities Transformation Board include:

- 11 Clinical Commissioning Groups in the North East and Cumbria - North East Association of Directors of Adult Social Services representing the

12 Local Authorities in the North East - Cumbria County Council - NHS England Specialised Commissioning - Provider organisations (NTW, TEWV, Cumbria Partnership, Danshell Group,

social care providers) - North East and Cumbria Learning Disability Network - Confirm and Challenge Group (supported by Sunderland People First) - Inclusion North - NHS Health Education North East

Representation is from senior leaders from each organisation who have the authority to deliver the transformation programme.

3. Understanding where you are

3.1 Baseline assessment of needs and services Information from a wide range of sources has been analysed to gain a baseline assessment of needs and services. This includes Learning Disability Self-Assessment Framework returns, Joint Strategic Needs Assessments, Joint Health and Wellbeing Strategies, Transforming Care data and HSCIC data. A baseline assessment of needs is attached.

3. Learning Disabilities Baseline Da

3.1.1 Population / demographics The Draft Service Model for Commissioners (NHS England and LGA, July 2015) identifies several cohorts of people that Fast Track plans should focus on. In order to understand these groups more fully further analysis of the North east and Cumbria data is underway. Initial analysis, as of end of June 2015, provides some insight and is displayed in the table below. The most robust data available is for inpatients (the


‘Assuring transformation’ data set). Further work needs to be done to quantify how many people are in the various community settings. What is the cohort (setting) How

big? Is this cohort changing?

North East & Cumbria population with a learning disability

~17,000 Likely to be an under-estimation. Likely to increase to over 20,000 by 2020.

People in inpatient settings (on 31.03.15) - acute admissions in learning

disability units - forensic rehabilitation - others including beds for

specialist neuropsychiatric conditions

- acute admissions within generic mental health service

- complex continuing care & rehabilitation

- non secure - low secure

106

55

22 14

8

4

2 1

Over the last year over 50% of people with a learning disability have been discharged from inpatient settings. Plans are in place to support significant numbers of people to transfer to a community setting with appropriate support packages. Supported by the CTR process.

People in secure settings (specialised commissioning) - Medium secure - Low secure - CAMHs Tier 4

148

37 86 25

6. What are the different cohorts- Spe

People with learning disability supported in the community - Residential care - Supported housing - Independent living - Family home with support - Those at risk of poor outcomes

or admission

TBC Further data collection/analysis is underway to gain a better understanding of people being supported in the community. To support people in a community setting and avoid unnecessary inpatient stays, preventative approaches and much earlier intervention are required. This requires systems to identify people most at risk of poor outcomes.

Further detail about inpatient cohorts can be found in the embedded baseline information and Transforming care summary. How is the system currently performing against the national outcome measures? The North East and Cumbria has surpassed the Transforming Care Discharge Ambitions discharging 61.25% of Inpatients into community settings. The Care and Treatment Review target has also been achieved. In terms of Adult Social Care, the Adult Social Care Outcomes Framework (ASCOF) measures two specific cohorts which relate directly related to people with Learning Disabilities:

- Proportion of Adults with Learning Disabilities living in stable accommodation. In 2013/14 the England average was 74.9% while the North East exceeded this at 80.6%.

- Working age people with Learning Disabilities in paid employment. The England average was 6.7% while the North East achieved 5.5% in 2013/14.


It should be noted that across the region, there are numerous locally determined performance measures and frameworks that monitor quality of life outcomes.

3.1.2. What is the case for change? The current experience for people with learning disabilities in the North East and Cumbria is very varied. This is, in part, apparent by looking at the data but also by listening to the stories of service users, families, providers and commissioners. However, there are also many challenges in understanding the true picture because of a lack of consistent data across the whole system. We understand pockets of activity such as patients located in-patient settings, but on the whole we have poor visibility of what these people’s needs are, how they are currently being met (or not), and what issues they are encountering.

• The available data (through the ‘Assuring transformation’ process) shows the

people with a learning disability who are in in-patient settings. A proportion of these patients require inpatient specialist care, but many of them can be managed in the community and these individuals are being identified as part of these plans.

• We can also see from this data that there are people in these settings for very long periods of time (up to 25 years).

• There are few other clear messages directly from the data, but this is probably indicative of the immaturity of information systems to allow the monitoring of people with learning disabilities. This is a key strand of the ‘case for change’ borne out by the observation that systems are fragmented and quality is very variable.


• The overwhelming picture drawn from a wide range of qualitative analyses highlights the fragmentation of the system and the many ‘hand-offs’ that occur at many levels of care or support of people with learning disabilities.

8. Case for change.docx

What are the current challenges within this baseline?

• A clear understanding of the baseline is challenging due to a lack of shared currency and shared data sources

• A lack of robust outcome measures (possibly a knock-on effect from poor information systems) means that progress had been hard to measure and is a key element that needs to change

• The length of time required to develop sustainable community-based alternatives to admission. Particularly housing, architectural based solutions

• Financial positions of many Local Authorities and their instability to financially support major change programmes.

• A lack of systems to identify people at risk of poor outcomes • Commissioning for specialised services is done on a system wide basis rather

than sub regional basis. • We have no control over admissions directed by the courts • The development of custody diversion schemes has increased throughput into

secure services as people are diverted into hospital • Lack of infrastructure in the wider community to assist in safe discharge of

people with history of offending behaviours • Availability of suitable premises and skilled providers • The need to make sure that patients don’t experience increased restrictions

by being placed in community settings • The impact of the North East and Cumbria Transformation plan on other

areas of the country. The North east and Cumbria are major importers of patients requiring treatment from other areas in England

• Also see section 3.1.4.

How can the baseline be improved? • Choice and control at the heart of ALL service provision and planning • Systematic early identification and intervention for those people at risk of poor

outcomes • Planned, proactive and coordinated care in the community • Effective Prevention and Management of Crisis • Helping people to stay out of trouble and supporting people who enter the

Criminal Justice System • A Consistently Highly skilled, confident and value driven workforce • Dedicated funding • Equitable service provision and high quality evidence based care • Specific focus areas:

o A standardised minimum data set across all providers to allow regular reporting of performance and activity


o An agreed set of outcome measures to allow benchmarking and tracking of performance

o Agreeing thresholds for admission and for those people that do require an inpatient stay improve the whole pathway from preadmission to post discharge

o Providing treatments tailored to individual need rather than a programmatic approach

o Implementing the North East and Cumbria Service and Care Principles and Standards

o Changing the approach to how and where treatments can be delivered o Transferring prisoners back to prison on successful completion of

treatment o Enhancing the function and delivery of the forensic outreach model and

rolling it out across the North East and Cumbria o Developing a menu of skilled providers

4. Develop your vision

4.1 Vision, Strategy and outcomes Our vision is for the North East and Cumbria to be the best place in England to live for a person with a learning disability and / or autism and a mental illness or behaviour that challenges. Our vision is holistic, recognising the importance of a range of factors that encompass the wider determinants of health, on an individual’s overall quality of life and outcomes. The vision requires system wide transformational change that cuts across traditional organisational boundaries and spans the entire life course. This plan touches on all of the ‘drivers’ associated with achieving a good quality of life and outcomes, however it does not profess to include the strategic approach and delivery plans for all of these areas and must be seen as part of a broader set of strategies, approaches and plans that are in place across the North East and Cumbria to improve the lives of people with learning disabilities. We will achieve our vision by working collaboratively with partners across health, social care and the third sector to strengthen support in the community for individuals and their families. We will develop a highly skilled, confident and value driven workforce who care and support people with learning disabilities. This will reduce reliance on the use of in-patient beds and/or breakdowns in someone’s care setting and support people much earlier to improve their quality of life and outcomes.

4.1.1 What are your aspirations for Learning Disability services and outcomes?

The North East and Cumbria will lead the way in achieving positive health and social care outcomes for people with learning disabilities using an inclusive and


collaborative approach to address barriers to inclusion. Building on person centred values, future pathways will focus on supporting people within their own community and reducing reliance on inpatient services. Specialist services will help prevent problems from arising in the first place, help to support an individual to use mainstream services and or participate in their local community e.g. employment, education, housing , friendships, relationship, leisure etc. People with learning disabilities who only have a mental health need will use mainstream mental health services. We will ensure that we make the most appropriate help available in a timely manner.

As a result of the changes described in this plan:

• choice and control will be at the heart of ALL service provision and planning • people will be identified and supported much earlier to improve their quality of

life and outcomes • care and support services will always be well coordinated, planned jointly and

appropriately resourced • people will be supported to avoid crisis and if they do occur, crisis situations

will be well managed • people will be helped to stay out of trouble and receive appropriate support if

they do enter the Criminal Justice System • there will be a highly skilled, confident and value driven workforce who

support people with learning disabilities • people will always receive high quality, evidence based care in the most

appropriate setting. Personal experience People with learning disabilities will live in their own home, in their local community supported by people who know them well. If in a staff supported living arrangement their staff team will be the right people, with the right values, knowledge, skill and competence to support them. People with learning disabilities and their families will know what support is available to them, have advocacy and support when they need it and will always receive well-coordinated, planned care. Community based care and support will help support families of people with learning disabilities to maintain close relationships and links with their relatives and avoid people being supported a long way from home. This will provide greater opportunities for enriched relationships with family members. People with learning disabilities will also have increased opportunities to live fulfilled lives. The regional ADASS learning disability work stream has informed local authority commissioning. A wide range of new accommodation options is being developed across the region, including individual service design, small-scale and bespoke developments, property refurbishments and larger scale core and cluster models. Capital funding for housing delivery is being drawn in from the Homes and Community Agency, from social investors, private capital and from providers using their own assets to fund new developments. The preferred model of support is independent supported living, which offers the highest level of security of tenure appropriate for any tenant. Where there is a need for specialist residential care, for


example where high levels of restrictive practice are required, local authorities are actively engaging with the provider market to ensure that high quality service options will be available locally. To embed this work, across the region local authority housing strategies are being refreshed to reflect the requirements of the Transformation agenda, with a number of authorities establishing “complex needs” housing task groups within that work. Such partnership working and progress on housing strategy implementation is reported to local Health and Wellbeing Boards. Health outcomes for individuals The evidence shows that having a learning disability increases the likelihood of developing physical and mental health problems. We want to ensure that services support people and their families to:

1. Maintain good physical and mental health wellbeing 2. Know when mental health and behavioural issues are developing at the

earliest point and get the right support 3. Reduce (50%) the in inappropriate use of psychotropic medication 4. Respond to and promote indicators of good physical health including obesity,

immunisation, diabetes, dental health. We would be looking to support reduction in A&E attendance and increased uptake of NHS cancer screening.

Specialist Learning Disability services While our ambition is for people to access mainstream services we also need to ensure that when a person needs specialist learning disability services these are clearly defined and provided by skilled and competent staff who are flexible and respond quickly to need. Care will be provided in a community setting by multidisciplinary teams the key components of this are described in the diagram below. We recognise that there is an ongoing need for access to specialist inpatient services for a small number of people with Learning Disability and/or Autism who have a mental health condition or display behaviour that challenges, however the admission would be part of the wider community pathway and the focus would be to return people to their home as soon as possible.


Sustainability This model will be sustained as a result of people living fulfilled lives and participating in their local community (a society that enables participation will inevitably have a healthier population reducing reliance on health and social care services). By ensuring people have their physical health care needs met fully there will likely be a reduction of behavioural issues that require significant intervention. We also know that having a learning disability increases the risk of developing ways of responding that others find challenging. A key part of our aspiration is the need to invest in the skills of the local community to ensure that the people within it feel competent, confident and supported to meet the needs of complex people who present with challenging behaviour. This will be delivered through skills training and proactive prevention but also through timely access to support when needed. This will help to keep people within their communities and prevent unnecessary hospital admissions.

4.1.2 What principles are you adopting and how will you know if you have succeeded?

The North East and Cumbria Transformation Programme have agreed to adopt the principles outlined in the National Service Model but have also collectively developed

People Living and Supported to Live in the Community Holistic multi-disciplinary

assessments. Individual person centred

plans that support across the life course and inform ISDs

Prevention and early intervention to increase people’s quality of life and prevent the need for more intensive support in the future.

Core services respond to meet people’s needs.

Specialist services respond quickly as required with the aim of maximising independence and quality of life.

In reach and integrated approach.

Care provided in or as close to the individuals home as possible. Home includes residential care, supported living and independent living.


11 regional standards and principles. There has been multi organisational partner agreement to adopt these standards and principles, which are closely aligned to the standards outlined within the national model of care.

Principles and Care Standards.pdf

The embedded document demonstrates how each of the North East and Cumbria learning disability standards and principles aligns to those within the national model of care and demonstrates our metrics for measuring success.

10. NE&C Principles & Standards aligned t

4.1.3 What outcomes will change and what will the change be? The outcomes that will change as a result of this transformation programme can be grouped into four broad categories:

• Reduced reliance on inpatient care • Improved quality of care • Improved quality of life • Improved service user experience

We will see a significant reduction in people needing to be in an in-patient hospital setting and placement breakdowns, ensuring stability for a person living in their home of choice. In addition improvements will be seen across a wide range of other measures.

What outcomes will change? What will the change be? / comments

Reduced reliance on inpatient care - Reduced admissions to inpatient learning

disability services - Reduced learning disability inpatient beds - Reduction in Length of Stay - Increased use of individual budgets

50% reduction in admissions to inpatient learning disability services 28 days / in line with MHA for Mental health admission Year on year increase

Improved quality of care - North East &Cumbria Care Principles and

Standards contain a variety of quality measures across key aspects of specialist and mainstream care

- Improved individual clinical outcomes

See NE&C Care Principles and Standards Further work required to agree individual


- Compliance with pre-admission and discharge best practice processes/CTRs

- Frequency and quality of care reviews - Medicines optimisation

- Compliance with NHS Improvement and CQC learning disability targets/standards

Primary care outcomes

- Continue year-on-year increase in % of people with health checks and health action plans

- Increased uptake of screening and immunisations

- Improved management of long term conditions (including diabetes and epilepsy management)

- Improvements in healthy lifestyle indicators (e.g. smoking status, BMI, etc.)

Secondary/Acute care outcomes: - Reduced A&E attendances - Reduced avoidable emergency admissions

clinical outcome measures Regular review of current treatments / prescribing in line with best evidence Further work is being completed to establish all baselines and ensure trajectories are also broken down to CCG/LA level to ensure that quality of care is improved across all areas in the North East and Cumbria

Improved quality of life - Reduction in avoidable and premature deaths - Increased placement stability - reduction in

unplanned respite - Improved safeguarding outcomes - Number and % of people in settled and secure

accommodation of their choice - Number and % of adults in employment - Individual measures of improved quality of life - Reduction in placement breakdown

NE&C Learning Disability Network working alongside the National Mortality Review Body to test processes Year on year improvement & equity across localities (ASCOF measures) Outcomes star / eHEF / Transforming Care: Quality of care measures

Improved service user experience - SAF measures - Feedback from Patient forums - Individual provider surveys, exit

questionnaires and feedback - Adherence to quality checker standards - Increase in reasonable adjustments:

o Improved accessibility of information o Increased length of time for

appointments o Flagging systems for people with

additional needs

SAF – provides a highly inclusive mechanism to measure improvement/change Across health and social care

Other measures to show that the new system has been successfully implemented - Workforce competence in PBS - Reduction in unplanned respite – development of respite options in the community - Access to Learning disability awareness training - Access to parenting programmes

A number of outcome measures have been trialled or are in development across the North East and Cumbria on a small scale:


• eHEF - while this framework measures outcome activity and improvement in service provision/lifestyle it does not identify other influencing factors, such as mental health on physical health outcomes. We would like to explore the options of developing this more widely to see if is sensitive to outcomes at an individual level. While we recognise that it is not intended to replace existing outcome tools for specific settings or for specific interventions; it does provide a clear and transparent overarching framework to look at planning around social, biological, behavioural, communication and service related factors and include those involved with an individual. This would be particularly helpful with commissioning and service provision and across health and social care settings.

• Joint work with Bangor University to look at Quality of Life measures linked to Positive Behavioural Support and workforce development

• Outcome Star - Work has already been undertaken with TEWV looking at this personalised outcome measurement tool. The use of such a tool supports integration with mainstream mental health services

• Education, Health and Care Plans for children and young people with Special Educational Needs- we need to ensure that we build on and enhance the information and outcomes contained in these plans as children and young people transition in to adulthood

• Assessment tools for service providers to ensure that they are providing quality services – this is an area that we need to work on collectively going forward and would link with the work around contracting and developing the provider market.

The North East and Cumbria has been actively involved in the Learning Disabilities Currency Development Project which aims to describe the needs of patients requiring input from NHS funded specialist health services traditionally labelled as "adult learning disability services". The first phase of data collection led to the development of nine learning disabilities-related needs groupings based on complexities in physical health, challenging behaviour, autism and level of learning disability. Approximately 25% of people with a learning disability were allocated to existing mental health and dementia needs groupings. The second phase of data collection and analysis will help understand how these needs groupings are used in practice (e.g. how service provision varies on the basis of need). There are also plans to use the data from the groupings to inform implementation of the national learning disabilities service model and workforce development (in collaboration with the Transforming Care Programme and Health Education England). The North East and Cumbria Fast Track has linked with NHS England to consider further development of outcome measures around treatments in line with the developing evidence base. We are excited about the work being proposed by the Transforming Care: Quality of Care Measures and will be identifying key individuals from across North East and Cumbria who can will be involved and contribute to this work.


5. Define your model of care

5.1 Proposed service changes

5.1.1 What will your future system look like?

The proposed model is based on the principles described in the national service model and is developed across the life span taking into consideration the changing needs and requirements of people with learning disabilities. Key themes for implementing the Transformation Programme:

• Choice and control at the heart of ALL service provision and planning • Systematic Early Identification and Intervention • Planned, proactive and coordinated care in the community • Effective Prevention and Management of Crisis • Helping people to stay out of trouble and supporting people who enter

the Criminal Justice System • A Consistently Highly skilled, confident and value driven workforce • Equitable service provision and high quality evidence based care in the

most appropriate setting

Choice and control at the heart of ALL service provision and planning This includes a new model for the way advocacy support is commissioned and developed. Improved systems and mechanisms to enable choice and control such as personal budgets and access to accessible information.


Having worked with people with Learning Disabilities, family carers, commissioners and providers in health & social care and advocacy providers, we now have a model that changes the way advocacy support is commissioned and developed. The new model includes:

• Rethinking Advocacy Commissioning - to take into account preventative aspects of supporting local communities and the need to invest in people’s capital to invest in a longer term vision of individual autonomy in all aspects of people’s lives as well as fulfilling statutory advocacy requirements.

• Rethinking the practice of Professional Advocates - to rethink how professional advocates practice to ensure they contribute to building people’s capital. There are various ways that we could do this including:

- Developing and investing in natural allies - Standard and routine connection to long term preventative approaches - Building and investing in people’s capital

For example, using funding allocated which would ordinarily fund a Professional Advocate whilst utilising that money differently i.e. to support 80% of a Professional Advocate model and the other 20 percent to support the development of self or citizen advocacy.

Personal budgets - By extending the use of personal health and social care budgets and supporting people to use and manage these effectively, people will have increased choice and control over all aspects of their life. To support the increased use of personal health budgets systems need to be easy to use and people need good information and will have access to independent advocacy and advice. Many of these support requirements are detailed in the 2014 Care Act. Systematic Early Identification and Intervention

• New systems will be developed to use information from health (information from a wide range of sources, primary care, maternity services, community


services, secondary care), social care, schools, criminal justice system) to systematically identify those people at risk of poor outcomes.

• A risk stratification tool will be part of the system to help community based multidisciplinary teams to prioritise the people who require targeted interventions.

• Proactive, preventative, individualised care will be provided by multi-disciplinary teams. Holistic assessments will be undertaken which will result in a co-produced personalised plan. These holistic assessments and preventative plans will consider all of the wider determinants of health impacting upon the individual.

• Families are part of the workforce development strategy to ensure that they are also upskilled in Positive Behaviour Support and opportunities for family leadership. This will also raise expectations and hold the system to account.

• Personal budgets will be utilised to provide a wider range of short breaks to both people with a learning disability and families.

Planned, proactive and coordinated care in the community • Everyone will have a co-produced person centred care and support plan (for

children and young people with special education needs this will be an Education, Health and Care plan).

• Care coordinators will be assigned to every individual • Multidisciplinary community teams will support people with learning disabilities

of all ages in the community. These teams will support people on two pathways of care: Targeted early intervention and crisis avoidance and management

• Robust mechanisms will be in place to monitor adherence to the plan • Pre-admission checks and CTRs are the norm for people as part of an

appropriate escalating response which is mobilised to support the individual. In response to increasing complexity a multi-disciplinary CTR should be undertaken in the community. A physical and mental health assessment should be included to provide an holistic assessment for the individual to minimise the need for admission.


• If on discussion within the MDT it is agreed that it is in the individuals best interests that an admission is appropriate then the MDT are responsible for setting goals for admission and discharge. The person will be at the heart of the decision making process alongside input from families and carers as appropriate.

• People with learning disabilities will be living in their local community in housing of their choosing and with people they want to live with

• Physical health needs will be robustly met through reasonably adjusted health and social care services. We will continue to increase year on year uptake of annual health checks for all people aged 14 years and above

• Early indications of deteriorating mental health or behaviour labelled as challenging will be identified very quickly and specialist health learning disability providers will scaffold social care providers to appropriately support people until stability is achieved.

• Joint health and social care commissioning arrangements will be used, pooling of budgets and joint personal budgets will ensure the system can provide flexibility to respond during times of instability in the person's mental/physical health enabling them to remain in their own home as far as possible.

• Resettlement plans for long stay patients (forensic or health based). Care packages will be person centred and delivered in line with the agreed service standards.

Effective Prevention and Management of Crisis


The intensive response to crisis and alternative to admission pathway is a relatively new model in some areas across the North East and Cumbria Fast Track and further work is required to test out, evaluate and refine it. Our model builds upon the Mental Health Crisis Care Concordat. People will have access to intensive 24/7 multi-disciplinary health and social care support to help prevent family or support package breakdown. It is suggested that as an alternative to admission there are broadly 4 types of ‘crisis’ response required for those people known to services in addition to the support they would be receiving from the local community teams.

1. The social care placement is breaking down due to staffing issues/burnout etc. previously this has often resulted in an admission as a place of respite/safety. In this situation we would be advocating the release of unqualified but PBS trained staff to support short term while the provider resolves the staffing situation. May be additional 12 or 24 hour support required for 7 days max. A co-produced crisis contingency plan will be agreed with the provider when the service is commissioned.

2. The person’s behaviour is deteriorating and staff are struggling to manage the situation. Under direction of qualified staff, unqualified experienced PBS trained staff would be deployed to check that the care plan/behaviour support plan was being adhered to and would provide advice/ guidance and modelling as per the behaviour support plan. This may last up to 4 weeks 24/7 similar to crisis home treatment teams. Further support and training may be provided by the wider multi-disciplinary team as required.

3. The individual’s presentation has changed significantly and they are at risk of harming themselves or others e.g. physical health decline/ change to environment. An assessment is required in situ where qualified staff are deployed to carry out observations and assessments within the patient’s own environment (assuming that is possible in multi-occupancy tenancies and they are safe). This may last up to 4 weeks 24/7 similar to crisis home treatment teams. Clinical leadership and decision making are key and daily review by senior staff will take place with senior staff contactable 8-8 or 24/7 to provide support guidance and direction. The agreed treatment plan would be overseen by person who is agreed as the most suitable to lead the assessment process (for example Consultant Psychiatrist and psychologist oversight where appropriate).

4. As in 3 but the risk is too high to the person, health staff and /or the person’s staff in their home environment and this cannot be safely managed in any community setting and therefore requires access to specific intervention in an inpatient setting

a. There are safeguarding issues that cannot be safely managed. This could be around other residents who may be vulnerable adults or it could be that there are children or other vulnerable family members in the household

b. There are specific historical risks in the community that mean that it is unsafe to treat them at home


c. It is not possible to implement assessment/treatment without causing significant distress/disruption/intrusion to others who share the home with the patient

d. There are legal implications that prevent treatment of this kind being quickly implemented within the home.

For scenarios 1 & 2 the team working with the individual need to put in place positive behaviour and crisis response plans, including detailed challenging behaviour escalation response and emergency management plans that do not focus solely on moving the person elsewhere . The plans will also need to support access when times get hard, and staying in the community setting is not possible, to short term flexible extra practical assistance and a wider spectrum of support resources (with pathways that reduce the length of time people spend in in-patient settings and better manage crises. Helping people to stay out of trouble and supporting people who enter the Criminal Justice System

11. Specialised Commissioning Fast Tr This strand of the model focuses on:

• The need for brief admissions in the early stages of treatment • Reduced in-patient beds • Reduced in-patient length of stay • Better service level discharge planning • Working with a different community client group • Enhanced Community Services offering new community treatment and care

packages delivered by an enhanced forensic community outreach team who provide:

o Comprehensive and rapid assessment (given risks managing in the community) , encompassing: Offending and criminogenic need Mental disorder / comorbidity Risk assessment

o Active community offender treatment Offender treatment programmes Mental disorder / comorbidity Trauma support

o Addressing social, educational and vocational needs o Direct input to support crisis o Support and training of adult learning disability and/or AMH teams o Primary and secondary prevention o Intense home support e.g. if sudden increase in risk and/or reduced

ability of home staff to support the service user o Promoting resilience in service users and/or carers (family or paid) o Complex case management

• CTO recall


• Flexible range of providers of housing and social care support in the community

• More robust transfer pathways • Prevention:

o Secondary prevention – identifying those near to offending / reoffending and doing intensive support work.

o Primary prevention – for example working in to schools etc. alongside CAMHs identifying those at particular risk. Access to a range mainstream preventative services such as drug and alcohol services.

A Consistently Highly skilled, confident and value driven workforce Positive Behavioural Support will underpin all care and support services - The health and social care workforce will demonstrate competence in positive behavioural support at all levels of organisations measured through the use of the PBS competency framework and contractual arrangements. PBS training will also be offered to families as part of the early intervention approach. The model will be delivered through the workforce proposals which are described in more detailed on the attached document. Equitable service provision and high quality evidence based care in the most appropriate setting All organisations and will adopt the 11 North East and Cumbria principles and care standards which describe the standards and the metrics that will be developed to ensure delivery & measure success. These standards are aligned to the national model and will ensure that care and support is delivered and monitored consistently to the highest levels of quality. Medicines optimisation is also included in the North East and Cumbria care principles and standards and is described in more detail in the enablers section below.

9. NEC Principles and care standards 28081. The table in the attached document begins to describe how care will be different and what we will measure in relation to each standard. Key components of our model to ensure that people with learning disabilities can access reasonably adjusted mainstream NHS services:

• Every Acute Hospital Trust has a learning disability liaison nurse that delivers strategic and direct support

• Learning disability primary care liaison is available across the region and will be further enhanced

• Health ‘Quality Checkers’ have also been trained in all localities and this will continue to be strengthened

• Mainstream and green light toolkit What enablers need to be in place for this system to operate?

Estates Community based facilities need to be identified


and commissioned for assessment, support and development of individual treatment plans. Quality of housing that is flexible to meet individual requirements. Recognising that buildings need to have the potential to be adapted based on the changing need of individuals. They need to be positioned in the community in a place that the individual can access local facilities and become part of the community.

IT Information Sharing protocols in place and being followed, to allow the sharing of information between organisations providing the different Tiers of service, to support service delivery to individuals and future service planning. New information system / database.

Finances and Commissioning Arrangements

Processes in place to enable joint CCG and Local Authority commissioning, including pooled budgets and risk share arrangements to facilitate commissioning of joint care packages. Financial and Resource agreements in place to facilitate the transition of clients from inpatient to community support. A high quality of information is needed to enable commissioning decisions to be made.

Workforce See specific workforce section. System to systematically identify and stratify at risk population

System in place to use data form multiple health and social care records to identify and risk stratify those people most at risk of poor outcomes.

Outcomes framework A shared outcomes framework will be adopted to measure system and individual outcomes.

Agreed areas for improvement for the use of medicines in people with learning disabilities

The Local Professional Pharmacy Networks (Northumberland, Tyne and Wear LPN, Durham, Darlington and Tees LPN and Cumbria LPN) have agreed to work collaboratively to undertake analysis and identify areas for improvement (recommendation 3 of NHS Improving Quality Winterbourne Medicines programme) in relation to use of medication by people with learning disabilities and behaviour that challenges.

13. Use of

medicines.docx


Reasonable Adjustments to mainstream services

All people who have learning disability will receive the majority of their care from universal services, with reasonable adjustments. To this end all providers of mainstream health and social care services must understand the variable and varying needs of this group, to communicate well with this population and their carers, and to provide care that is co-ordinated with other agencies.

Work with Care Quality Commission (CQC) to develop flexible care options that provide bespoke solutions for individual Inspection frameworks

Work with CQC to ensure the new models of care and provision will meet the required inspection frameworks. People will be supported in safe places that enable them to thrive and maximise opportunities through flexible and resilient models supported by relevant CQC regulations.

5.1.2 How will this be different for people with a learning disability and their families


Peter’s Story Peter is 28 years old and has significant learning disabilities and some physical health problems. He had a difficult upbringing with a number of failed school placements due to challenging behaviours and a series of support workers with no continuity. Since leaving college at 23 he has had limited daily activities and stays at home with his mum. He is on a lot of medication from the GP which he has always been on but mum is not sure what it is for. Mum and Peter have recently moved into the area and have not been known to services locally. Mum has started to see her GP quite regularly as she is finding it increasingly difficult to cope with Peter and is finding his behaviours more challenging and limiting what she can do as she is socially isolated and has minimal support. Peter has not been to the GP, he has just received repeat prescriptions since the move. He has always struggled to go to the GP. Peter’s mum really loves him and has always cared for him however she is at the end of her tether and worries about what will happen to Peter. She worries that he will hurt her or himself and end up in hospital and not come home. She is desperate for advice and information and to be told how she can help. She wants to be included and to be heard.

Mum is given advice and support while Peter is at school She has a named person that she can contact who knows her and Peter well If they are not there she knows she can ring a number for help 24/7 Peter and his mum are offered a range of services and choose ones that seem to meet their needs best Mum is also offered some training so she can understand why Peter is behaving the way he is. It also looks at general strategies to help manage Peter’s behavior Peter finds these meetings very hard so his mum will meet with his nurse or social worker and try and get Peter’s views or ideas. An advocate is not needed at the moment

It is not always appropriate for mum and Peter to go out together and Peter needs his own space. Some support is identified for Peter via social care and he is involved in selecting & choosing the staff who will work with him Peter is prone to periods when he feels very unwell and will ‘lash’ out when mum asks him to do things. Previously he has had a medication increase to help but the team would like to work with mum and Peter to see if there is anything else they can do This forms part of the co-produced care plan, which includes funding and was agreed by all, including Peter

Peter will receive treatment in line with NICE guidance or good practice guidance to support his behavior and also for his moods He is supported to go to his GP and ‘well man’ clinics. He receives a treatment package tailored to his needs including support from the local pharmacist to look at all his medication Peter and his mum will have access to social care to help them with social issues Peter or his Mum can request a Review at any point

As part of the care plan all have agreed what is best to help Peter ‘stay well’ The crisis contingency plan has been used once. Mum phoned out of hours and while the person on the phone did not know Peter they had all the information to hand so could get some additional support from the social care provider which allowed mum to stay at a new friend’s house giving Peter and his staff some space which allowed things to calm down. Previously Peter might have had to go in to hospital Peter’s GP will also receive a copy of this plan along with any early warning signs and initial management plan Copies will also be made available to relevant people in Peter’s care plan with his agreement if possible


5.1.3 How will this be different for staff and providers

- Joint planning, decision making and allocation of resources - Ease of access to a range of professionals and specialist support when they

need it 24/7 - Being part of a multi-disciplinary team focused around the needs of individuals - Clarity on roles and responsibilities - Shared values and philosophy with the multi-disciplinary team supporting an

individual - Effective signposting - Long term commitment to support people safely in their own homes - Supporting from a range of sources - Skilled, supported, and resilient workforce

5.2 Strategic alignment

5.2.1 How does this fit with other plans and models to form a collective system response?

This plan has been developed based on the regional vision and local strategies in line with national guidance.


The North East and Cumbria principles and standards have a focus on early intervention and this is embedded throughout our plans. These address the recommendations made within the “Winterbourne View: Time for Change”, recommendations by Sir Stephen Bubb in “Winterbourne View-Time is Running Out” and other published national guidance. We have worked with our locality Clinical Commissioning Groups and Local Authorities to develop targeted local plans. This ensures alignment with our regional model of care and the service recommendations outlined within the NHS England National Service Model. Crisis support is another main focus within our plan. We have developed a regional principle to improve this area of health care to ensure every locality in the North East and Cumbria has a 24/7 community based admission avoidance and crisis intervention service. This aligns with the standard within the NHS England National Service Model of access to specialist Health and Social Care support in the community. There is also alignment to the Mental Health Crisis Care Concordat. Our regional plan specifies commissioning intentions that will deliver enhanced development of the workforce. This will provide improved support for people with learning disabilities, which aligns to guidance published by NHS England – Ensuring Quality Services regarding the provision of accredited training that is up to date with best practice. An important aspect of our regional plan and commissioning intentions is that of joint NHS and social care planning is to be undertaken for every individual with joint funding mechanisms in place. This is to commission individualised packages of care


and support. This addresses recommendations in the Sir Bubb report and the Transforming Care Concordat.

Our plan addresses recommendations in the Sir Bubb report relating to advocacy, wherein we will ensure the provision of advocacy services for people and their families in their community and within services. We will continue to align our plans with the development of joint health and wellbeing strategies, housing strategies, development of vanguard models of care and local mental health strategies. We will utilise joint strategic needs assessments and local and national tools to inform future plan developments.

14. Key policy and guidance references.d

5.2.2 What will these changes depend on from other strategies / plans? Strategies / Plans Dependencies

Transforming Care

• Empowering individuals • Right care in the right

place • Regulation and inspection • Workforce • Data and information

Changes will depend on continue to ensure that the appropriate steps are in place to deliver transforming care.

Embedding of the new approach to Care and Treatment reviews as standard will support ensuring that we develop services in the right place at the right time. This will ensure that patients who are admitted to hospital are there for only the time required before returning home.

Upskilling and improvement in training for providers of care to people who have a learning disability so high quality care in the NE&C is the standard.

Ensuring that there is effective and secure multi agency data sharing arrangements and that these are in place.


NE&C CCG 5 year Plans – Common Characteristics

• People directing elements of their care

• Primary care at the centre • Deliver the needs of our

population in an integrated way

• Access to services 7 days per week

• Closer working with providers

• Winterbourne View • New models of care

People directing elements of their care - People will be involved as much as they want to be in every decision about their care, what care they want and how and where they want it delivered. Patient choice will direct how we continue to commission services in the future.

Primary Care at the centre - Primary care will be at the heart of the community, coordinating peoples care. Every contact will count.

Deliver the needs of our population in an integrated way - Deliver the needs of the population in an integrated way with a credible alternative to hospital care, with a focus on wrap around support. Requirement for proactive and flexible community provision.

Access to services 7 days per week –Access seven days a week to the most appropriate urgent and emergency care, with Primary Care at the centre. Matching capacity to demand.

Closer working with providers - Work with providers closely to innovate and develop new ways of working to ensure the adoption of seven day clinical quality standards and the development of efficient and productive services.

Winterbourne View – Time is Running Out, Sir BUBB report (6 month independent review of the Transforming Care and Commissioning Steering Group

Vanguards & Integrated Care Pilots - Proposed changes to the way health and social care will operate will have an impact on the commissioning of services for people with a learning disability. As the locality plans for transforming learning disability services are further developed alignment to Vanguards and Integrated Care Pilots will be included and learning shared.

Better Care Fund By April 2020, it is expected that after 5 years of investment from the BCF there is to be improvements in care and outcomes and these will be felt by users across the health and social care community. Impact on funds being transferred to local authorities to manage budgets, especially with schemes and projects which are under way with BCF funding and to ensure they continue and are sustainable.

Joint Health and Social Care Actions and improvements as directed from the self-


Self- Assessment Framework (JHASCSAF)

assessment to support and enable people who have a learning disability to:

• Stay healthy • Keep safe and • Live well

A key element of the self-assessment identified was the need to improve access to general practice and update of annual health checks.

Draft Service Model for Commissioners

The guidance will be seen as the go to guidance as will incorporate all NICE guidance going forward and this will need to be factored into changes we will make in the NE&C.

The 9 standards of ‘what good services look like’. The NE&C regional standards are aligned to these so we can work towards ‘what good looks like’.

The development and implementation of joint commissioning teams and arrangements (e.g. through S75 pooled fund arrangements) to pool skills and resources to develop high quality coordinated services.

Mencap - Death by Indifference Ensuring that all sections of the health and social care services have awareness of learning disabilities especially:

• Capacity and ability to consent • Key role of carers in interpreting distress cues • Consult and involve families throughout • To be more suspicious when investigating

potential health problems to ensure the person receives the correct care and treatment

This needs to be at the centre of the patients care and adjustments made to ensure that the person who has a learning disability receives the same high standard of care.

NICE Guidelines

Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges (NG11)

Challenging Behaviour and Learning Disabilities Overview (Pathway)

Current guidelines focus on general principles to which NE&C plans are aligned and depend on key steps occurring:

• Partnership working • Understanding the individual and their specific

needs • Organise • Deliver • Promotion of annual health checks • Support for families and carers • Training for staff

https://www.nice.org.uk/guidance/ng11






Proposed Guidelines

Challenging Behaviour and Learning Disabilities (October 2015)

Mental Health in people who have a Learning Disability (September 2016)

There are several guidelines being prepared which will need to be reviewed when published in the future to ensure the NE&C continue to provide effective services to continue to meet the needs of our population.

6 Plan for success

6.1 Workforce, Education and Training Considerations

6.1.1 What are the programmes of change to deliver this new model?

The system-wide transformational change described in this plan requires a robust programme approach to support delivery. The implementation plans are working documents and are being further developed and refined. The following task and finish groups have been identified to take forward the key areas of change:

• IT (Data sharing agreements between health and social care, summary plan for people developed (systems in place to flag and share summary information about individuals between services) and create a system to systematically identify and stratify at risk population)

• Finances and Contracting Arrangements (agreed decision making and specifications)

• Workforce Development (competence framework, Workforce Hub) • Medicines Optimisation - agreed areas for improvement for the use of

medicines in people with learning disabilities • Market engagement • Outcomes framework (implementation of standards) • Pathway development:

o Early intervention (assessment and care planning) o Crisis response (assessment and care planning) o Preventing admission (and re-admission) o Facilitating timely discharge o Children and Young people including transition services

• Rethinking advocacy • Reasonable Adjustments to mainstream services • Work with Care Quality Commission (CQC) to develop flexible care options

that provide bespoke solutions for individual Inspection frameworks. Some of the high level milestones are described in the attached documents.

15. Implementation plan Learning Disabilit

15a.Route Map - Fast Track C and NE.x


Each Clinical Commissioning Group and Local Authority in the North East and Cumbria have developed locality implementation plans identifying key actions required to deliver the vision and embed the care principles and standards. Each locality plan closely aligns to the collective principles and standards of the programme and sets out the following:

- What needs to be in place in the locality to deliver the model of care and ensure the North East and Cumbria service and care principles and standards are achieved

- Identification of risks and issues with mitigation plans - Details of any assumptions and dependencies - Stakeholder engagement plans - Proposals for investment

16. Cumbria Fast Track Locality Plan.do

17. Durham Darlington Fast Track

18. Newcastle Gateshead Fast Track

20. Northumberland Fast Track Locality Pla

19. North Tyneside Fast Track Locality Pla

21. South Tyneside Fast Track Locality Pla

22. Sunderland Fast Track Plan.docx

Tees Fast Track Locality Plan.docx

Planned changes will also be considered at a provider level, with clusters of commissioners working collaboratively to ensure optimal service configurations are achieved. New services will be designed as part of the shift of services to a community setting. The stage of development of these services varies across the region depending on historical commissioning of services. Areas are sharing best practice and learning across the region and adopting best practice seen nationally. Community based service will see the greatest change as set out in the local implementation plans. New capacity will be required within the community setting; a high level of this is expected to come from existing capacity within the inpatient services shifted to community based settings. Delivery of local plans will need to be supported by robust HR processes to identify staffing requirements and ensure appropriate staff engagement to realign resources. Cultural change needs to be managed with staff within the provider organisations. Capability changes will be needed to reskill and retrain staff and support them taking on new roles as necessary. See the workforce section (7.2) for further details. Process changes (e.g. pathways) will need to be undertaken to ensure services are designed with the individual at the heart of the pathways. Lean methodology will be one of the tools used to facilitate this. Pathways will be standard where possible providing a single, transparent pathway between all providers. All providers, individuals and their families will understand the pathway and be involved in the design process. The pathways identified for development are as set out above.


System and IT changes will be needed to support the implementation of the new services. Data sharing agreements between health and social care will be developed to ensure key elements of the individuals care are appropriately captured and shared to improve the delivery of their care and outcomes for them as individuals. A summary plan will be created and agreed to share information within the whole system so that staff can proactively manage the care for the patient using accurate and timely information from other partners. As part of the initial scoping work for the Transformation programme a Driver Diagram was created to help understand the current system and how it needs to be developed to deliver the vision. The diagram is attached below for reference.

24. Driver diagram scoping work.pptx

6.1.2 Who is leading the delivery of each of these programmes, and what is the supporting team and governance to deliver it?

Key leads / accountabilities, Resourcing and Programme governance

Key accountable leads (as detailed in the locality plans) have been identified for each locality, CCG and Local Authority to provide the main point of contact for their organisation throughout the development and implementation of the programme. The document below sets out the Programme organisation and Structure that includes the key leads roles and responsibilities. The Programme Governance structure and Transformation Programme Board Terms of Reference are presented in section 3.1. NHS North of England Commissioning Support Unit has provided support to the North East and Cumbria Fast Track throughout the development of their transformation plan. This has included support on:

• Data analysis, intelligence and modelling • Establishing robust programme structures and establishing a Programme

Management Office • Supporting the North East and Cumbria Learning Disabilities Transformation

Board • Communication and stakeholder engagement • Sharing best practice and lessons learned • Supporting development of Service and Care Standards • Developing funding and commissioning options

6.1.3 What are the risks, assumptions, issues and dependencies?

Are there any material assumptions not already captured elsewhere?

The attached document provides a list of assumptions that underpin the plan and delivery.


25. Assumptions.docx

25a.Trajectory Rationale_v2.0(23.09

6.1.3.a Key Dependencies

Organisations that are not part of this unit of planning?

There are other partner agencies that need to be more involved in discussions and they will be included within the stakeholder engagement plan:

• Criminal justice system as we recognise that they will need to be involved in the transfer of people being placed in the community. Need to be aware that there will be some people living in the community that may need additional support and resource.

• Primary care as there will be individuals being supported in the community accessing mainstream services. Raise awareness of the individuals and their circumstances. They may need more intensive support and care management.

• Police so that we raise awareness of the individuals living in the community and provide additional education to the workforce. Police could potential be involved in MDT discussions.

• Council services to raise awareness with them that include housing and leisure providers to ensure people are supported to access services.

External policies / external changes?

Interdependences have been described throughout this plan. The Transformation Board are sighted on these and actions to ensure these are factored into local developments. The shift of responsibilities from NHS England to CCGs needs to be understood and factored into commissioning arrangements. NHS England and all CCGs are represented within the governance structures for the programme of work. Education and Health Care plans need to be considered as they are created for individuals and the links with the teams managing people from children to adult services.

6.1.3.b Key Risks

All local plans include the risks and issues that have been identified to date. These and Programme level risks and issues are included within the attached log below. A key risk and concern is that an individual that has been supported in an inpatient setting and moved to a community setting may become more vulnerable. There is a potential higher risk to the individual and people in the community if they are not supported and care for effectively. The mitigation to this is to ensure the individuals do have robust care plans and that they have access to early intervention and a responsive crisis service within the community.


A risk that has been identified is that current providers of inpatient facilities may not be viable with the reduction of beds that are being planned for. There will be a shift of people who step down from specialist commissioned services into mainstream inpatient facilities and community based services. This additional demand will create additional pressures on services that will need to be considered and managed as part of the change programme. Having high quality service providers that meet the standards and expectations of what a good service looks is a challenge/risk that a number of organisations have identified. The planned market engagement and provider development will address this but the pace of change needs to be timely enough to respond to the demands on community based services. The attached risk and issues log has the following sections identified within in to ensure all of these elements have been considered and mitigating actions detailed to address these:

• Reputational • Legal • Safety • Financial • Programme Delivery

26. Learning Disabilities Risks and I

6.1.3.c Key Enablers for Success As set out in section 6.1.1 there are a number of enablers that need to be in place for the system to deliver high quality services:

• Estates • IT • Finances and Commissioning Arrangements • Workforce • System to systematically identify and stratify at risk population • Outcomes framework • Agreed areas for improvement for the use of medicines in people with

learning disabilities • Reasonable Adjustments to mainstream services • Work with Care Quality Commission (CQC) to develop flexible care options

that provide bespoke solutions for individual Inspection frameworks

Requirements for procurement of new services?

Some services will be commissioned by existing providers. There will be some elements of the service that will need to be procured.


Individual Service Designs will need to be responsive to meet the individual packages of care within tight timeframes. The plan is to commission with a range of high quality providers so that they can be utilised as individual plans identify the services of specific provider services are required. There needs to be reasonable adjustments to mainstream services so that individuals are supported to live successfully in the community. Workforce development and organisational development?

The workforce needs to be fit for practice and purpose with integrated care models understood by all grades of staff across the disciplines. Local plans also include elements of the developments needed for the local workforce.

6.2 Workforce, Education and Training Considerations

6.2.1 Question A

Does the plan require reconfiguration of existing workforce where provider(s) are remaining the same?

The workforce development plan recognises the need for reconfiguration of services and the development of new and existing staff within existing provider organisations. Workforce development is identified as a major priority and key theme for the north east and Cumbria. The learning disability sector across the region is in agreement about the need to develop capacity and competence in local services. Workforce development within the Transformation Programme will ensure we have the right people with the right skills and knowledge and behaviours to deliver personalised, preventative and safe support. Which providers will need to reconfigure the existing workforce: The main commissioned NHS providers and others that are locally commissioned will be reconfiguring their workforce:

• Northumberland, Tyne and Wear NHS FT • Tees Esk and Wear Valley NHS FT • Cumbria Partnership NHS Trust • South Tyneside NHS FT • Northumbria Healthcare NHS FT • Social Care providers in the community (independent and voluntary)

As part of the market development we will engage with wider provider organisations such as those within the independent, voluntary and private sectors. Does the implementation plan specify competency frameworks to be deployed in support of workforce reconfiguration? Please Identify. See embedded Workforce Development Plan.


Health and social care workforce commissioning will influence and shape the labour market including co-producing commissioning plans that are clear about financial investment and disinvestment, take into account the needs of different providers and are rooted in Positive Behavioural Support as a central thread. Developing innovative joint commissioning practice will be required to encourage providers to pool resources, work collaboratively and find creative solutions to learning and competency development. Commissioners are key in articulating the workforce requirements within service specifications, and including metrics and specific funding for workforce development within contracts. The North East and Cumbria will ensure robust contract management to support providers deliver a workforce with the right people with the right skills, values, culture and knowledge and behaviours to deliver personalised, preventative and safe support.

Does the implementation plan address Positive Behaviour Support/positive and safe related education and training needs? Across health and social care, statutory and the independent sector the workforce plan specifies: the use of the Positive Behavioural Support Competency Framework that will underpin the development of the North East and Cumbria Positive Behavioural Support Hub; The North East and Cumbria PBS Hub will be co-ordinated, planned, network for the development and delivery of accredited training and bring together local expertise to develop full range of training, supervision and coaching for front line staff, their supervisors, managers and families. The plan states that initial scoping work will be carried out by a local university to undertake action research approach to scope, develop, test, implement and analyse the results of a mapping exercise of workforce development against regionally agreed PBS knowledge, skill and competencies required for all levels of staff. The scoping work will identify the needs of the existing a future workforce including different roles not currently available. There will be a requirement to develop new education and training across the health and social care workforce. Health Education North East has agreed to lead this workforce development steering group supported by key stakeholders from across the system.

Does the implementation plan identify how Training Needs Analysis will be undertaken and how results will be employed to support effective education and training commissioning? The initial scoping work will identify needs. This will be undertaken by a local University.

Does the implementation plan identify employment of apprenticeships, assistant practitioners, advanced practitioners and/or physician associates? Once the scoping work has been completed this will identify the workforce requirements and the skill mix of staff needed to deliver the plans. Does the implementation plan require the development of any new roles to support the new delivery model?


Once the scoping work has been completed this will identify the workforce requirements and the skill mix of staff needed to deliver the plans.

Is there a requirement to develop new education and training to support deployment of new roles? Please specify. Please refer to the following Workforce Development Plan for details of the above:

12. Workforce Development Plan.do

6.2.2 Question B

Please refer to the Workforce Development Plan as above. It is to be expected that workforce commissioning will need to influence and shape the labour market including co-producing commissioning plans that are clear about financial investment and disinvestment, take into account the needs of different providers and are rooted in Positive Behavioural Support as a central thread. Developing innovative joint commissioning practice will be required to encourage providers to pool resources, work collaboratively and find creative solutions to learning and competency development. Commissioners are key in articulating the workforce requirements within service specifications, and including metrics and specific funding for workforce development within contracts. The scoping work to be undertaken will provide the capacity and capability across all providers to identify workforce, education and training needs. The nationally agreed Positive Behaviour Support Competency Framework will be deployed in our workforce development plans. We are investigating the advantages using the PBS competency framework to enable expansion of initiatives to incorporate broader workforce development programme similar to the same developed by Health Education West Midlands. Learning disability leadership programme: The North East and Cumbria will proactively develop leaders who have both the skills and ambition to lead today and in the future across the health and social care systems especially with a focus on transforming services to redress the poor outcomes that continue to occur for many people with a learning disability. The aim of the programme is to identify as a minimum, learning opportunities for 15 senior leaders and provide a comprehensive leadership joint health and social care development programme. An additional aim is to identify learning opportunities for at least 5 family carers within the cohort. Nominations will be encouraged from senior commissioners from a range of backgrounds across Local Government and the NHS who have experience and passion about learning disability.

6.2.3 Question C

• What is the estimate of costs for workforce, education and training elements within answers to Question A?


• What is the estimate of costs for workforce, education and training elements within answers to Question B?

• What is the estimate of total costs for workforce, education and training elements within answers to Question A and B?

£188,938 is sought from Transformation Programme budget to resource the following:

• PBS Training delivery team £101,500 • Workforce development in dentistry £17,438 • Learning disability leadership programme £70,000

Match funding arrangements are in place with Health Education North East who are fully supportive of the proposals and have agreed to lead the workforce development task and finish group. HENE has committed £100,000 initially to provide resource for the scoping work (£30,000) and a contribution (£70,000) to the Learning Disability Leadership Programme. The leadership Programme will cost £200,000 in total so discussions are underway to source funding from Health Education England, North East Leadership Academy and Academic Health Science Network for the outstanding resource required for the Leadership Programme which is £60,000.

6.2.4 Stakeholder Engagement Who has a stake in this plan?

The key stakeholders that have been identified and we are actively working with include: the 13 Local Authorities across the North East and Cumbria, 11 Clinical Commissioning Groups across the North East and Cumbria, the North East and Cumbria Learning Disability Network, NHS England Specialised Commissioning, the NHS service providers including primary care, community services, acute care, specialist learning disability service providers, North of England Commissioning Support (NECS), people with learning disabilities, carers and their families, the voluntary and community sector, NHS England Learning Disability Transformation Team, wider stakeholders such as public health and the criminal justice system, private providers of services for people with learning disabilities and regulators. The embedded diagram shows all stakeholders involved in the development and delivery of the programme at a high level.

27. Stakeholders with key roles and res

People, Families & allies will contribute to the development of the Transforming Care plans, actions & changes including the integration of the broader issues for people with learning disabilities in the North East & Cumbria.


As in section 7.1.3a there are some stakeholders we need to further engage with such as the criminal justice system, children’s services, primary care and wider council services to ensure they are involved in developing services and/or aware of the impact they will have on individuals. A Confirm and Challenge Group has been established to enable people with learning disabilities, their families and representatives to link with the regional Winterbourne View Group to offer solutions, ideas and questions. The group will also identify those parts of the ‘pathway’ where more thought or planning is needed to ensure all people with learning disabilities can have good community based support. A representative from the Confirm and Challenge Group attends the Transformation Programme Board, supported by Inclusion North. The role of the group is to make sure stakeholders have a way of working with local people on plans, decisions and checking, share the easy to understand information and make sure there are local updates and base their work on what people and families say is important. This will be achieved by working with a small group of self-advocates & families with an interest in or experience of the issues to:

- Provide a confirm & challenge function to the regional group – offering solutions, ideas & questions

- Get to grips with the issues – understanding it and preparing for work with colleagues at the regional groups

- Identifying those parts of the ‘pathway’ where more thought or planning is needed to ensure all people with learning disabilities can have good community based support.

- Agreeing one or two outcome measures from the regional groups’ priorities that the group can create information on to help local leaders

- Linking to local & national ideas or debates - Follow up actions agreed with the group between meeting - Support the members to design (& then implement) a way of sharing their

learning & work with other self-advocate & family leaders We are in the process of establishing a working group relating to specialist services to begin this work programme and there is a well-established secure services forum to which representatives of all the key stakeholders are invited. To make the plan work, the involvement of service users and carers will be essential. We already have good links with the national service user group and the service user group at TEWV have been leading on a number of national service user led initiatives like ‘My shared pathway’ which is a collaborative approach to care planning incorporating the implementation of service user audits of CPA processes. We would wish to continue with this relationship and would do this via the vehicle of the national recovery and outcomes group. Please see embedded the communication and engagement plan. The easy read summary of the plan has been uploaded separately.


28. Fast track learning disabilities tra

How have they been involved?

There have been many stakeholder involved in the production of this plan. Preceding the Fast-Track work, for over 3-years, the regional Learning Disabilities Network, Local Authorities and Clinical Commissioning Groups with partners have been active in the North east and Cumbria. There have been a number of working groups including the Learning Disability Clinical Leads Forum that includes Local Authority and senior health colleagues working together on a wide range of service issues including post-Winterbourne / Transformation activity. This work has fed directly into the regional ADASS learning disability work stream, chaired by Lesley Jeavons (Deputy SRO for the Fast track area),which features identified representatives from each Local Authority. Consequently, Local Authority representation and participation has been significant in a number of planning workshops and seminars which have informed the Fast Track plan, playing a key role in relation to provider engagement and market management. A number of engagement events have taken place as the vision and plan have been developed. A wide range of stakeholders were involved in a region-wide event in April which set the vision for transforming learning disabilities across the North East and Cumbria. At the event and subsequently, stakeholder representatives have considered the evidence of key issues identified by people and families about local services to inform their transformation work. This includes work on advocacy in the North East and nationally (as previously stated). This work is informing locality plans in each area. This includes:

• issues identified by the North East Partnership between 2012 to date; • themes of feedback around rights of people and their families connected to

housing, choice and security of tenure in the Bubb report; • the key points raised at the national event hosted by Change In the North

East (a joint consultation event with people and families on the Green Paper); • feedback from local groups and providers’ involvement of groups in their

localities; • the kind of support, models and rights people expect being fed back through

local reference groups linked to providers in and across the localities. There has also been feedback from some people in the North east on Finding Common Purpose. http://www.local.gov.uk/web/lg-procurement/health-and-social-care. The Confirm and Challenge Group has set principles they believe all stakeholders should adopt as part of the Transformation Programme and also recommended ways of working in a report to the Transformation Board as embedded in the next section.

http://www.local.gov.uk/web/lg-procurement/health-and-social-care

http://www.local.gov.uk/web/lg-procurement/health-and-social-care


The development of this plan has required a range of experience, expertise and skills including a breadth of clinical and social care expertise form across the system, to challenge and refine the model of care and pathways. Even wider engagement and involvement is required to develop the detailed plans that support this transformation programme and the involvement of service users and carers will be essential. Particular areas of focus for further engagement activity include, the Criminal Justice System, housing, children and young people’s commissioners and providers, Healthwatch, public health and education. How will they be involved in the future?

A wide range of stakeholders are represented on the Transformation Board. Further work is currently being undertaken to complete the detailed mapping of stakeholders for each area as part of the region-wide strategy for communications and engagement and a specific recommendation from the Confirm and Challenge Group. Further work is needed to clarify future governance arrangements with all stakeholders to ensure they all know what the approach is going to be to oversee the delivery of the Transformation Programme. The processes for decision making regionally and locally need to be explicitly understood and embedded. There needs to be engagement of wider commissioning and provider teams not just the stakeholders who have already been working to produce the current plans. The clear rationale for service change needs to be communicated and the ‘What’s In It For Me’ framework will be a good tool to build on the process of further engaging with stakeholders. Co-production of the plans is important to all key stakeholders. A group of people with learning disabilities and family representatives supporting the transformation board work will provide ‘confirm and challenge’ support (the Confirm and Challenge Group who will report to the Transformation Board). They have recommended that detailed stakeholder mapping is shared for each of the localities and the Confirm and Challenge Group will, in turn, connect with other groups across the region (see embedded document ‘working with people recommendations’). The North East and Cumbria are committed to engaging with people with Learning Disabilities and their families as detailed in the attached document that the Transformation Board are fully supportive of:

30. Working with people recommendati

The communication and engagement strategy and plan is being developed at a North East and Cumbria-wide level and will be aligned to each locality, and to national communications. The communications lead will be part of the national communications group. These activities will make sure that the Transformation Programme Board can continue to


gain the commitment for change and transformation. It is designed to sustain the commitment of key stakeholders and to drive the transformation of the care for local people, their carers and families with experience of learning disabilities. It will be tested with the Confirm and Challenge Group, which underpins the co-production approach. A cascade communications approach will be used to align key messages through existing communications channels through each stakeholder organisation in accessible and easy read formats and align these with local engagement plans. There will be a regular process of review through a transformation programme communications and engagement ‘virtual’ sub group and the Confirm and Challenge Group led by the project manager and the communications and engagement support. We will plan, and track, all communication and engagement to make sure that it is supportive and timely, avoiding information overload for stakeholders, at the same time continually/ regularly reviewing the level of engagement. An iterative process will be used undertaken by a communications and engagement sub- group of the transformation board. Plans and delivery will be monitored to gauge the effectiveness of messages with the Transformation Board and the Confirm and Challenge Group, as well in each locality with key stakeholders. The general approach will be to gather input, develop the strategy and plan and execute it with the co-production of people with learning disabilities, through North East and Cumbria representatives supported by Inclusion North and through each of the localities. We have already started to consider what works best for each of the localities as part of the stakeholder mapping and will build on this feedback. As part of the stakeholder mapping we are currently in an inquiry phase the “inquiry phase” to develop a community of practice; alongside what we already know. Through this we will be able to identify our audience, purpose, goals, and vision for this community and our strategy for communicating with it. Key stakeholders on the Transformation Board and wider are being asked about gaps (is everyone involved who should be) and key issues (learning and best practice, tasks, gaps, specific and recommended communications channels). This community of practice will provide the shared context and support key messages, enable dialogue, stimulate learning between stakeholders as part of the Transformation Programme, capture and diffuse existing knowledge to help people improve their practice, introduce collaborative processes to groups and organisations, generally helping people organise around purposeful actions that deliver tangible results to transform local services. A confirm and challenge group has been established to enable people with learning disabilities, their families and representatives to link with the regional Winterbourne View Group to offer solutions, ideas and questions. The group will also identify those parts of the ‘pathway’ where more thought or planning is needed to ensure all people with learning disabilities can have good community based support. A confirm and


challenge checklist as below has been developed to help support the development and delivery of the Fast Track plan and this will be used throughout implementation by all partners in the programme.

31. Confirm and challenge checklist.do

7 Financials

7.1 What investment is required and what are the programme costs of delivery? The North East and Cumbria Region are requesting Transformation funding of £2,710,900. The funding requirement is made up of a revenue requirement of £2,240,900 and a capital requirement of £470,000. In summary the Transformation funding will be used as follows: Key area of Required Funding Required

Revenue £ Required Capital £

Total £

Strengthening and Developing Community Support

1,031,500 1,031,500

Workforce Development 256,400 256,400

Market Development and stimulation

44,500 44,500

Transitional placements/ emergency capacity and support for partial closures

623,500 623,500

Modifications, Refurbishments/ Capital works/ and provision of specialist Equipment

470,000 470,000

Project support and Development

135,000 135,000

Support to VCS and Community Groups

50,000 50,000

Rethinking Advocacy 100,000 100,000

Totals 2,240,900 470,000 2,710,900

Match Funding – Our Local Buy In - £2.711m The North East and Cumbria Clinical Commissioning Groups and key stakeholders can demonstrate a serious commitment to transforming Learning Disability services


having committed to investing over £2.711m between them in new or improved Learning Disability services in the 2015/16 financial year. Key elements of this investment include

• £1.4m investment in a new service to support ADHD and ASD across Northumberland and Tyne and Wear commissioned from Northumberland Tyne and Wear Mental Healthcare Trust

• £800k investment in community services to improve provision for Learning disabilities across Teesside and Durham areas

• £150k investment in Advocacy, Co-production of plans and Carers support • HENE have also committed £160k of funding to support and match fund

workforce development included within the Transitional bid. The region believes that if funding is approved for the bid it will:-

• Be deliverable in the timescales • Support the development of a sustainable model to drive forward the

Transformation of Learning Difficulty services • Allow the shift in service delivery to become a reality • Ultimately support the ambition and aims of the Region

Further detailed analysis and modelling is underway to develop the underpinning financial model, complete the NHS England finance template and further describe the planning assumptions. A summary of the initial working assumptions is included in Section 6.1.3.

0


Governing Body

Agenda Item: 69

1st December 2015

Title Urgent Care Strategy 2015-20


Category

Strategy &

Planning ☒

Performance &

Operational ☐

Governance &

Assurance ☐


Jackie Kay

Clinical Sponsor

Andrea Jones

Author of Report Anita Porter

Recommendation(s) The Governing Body are asked to note the contents of the report

and approve the final version of the Urgent Care Strategy 2015-20 attached as Appendix 1.

Executive Summary

This report provides Governing Body with the final version of the Urgent Care Strategy 2015-20 and requests approval ahead of it being presented to the Darlington Health and Wellbeing Board on 19th January 2016 for endorsement. This final strategy is now presented following the final draft version being presented to Governing Body on the 15th September 2015. The final draft strategy was updated, taking into account feedback received from an engagement exercise undertaken during August/September and comments from an externally commissioned proof reader through NECS Communications Team. This final strategy has now been approved by North Durham CCG, Durham Dales, Easington and Sedgefield CCG and County Durham Health and Wellbeing Board.

Clinical Engagement

The strategy has been developed by partners of the County Durham and Darlington System Resilience Group. The strategy aligns with the Clinical Strategy produced by County Durham and Darlington NHS Foundation Trust and all partners have

1

been given opportunity to engage clinically within their own organisation as they feel appropriate. In Darlington the strategy is aligned with the direction of travel to fully integrate the urgent care services within Darlington Memorial Hospital.


The strategy provides evidence of the strategic direction of travel for urgent and emergency care over the next five years across County Durham and Darlington. NHS England have had opportunity to review the final version of the strategy that went to System Resilience Group on 9th October 2015 for approval and have fed back positive views on both the strategic direction, action plan and overall document. They requested prioritisation of the action plan which is already planned to be addressed through the System Resilience Group.


No. It is expected that Equality Impact Assessments are undertaken on indiviudal projects within the strategy action plan as part of the local implementation process.

Attachments Final Urgent Care Strategy 2015-20




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2.


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3.


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2

5.




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Community Council 27th August 2015 Darlington CCG Management Executive 8th September 2015 Darlington CCG Governing Body 15th September Joint Management Team 29th Sepember 2015 Health and Partnerships Scrutiny Committee 4th November 2015


Health and Wellbeing Board 19th January 2015 (for endorsement)

3

Urgent Care Strategy 2015-20 1. Introduction 1.1. This strategy (Appendix 1) has been developed by the County Durham and

Darlington System Resilience Group and has been shaped by the standards encompassed within NHS England’s Planning Guidance, Everyone Counts 2015/16 to 2019/20, key National and local reviews of urgent and emergency care services, NHS England’s Five Year Forward View and the recently introduced Eight High Impact Interventions for urgent and emergency care.

1.2 The Transforming Urgent and Emergency Care Review proposed a new National

vision urgent and emergency care which has now been adopted and is being heavily promoted by NHS England. The National vision has two key aims:

• People with urgent but non-life threatening needs must have a highly responsive,

effective and personalised service outside of hospital – as close to home as possible, minimising disruption and inconvenience for patients and their families;

• People with serious or life-threatening emergency needs should be treated in

centres with the very best expertise and facilities in order to reduce risk and maximise their chances of survival and recovery.

1.3 NHS England published further guidance to help local commissioners and providers

understand the practical elements of the vision and are providing support to facilitate local implementation throughout this year. This guidance has been reflected appropriately within the strategy.

1.4 The main elements of the National approach underpinning the aims of the vision are:

• Self-care – through more easily accessible information about self-treatment option, pharmacy promotion and better access to NHS 111

• Right advice or treatment first time – through an enhanced NHS 111 service which is easier to access and supported by a range of clinicians

• Faster, convenient, enhanced service – to General Practice, primary and community care services aimed at providing care as close to home as possible and prevention unnecessary admissions to hospital

• Identify and designate available services in hospital based emergency centres - aiming to ensure that urgent and emergency care services work cohesively together as an overall Urgent and Emergency Care Network so that the whole system becomes more than just a sum of it’s parts

1.5 In the North East, the Urgent and Emergency Care Network will cover the North East

Region, North Cumbria and Hambleton, Richmondshire and Whitby Clinical Commissioning Group area. The purpose will be to improve the consistency and quality of urgent and emergency care by addressing together challenges in the

4

urgent and emergency care system that are difficult for single System Resilience Groups to achieve in isolation.

1.6 The County Durham and Darlington System Resilience Group overall responsibility

for the capacity planning and operational delivery urgent and emergency care across the health and social care system.

Local Context 1.7 The County Durham and Darlington System Resilience Group (SRG) has developed

the County Durham and Darlington Urgent Care Strategy 2015-20 and will be responsible for overseeing the implementation of the Urgent Care Strategy locally.

1.8 Local Clinical Commissioning Group’s will be responsible for ensuring their local

urgent care pathway is implemented line with the principles agreed within this strategy. This includes ensuring that appropriate local engagement takes place in relation to individual actions within the strategy action plan.

1.9 The SRG is chaired by the Chief Clinical Officer from Durham Dales, Easington and

Sedgefield Clinical Commissioning Group with representation from North Durham Clinical Commissioning Group, Darlington Clinical Commissioning Group, both Local Authorities and all key stakeholders involved in the delivery of urgent and emergency are across County Durham and Darlington.

1.10 In line with the National vision, the local vision for urgent and emergency care that

has been developed is: ‘Patients are seen by the right health/social care professional, in the right setting, at

the right time, to the highest quality and in the most efficient way providing the best outcome for the patient.’

1.11 This vision incorporates the whole urgent and emergency care system from

pharmacies, GP Practices and other primary care services, secondary care community services and acute hospital provision.

1.12 To implement the vision, the identified actions have been aligned to seven

objectives:

• People are central to designing the right systems and are at the heart of decisions being made;

• Patients will experience a joined up and integrated approach regardless of the specific services they access;

• The most vulnerable people will have an a plan to help them manage their condition effectively to avoid the need for urgent and emergency care;

• People will be supported to remain at their usual place of residence wherever possible;

• The public will have access to information and guidance in the event of them needing urgent or emergency care;

5

• The patient will be seen at the right time, in the right place, by a person with the appropriate skills to manage their needs;

• The patient will not experience any unnecessary delay in receiving the most appropriate care.

1.13 The County Durham and Darlington System Resilience Group would like to ultimately

see the following model commissioned for patients requiring urgent and/or emergency care.

1.14 The main focus of the model is the availability of a range of community based

services including pharmacy, promotion of self-care, NHS 111, GP Paramedic Support, extended primary care joined up with secondary community care services providing a timely and effective service to patients who are quickly and safely directed to access the relevant service to meet their presenting health needs.

1.15 For those with urgent needs they will be quickly and safely directed to attend an

urgent care service and those will serious or life threatening health conditions will be quickly, safely and effectively assessed and treated in an Accident and Emergency Department.

1.16 The County Durham and Darlington Urgent and Emergency Care Strategy 2015-20

is a high level strategy with each Clinical Commissioning Group responsible for developing implementation plans including appropriate local engagement to deliver on actions they have responsibility for leading on.

1.17 Implementation of the strategy is focused on a collaborative approach across commissioners and providers, developing an evidence based urgent and emergency care system, with equitable access to high quality, safe and effective urgent and emergency care services at the right time and in the right place, that comfortably achieves the constitutional standards for urgent and emergency care.

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1.18 It is important to note that the urgent and emergency care system locally, in inextricably linked to wider regional provision as acute hospitals provide mutual aid to each other at times or pressure and the North East Ambulance Service being responsible for the co-ordination and response to both emergency and urgent healthcare needs through 999 services and NHS 111 across the region.

1.19 For this reason the action plan within the strategy identifies both local and regional

actions with the regional actions. Local actions will be the responsibility of local commissioners and providers across County Durham and Darlington. The SRG members will contribute to the development and delivery of regional actions but overall responsibility will sit with the Urgent and Emergency Care Network for the implementation of these actions across the region to ensure consistent service and effective use of resources.

Local Engagement 1.20 During August/September 2015 all Clinical Commissioning Groups shared the final

draft of the strategy with their Patient Reference Groups and other local engagement meetings in including, in Darlington Joint Management Team on 29th September and the Health and Partnerships Scrutiny Group on 4th November. Groups were invited to feedback on any errors or omissions and to make suggestions about how best to implement the strategy within each local area and who else needs to be involved.

1.21 As part of this process in Darlington, a final draft of the strategy was presented to

Darlington CCG Executive Committee on 8th September 2015 and to Darlington CCG Governing Body on 15th September 2015.

1.22 The final version of the strategy (Appendix 1) has taken into account feedback

received during August/September and comments from an externally commissioned proof reader through NECS Communications Team.

1.23 The feedback was categorised as follows:

• Positive feedback supporting the strategy; • Suggestions that need to be addressed in the final strategy; • Lengthy document; • Feedback relating to local implementation – to be addressed by local

CCG’s; • Feedback relating to the national approach and therefore must do’s; • Suggestions about who needs to be involved in implementation.

1.24 From suggestions received a number of minor changes were made to the final

document including strengthening the wording around demand management to reflect that this is the responsibility of all partners, reversing the flow of information in Section 5 ‘Where are we now?’ and additional actions in respect of strengthening the frail elderly pathway to prevent avoidable admissions and to specifically capture the work being progressed within Darlington Memorial Hospital to include urgent care and improve care for patients.

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1.25 There were a number of references to the strategy being a lengthy document. A

summary version of the strategy and plan on a page will be produced when the strategy has been fully finalised.

1.26 This report presents the final strategy and requests Governing Body’s approval of the

final version of the strategy (Appendix 1) ahead of it being presented to the Darlington Health and Wellbeing Board on 19th January 2016 for endorsement.

1.27 Once the final strategy is formally approved by all three Clinical Commissioning

Group Governing Body’s, work will be undertaken by NECS Communications Team to produce a polished version including Plan on a Page and summary version to ensure that the key messages of the strategy are accessible to all.

2. Implications and risks 2.1 The following were incorporated into the final version of the strategy resulting from

feedback received from both the Darlington Unit of Planning and Darlington CCG Executive Committee during winter 2014/15:

• Public engagement work undertaken by Darlington Clinical

Commissioning Group; • Reference to the Securing Quality in Health Services (SeQIHS)

programme; • The Darlington Multi-disciplinary Team approach for older people; • The Integration of the in-hours Urgent Care Centre with Darlington

Memorial’s A&E department; • The NHS 5 Year Forward View (Oct 2014); • Mental health urgent and emergency care services; • Children’s and young people’s urgent and emergency care services.

2.2 During the engagement that took place during August and September, in Darlington,

Joint Management Team requested that a further, more detailed report was presented to the group with a specific focus on the future of Darlington Memorial Hospital. Specifically the report was to share the analysis, performance, activity and plans for Darlington Memorial Hospital Urgent Care and Emergency Department and how this related to the SeQUIS programme of work.

2.3 A request has been made to the Operations Director of CDDFT following the Joint

Management Team Meeting at the end of September 2015 who agreed to prepare the report and submit directly to Darlington Clinical Commissioning Group for approval.

2.4 NECS has requested that CDDFT’s final report is forwarded onto them so it can be

appended to the Health and Wellbeing Board report. 2.5 Reference has been made within the strategy that all Clinical Commissioning Groups

will undertake their own local engagement to develop their own urgent and

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emergency care service arrangement in line with the overarching strategic approach set out in the strategy.

2.6 Supported by National evidence about what works well Darlington Clinical Commissioning Group are working with County Durham and Darlington NHS Foundation Trust to reconfigure the existing Accident and Emergency Department within Darlington Memorial Hospital to enable an integrated emergency and urgent

care service to be delivered 24/7. The aim is to provide local people with equitable access to sustainable, high quality, safe and effective urgent and emergency care services at the right time and in the right place.

3. Recommendations The Governing Body are asked to note the contents of the report and approve the final version of the Urgent Care Strategy 2015-20 attached as Appendix 1.

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Appendix 1

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Key contributors

This strategy has been written by Anita Porter, Senior Commissioning Support Officer, North of England Commissioning Support Unit with and on behalf of County Durham and Darlington System Resilience Group Members whose representation is comprised of:

• NHS North Durham Clinical Commissioning Group (ND CCG)

• NHS Durham Dales, Easington and Sedgefield Clinical Commissioning Group (DDES CCG)

• NHS Darlington Clinical Commissioning Group (DCCG)

• Durham County Council (DCC) • Darlington Borough Council (DBC) • County Durham and Darlington

NHS Foundation Trust (CDDFT) • North Tees and Hartlepool NHS

Foundation Trust (NTHFT) • Local Pharmaceutical Committee

(LPC)

• City Hospitals Sunderland NHS Foundation Trust (CHSFT)

• North East Ambulance Service NHS Foundation Trust (NEAS)

• County Durham Healthwatch • Darlington Healthwatch • Tees, Esk and Wear Valleys NHS

Foundation Trust (TEWV) • NHS 111 • North of England Commissioning

Support Unit (NECS) • NHS England • Durham Police Authority • Durham and Darlington Fire and

Rescue Service

All organisations logos will be inserted here in final published version.

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Foreword The System Resilience Group are currently working within a health and social care system that is rapidly evolving. Legislation that underpins the delivery of health and social care has been recently revised and the need to continue to strive to deliver high quality healthcare, maximising the benefit to patients from limited resources remains a fundamental challenge. In recent times, there has been increasing pressure placed on urgent care systems as patients seek greater assurance regarding their condition and rapid response from services. We are keen that this highly responsive provision remains, but that, wherever possible, patients are treated in the right place, at the right time and by the right professional. Thus, urgent care should not be thought of as a stand-alone, discrete service but an integrated philosophy embedded within patient pathways to ensure that our patients receive a joined-up approach to their care, from all agencies involved, ideally in the community where they live. The System Resilience Group for County Durham and Darlington has taken a whole systems approach in developing the strategy to ensure these principles are embedded from the beginning. Evidence suggests that attendances at emergency departments continue to rise, a significant proportion of which could have been more appropriately dealt with by primary and community services. Previous engagement has shown that this is what patients would prefer. This would also result in better utilisation of specialist emergency department skills, and enable more effective relationships between the patient and their primary care clinician in managing their condition. This Urgent Care Strategy aims to improve people’s ability to care for themselves through patient self-management programmes, improve patient access to urgent care from primary and community services and improve emergency care provision provided within hospital settings and by ambulance services. There are a number of principles that underpin how all partners will work together and develop:

• a whole-system approach that has the patient journey and experience at the heart of the planning process;

• urgent care services are easier to navigate for patients as well as clinicians and those in social care or children’s services, through the strengthening of the NHS 111 as a single point of access service;

• services that are streamlined to avoid duplication, utilising the options to co-locate services to drive efficiency and patient safety;

• close working relationships with all our stakeholders to develop an integrated approach, using shared records and information technology systems, and ensuring communication between services is optimised and systems of monitoring are standardised;

• a preventative approach through patient self-management programmes; • primary and community services that support the prevention of hospital admissions and

support hospital discharge, with particular reference to services supporting the frail elderly and those with complex needs;

• a better patient experience for people who have emergency care needs or who need a stay in hospital;

• partnership working with neighbouring boroughs, to ensure patient care is not compromised by boundary issues.

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Contents

Section Heading Page Number

Foreword from Chair of System Resilience Group 2

1.0 Executive Summary 4 2.0 Introduction 6

3.0 What Should Good Urgent and Emergency Care Look Like? 9

4.0 National and Local Context 13 5.0 Where Are We Now? 19

6.0

What We Want • Current Clinical Commissioning Group

Priorities • Urgent and Emergency Care Pathway Gaps

30 30

33

7.0 How Are We Going To Get There? • High Level Action Plan

41 42

8.0 How Will We Measure Success? 51 9.0 Governance Structures 53

Appendix 1 Urgent Care Strategy 2014 – 2019 Plan on a Page 55

Appendix 2 Eight High Impact Interventions 56 Appendix 3 Local Performance and Activity Information 57

Appendix 4 Key National and Local Policy and Best Practice Documents

61

Appendix 5a Appendix 5a – Map of Current Services: Hospital Sites, Urgent Care Centres and GP Practices

63

Appendix 5b Appendix 5B – Map of Current Services: Community Pharmacies 64

Appendix 6 Glossary 65

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1 Executive summary

1.1 The Department of Health defines urgent and emergency care as the range of healthcare services available to people who need medical advice, diagnosis and/or treatment quickly and unexpectedly. This could include, for example, accident and emergency (A&E), walk-in, and minor injury and illness services.

1.2 Nationally, statistics from NHS England Winter Health Check, March 2015, states

that since the winter of 2009/10 there has been a 14.1% increase in A&E attendances, and a leap of 26.3% since the winter of 2004/5. Emergency admissions have risen by 8.8% since the winter of 2009/10 and by 25.7% since 2004/5.

1.3 Between November to February 2014/15 there was a total of 7,063,000 A&E

attendances, 190,000 more than the same period last winter. At its peak the system managed 446,000 attendances within one week during December 2014, followed by 440,000 the following week. Both record figures recorded for a winter period. Actual admissions showed a similar increase in demand, with a total of 1,821,000 during 2014/15, compared to 1,770,000 the previous winter.

1.4 Two key factors are clearly identified as contributing to the growing pressures on

A&E: • An ageing population with increasingly complex needs is leading to ever rising

numbers of people needing urgent or emergency care. • Many people are struggling to navigate and access a confusing and

inconsistent array of urgent care services provided outside of hospital, so they default to A&E.

1.5 This strategy has been developed by the County Durham and Darlington System

Resilience Group supported by NHS Improving Quality (NHS IQ). The strategy covers the period 2015 to 2020 and has been shaped by the standards encompassed within NHS England’s Planning Guidance, Everyone Counts 2015/16 to 2019/20, key national and local reviews of urgent and emergency care services, NHS England’s Five Year Forward View, and the Eight High Impact Interventions.

1.6 The local vision for this strategy has been agreed by the System Resilience Group

as:

‘Patients are seen by the right health/social care professional, in the right setting, at the right time, to the highest quality and in the most efficient way providing the best outcome for the patient.’

1.7 The vision is underpinned by seven objectives. All actions stated within the action

plan help to achieve one or more of the seven objectives. Overall the strategy aims to ensure that all patients are seen by the right person, in the right setting at the right time, as well as having a key focus on reducing demand overall for urgent and emergency care services to ensure resources can be appropriately targeted and effective.

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1.8 To achieve the above, there are a number of agreed principles that underpin how all partners will work together and develop:

• a whole-system approach that has the patient journey and experience at the heart of the planning process;

• urgent care services are easier to navigate for patients as well as clinicians and those in social care or children’s services, through the strengthening of the NHS 111 as a single point of access service;

• services that are streamlined to avoid duplication, utilising the options to co-locate services to drive efficiency and patient safety;

• close working relationships with all our stakeholders to develop an integrated approach, using shared records and information technology systems, and ensuring communication between services is optimised and systems of monitoring are standardised;

• primary and community services that support the prevention of hospital admissions and support hospital discharge, with particular reference to services supporting the frail elderly and those with complex needs;

• a better patient experience for people who have emergency care needs or who need a stay in hospital;

• partnership working with neighbouring boroughs, to ensure patient care is not compromised by boundary issues.

1.9 To achieve the local vision for urgent and emergency care, several workstreams will provide a focused approach to the delivery of the strategy action plan and will be responsible for reporting progress into the System Resilience Group on a monthly basis.

1.10 In order to evidence that the implementation of the strategy is a success, there are a

number of critical success factors identified. These include the constitutional key performance measures but also that:

• patients report that they are accessing the right service, at the right time, first time;

• positive patient reports of their experience of all urgent and emergency care services within the system;

• providers feel supported and have sufficient resources to meet patient needs; • commissioners feel their investment is cost effective and resulting in positive

patient outcomes. As part of the work to consider how best to implement this strategy, the System

Resilience Group will consider the best ways to effectively measure these success factors.

1.11 Appendix 1 provides a summary ‘plan on a page’ of the whole strategy. 1.12 The County Durham and Darlington System Resilience Group overall responsibility

for the capacity planning and operational delivery urgent and emergency care across the health and social care system. The System Resilience Group will be responsible for overseeing the implementation of the Urgent Care Strategy.

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2 Introduction

2.1 There is a national focus on urgent and emergency care services across England. In

response to this, the County Durham and Darlington System Resilience Group have developed this urgent care strategy specifically focusing on the standards in Everyone Counts 2015/16 to 2019/20. The strategy sets out a joint vision and patient centred principles, together with whole systems solutions to achieving them.

2.2 The strategic direction set out in this strategy will engage the public, key

stakeholders, Overview and Scrutiny Committee, and Health and Wellbeing Boards to make sure it is right for County Durham and Darlington.

2.3 Members of the System Resilience Group that have been involved in the

development of this strategy include Durham Dales, Easington and Sedgefield Clinical Commissioning Group who Chair the System Resilience Group working in partnership with North Durham Clinical Commissioning Group, Darlington Clinical Commissioning Group, Durham County Council; Darlington Borough Council; County Durham and Darlington NHS Foundation Trust; Durham Police Authority; County Durham and Darlington Fire and Rescue Service; Tees, Esk and Wear Valleys NHS Foundation Trust; North East Ambulance Service; County Durham Healthwatch; Darlington Healthwatch; Local Pharmaceutical Committee; other local acute trusts and NHS England.

2.4 The Chair of each System Resilience Group meet together every month at the

Urgent Care Network. This meeting supports System Resilience Group Chairs to have a regional focus, commission some services regionally, share good practice and information.

2.5 Local commissioners and providers are committed to the development of an evidence-based service model that will provide local people with equitable access to high quality, safe and effective urgent care services at the right time and in the right place. The consolidation of urgent care provision across County Durham and Darlington will deliver on our commitment to provide urgent care services that are geographically located to provide equity and consistency of service.

2.6 To ensure that the public and key stakeholders are appropriately involved in the local

development of urgent and emergency care in line with this strategy, across County Durham and Darlington, engagement work in relation to specific actions included within the strategy action plan will be undertaken by individual Clinical Commissioning Groups as the strategy action plan is realised over the next five years.

2.7 To support local healthcare provision in England, the NHS Constitution sets out the

principles and values under which all healthcare services should operate. First developed in 2009 as part of the NHS Next Stage Review led by Lord Darzi, it also sets out the rights and responsibilities of the public, patients and staff delivering and benefitting from healthcare services provided by the NHS. The current version was updated in April 2013.

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2.8 Underpinning the NHS Constitution are a number of rights that clearly specify maximum waiting times and emergency care response times that all patients should be able to expect. These standards are regularly monitored locally through the System Resilience Group as well as by NHS England and will be used to help measure success in the delivery of this strategy. For urgent and emergency care these include:

• A maximum four-hour wait in A&E from arrival to admission, transfer or discharge.

• All ambulance trusts to respond to 75 per cent of Category A (the most urgent) calls within eight minutes and to respond to 95 per cent of Category A calls within 19 minutes of a request being made for a fully equipped ambulance vehicle (car or ambulance) able to transport the patient in a clinically safe manner.

(Handbook to the NHS Constitution, March 2013) 2.9 In addition to the above constitutional rights for general urgent and emergency care, the System Resilience Group will also be responsible for monitoring the 62-day cancer and diagnostic waiting times. The constitutional rights for patients in relation to these are:

• A maximum two month (62-day) wait from urgent referral for suspected cancer to first treatment for all cancers.

• A maximum 62-day wait from referral from an NHS cancer screening service to first definitive treatment for cancer.

• A maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers).

• Start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions.

• Be seen by a cancer specialist within a maximum of two weeks from GP referral for urgent referrals where cancer is suspected.

(Handbook to the NHS Constitution, March 2013) 2.10 The support structure to implement the national urgent care vision within each region and locally to each Clinical Commissioning Group area will include an Urgent and Emergency Care Network, replacing the current Urgent Care Networks, working across several Clinical Commissioning Group geographical areas enabling strategic oversight of urgent and emergency care on a regional footprint and that patients with more serious or life threatening conditions receive treatment in centres with the right facilities. 2.11 In the North East, the Urgent and Emergency Care Network will cover the North East Region, North Cumbria and Hambleton, Richmondshire and Whitby Clinical Commissioning Group area. The purpose will be to improve the consistency and quality of urgent and emergency care by addressing together challenges in the urgent and emergency care system that are difficult for single System Resilience Groups to achieve in isolation. 2.12 The County Durham and Darlington System Resilience Group overall responsibility

for the capacity planning and operational delivery urgent and emergency care across the health and social care system. The System Resilience Group will be responsible for overseeing the implementation of the Urgent Care Strategy.

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2.13 Improving the urgent and emergency care pathway across County Durham and

Darlington is included in all three Clinical Commissioning Group’s current Commissioning Intentions. In January 2015 the County Durham Health and Wellbeing Board referred to the Better Care Fund Strategy target to reduce emergency admissions and overall activity across the urgent and emergency care system by 3.5%.

Vision, outcomes and objectives

2.14 The local vision for this strategy has been agreed by the System Resilience Group as:

‘Patients are seen by the right health/social care professional, in the right setting, at the right time, to the highest quality and in the most efficient way providing the best outcome for the patient.’

Outcome

2.15 The overall outcome for the whole strategy is an urgent and emergency care system that is able to meet the needs of the County Durham and Darlington population, both adults and children, within the resources available, delivering improved quality and patient experience. Strategy objectives

2.16 The implementation of the strategy will be overseen by the System Resilience Group, with the establishment of specific sub-groups, as required, to explore, design, plan and implement the projects to meet stated objectives and outcomes.

2.17 Seven objectives have been developed together by all partners during a series of workshops held to facilitate the strategy development. The objectives have been based on the key national messages and local strategic direction for urgent and emergency care services. The seven local objectives are:

Seven Local Objectives

1 People are central to designing the right systems and are at the heart of decisions being made.

2 Patients will experience a joined up and integrated approach regardless of the specific services they access.

3 The most vulnerable people will have a plan to he lp t hem m anage the i r cond i t ion e f fec t i ve l y t o avo id the need f o r u rgent and em ergenc y ca re .

4 People will be supported to remain at their usual place of residence wherever possible.

5 The public will have access to information and guidance in the event of them needing urgent or emergency care.

6 The patient will be seen at the right time, in the right place, by a person w i th t he appropr ia te sk i l l s to manage their needs.

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Seven Local Objectives

7 The patient will not experience any unnecessary delay in receiving the most appropriate care.

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3 What should good urgent and emergency care services look like? National approach 3.1 The national vision for urgent and emergency care is captured within Transforming

urgent and emergency care services in England. Urgent and emergency care review end of phase one report High quality care for all, now and for future generations. Professor Sir Bruce Keogh, November 2013 with two aims:

1 People with urgent but non-life threatening needs must have a highly responsive,

effective and personalised service outside of hospital – as close to home as possible, minimising disruption and inconvenience for patients and their families.

2 People with serious or life-threatening emergency needs should be treated in

centres with the very best expertise and facilities in order to reduce risk and maximises their chances of survival and recovery.

3.2 The diagram below represents the look and design of the new system proposed by Sir Bruce Keogh.

(Transforming urgent and emergency care services in England, Nov 2013, Page 23) 3.3 As well as the Keogh review, a number of other national reviews of urgent and

emergency care and subsequent guidance have been produced in recent years: • The walk-in centre review: final report and recommendations, Monitor,

February 2014. • Emergency admissions to hospital: managing the demand, Comptroller

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and Auditor General Health, October 2013. • A promise to learn – a commitment to act: improving the safety of patients

in England, National Advisory Group on the Safety of Patients in England, August 2013.

• Review into the quality of care and treatment provided by 14 hospital trusts in England: Professor Sir Bruce Keogh, July 2013.

• Report of the Mid Staffordshire NHS Foundation Trust public inquiry executive summary, Robert Francis QC, February 2013.

• Emergency care and emergency services: view from the frontline, Foundation Trust Network, 2013.

3.4 Together these reviews provide a clear agenda for improving urgent and emergency

care systems across the country with a view to achieving the national vision: • Help people to manage their own health through self-care and

management for urgent but non-life threatening needs. • Help people with urgent care needs to get the right advice in the right

place at the right time, including enhancing the current NHS 111 service to facilitate this.

• Provide responsive urgent care services outside of hospital so that people with non-emergency needs no longer choose to seek treatment at A&E departments.

• Introduce two levels of emergency departments, Emergency Centres and Major Emergency Centres, to ensure that people with serious or life-threatening emergency care needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery.

• Connect urgent and emergency care services together in emergency care networks so the overall system becomes more than just a sum of its parts.

3.5 Underpinning the national vision and work being progressed to put it in place, some

of the national reviews focused on improving hospital standards, patient safety and performance, underpinning the fundamental need to deliver high quality care. These reviews called for cultural change enabling transparency, accountability, clear standards that services were measured by that patients understood with evidence-based compliance.

3.6 Captured by Sir Bruce Keogh in his review of 14 trusts reporting high mortality rates

(July 2013), but key to all the reviews into hospital practices and performance, five key areas were identified as safety, workforce, clinical and operational effectiveness, governance and leadership. With these in mind, Keogh identified eight ambitions for hospitals in England to deliver.

Keogh Review Ambitions

1 Demonstrable progress towards reducing avoidable deaths in our hospitals.

2 Confident and competent use of data and other intelligence for the forensic pursuit of quality improvement by leaders of provider and commissioners.

3 Patients, carers and members of the public will increasingly feel treated as vital and equal partners in the design and assessment of their local NHS.

4 Patients and clinicians will be involved in and have confidence in the quality assessments

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made by the Care Quality Commission. 5 Professional, academic and managerial isolation for hospitals will be a thing of the past.

6 Nurse staffing levels and skill mix will appropriately reflect the caseload and the severity of illness of the patients.

7 Junior doctors in specialist training will not just be seen as the clinical leaders of tomorrow, but clinical leaders of today.

8 All NHS organisations will understand the positive impact that happy and engaged staff have on patient outcomes, including mortality rates, and will be making this a key part of their quality improvement strategy.

3.7 With exceptional A&E, emergency ambulance and NHS 111 pressures, and learning experienced during winter 2014/15, NHS England developed Eight High Level Interventions, detailed in Appendix 2, that all have key benefits to improving urgent and emergency care services for patients. As such the Eight High Impact Interventions are non-negotiable and therefore now underpin this strategy implementation and local actions stated within the action plan have been aligned where possible. Local approach 3.8 Using the national approach and applying its principles locally in County Durham and Darlington, Clinical Commissioning Groups need to ensure effective use of existing services such as primary care, community nursing, NHS 111 services and other rapid response services as part of their strategies for urgent and emergency care. The national approach support people being assessed and treated as close to home as possible, reducing the pressure on acute resources and ensuring patients are supported in the right place at the right time.

3.9 The County Durham and Darlington System Resilience Group would like to ultimately see the following model commissioned for patients requiring urgent and/or emergency care.

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Securing quality in health services (SeQIHS) 3.10 The Securing Quality in Health Services (SeQIHS) Programme was established in

2012 by the former Primary Care Trusts across County Durham, Darlington and Tees and has been continued by the five Clinical Commissioning Groups across this geographical area, working also in association with Hambleton, Richmondshire and Whitby Clinical Commissioning Group. The programme is focused on continuing to improve and sustain high quality hospital services in the Durham, Darlington and Tees area.

3.11 The programme is looking at delivering agreed clinical quality standards in the

following clinical areas: A&E, acute medicine, acute surgery, critical care, acute children’s care, maternity and neonatology, and interventional radiology in the context of the financial and workforce resources available to support implementation of the standards.

3.12 In the latest phase of the programme, clinicians from secondary and primary care

have been working together to describe a model of care that will maximise our ability to deliver the standards.

3.13 During the lifetime of this urgent and emergency care strategy, it is anticipated that

the SeQIHS Programme will make recommendations on the model of care and configuration of services and opportunities to commission services differently, based on the principle of keeping services local wherever possible and centralise services where necessary.

3.14 The model will aim to describe different levels of care and the number of sites where

this care will be available. It is essential that these recommendations fit with the urgent and emergency care services in primary care and in the community to ensure that patients receive the right care in the right place in a timely manner.

3.15 There is a substantial amount of work to be carried out to deliver the next phase of

planning, including expanding the public and stakeholder engagement and involvement, developing a long list of scenarios and reducing it to a short list of options, modelling and evaluating the options and ensuring that any proposals that emerge on a County Durham and Tees area are consistent with local plans and developments.

3.16 The County Durham and Darlington System Resilience Group welcomes the work to

date undertaken by the SeQISH programme and recognising necessity for this to be taken forward to ensure a sustainable urgent and emergency care system across the south of the region.

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4 National and local context

National statistics 4.1 Nationally, statistics from NHS England Winter Health Check (March 2015) states that since the winter of 2009/10 there has been a 14.1% increase in A&E attendances, and a leap of 26.3% since the winter of 2004/5. Emergency admissions have risen by 8.8% since the winter of 2009/10 and by 25.7% since 2004/5.

4.2 Between November to February 2014/15 there was a total of 7,063,000 A&E attendances, 190,000 more than the same period last winter. At its peak the system managed 446,000 attendances within one week during December 2014, followed by 440,000 the following week. Both record figures recorded for a winter period. Actual admissions showed a similar increase in demand, with a total of 1,821,000 during 2014/15, compared to 1,770,000 the previous winter. 4.3 NHS 111 faced similar unprecedented levels of demand, managing 4.6 million calls during winter 2014/15. This represents an increase of one million calls, or 27% on the same period the previous year. Nationally of all the calls triaged, just 11% had ambulances dispatched and 7% were recommended to A&E. 4.4 It is recognised that these figures demonstrate the increased patient needs that staff had to cope with this winter, during which time the NHS in England continued to provide a robust service, admitting, treating and discharging more than nine out of ten people across the course of the winter. 4.5 The current urgent and emergency care system has complex supply and demand flows and some national recruitment challenges, particularly for GPs, paramedics and key acute and emergency medicine staff. 4.6 Two of the key factors contributing to the increased levels of demand on A&E departments are:

• An ageing population with increasingly complex needs is leading to ever rising numbers of people needing urgent or emergency care.

• Many people are struggling to navigate and access a confusing and inconsistent array of urgent care services provided outside of hospital, so they default to A&E.

National guidance 4.7 The current national direction and guidance has evolved in recent years. Since 2010,

policy objectives have evolved with commissioning responsibilities transferring to Clinical Commissioning Groups, a focus on offering patients greater choice, high quality care and the challenges of both financial and increasing demand pressures on the urgent and emergency care system resulting in several instrumental national reviews bringing together some fundamental questions to be addressed and offering a new vision, proposed design of urgent and emergency care for the future and a blueprint for achieving it.

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4.8 The Everyone Counts Planning for Patients Guidance 2014/15 to 2018/19 set out a five year strategic plan for Clinical Commissioners. With a focus on quality, convenient access to services for all, driving change through innovation and value for the public purse, the guidance set a challenging agenda of transformational change for Clinical Commissioning Groups around the county.

4.9 The NHS Five Year Forward View (October 2014) sets out the key focus for how the NHS will be sustained and improved for everyone over the next five years with an emphasis on prevention, health promotion and greater patient control of their own care. Enabling people to be responsible for their own health will result in people living healthier lives, and help ensure that urgent and emergency care resources are available for those who really need them. 4.10 The NHS Five Year Forward View includes integration of A&E departments, GP out- of-hours services, urgent care services, NHS 111 and ambulance services. The guidance sets out opportunities for new models of care, such as a multi-specialty community provider – where GPs are enabled to combine with nurses, and other community health and social care, to create integrated out-of-hospital care. 4.11 In August 2014, NHS England published ‘Transforming urgent and emergency care

services in England. Update on the urgent and emergency care review, urgent and emergency care review team’ an update on progress in addressing the system changes highlighted by Sir Bruce Keogh. The update acknowledged that the vision set out in the original report would take three to five years to put in place and set out work progressed to date including:

• Working closely with local commissioners in developing five year strategic and two year operational plans.

• Undertaking trials for new models of delivery for urgent and emergency care and seven-day services.

• Developing new ways for paying for urgent and emergency care services, in partnership with Monitor.

• Completing and introducing a new service description for NHS 111. • Provision of commissioning guidance to support new ways of delivering

urgent and emergency care. 4.12 NHS England are developing a suite of guidance documents and tools to facilitate

the achievement of the national vision including the Eight High Impact Interventions, supporting a fundamental shift towards new ways of working and models of urgent and emergency care.

4.13 With regard to supporting Mental Wellbeing, HM Government published the Mental

Health Crisis Care Concordat, February 2014, which is a joint statement committing a range of key partners to ‘…work together to improve the system of care and support so people in crisis, because of a mental health condition, are kept safe and helped to find the support they need – whatever the circumstances in which they first need help – and from whichever service they turn to first.’ The Mental Health Concordat also has a key focus on supporting the recovery of people with mental health problems.

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4.14 A new three part payment system for urgent and emergency care consisting of a guaranteed element (core), a variable element to account for fluctuations in demand (volume based) and a payment element linked to outcomes and performance is planned to be introduced across both urgent and emergency care services nationally. Currently there are often different payment systems in place for different types of urgent and emergency care services which act as a barrier to services working together. The new payment system will address the barriers and act as a driver for services collaborating and working together.

Local statistics 4.15 Appendix 3 details local performance for 2013/14 and 2014/15 against the national

constitutional performance measures for urgent and emergency care. Reflecting the national trends, locally there has been increasing demands on the whole urgent and emergency care system from GP practices, urgent care services and A&E departments. All local acute trusts have seen an increase in both attendances at A&E and actual admissions during winter 2014/15. Alongside this, all services are experiencing increasing complex and multiple health needs as people grow older and their frailty increases.

4.16 Nationally, the expectation is that all acute trusts assess and treat a minimum of 95% of people within both urgent (Type 3) and emergency (Type 1) care within four hours. Locally this has fluctuated, with performance by City Hospitals of Sunderland and sometimes County Durham and Darlington NHS Foundation Trust particularly struggling to meet the target consistently. In Sunderland, the introduction of the ‘Perfect Week’ in March 2015 has yielded some improved results. North Tees and Hartlepool NHS Foundation Trust have fared better overall and have recovered their performance much quicker. 4.17 Emergency ambulances should be able to handover the patient to the A&E department

safely and be able to get back on the road within 15 minutes. At peak times this target is much more difficult to achieve and handover times can increase. Locally there are stark differences between the ambulance handover times achieved between the North East Ambulance Service and each acute trust with North Tees and Hartlepool achieving the best performance.

4.18 The number of people having to wait to be discharged from hospital due to a hold up of their discharge plan being put in place varies significantly between acute trusts. City Hospitals of Sunderland have seen a significant decline in the numbers of delayed discharges experienced over the last two years, County Durham and Darlington have also experienced a recent decline, and North Tees and Hartlepool are experiencing an increasing trend. There is still a significant amount of work to do locally to ensure that discharge processes are working more effectively to prevent delays in transfers of care and this is a current key priority for County Durham and Darlington System Resilience Group.

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Local demographics and health inequalities – County Durham 4.19 The health of people living in County Durham has improved significantly over recent

years, but remains worse than average for England. Health inequalities remain persistent and pervasive. Levels of deprivation are higher and life expectancy is lower than average for England. Local priorities for tackling these inequalities include reducing smoking, tackling childhood and adult unhealthy weight, promoting breastfeeding, reducing alcohol misuse, reducing teenage conceptions (and promoting good sexual health), promoting positive mental health, and reducing early deaths from heart disease and cancer.

4.20 Much of the population in County Durham suffer from avoidable ill-health or die

prematurely from conditions that are preventable. Lifestyle choices remain a key driver to reducing premature deaths but it is clear that social, economic and environmental factors also have a direct impact on health status and can worsen existing ill health.

4.21 The vision for the County Durham Joint Health and Wellbeing Strategy is to:

‘Improve the health and wellbeing of the people of County Durham and reduce health inequalities’

Central to this vision is the belief that decisions about the services provided for service users, carers and patients, should be made as locally as possible and involve the people who use them. The vision is supported by the following Strategic Objectives that outline the areas of priority for the Board: 1. Children and young people make healthy choices and have the best start in life 2. Reduce health inequalities and early deaths 3. Improve the quality of life, independence and care and support for people with

long term conditions 4. Improve the mental and physical wellbeing of the population 5. Protect vulnerable people from harm 6. Support people to die in the place of their choice with the care and support that

they need 4.22 In County Durham some of the demographic trends are:

• The population in 2013 was reported to stand at 515,900. • The 65+ age group was projected to increase from almost one in five people

in 2013 (19.2%) to nearly one in four people (24.7%) by 2030, which equates to an increase of 39.8% from 99,000 to 138,400 people.

• The proportion of the County’s population aged 85+ is predicted to almost double (+ 95.2%) by 2030.

• Life expectancy is improving for both males (77.9) and females (81.5), but is still below the England average (79.2 for males), (83 for females).

(Joint Strategic Needs Assessment 2014 statistics) 4.23 Social isolation and loneliness is a significant and growing public health challenge for

County Durham’s population. It affects many people living in County Durham and has a significant negative effect on health and wellbeing across the life course. Anybody can be affected by social isolation or loneliness and it can ‘affect any

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person, living in any community’. It is costly to local health and care services and can increase the chances of premature death.

(Adapted from County Durham Joint Health and Wellbeing Strategy 2015-2018) 4.24 The County Durham Joint Health and Wellbeing Strategy states that ‘A Wellbeing for

Life Service has been implemented to help people achieve a positive physical, social and mental state. The wellbeing approach goes beyond looking at single-issue healthy lifestyle services and a focus on illness, and aims to influence the circumstances that help people to live well, and build their capacity to be independent, resilient and maintain good health for themselves and those around them’. This is in addition to a range of other services to support people to remain health and as independent as possible, including short term rehabilitation.

Local Demographics and Health Inequalities – Darlington 4.25 In Darlington some of the demographic trends are:

• The current population is estimated to stand at 105,564. • By 2020 the over 50 population is projected to be 44,220 (40% of the total

population) and the over 65s projected to rise to 22,306 (20% of the total population).

• Darlington has some of the most deprived areas in England, and is ranked 75th most deprived local authority out of 326 in England (IMD 2010).

• People in Darlington are living longer. However, life expectancy remains slightly less than the average for England. On average males are living to 78 years (England average 78.9 years) and women 82.4 (England average 82.9 years).

(Adapted from Strategic (Single) Needs Assessment Refresh 2013, Darlington Borough Council) 4.26 The health of people in Darlington is generally worse than the rest of England with some specific local health inequalities to be addressed. These include: 18% of children being classified as obese; long-term health prospects are undermined by above average number of children living in poverty and below-average breastfeeding rates; alcohol-related hospital admissions remain high; the health effects of individual lifestyle choices, particularly smoking, drinking, lack of exercise and poor sexual health are significant, and there is growing concern about the emergence of mental health issues linked to poverty as both a cause and effect. 4.27 Darlington’s Sustainable Community Strategy1 contains two specific objectives focused on helping to improve the health and wellbeing of people living in Darlington: ‘more people healthy and independent’ and ‘more people active and involved’ both aimed at addressing the above health inequalities. 4.28 The ‘Healthy Darlington’ approach is now supporting people to eat well, be more

active and live longer, and together with a range of wider initiatives is encouraging people to take care of themselves, with more people using the support and facilities available to make lifestyle choices that support active, healthy living. This is combined with a growing culture of volunteering and active citizenship, in which more

1 ‘One Darlington Perfectly Placed’ 2008-2026 Revised May 2014

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and more people are choosing to take care of others or of their neighbourhood as a lifestyle choice, through the growing ‘social capital’ of volunteering programmes.

Darlington is an active, engaged community of citizens first and foremost, rather than service users.

(Adapted from One Darlington, Perfectly Placed, May 2014 Refresh) 4.29 The increasing aging population across both County Durham and Darlington coupled

with the challenges of addressing poor personal health choices and health inequalities are significant and impact on the demand for our local urgent and emergency care services across the whole system.

Local plans 4.30 The whole system needs to be robust enough to support people to become healthy,

stay healthy, and react quickly and effectively when someone needs support. There are a range of local plans developed by all organisations who are members of the County Durham System Resilience Group to support these aims with a wide variety of innovative local approaches and actions. Appendix 4 details a list of current local plans and strategies. The table below contains some broad themes of what all the plans aim to achieve across the county, together with how this whole systems approach supports the urgent and emergency care system: Broad Theme What does this mean? How does this support the

urgent and emergency care system?

Helping people to look after themselves better

Local information and initiatives to encourage people to eat healthily, take regular exercise, reduce or stop smoking, reduce alcohol intake, reduce stress levels, and the development of social networks and support.

Reducing unnecessary demand on urgent and emergency care services by helping people to remain fit and healthy wherever possible.

Helping people to take responsibility for their health and wellbeing

Providing clear and easy to access information and advice about where to go for help, providing health checks, and guidance and support to enable self-care.

People feel supported to be confident and informed about when and where to go for help with their health needs, using pharmacies, GP practices and urgent care services appropriately depending on their level of health need.

Helping people to maintain their independence

Information and advice, social care, planned and reactive, intensive, health and social care services such as intermediate care, for people with complex health and social care needs.

These services are crucial to help people remain at home when it is safe for them to do so, avoiding unnecessary hospital admission, admissions to long-term care and supporting appropriate, safe hospital discharges.

Making sure that people have rapid access to appropriate health and social care service when they need them

Ensuring that local health and social care services are appropriately resourced and joined up to provide rapid interventions when people need them.

Urgent and emergency care resources can be targeted appropriately to make sure people who have urgent or life-threatening health needs receive help in a timely manner.

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5 Where are we now? 5.1 This section explains how the urgent and emergency care system is currently

managed and what the main services are that currently operate across County Durham and Darlington. The tables detail how these services are currently spread across the county.

5.2 Appendix 5a and 5b details the locations of the main urgent and emergency care

services across County Durham and Darlington. How is the urgent and emergency care system managed? 5.3 A robust planning and assurance process is in place, managed nationally by NHS

England and locally through each System Resilience Group, to make sure that all organisations contributing to the urgent and emergency care system are appropriately prepared to effectively manage anticipated peak times of demand. This includes the winter period but also other times such as bank holidays.

5.4 The process is supported by national guidance and local experience on where the

system needs additional capacity at peak times, and good practice with a focus on continuously improving key areas such as patient flow, ambulance handover management and discharge planning.

5.5 A sub group of the System Resilience Group focuses specifically on improving

hospital discharge processes reducing the number of Delayed Transfers of Care (DTOC). Smooth and effective discharge processes help reduce the time spent in an acute hospital bed, therefore improving overall patient flow through the hospital as well as making sure that people returning home from hospital have timely access to the right health and social care support to meet their needs.

5.6 Part of the process is the appropriate allocation and management of resilience

funding through the System Resilience Group. For the last two years the County Durham and Darlington System Resilience Group have taken a fair shares approach to the distribution of this funding across all major providers in the system to help them put additional capacity in place during peak demand periods.

5.7 Spend of allocated funding and delivery of agreed capacity and resilience projects

agreed are then monitored both locally and nationally with providers required to evaluate their projects at the end of the winter period. Through this process the System Resilience Group partners can continuously refine what initiatives are producing the most benefits on the system and inform where any future funding would be most effectively targeted.

5.8 The System Resilience Group monitors performance on a monthly basis against the

NHS Constitutional Standards for Urgent and Emergency Care, 62-day cancer wait timescales, referral to treatment timescales and diagnostics.

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5.9 A review of how the System Resilience Group currently works is planned, providing opportunity for partners to discuss and agree together how to ensure a genuine collaborative and partnership approach to the overall work programme for the System Resilience Group including the delivery of this strategy action plan.

5.10 Throughout the winter, North of England Commissioning Support Unit provide a

Surge Management Service on behalf of the North East and Cumbria Clinical Commissioning Groups. The Surge Management Team provide an essential co-ordination and communication point for all foundation trusts and the North East Ambulance Service.

5.11 The team co-ordinate daily conference calls and provide up to date information to

help manage capacity across the emergency care system. A Winter Web specifically dedicated to the sharing of information and management of capacity across the regional urgent and emergency care system is in place to support communication across the region.

Primary care and community services GP practices 5.12 General Practitioners (GPs) look after the health and wellbeing of people in their

local community. They support people with a wide range of health needs and also provide health education, offer advice on stopping smoking, diet and fitness, run clinics, give vaccinations and carry out simple surgical procedures. GP practices include a range of staff, for example, nurses, healthcare assistants, practice managers, receptionists and other staff. They work as a team and closely with other community health and social care services including health visitors and midwives, to make sure people receive the best support and advice for their individual needs.

5.13 Some GP practices have additional ‘branch’ locations so they can deliver services

closer to their population. The location of GP practices and their ‘branch’ locations can be seen in Appendix 5a.

5.14 All three Clinical Commissioning Groups currently have extended GP practice

working arrangements in place to facilitate increased capacity, flexibility and availability of GP appointments. These vary locally and are detailed in Table 3.1b. This type of service is important in supporting the move towards seven-day services available within primary care.

Community pharmacies 5.15 Community pharmacies provide a wide range of NHS services summarised in the table below. Overall they offer free and confidential health advice without the need for an appointment.

Service Provided All Pharmacies Dispensing of drugs / drug tariff appliances / elastic hosiery

Repeat dispensing Disposal of unwanted medicines Health advice, travel health advice Promotion of healthy lifestyles Signposting to other healthcare providers

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Most Pharmacies Medication use reviews and prescription interventions Support for people starting to take new medicines Advice on minor ailments Sexual health services Support for stopping smoking

Some Pharmacies NHS health checks Anticoagulant (warfarin) monitoring clinic Substance misuse services Needle and syringe exchange services Alcohol interventions Pandemic and seasonal flu vaccination services Palliative care Services Medication support to care homes Out of hours services – Sunday and bank holidays on a rota basis and 100 hour pharmacies

(Summarised from ‘Services available through our Community Pharmacies’ County Durham and Darlington Local Pharmaceutical Committee July 20122)

5.16 The majority of pharmacies support with minor ailments providing advice and dispensing of prescribed medication. Examples of minor ailments include sore throats, headaches, earache, temperature, allergic contact dermatitis, hay fever, head lice and infant teething. 5.17 Appendix 5b details the location of all community pharmacies in County Durham and Darlington. Telephone advice – NHS 111 5.18 NHS 111 is the NHS non-emergency number. Across the North East region, the

North East Ambulance Service provide the NHS 111 service. This includes a telephone triage service staffed by trained advisors, supported by healthcare professionals. This service will ask a range of questions to assess a person’s symptoms, enabling them to be directed to the right medical care for their needs. The service is for a wide range of situations where urgent medical support is required but the situation is not life threatening. The service is free to access and available 24 hours a day, 365 days a year.

Other community services 5.19 A wide range of local community health and social care services exist across County Durham and Darlington providing support to the current urgent and emergency care pathway. These include community mental health teams, statutory social care assessment and support, voluntary sector services for example British Red Cross, home from hospital services and hospices. 5.20 It should be noted that some work areas for improving the current local urgent and emergency care pathways link directly to work already being progressed within other pathway areas such as intermediate care, palliative and end of life and frail elderly. As such this strategy will not duplicate work being progressed elsewhere but will work collaboratively to ensure that actions being progressed within other workstreams are delivered in line with the requirements for urgent and emergency care pathway improvements. 2 http://www.durhamlpc.org.uk/Assets/Contractors_PDFs/0E_AF_75_EE_40_OE/CD_D_Pharmaceutical_Services.pdf

http://www.durhamlpc.org.uk/Assets/Contractors_PDFs/0E_AF_75_EE_40_OE/CD_D_Pharmaceutical_Services.pdf

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5.21 Across County Durham only, an Intermediate Care Plus service, funded through the Better Care Fund, includes a range of intensive short-term health and social care services to help people get back on their feet has been running through a Single Point of Access from April 2014. The service expands the existing integrated health and social care services by:

• bringing together existing community-based short-term intervention services; • adding significant capacity to the existing intermediate care pathway; • providing new, additional community-based short-term health and social care

services; • all under one umbrella, for people who need rehabilitation and recovery

support, either within the community and for people returning home from hospital;

• providing a single point of access for health and social care professionals through 24 hours a day, seven days a week, including bank holidays.

5.22 In Darlington, the Responsive Integrated Assessment Care Team (RIACT) is the intermediate care and re-ablement service that supports older people through a range of health and social care professionals and support from the voluntary sector to provide a comprehensive community-based assessment and support service. The service supports older people to stay out of hospital where they can be supported safely and appropriately at home, and helps people with their recovery and rehabilitation following a stay in hospital. The service is central to the Multi- disciplinary Team work that is taking place as part

of the Better Care Fund projects. 5.23 Improving Palliative and End of Life Care is being led by all three County Durham

and Darlington Clinical Commissioning Groups with a Strategic Commissioning Plan in place between 2013 and 2018. The strategy focuses on the establishment of a new social system for palliative and end of life care, which operates for the best interest of the patient and works together to deliver the best care possible. This will improve collaborative working, strengthen joint ownership and reposition patients and their carers at the centre of the work. Key Palliative and End of Life Strategy deliverables that also facilitate improvements in the urgent care systems include:

• development of single point of access making it easier for palliative patients to know where to go for support;

• development of the multi-disciplinary approach to advanced care planning and emergency care planning;

• standard application of the Deciding Right (A North-East initiative for making care decisions in advance);

• keeping people at home through rapid response, palliative care at home, carer services, implementation of the Deciding Right with regard to care homes.

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Table 5.1a Urgent and emergency care services in County Durham and Darlington Type of Service

What is it for?

Level of need How is it accessed? Hours of Operation

North Durham Durham Dales, Easington and Sedgefield Darlington University Hospital of

North Durham

Shotley Bridge

Community Hospital

Seaham Primary

Care Centre

Easington Health-works

Peterlee Community

Hospital

Bishop Auckland General Hospital

Darlington Memorial Hospital

Dr Piper House

Accident and Emergency

Life-threatening conditions

Emergency • Emergency Ambulance Transfer

• GP referral • Walk-in

24/7, 365 days of the year

In-hours Urgent Care

Minor illness and injury

Urgent • Booked appointments

• Walk-in • Telephone

appointments • Home visits

8am to 6pm Monday to Friday

Out of Hours Urgent Care


Urgent • Walk-in • Telephone


6pm to 8am Monday to Friday, Weekends and Bank Holidays

Walk-in Centre


Urgent • Walk-in only • No need to book

appointments

8am to 8pm Monday to Sunday

GP Out of Hours Service


Urgent • Telephone appointments

• Home visits

6pm to 8am Monday to Friday, Weekends and Bank Holidays

Minor Injury Service

Minor injury only*

Urgent • Walk-in • Telephone


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Table 5.1b Urgent and emergency care services in County Durham and Darlington Type of Service

What is it for?


North Durham Durham Dales, Easington and Sedgefield Darlington

GP Practices Minor illness and injury

Urgent and Non Urgent/ Routine

• Booked appointments

• Telephone appointments

• Home visits

8am to 6pm Monday to Friday 31 40 11

Extended GP Practices Opening


Urgent and Non Urgent/ Routine

• Booked appointments

• Telephone appointments

• Home visits

Hour of extended GP practice opening vary

Extended opening times vary between local GP practices including appointments on Saturday mornings.

South Durham Health: 10 x practices open Saturday 8am – 12pm Durham Dales Health: 5 x practices open Saturday 8am – 1pm Intrahealth: 1 practice open Saturday and Sunday 8am – 8pm 1 practice open Saturday 8am – 1pm 1 practice open Saturday 9am – 12pm

Most GP practices offer extended opening hours but these vary between practices

Pharmacies Minor illness and injury

Urgent and Non Urgent/ Routine Advice and Information

• Walk-in • Telephone

advice and information

Pharmaceut-ical Needs Assessment 52 73 23

NHS 111 Minor illness and injury

Urgent Advice and Information

• Telephone 24/7, 365 days of the year

Regional Service

Intermediate Care Plus

Prevention of hospital admission and supporting discharge

Non urgent Intensive community based interventions

• Single point of access for health and social care professionals


Responsive Integrated Assessment Care Team (RIACT)

Prevention of hospital admission and supporting discharge

Non urgent Intensive community based interventions

• Single point of access for health and social care professionals


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Urgent and emergency care transport Life threatening situations 5.24 The North East Ambulance Service provide emergency ambulances staffed with

paramedics and emergency care assistants, responding to a wide variety of serious or life-threatening calls. Working alongside ambulance crews, a Rapid Responders Team also provide paramedic rapid response to commence emergency treatment

before the ambulance arrives on scene. 5.25 In some serious emergencies, you could also be treated by a medical team from the Great North Air Ambulance. The medical team on the helicopter includes an acute consultant (for example, anesthetists, emergency department consultant) and a paramedic who are skilled in treating patients who have serious traumatic injuries. Urgent situations 5.26 At present transport is provided for doctors to visit patients at home and for patients

who are unable to travel to the GP practice or urgent care service on their own. Non urgent situations 5.27 Non urgent transport is currently provided by the North East Ambulance Service’s

Patient Transport Service. This planned service takes members of the public to and from their homes to outpatients' appointments, dialysis, chemotherapy, clinics, physiotherapy or non-urgent transfers between different hospitals.

5.28 This service covers Teesside, South Tyneside, North Tyneside and Northumberland,

as well as County Durham and Darlington, and undertakes over a million journeys every year. Crews are trained as ambulance care assistants with specialist knowledge of comprehensive first aid, driving skills and patient moving and handling techniques. Some GP practices organise their own non-urgent patient transport directly outwith this service.

Table 5.2 Emergency and urgent care transport

Type of Service

What is it for?


Coverage

999 Emergency Ambulance Great North Air Ambulance

Life-threatening conditions

Emergency • Telephone 24/7, 365 days of the year Regional

Urgent Care Transport

Minor illness or injury

Urgent • By professionals who need to arrange urgent transport for their patients

24/7, 365 days of the year County Durham and

Darlington

Patient Transport Service

Minor illness or injury Routine appointments Hospital Discharge

Non urgent • By professionals who need to arrange urgent transport for their patients

24/7, 365 days of the year Regional

http://www.greatnorthairambulance.co.uk/

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Mental health services 5.29 Urgent and emergency services specifically for people with acute mental health

needs are detailed in Table 5.3. The two Crisis Teams, one located in North Durham and one in Darlington (but also providing services across South Durham), manage all admissions to mental health inpatient beds and provide an intensive home treatment service supporting prevention of admission and early supported hospital discharge.

5.30 For those individuals who would ordinarily benefit from intensive home treatment but

are unable to receive this in their own home, each locality provides a nine bedded crisis recovery house to support short-term interventions and prevent hospital admissions. This service has recently been rated as outstanding against the Care Quality Commission’s standards for ‘caring’ for its person centred approach.

5.31 The acute liaison service provides three main roles – multi disciplinary assessment

of individuals attending A&E departments, ward-based support for acute hospital staff, and disciplinary assessment of those presenting with medically unexplained physical symptoms. The service ensures that people with mental health needs or presenting symptoms receive the specialist assessment and support they need.

5.32 A two year pilot crisis and liaison service is currently running across County Durham,

working closely with emergency departments and other services, it will undertake assessment and intervention support for children and adolescents out of hours. The pilot does not currently operate in Darlington.

Table 5.3 Urgent and emergency mental health services

Type of Service

What is it for? Level of need How is it accessed? Hours of Operation

North Durham

Durham Dales,

Easington and

Sedgefield

Darlington

Adult Mental Health Crisis Teams

Potential life-threatening conditions

Emergency

• Telephone • Self-referral by

people known to mental health


Children’s Mental Health Crisis Teams


• Referral • By professionals

who need to

Not 24/7

Children and Adolescent Mental Health Crisis and Liaison Service (Pilot)


Emergency

• Telephone • Self-referral by

people known to mental health services or professional


Crisis Recovery Beds

Urgent mental health needs

Urgent

• By professionals who need to arrange urgent transport for their patients


Mental Health Inpatient Beds


Acute Liaison Mental health assessment

Urgent • Health professionals based at acute hospital sites

Not 24/7

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Children and young people’s services 5.33 The Poorly Child Pathway aims to integrate all aspects of child health and includes pathways which support specialist referral / intervention. Children who attend an emergency department with two episodes of asthma in 12 months are referred to a Consultant Paediatrician. There is also additional support from the paediatric respiratory nurse. 5.34 Clinical pathways for managing common children’s illnesses have been developed within the Poorly Child Pathway. Within these pathways there are three categories of severity of illness:

Well enough to go home

Requires further management/ supervision/ assessment

Requires hospital admission

5.35 In Darlington Memorial Hospital, limited support is available from an advanced paediatric nurse practitioner within the emergency department. This is not currently available at University Hospital of North Durham. Both sites benefit from a consultant paediatrician up to 10pm weekdays and six hours in paediatric wards at weekends. 5.36 Paediatrics services provided by County Durham and Darlington NHS Foundation Trust currently do not support urgent care centres. Alcohol harm reduction services 5.37 In Durham, there were 2,063 alcohol related ambulance callouts in 2012/13 reducing

slightly to 2,011 in 2013/14. Saturday and Sunday see consistently higher alcohol related ambulance callouts with peak times of 10pm. Males generally have more alcohol related ambulance callouts than females. The age group 20-29 category accounted for the highest numbers of alcohol related ambulance callouts. A high proportion of alcohol related ambulance callouts are from the most deprived wards. In Darlington, despite a reduction from 2,417 to 2,336 alcohol related admissions during 2012, the current rate for alcohol related admissions still remains high.

5.38 Despite these statistics there is a limited understanding of the demand on A&E services in relation to alcohol. One of the main reasons for attendance at A&E is an injury rather than alcohol itself. 5.39 The 2015 Local Alcohol Profile for England shows that the rate of alcohol specific

hospital admissions in County Durham is 468 per 100,000 and remains higher than the England average. The rate of alcohol specific hospital admissions for men is 606 per 100,000 and has increased by 2% over time. Alcohol specific hospital admissions for women is 340 per 100,000 and has increased by 18% over time.

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5.40 There are a number of individuals who have alcohol issues, (chronic, mental and behavioural) who are likely to frequently attend urgent care and emergency departments, and more needs to be done to ensure comprehensive recovery support services are available in the community to provide appropriate support and help reduce the number of frequent attenders.

5.41 In 2013/14 there were 186 alcohol related ambulance callouts for young people

under the age of 18 across County Durham. A number of emergency department staff in both University Hospital of North Durham and Darlington Memorial Hospital have been trained in identification and brief advice for young people.

5.42 In County Durham, Lifeline provides alcohol and drugs treatment and recovery

support for both young people and adults. In Darlington, the North East Council on Alcoholism (NECA) provides alcohol and drugs treatment and recovery support for both young people and adults. The police and Druglink also run an Alcohol Diversion Scheme for low level/first time offenders who pay to attend an awareness course in lieu of further criminal action and/or fines. We are also in early stages of looking at lessons learned from a Local Alcohol Action Area pilot undertaken recently in Middlesbrough, with a view to adopt partnership good practice across the Tees Valley.

Urgent care services 5.43 Urgent care services are split into different types but they all provide assessment and

treatment for non life-threatening situations. The different services are: • Urgent care centres. • Minor injury units. • GP out-of-hours • Walk-in centres.

5.44 In County Durham, an urgent care service is currently provided by County Durham

and Darlington NHS Foundation Trust across six urgent care centres located around the county. There is also a separate walk-in service in Easington provided by Intrahealth.

5.45 Some of the common injuries and ailments that can be treated by these services

include: chest infections, urine infections, minor burns and scalds, wound infections, suspected eye infections, fevers, cuts, sprains and strains, hand, foot and wrist fractures, insect and animal bites and minor head injuries. Minor injury units usually just assess and treat minor injuries whereas urgent care services, including walk-in centres, may also treat minor illnesses depending on the local service arrangements.

5.46 There are differences in the urgent care services currently available in different

locations. Table 3.1a shows some differences in how these services are currently provided.

5.47 One of the main differences is when urgent care services are open. Some are

only open during the day (in hours), some are only open overnight, weekends and on bank holidays (out of hours). Some are open all the time (in hours and out of

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hours).

5.48 As part of the range of urgent care services currently available, a GP out–of-hours service operates across the county with GPs based overnight, at weekends and bank holidays in some of the urgent care centres.

Accident and emergency departments 5.49 Located on acute hospital sites, A&E departments provide round the clock,

consultant-led care for life-threatening situations such as:

• loss of consciousness; • acute confusion and fits that are not stopping; • continuing, severe chest pain; • breathing difficulties; • severe bleeding that cannot be stopped.

5.50 County Durham and Darlington NHS Foundation Trust provide A&E departments

located in Darlington Memorial Hospital and University Hospital of North Durham. Both hospitals in County Durham and Darlington provide 24 hour consultant-led A&E care. This includes critical care, ambulatory care, acute medicine and surgery. Stroke and vascular surgery is also provided at University Hospital of North Durham.

5.51 Hospitals that have A&E departments that provide this level of emergency care are

referred to as being able to provide a Type 1 A&E response. A Type 1 response means ‘A consultant-led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients’.3

5.52 A lot of work was undertaken at both hospital sites during 2014 including improving

the Ambulatory and Rapid Assessment and Treatment routes for patients to ensure that each patient is seen by the right clinician in the A&E department, first time, every time. Beginning with an initial decision by a Nurse Navigator (senior nurse/doctor), patients are guided to the most appropriate practitioner for their needs. Successful pilots of this initiative across both hospital sites resulted in full implementation from 1st April 2014.

5.53 Recent expansion of the Medical Assessment Unit and medical bed capacity has

also taken place within the University Hospital of North Durham enabling patients to be directed to the Medical Assessment Unit, where appropriate, without the need for them to first be assessed within the A&E department.

5.54 Some people living in County Durham and Darlington may also use one of the acute

hospitals located outside County Durham and Darlington. For example, Sunderland Royal Hospital provided by City Hospitals Sunderland NHS Foundation Trust, the Queen Elizabeth Hospital located in Gateshead or the University Hospitals of North Tees or Hartlepool that are provided by North Tees and Hartlepool NHS Foundation Trust

3 Emergency Care Weekly Situation Report Definitions, NHS England, April 2014

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6 What we want 6.1 The County Durham and Darlington System Resilience Group’s strategic direction,

set by this strategy will influence individual CCG commissioning intentions. CCG’s will then work with their partners to develop local solutions.

6.2 Local analysis of our urgent and emergency care system and supporting national

evidence has identified the main challenges that we need to address in County Durham and Darlington to achieve our local vision:

• Increased demand across the whole system for both urgent and emergency

care; • An ageing population and increasing numbers of people with long-term

conditions and complex needs; • A need to ensure vulnerable patients with complex needs, including the frail

elderly have proactive and effective support in place to reduce the need for admission to hospital;

• An urgent and emergency care system difficult for both patients and professionals to find their way around;

• Urgent and emergency care services that appear unrelated or fragmented; • Current systems that are unable to meet future expectations and demand; • A lack of up to date ‘real-time’ understanding of how demand flows around the

system, particularly surge activity; • Current potential for duplication and inefficient use of staff resource and skills; • Historical poor performance in consistent achievement of the A&E 95%

constitutional target, and achievement of timely ambulance handover times; • Reducing the average length of time people need to spend in an acute

hospital bed; • Improving discharge processes to increase patient flow and patient

experience; • Poor public perception of timely GP appointment availability within primary

care.

6.3 This section identifies the current Clinical Commissioning Groups’ priorities for urgent and emergency care in their local area and the gaps in the current urgent and emergency care pathway.

6.4 Section 7 – ‘How are we going to get there?’ details the actions that will be

implemented both locally and regionally to address the challenges, meet the gaps and deliver both the local vision for County Durham and Darlington and the national vision for urgent and emergency care.

Current Clinical Commissioning Group Priorities 6.5 North Durham Clinical Commissioning Group North Durham Clinical Commissioning Group is working closely with County Durham and Darlington NHS Foundation Trust to support their redevelopment of the emergency care department at University Hospital of North Durham, and also working in collaboration with neighbouring Durham Dales, Easington and Sedgefield

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Clinical Commissioning Group in the development of urgent and emergency care services. Their approach to urgent and emergency care fits with their primary care strategy which supports the development of responsive GP practice-based services over seven days. 6.5.1 Gaps in Current Provision Two of the key gaps currently identified in North Durham are the need to ensure the physical urgent and emergency care needs of children and young people are met, and that there is a comprehensive and effective minor injury/illness pathway available in-hours within the emergency department. 6.5.2 Immediate Priorities North Durham Clinical Commissioning Group have engaged with the public to

develop their local urgent and emergency care strategy. Their strategy includes a range of actions that recognises GP practices supported by health and social care community services as being central to providing an accessible and responsive seven day service that is able to swiftly and effectively meet local urgent care needs. Some of the current priorities over the next 12 months include:

• Working with County Durham and Darlington NHS Foundation Trust to

develop plans for the provision of a new emergency care centre on the University Hospital of North Durham site.

• Monitor the impact of the recently implemented Local Divert Policy to help manage emergency care activity more effectively.

• Following a successful pilot, roll out direct booking of GP practice appointments NHS 111 service.

• Review GP out-of-hours service and consider future fit with integrated service.

• Expand community primary care support to vulnerable patients during week end by providing a GP-led service supported by community matrons and district nursing.

• Support the implementation of the Local Mental Health Crisis Care Concordat action plan.

• Evaluate paediatrics urgent appointments pilot within Cedars Medical Practice, currently facilitating priority urgent GP appointments after school for children and teenagers.

6.5.3 Patient Engagement During the summer of 2014, North Durham Clinical Commissioning Group engaged the

public and key stakeholders on their views about how urgent care is provided. The engagement exercise included online information and feedback forms, and a wide distribution of information about the proposals across health and social care acute community facilities such as hospital waiting areas, GP practices, libraries and leisure centres, focus groups and drop-in sessions.

The feedback received has helped shape the Clinical Commissioning Group’s local

urgent care strategy. The engagement exercise also identified a general need for the public to have a better understanding of the difference between urgent care and

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emergency care, and that patients value their GP practice and in some areas would like to see improvements in access to appointments.

6.6 Durham Dales, Easington and Sedgefield Clinical Commissioning Group 6.6.1 Gaps in Current Provision Durham Dales, Easington and Sedgefield Clinical Commissioning Group (DDES CCG) are currently reviewing their local urgent care services and are exploring the potential for GP practices to provide more urgent care capacity through better access during the day and extended opening. As part of this work, an audit of the type of healthcare needs currently supported through the existing urgent care services during April to September 2014 was undertaken to help the Clinical Commissioning Group develop a better understanding of the patient needs within urgent care and identify any gaps or duplication in existing service provision. 6.6.2 Immediate Priorities The Clinical Commissioning Group has considered national guidance in developing its

local approach to urgent care. Building on feedback from engagement work undertaken during 2014 with patients using the existing urgent care services, the proposed approach is to place GP practices at the heart of the urgent care system providing access to responsive primary and community care services seven days a week.

Work is continuing to understand the activity, trends, patient flows and resource

distribution within current urgent care services, and further engagement and consultation with primary and acute care clinicians, patients and the public will take place.

6.6.3 Patient Engagement During 2014, DDES CCG undertook an Experience Led Commissioning approach to

ask the public and key stakeholders how best to support people with urgent care needs in community settings. The engagement exercise included mapping both patient and frontline staff experiences in particular of primary care (especially general practice and community pharmacy), out of hours GPs, accident and emergency, urgent care centres, self-management of long-term conditions and unexpected health issues, maintaining mental and emotional wellbeing, and community-based support.

The key message from patients was that urgent care centres are their second choice

or last resort, with their first choice being their own GP practice. There were also some suggestions around better communication to help people feel

informed, confident and supported when they become ill, and to understand their health issues when they are with urgent care professionals.

6.7 Darlington Clinical Commissioning Group 6.7.1 Gaps in Current Provision The main gap in the urgent and emergency care pathway currently identified by Darlington Clinical Commissioning Group is the need for integration between

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emergency and urgent care services, particularly within the A&E department within Darlington Memorial Hospital. 6.7.2 Immediate Priorities Supported by national evidence about what works well, Darlington Clinical

Commissioning Group are working with County Durham and Darlington NHS Foundation Trust to reconfigure the existing A&E department within Darlington Memorial Hospital to enable an integrated emergency and urgent care service to be delivered 24/7. The aim is to provide local people with equitable access to sustainable, high quality, safe and effective urgent and emergency care services at the right time and in the right place.

6.7.3 Patient Engagement Healthwatch Darlington hosted two engagement events on behalf of Darlington Clinical Commissioning Group in February 2015. The events attracted over 100 people and focused on exploring better future models of care with the public. The events were informed by NHS England’s Five Year Forward View, explaining why change is needed and what services could look like in Darlington for a range of healthcare services including urgent care, primary care and pharmacy. Urgent and emergency care pathway gaps 6.8 The current gaps in the urgent and emergency care pathway across County Durham

and Darlington that need to be addressed to deliver the local vision have been aligned to the seven objectives of the strategy.

6.9 Objective 1: People are central to designing the right systems and are at the heart of decisions being made.

Over the years urgent and emergency care systems in County Durham and Darlington have evolved as a result of changes in both national and local policy, time limited funding streams and available resources. Although public and patient engagement has taken place, this strategy provides an opportunity to engage on a local vision across the whole of County Durham and Darlington.

During the life of this strategy, Clinical Commissioning Groups and other key stakeholders within the System Resilience Group will continue to engage with their partners, the public, patients and clinicians to shape and deliver the local vision within their geographical area. This may mean requesting feedback on experience of current services, helping to shape local services and consultation on proposed solutions. The exact nature of engagement and consultation work will vary depending on the nature of the issue the Clinical Commissioning Group is trying to resolve within the overall urgent and emergency care pathway. 6.10 Objective 2: Patients will experience a joined up and integrated approach regardless of the specific services they access. Recent national guidance is supporting the development of an ‘integrated service’ approach between NHS 111 and both in and out–of-

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hours primary and urgent care services across each Urgent and Emergency Care Network area. The key elements of this new model have been consulted on across the country by NHS England and the resulting guidance will support regional and local implementation. In County Durham and Darlington, aspects of this model are already in place with NHS 111 being able to book some direct GP practice and urgent care appointments directly into clinical systems, and NHS 111 having some clinical support to help ensure ambulances are appropriately dispatched to those who really need them. Locally, there is a need to integrate the falls and frail elderly pathway to ensure an integrated approach to falls prevention for older people, and all Clinical Commissioning Groups have been considering their current make up of primary and urgent care services in their local community and how these can be developed to provide a truly integrated and responsive primary and urgent care approach for local patients. There is a need to continue this work as part of the delivery of this strategy to help achieve the overall local vision. This will include progressive work to develop an integrated primary care and secondary care offer within each Clinical Commissioning Group area with local clinical hubs that can provide comprehensive assessment and treatment in the community. There is a challenge within each Clinical Commissioning Group area to ensure that the future local arrangements fit with the national ‘integrated service’ for both in and out-of-hours so that the patient receives a smooth service from accessing NHS 111 for assistance to being assessed and treated locally for all primary and urgent care needs, seven days a week, 365 days of the year. To achieve the above, current work to review and understand current services, research and develop best practice local models will continue, with options being considered that may include extended hours services, stronger integration between primary and secondary care and expanding direct booking of GP appointments by NHS 111 and development of local minor illness and injuries pathways. To achieve an integrated approach that works effectively for both clinicians and patients, the System Resilience Group partners will need to support the development of appropriate clinical access to patient records to facilitate clinicians to provide the safest outcome for the patient’s needs. 6.11 Objective 3: The most vulnerable people will have a plan to help them manage their condition effectively to avoid the need for urgent and emergency care.

Across all Clinical Commissioning Groups, work has been progressed within primary care to identify the most vulnerable patients at risk of a hospital admission and to make sure they have a joined-up health and social care plan in place providing them with both a proactive and reactive multi-disciplinary team approach to their care needs. The purpose of this it to provide a proactive approach to helping people maintain their health, respond quickly to prevent a deterioration in patient’s health, provide proactive and appropriate clinical support in line with their

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individual needs and help prevent an unnecessary hospital or long-term care admission, and support people with safe discharge where a stay in an acute hospital bed has been necessary. In addition, some work has been undertaken to identify and understand the needs of people who are the most frequent attenders at A&E departments within County Durham and Darlington NHS Foundation Trust, and developing proactive care management plans to help better support their needs and prevent their need to regularly attend A&E at an emergency. However, there is still work to be done to help people take responsibility for their own welfare and support the self-management of long-term conditions. Current gaps that need to be addressed include:

• The need to embed the role of peer support, voluntary sector and community networks to help and support people to self-care.

• The development of a strategy to help people self-care through individual focused agreed anticipatory care plans.

• The need to review and develop local falls prevention arrangements, particularly comprehensive management plans within care homes to prevent falls and reduce unnecessary ambulance conveyances and acute admissions.

• Continue the current work to develop comprehensive care management plans across primary, secondary and emergency care to proactively support the people who are the most regular attenders at A&E departments.

6.12 Objective 4: People will be supported to remain at their usual place of residence wherever possible. Across all Clinical Commissioning Groups, gaps have been identified in how current primary, urgent and emergency care services work together to make sure that vulnerable people receive timely and appropriate healthcare and/or social care support so that their health needs can be safely managed at home wherever possible. This approach helps prevent unnecessary hospital admissions and re- admissions, ensuring acute hospital resources are targeted at those who need acute care, minimises disruption and inconvenience for patients and their families, and helps achieve the best outcome for the patient. These services also support patients with timely, safe hospital discharge. Some work has already been progressed, including extended opening hours for GP practices, significant expansion of intermediate care arrangements in County Durham, a vulnerable adults wraparound service in Durham Dales, Easington and Sedgefield, and aligning community matrons or advanced nurse practitioners and GP practices to care homes. However, this work needs to continue as part of this strategy implementation to make sure that everyone whose health could be supported at home, has access to the right support for them, when they need it. Remaining work to achieve this objective includes:

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• Making sure that the deciding rights of palliative care patients who have chosen not to be transported to hospital are implemented to respect people’s preferred place of death and reduce the number of people dying within 48 hours of a hospital admission.

• Review and evaluate the effectiveness of a range of local additional clinical support to care homes and understand the impact on reducing acute hospital admissions and re-admissions.

• Further development of primary and secondary care clinical hub arrangements supporting care homes and people within their own homes to make sure everyone has responsive, timely and effective health and social care interventions to avoid a hospital admission where appropriate, and support people with timely safe hospital discharge seven days a week.

• Clarification of the scope of the emergency medication service following evaluation, and training and education of health and social care staff in the proper use of inhalers as a preventative measure.

• Clarification of the scope of the minor ailments service in light of availability of real time data.

• There is need to improve the skills of health and social care staff to ensure the consistent application of medication reviews for frail elderly people.

• Developing responsive children's community services that are integrated with urgent and emergency care services. This includes increasing specialist community paediatric capacity to help further support children and their families at home with acute and chronic disease management.

• Ensuring special patient notes are up to date and available for paramedics to contact local clinical support for vulnerable patients.

• Developing intermediate care services in line with the outcome of local reviews.

6.13 Objective 5: The public will have access to information and guidance in the event of them needing urgent or emergency care. One of the key challenges locally is to create an urgent and emergency care system that proactively supports people to use primary and urgent care services as a first port of call for urgent needs, as opposed to going straight to A&E. Over winter 2014/15 a comprehensive Keep Calm campaign used a wide variety of media to encourage people to go to the right service to meet their health needs, and only going to A&E departments for emergency health needs. Ensuring patient education and public health messages continue to be a high priority focus and work is progressing with NHS England and local System Resilience Groups through the Urgent and Emergency Care Networks to make sure that national and local messages are consistent to the public, particularly during winter. More work to be done to address patient perception that a GP appointment may not be available in a timely manner, or that is convenient by asking people who attend A&E departments whether and how they have tried to access primary and urgent care services before attending A&E and, if so, what barriers they faced so that any perceived or actual barriers to accessing primary and urgent care services locally can be addressed.

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There is also a need to make sure the current community pharmacy services are fully utilised, and key services such as advice on new medications and medicine use reviews are undertaken consistently by all pharmacies.

6.14 Objective 6: The patient will be seen at the right time, in the right place, by a person with the appropriate ski l ls to manage their needs. Achievement of objective six within the delivery of this strategy is fundamental to ensure that people receive timely support with all their healthcare needs and are not passed between services. This wastes time, creates unnecessary expensive duplication, is demoralising for staff and means that scarce resources are not being effectively used.

A great deal of work is already being undertaken towards providing an urgent and emergency care system that makes sure that people access the pathway at the right place to ensure their health needs are assessed and met first time, every time. However, with such a complex system there is a great deal of work still to do before the right systems are in place to meet this objective. Current gaps and issues that still need to be addressed include:

• Completing the full relocation of the urgent care service in Darlington within the A&E department in Darlington Memorial Hospital.

• Reducing inappropriate emergency ambulance dispatches to A&E departments by reviewing the clinical triage arrangements with NHS 111 to make sure they are sufficient and working effectively.

• Reducing inappropriate emergency ambulance dispatches to A&E departments by ensuring effective clinical support is in place for paramedics including timely response from local primary and urgent care services.

• Reduce inappropriate referrals to ambulatory care and increase appropriate referrals from A&E departments.

• Monitor progress in the two year reduction trajectory for See, Treat and Convey activity and associated increases in Hear and Treat and See and Treat activity.

• There is a need to make sure crisis and liaison support for children and adolescents with mental health needs are sufficient and effective across County Durham and Darlington.

• There is a need to make sure that clinical and referral pathways into recovery services for both adults and young people with an alcohol dependency are sufficiently robust and effective across County Durham and Darlington.

• Reviewing and expanding Community Mental Health Services across County Durham and Darlington to support people in mental health crisis including people with dementia, and providing a patient centred response.

• All System Resilience Group members need to work proactively with the Directory of Service Team to continuously improve access to the NHS Pathways Directory of Service for County Durham and Darlington to promote easier and faster access to appropriate services across health and social care.

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6.15 Objective 7: The patient will not experience any unnecessary delay in receiving the most appropriate care. This objective is linked closely to objective six, in making sure that people do not receive any delays in their assessment or treatment of their healthcare needs. If people are able to access the right service, first time, every time, it should significantly reduce any delays patients experience in accessing the clinical support they need to address their healthcare needs. However, this objective specifically focuses on ensuring there is no waste in the process or shortage of resources once people arrive at the right service, to make sure their needs can be addressed quickly. One of the key areas that urgent and emergency care systems across the country struggle with is patient flow from entering A&E departments, right through to being discharged from an acute hospital bed, in a timely manner, with the right health and social care support in place, where appropriate. This is particularly important for people with multiple health needs who often need multi-disciplinary support when they return home. There is a significant focus from both NHS England and locally within the System Resilience Group by all partners to help improve all aspects of patient flow through an acute hospital. The key areas that need to be addressed include:

• Ensuring that Rapid Assessment and Treat is in place to support patients in A&E

and Medical Assessment Units to receive safer and more appropriate care as they are reviewed by senior doctors early on.

• Making sure that consultant-led morning ward rounds take place seven days a week so that discharges at the weekend are at least 80% of the weekday rate and at least 35% of discharges are achieved by midday throughout the week. This will support patient flow throughout the week and prevent A&E performance deteriorating on Monday as a result of insufficient discharges over the weekend.

• Making sure that there is sufficient discharge management and alternative capacity such as discharge-to-assess models are in place to reduce the DTOC rate to 2.5%. This will form a stretch target beyond the 3.5% standard set in the planning guidance.

• Complete the redevelopment of University Hospital of North Durham’s A&E department to significantly increase capacity, improve patient flow and patient experience.

• Improving ambulance handover times at A&E departments supporting County Durham and Darlington patients.

• Making sure that the ambulatory care service provided by County Durham and Darlington NHS Foundation Trust has sufficient capacity to manage demand.

• Ongoing work to reduce unnecessary breaches of the 95% four-hour wait target.

• Use collated primary, urgent and emergency care demand levels to help understand fluctuations in overall levels of demand across the whole system, particularly surge activity.

• Continue to develop and improve initiatives that reduce acute bed length of stay, particularly for people aged 75 and over.

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• The regional management of demand for emergency ambulances through the Regional Flight Deck and local arrangements in North Durham will need to be reviewed and evaluated to determine their effectiveness.

• There is a need to undertake a full review of the patient transport service and discharge transport services to make sure that these services are able to meet demand, are robust and cost effective.

• Work to better understand blockages and pressures throughout the urgent and emergency care pathway, and the most effective approach to alleviate these pressures will need to be further explored, possibly through the use of NHS England’s Data Intelligence Tool.

• Ensuring that the mental health acute care pathway processes are as efficient as possible to make sure patients receive a timely response and improve patient experience.

• Expand the current mental health acute liaison service in A&E to 24/7 coverage.

• Ensure that the re-configurations of A&E departments in both Darlington Memorial Hospital and University Hospital of North Durham include the integration of children’s care that is also sufficiently resourced.

• County Durham and Darlington NHS Foundation Trust need to make sure that their consultant ward rounds are timely, efficient and effective in facilitating morning and weekend discharges to improve patient flow.

• Although some work has been progressed there is an overall need to develop seven-day service access to a range of key clinical services to support effective discharge management. These include diagnostics, access to diagnostic scanners, cardio-pulmonary tests and pharmacy.

• Timely access to care packages, particularly at times of pressure, during weekends and bank holidays needs to improve.

• The process for people accessing prescribed medication from community pharmacies following discharge from hospital could be streamlined.

• There is a need to put in place an effective Discharge to Assess4 model reducing delays in hospital discharge.

NHS 111 regional workplan 6.16 There are a number of gaps and issues to be addressed in the urgent and emergency care

pathway across County Durham and Darlington that are similar or the same as gaps and issues experienced in other parts of the region. The remit of the Urgent and Emergency Care Network is to look at those challenges that are too big for one System Resilience Group to resolve on their own or to make sure there is a consistent solution in place across a region to prevent duplication of resources.

6.17 A regional workplan has been developed which includes the gaps and issues highlighted in

bold under each of the above objectives that will be addressed regionally with input from our local System Resilience Group.

4 Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders; NHS England, February 2014

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7 How are we going to get there?

7.1 To address the current challenges The County Durham and Darlington System Resilience Group have agreed to work collaboratively to provide:

• integrated urgent care services embedded into patient pathways; • joined up pathways ideally in the community where patients live; • simpler, safer and more effective services; • improved patient experience and outcomes; • a collaborative response to addressing and resolving system pressures

across the whole health economy; • better quality and value for the tax payer; and • overall the right care, in the right setting, at the right time.

7.2 In essence, the future of emergency and urgent care services across County Durham and Darlington will seek to meet the seven strategy objectives. All partners will need to work jointly, proactively and effectively to review existing resources and pathways, explore alternative options for provision and consider joint commissioning opportunities to make best use of the resources available and ensure a joined up approach for patients.

7.3 Whilst this strategy intends to deliver a shared vision over the next five years, it is acknowledged that health and social care is continually developing and changing and this strategy will need to be reviewed annually to ensure it continues to meet the needs of the population.

7.4 The urgent care strategy actions will be implemented through three workstream areas with specific actions aligned to each workstream. Project leads will be identified for each action. The System Resilience Group will oversee the implementation of the whole action plan, receiving updates and monitoring progress on a monthly basis.

7.5 Each project lead is responsible for ensuring that each project area is supported by the key enablers, communication, workforce, information management and technology, and engagement during the implementation process. Links to other care pathways 7.6 It should be noted that some of the actions identified within this strategy link directly

to work being undertaken within other care pathways, such as the frail elderly and end of life pathways. A joined up approach to prevent duplication will be implemented where appropriate.

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High Level Action Plan This action plan will be reviewed monthly by the System Resilience Group to monitor progress and updated annually during the life of the strategy. The implementation of the actions identified below will, in the main, be the overall responsibility of the County Durham and Darlington System Resilience Group. However, those that are the overall responsibility of the regional Urgent and Emergency Care Network have been separately highlighted. Overall addressing and resolving the system pressures and ensuring an improved patient experience and better patient outcome is the collective responsibility of the whole health economy. Those actions that are also aligned to the delivery of NHS England’s Eight High Impact Interventions have also been clearly identified.

Reference Action Lead Commissioner

Lead Provider/s

Governance Lead

Fit with Eight High Impact Interventions

Objective 1: People are central to designing the right systems and are at the heart of decisions being made 1.1 All System Resilience Group commissioners and providers will ensure

that appropriate public, patient and clinical engagement and consultation takes place in the delivery of strategy actions to make sure people are able to input their views into the development of local urgent and emergency services in line with the strategy vision

Clinical Commissioning Groups Local Authorities

All SRG Providers

System Resilience Group

Objective 2: Patients will experience a joined up and integrated approach regardless of the specific services they access

2.1 Review current provision where appropriate and develop an 'integrated service' for NHS 111 and in and out-of-hours primary care across the Urgent and Emergency Care Network

All Regional System Resilience Groups

All relevant providers

Urgent and Emergency Care Network

2.2 Review and develop local arrangements for enabling GP practices to provide extended hours/additional capacity and increased access opportunities providing a responsive service to both primary and urgent needs seven days a week

Clinical Commissioning Groups

GP Federations


2.3 Review, research and develop community-based urgent care clinical hub arrangements within primary and urgent care, ensuring appropriate fit with the Urgent and Emergency Care Network ‘integrated service’




2.4 Develop robust links with the Frail Elderly pathway to ensure each care home has effective arrangements with primary care, pharmacy and falls services for prevention and response training, to support management falls without conveyance to hospital where appropriate

Clinical Commissioning Groups Local



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Lead Provider/s

Governance Lead


Authorities 2.5 Ensure local primary and community services are integrated

effectively to provide proactive and reactive support to those at risk of a hospital admission, particularly frail, elderly people who may also have complex needs.




2.6 Support the development of appropriate clinical access to patient records to facilitate clinicians to provide the safest outcome for the patient’s needs




2.7 Expand NHS 111’s ability to directly book appointments with GP practices Clinical Commissioning Groups

GP Federations


Objective 3: The most vulnerable people will have a plan to help them manage their condition effectively to avoid the need for urgent and emergency care

3.1 Embed the role of peer support, voluntary sector and community networks to help and support people to self-care

Local authorities All relevant providers


3.2 Develop a clear strategy to help people self-care through individual focused agreed anticipatory care plans




3.3 Review existing arrangements and make sure a robust falls prevention approach is in place including comprehensive care management plans for all care homes with primary care, pharmacy, and falls services for prevention and response training, to support management of falls without conveyance to hospital where appropriate


All Care Home Providers


3.4 Continue to develop comprehensive care management plans across primary, secondary and emergency care to proactively support the people who are the most regular attenders at A&E departments


County Durham and Darlington NHS Foundation Trust


Objective 4: People will be supported to remain at their usual place of residence wherever possible 4.1 Ensure that the deciding rights of palliative care patients who have

chosen not to be transported to hospital are robustly implemented in all Clinical Commissioning


System Resilience

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Lead Provider/s

Governance Lead


circumstances to respect people’s preferred place of death and reduce the number of people dying within 48 hours of a hospital admission

Groups Group

4.2 Review and evaluate the effectiveness of a range of local additional clinical support to care homes and understand the impact on reducing acute hospital admissions and re-admissions




4.3 Further develop the range of primary and secondary care clinical support to care homes and people within their own homes to make sure everyone has responsive, timely and effective health and social care interventions to avoid a hospital admission where appropriate, and support people with timely safe hospital discharge seven days a week




4.4 Clarify the scope of the emergency medication service following evaluation, and training and education of health and social care staff in the proper use of inhalers as a preventative measure


Community Pharmacies


4.5 Clarify the scope of the minor ailments service in light of availability of real time data




4.6 Improve the skills of health and social care staff to ensure the consistent application of medication reviews for frail elderly people




4.7 Develop responsive children's community services that are integrated with urgent and emergency care services. This includes increasing specialist community paediatric capacity to help further support children and their families at home with acute and chronic disease management




4.8 Ensure special patient notes are up to date and available for paramedics to contact local clinical support for vulnerable patients


North East Ambulance Service


4.9 Develop intermediate care services in line with the outcome of local reviews

Local Authorities

County Durham

System Resilience

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Lead Provider/s

Governance Lead


and Darlington NHS Foundation Trus

Group

Object ive 5: The public will have access to information and guidance in the event of them needing urgent or emergency care

5.1 Develop and implement patient education and public health messages, particularly throughout winter for urgent and emergency care services, that are appropriately aligned to key national messages


NECS Comms Team


5.2 Strengthen patient feedback mechanisms to include feedback from patients attending A&E about any perceived or actual barriers they have encountered in trying to first access a GP or urgent care appointment within a timely manner




5.3 Ensure public and patient education about the breadth and accessibility of community pharmacy services is comprehensive and effective to make sure community pharmacy services are fully utilised


NECS Comms Team


5.4 Ensure that community pharmacies provide consistent delivery of key services such as advice on new medications and medicine use reviews




Objective 6: The patient will be seen at the right time, in the right place, by a person with the appropriate ski l ls to manage their needs

6.1 Complete the full relocation of the urgent care service in Darlington within the A&E department in Darlington Memorial Hospital

Darlington Clinical Commissioning Group



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Lead Provider/s

Governance Lead


6.2 Reduce inappropriate emergency ambulance dispatches to A&E departments by reviewing the clinical triage arrangements with NHS 111 to make sure they are sufficient and working effectively




6.3 Reduce inappropriate emergency ambulance dispatches to A&E departments by ensuring effective clinical support is in place for paramedics including timely response from local primary and urgent care services




6.4 Monitor progress in the two year reduction trajectory for See, Treat and Convey activity and associated increases in Hear and Treat, and See and Treat activity;




6.5 Reduce inappropriate and increase appropriate referrals to ambulatory care within County Durham and Darlington hospitals




6.6 Make sure crisis and liaison support for children and adolescents with mental health needs is sufficient and effective across County Durham and Darlington


Tees, Esk and Wear Valleys NHS Foundation Trust


6.7 Make sure that clinical and referral pathways into recovery services for both adults and young people with an alcohol dependency are sufficiently robust and effective across County Durham and Darlington

Local Authorities

Relevant community support services


6.8 Review and expand Community Mental Health Services across County Durham and Darlington to support people in mental health crisis including people with dementia, and providing a patient centred response




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Lead Provider/s

Governance Lead


6.9 Make sure that the NHS Pathways Directory of Service for County Durham and Darlington is comprehensively populated with up to date and accurate information to promote easier and faster access to appropriate services across health and social care


All SRG Providers


Objective 7: The patient will not experience any unnecessary delay in receiving the most appropriate care 7.1 Ensure that Rapid Assessment and Treat is in place to support patients in A&E

and Medical Assessment Units to receive safer and more appropriate care as they are reviewed by senior doctors early on




7.2 Make sure that consultant-led morning ward rounds take place seven days a week so that discharges at the weekend are at least 80% of the weekday rate and at least 35% of discharges are achieved by midday throughout the week. This will support patient flow throughout the week and prevent A&E performance deteriorating on Monday as a result of insufficient discharges over the weekend




7.3 Make sure that there is sufficient discharge management and alternative capacity such as discharge-to-assess models are in place to reduce the DTOC rate to 2.5%. This will form a stretch target beyond the 3.5% standard set in the planning guidance




7.4 Complete the re-development of University Hospital of North Durham’s A&E department to significantly increase capacity, improve patient flow and patient experience

North Durham Clinical Commissioning Group



57


Lead Provider/s

Governance Lead


7.5 Complete the extension of A&E at Darlington Memorial Hospital to include urgent care and improve care for patients

Darlington Clinical Commissioning Group



7.6 Significantly improve ambulance handover times in line with contractually agreed targets at A&E departments supporting County Durham and Darlington patients


County Durham and Darlington NHS Foundation Trust North East Ambulance Service


7.7 Make sure that the ambulatory care service provided by County Durham and Darlington NHS Foundation Trust has sufficient capacity to manage appropriate demand




7.8 Ensure consistent achievement of maximum four-hour wait in A&E from arrival to admission, transfer and discharge at 95% as a minimum


All Acute Trusts reporting to the System Resilience Group


7.9 Use collated primary, urgent and emergency care demand levels to help understand fluctuations in overall levels of demand across the whole system, particularly surge activity


GP Federations Urgent Care


58


Lead Provider/s

Governance Lead


Service Providers Acute Trusts

7.10 Continue to develop and improve initiatives that reduce acute bed length of stay, particularly for people aged 75 and over




7.11 Review and evaluate the implementation, management and effectiveness of the Regional Flight Deck




7.12 Review and evaluate the implementation, management and effectiveness of the Regional Divert Policy




7.13 Review and evaluate the implementation, management and effectiveness of the North Durham Local Divert Policy

North Durham Clinical Commissioning Group



7.14 Complete a full review of the Patient Transport Service and discharge transport services and implement any agreed recommendations to make sure that these services are able to meet demand, are robust and cost effective




7.15 Work to better understand the blockages and pressures throughout the urgent and emergency care pathway and the most effective approach to alleviate these pressures, possibly through the use of NHS England’s Data Intelligence Tool


All SRG Providers


7.16 Ensure that the mental health acute care pathway processes are as efficient as possible to make sure patients receive a timely response and improve patient experience


Tees, Esk and Wear Valleys


59


Lead Provider/s

Governance Lead


NHS Foundation Trust

7.17 Expand the current mental health acute liaison service in A&E to 24/7 coverage




7.18 Ensure that the re-configuration of A&E departments in both Darlington Memorial Hospital and University Hospital of North Durham include the integration of children’s care that is also sufficiently resourced




7.19 Develop seven-day service access to a range of key clinical services to support effective discharge management including diagnostics, access to diagnostic scanners, cardio-pulmonary tests and pharmacy




7.20 Ensure timely access to care packages, particularly at times of pressure, during weekends and bank holidays across both County Durham and Darlington

Local Authorities

Local Authorities


7.21 Streamline the process for people accessing prescribed medication from community pharmacies following discharge from hospital




60

8 How will we measure success? 8.1 There are a number of critical success factors which are essential in order to deliver

the plan outlined in this strategy which is outlined below.

Firstly there should be an improvement across all Clinical Commissioning Groups in terms of the constitutional standards as mentioned in Section 2.8 and 2.9 but most specifically in relation to the two relating directly to urgent care:

• A maximum of a four-hour wait in A&E from arrival to admission, transfer or

discharge. • All ambulance trusts to respond to 75 per cent of Category A (the most

urgent) calls within eight minutes and to respond to 95 per cent of Category A calls within 19 minutes of a request being made for a fully equipped ambulance vehicle (car or ambulance) able to transport the patient in a clinically safe manner.

8.2 In addition there will be other indicators of success, including:

• Patients report that they are accessing the right service, at the right time, first time. These reports may come via patient feedback channels such as patient surveys or the friends and family test.

• Positive patient reported experience of all urgent and emergency care services within the system. Again, this would come via surveys or general feedback.

• Providers feel supported and have sufficient resources to meet patient need. • Commissioners feel their investment is cost effective and resulting in positive

patient outcomes. • Completion of actions stated within the strategy action plan. • Minimum 3.5% reduction in overall demand for urgent and emergency care

across the whole system. • Consistent achievement and over-achievement of the national 95% A&E four-

hour wait target. • An improvement in handover times for ambulances at County Durham and

Darlington NHS Foundation Trust in line with contractual targets. • A sustained reduction in delayed transfers of care with consultant-led morning

ward rounds seven days a week so that discharges at the weekend are at least 80% of the weekday rate and at least 35% of discharges are achieved by midday throughout the week.

• An increase in the number of patients who use primary care as their first stop for urgent care.

• Able to evidence a reduction in: o acute length of stay; o inappropriate re-admissions; o admissions for people aged 75 and over; o reduction in unavoidable deaths in acute settings.

• Services feel they have been enabled to work in a joined up or integrated way.

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8.3 As part of the work to consider how best to implement this strategy, the System Resilience Group will consider the best ways to effectively measure these success factors. 8.4 There are a number of key behaviors that will be required from all commissioners and providers contributing to the implementation of this strategy to achieve the critical success factors set out above. These include:

• Strong leadership that empowers individual staff to take

responsibility and make appropriate decisions; • An ability to lead and drive forward cultural change in a positive way; • The commitment of all stakeholders from frontline staff to executive

teams to implementing the strategy; • A commitment to work collaboratively; • A determination and mature approach to working through difficult

issues collaboratively; • A recognition that addressing and resolving system pressures is the

responsibility of the whole health economy; • A resolve to ensure that positive patient experience is at the heart of

all system changes undertaken.

62

9 Governance structures

9.1 The System Resilience Group will be responsible for the ownership, oversight and monitoring of the implementation of the strategy action plan.

9.2 Each lead for the actions currently being progressed by the System Resilience

Group will be required to provide an update on risks and action taken to mitigate risks on a monthly basis.

9.3 The groups will use the NHS Change Model and its key components to develop the

projects, and identify the key enablers and levers that need to be implemented, such as funding streams or outcome measures, to enable transformational change.

9.4 The System Resilience Group is supported by local decision making within partner

organisations’ own Management Meetings and Boards. NHS England’s Durham, Darlington and Tees Area Team has a close working relationship with the SRG, attending the meetings and providing an overall assurance role.

System Resilience Group – Governance Structure September 2015 9.5 More detail on what each of these bodies does is below:

• Health and Wellbeing Board - legal body, responsible for health and wellbeing strategy and ensuring joined up local approach to health and wellbeing overall. The County Durham and Darlington System Resilience Group reports into both local Health and Wellbeing Boards to ensure appropriate engagement and ratification of key areas of work, for example, the urgent care strategy.

• Urgent and Emergency Care Network - based on the geographies required to give strategic oversight of urgent and emergency care on a regional area.

• NHS England - national assurance of local SRG plans and delivery. • Clinical Commissioning Groups Governance Meetings - local decision making.

Denotes direct reporting requirement

Denotes information sharing, engagement and/or advice

Health and Wellbeing Board


Overview and Scrutiny

County Durham and Darlington System Resilience Group (SRG) NHS England Public and Patient

Clinical Commissioning Groups Governance Meetings

SRG Members Governance Meetings

63

• SRG Members Governance Meetings - local decision making. • Public and Patient - public and patient engagement to support the work of the

System Resilience Group is a crucial aspect to ensure the system changes implemented over the life of the strategy are in line with the needs of the public and patients. Appropriate targeted engagement will be undertaken by lead organisations for specific strategy actions as opposed to be being led by the System Resilience Group itself. However, the learning will inform the overall strategic direction as well as help shape local service delivery models.

• Overview and Scrutiny - provides public scrutiny to strategy and system development. The SRG ensures involvement of local Overview and Scrutiny Committees in proposed service changes and the strategy development.

• County Durham and Darlington System Resilience Group - drives delivery, quality, performance, operational resilience, key system improvements, and ensures financial balance.

64

APPENDIX 1 –– Urgent Care Strategy 2015 – 20 Plan on a Page

To be inserted. Summary of vision, objectives, actions, outcomes

65

APPENDIX 2 – Eight High Impact Interventions

No. High Impact Interventions

1 No patient should have to attend A&E as a walk in because they have been unable to secure an urgent appointment with a GP. This means having robust services from GP surgeries in hours, in conjunction with comprehensive out-of-hours services.

2 Calls to the ambulance 999 service and NHS 111 should undergo clinical triage before an ambulance or A&E disposition is made. A common clinical advice hub between NHS 111, ambulance services and out-of-hours GPs should be considered.

3 The local Directory of Services supporting NHS 111 and ambulance services should be complete, accurate and continuously updated so that a wider range of agreed dispositions can be made.

4 SRGs should ensure that the use of See and Treat in local ambulance services is maximised. This will require better access to clinical decision support and responsive community services.

5

Around 20-30% of ambulance calls are due to falls in the elderly, many of which occur in care homes. Each care home should have arrangements with primary care, pharmacy and falls services for prevention and response training, to support management falls without conveyance to hospital where appropriate.

6 Rapid Assessment and Treat should be in place, to support patients in A&E and Assessment Units to receive safer and more appropriate care as they are reviewed by senior doctors early on.

7

Consultant-led morning ward rounds should take place seven days a week so that discharges at the weekend are at least 80% of the weekday rate and at least 35% of discharges are achieved by midday throughout the week. This will support patient flow throughout the week and prevent A&E performance deteriorating on Monday as a result of insufficient discharges over the weekend.

8

Many hospital beds are occupied by patients who could be safely cared for in other settings or could be discharged. SRGs will need to ensure that sufficient discharge management and alternative capacity such as discharge-to-assess models are in place to reduce the Delayed Transfers of Care (DTOC) rate to 2.5%. This will form a stretch target beyond the 3.5% standard set in the planning guidance.

66

APPENDIX 3 – Local performance and activity information 2013-15 Maximum four-hour wait in A&E from arrival to admission, transfer or discharge at 95% The ability of each individual trust to achieve the minimum 95% target each quarter and over the year as a whole varies.

67

Ambulance Handovers All ambulance trusts to respond to 75 per cent of Category A (the most urgent) calls within eight minutes and to respond to 95 per cent of Category A calls within 19 minutes of a request being made for a fully equipped ambulance vehicle (car or ambulance) able to transport the patient in a clinically safe manner. The ability of each individual acute trust to ‘clear’ an ambulance that arrives at A&E within 15 minutes varies considerably.

68

Delayed Transfers of Care

There is a strong focus from NHS England in reducing all delayed transfers of care whether the initial causal factor is health or social care related.

69

Emergency Attendances

Locally all three acute hospital trusts experienced an increase in the overall number of emergency attendances during winter 2014/15.

Both nationally and locally the number of admissions has seen an increase during winter 2014/15.

70

APPENDIX 4 – Key national and local policy and guidance National policy and guidance

• NHS Five Year Forward View, October 2014 • NHS Operating Framework 2014/15 • NHS England Winter Health Check, March 2015 • Transforming urgent and emergency care services in England, November 2013 • NHS England: Improving A&E Performance Gateway Reference: 00062 • NHS England: Improving and sustaining cancer performance Gateway Reference:

03614 • Royal College of General Practitioners Guidance for Commissioning

Integrated Urgent and Emergency Care – A Whole System Approach (2011)

• Primary Care Foundation – Breaking the mould without breaking the system (2011)

• National Ambulance Commissioners Group Achieving Integrated Unscheduled Care - the view from the National Ambulance Commissioners Group (2010)

• Department of Health Equity and Excellence: Liberating the NHS (2010) • Department of Health A Vision for Adult Social Care (2010) • The King’s Fund: Avoiding Hospital Admissions (2010) • Department of Health Equity and Excellence: Liberating the NHS (2010) • Health and Social Care Act 2012 • The Francis Report (2013) http://www.midstaffspublicinquiry.com/report

(accessed 8 April 2013) • Urgent Care Strategy 2013–2018, Hartlepool and Stockton on Tees CCG • Safe, compassionate care for frail older people using and integrated care

pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders; NHS England, February 2014

• Handbook to the NHS Constitution, March 2013 • Mental Health Crisis Care Concordat Improving outcomes for people experiencing

mental health crisis, HM Government, February 2014 Local policy and guidance

• County Durham and Darlington NHS Foundation Trust Clinical and Quality Strategy: Right First Time 24/7 2014 http://www.cddft.nhs.uk/about-the-trust/quality-matters-our-clinical-and-quality-strategy/right-first-time-247,-our-evolving-clinical-strategy.aspx

• North Durham; Durham Dales, Easington and Sedgefield; and Darlington Clinical Commissioning Groups: Improving Palliative and End of Life Care: Strategic Commissioning Plan 2013–18 http://democracy.durham.gov.uk/documents/s42228/Item%208%20-%20Appendix%202%20%20Improving%20Palliative%20and%20End%20of%20Life%20Care%20Strategic%20Commissioning%20Plan%202013-20.pdf

• County Durham and Darlington Fire and Rescue Service: Three Year Strategic Plan 2015-18 Consultation Document https://www.ddfire.gov.uk/service-plans

• County Durham and Darlington Local Resilience Forum: Annual Report 2013-14 https://www.durham.police.uk/Information-and-advice/Pages/Local-Resilience-Forum.aspx

http://www.midstaffspublicinquiry.com/report

http://www.cddft.nhs.uk/about-the-trust/quality-matters-our-clinical-and-quality-strategy/right-first-time-247,-our-evolving-clinical-strategy.aspx



http://democracy.durham.gov.uk/documents/s42228/Item%208%20-%20Appendix%202%20%20Improving%20Palliative%20and%20End%20of%20Life%20Care%20Strategic%20Commissioning%20Plan%202013-20.pdf



https://www.ddfire.gov.uk/service-plans

https://www.durham.police.uk/Information-and-advice/Pages/Local-Resilience-Forum.aspx

https://www.durham.police.uk/Information-and-advice/Pages/Local-Resilience-Forum.aspx

71

• Tees, Esk and Wear Valleys NHS Foundation Trust: Business Plan 2014-16 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340252/TEWVALLEYS_Operational_Plan_April_2014_-_March_2016_1_.pdf

• County Durham Partnership: The Sustainable Community Strategy for County Durham 2014-30 http://www.countydurhampartnership.co.uk/Pages/CDP-SustainableCommunityStrategy.aspx

• County Durham Health and Wellbeing Strategy http://www.durham.gov.uk/jhws • North Tees and Hartlepool NHS Foundation Trust: http://www.nth.nhs.uk/our-

vision • North East Ambulance Service: Strategic Plan Summary for 2014-19 North East

Ambulance Service NHS Foundation Trust • City Hospitals Sunderland NHS Foundation Trust: Operational Plan 2014-16 • https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338

071/SUNDERLAND_Operational_Plan_14-16_1_.pdf • Durham County Council: Council Plan 2015-

18 http://www.durham.gov.uk/media/4847/Council-Plan-2015-2018/pdf/CouncilPlan2015-2018.pdf

• Darlington Partnership: One Darlington Perfectly Placed 2008–26 revised May 2014 http://www.darlington.gov.uk/media/362819/one-darlington-perfectly-placed.pdf

• Sunderland Clinical Commissioning Group: Sunderland Health & Care System Strategic Plan 2014-19: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/392969/SUNDERLAND_Publishable_Summary_Strategic_Plan_1415.pdf

• Hartlepool and Stockton-on-Tees Clinical Commissioning Group: Clear and Credible Plan Refresh 2014/15 – 2018/19 http://www.hartlepoolandstocktonccg.nhs.uk/wp-content/uploads/2013/11/HAST_CCG_5_YEAR_PLAN_FINAL_INTERNAL_WEB-15-August.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340252/TEWVALLEYS_Operational_Plan_April_2014_-_March_2016_1_.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340252/TEWVALLEYS_Operational_Plan_April_2014_-_March_2016_1_.pdf

http://www.countydurhampartnership.co.uk/Pages/CDP-SustainableCommunityStrategy.aspx

http://www.countydurhampartnership.co.uk/Pages/CDP-SustainableCommunityStrategy.aspx

http://www.durham.gov.uk/jhws

http://www.nth.nhs.uk/our-vision

http://www.nth.nhs.uk/our-vision

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338071/SUNDERLAND_Operational_Plan_14-16_1_.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338071/SUNDERLAND_Operational_Plan_14-16_1_.pdf

http://www.durham.gov.uk/media/4847/Council-Plan-2015-2018/pdf/CouncilPlan2015-2018.pdf

http://www.durham.gov.uk/media/4847/Council-Plan-2015-2018/pdf/CouncilPlan2015-2018.pdf

http://www.darlington.gov.uk/media/362819/one-darlington-perfectly-placed.pdf

http://www.darlington.gov.uk/media/362819/one-darlington-perfectly-placed.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/392969/SUNDERLAND_Publishable_Summary_Strategic_Plan_1415.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/392969/SUNDERLAND_Publishable_Summary_Strategic_Plan_1415.pdf

http://www.hartlepoolandstocktonccg.nhs.uk/wp-content/uploads/2013/11/HAST_CCG_5_YEAR_PLAN_FINAL_INTERNAL_WEB-15-August.pdf



72

Appendix 5a - Map of current services: hospital sites, urgent care centres and GP practices

73

Appendix 5b – Map of current services: community pharmacies

Appendix 6 - Glossary Acute Care A type of secondary care where a patient receives short-term

treatment for a severe injury or episode of illness, an urgent medical condition, or during recovery from surgery. In medical terms, care for acute health conditions is the opposite from chronic care, or longer term care.

Acute Liaison (mental health)

This service aims to increase the detection, recognition and early treatment of mental health problems, for people within an acute hospital setting.

Acute Medicine

Medicine concerned with the immediate and early specialist management of adult patients with a wide range of medical conditions who present in hospital as emergencies.

Ambulatory Care

The treatment of a condition that is urgent but that does not need to be assessed and treated within an Accident and Emergency Department. Ambulatory care services may provide assessment and treatment services but the service itself may be provided outside the hospital.

Chronic Care

A type of care that treats pre-existing or long-term illness. Without effective treatment, chronic conditions may lead to disability.

Clinical The assessment and treatment of actual patients in relation to their healthcare needs.


NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England.

Clinician A person, such as a doctor or a nurse, who is trained and qualified in the assessment and treatment of medical needs for actual patients, as opposed to a person studying medical research in a laboratory.

Consultant

Medical staff who mainly deliver expert clinical care usually within a team, including the ability to recognise and manage the more complex healthcare needs.

Critical Care

The specialised care of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring, usually in intensive care units. This type of care is also known as intensive care.

Emergency Care

A type of care that provides assessment and treatment for people with serious or life-threatening conditions.

Emergency Department

Emergency Department (ED): also known as Accident and Emergency (A&E), or casualty department, is a medical facility specialising in acute care for patients who present without prior appointment, either by their own means or by ambulance.

Experience Led Commissioning

An approach to planning and buying healthcare services. It is built around the idea that if commissioners listen to and deeply understand people’s experiences, they will design better, more person-centred services that deliver better care.

General Practitioner

A medical practitioner who treats acute and chronic illnesses and provides preventative care and health education to patients within a primary care setting.

Interventional Radiology

An independent medical specialty that uses minimal invasive procedures to diagnose and treat diseases.

Medical Assessment Unit Usually receives acutely ill medical patients from primary care via GP

https://en.wikipedia.org/wiki/Disability

75

referral and referrals from the Emergency Department.

Monitor Sector regulator for health services in England, Monitor's job is to make the health sector work better for patients.

Multi-disciplinary

Group of professionals from one or more clinical disciplines who together make decisions regarding recommended treatment of individual patients.

Multi-speciality community provider

Under this new care model outlined in the NHS Five Year Forward View, GP group practices would expand, bringing in nurses and community health services, hospital specialists and others to provide integrated out-of-hospital care. These practices would shift the majority of outpatient consultations and ambulatory care to out-of-hospital settings.

Neonatology

Subspecialty of paediatrics that consists of the medical care of newborn infants, especially the ill or premature newborn infant. It is a hospital-based specialty, and is usually practiced in neonatal intensive care units (NICUs).

NHS 111 A three digit telephone service introduced to improve access to NHS urgent care services.

NHS Commissioning Assembly

The community of leaders for NHS commissioning – the ‘one team’ which will deliver better outcomes for patients.

NHS Constitution The NHS document that sets out rights for patients, public and staff, and outlines the NHS commitments and responsibilities to make sure the NHS operates fairly and effectively.

Paediatrics The branch of medicine that deals with the medical care of infants, children and adolescents.

Primary Care

The healthcare given by a health provider who typically acts as the first point of consultation for patients within the healthcare system and co-ordinates other specialists that the patient may need, for example, GPs.

Secondary Care Secondary care means the healthcare services provided by medical specialists and other health professionals who generally do not have first contact with patients. This may include medical staff who work in an acute hospital environment and those who work within community healthcare teams.

See and Treat A system developed with the aim of reducing waiting times between patients, thereby reducing the overall maximum wait that some patients experience.

Self-care Personal health maintenance. Any activity of an individual, family or community with the intention of improving or restoring health, or treating or preventing disease.

Unscheduled Care A term used to describe any unplanned health or social care. Also known as urgent and emergency.

Urgent Care

The delivery of ambulatory care in a facility dedicated to the delivery of medical care outside of the hospital emergency department.

Urgent Care Centre A centre where urgent but non-life threatening conditions can be treated.

Whole Systems Approach A whole systems approach is a generic term that means the inclusion of all organisations involved in the commissioning and provision a group of services. Within urgent and emergency care the whole system includes pharmacies, GP Practices, social care, urgent care centres, walk-in or minor injury units, community services, for example District Nursing and Intermediate Care and Acute Hospitals both community hospitals and those with an A&E department.

https://en.wikipedia.org/wiki/Patients

76


Governing Body

Agenda Item: 70

1 December 2015

Title Securing Quality in Health Services (SeQiHS)


Category

Strategy &

Planning ☐

Performance &

Operational ☐

Governance &

Assurance ☒


Ali Wilson - Chief Officer

Clinical Sponsor

Andrea Jones

Author of Report Jon Tomlinson, SeQIHS Programme Director


• Approve the draft Terms of Reference for the Joint Committee

• Approve the proposed constitution amendments

Executive Summary

In order to secure timely decision making as the SeQIHS programme starts the next phase towards public consultation, a review of the governance arrangements for the programme has been undertaken in order to make decisions and agree documentation in a timely manner. In line with the existing governance CCG arrangements, the form used in other health systems and more recently for co-commissioning is the mechanism of a Joint Committee of CCGs. A constituional ammendment and an amended scheme of delegation is required in order to establish the governance arrangments. A Draft Terms of Reference is provided for approval.

Clinical Engagement

Engagement with secondary care clinicians and primary care clinicians is ongoing.

Does this report provide evidence of assurance for the Assurance Framework and / or mitigate risk included

Risks within the SeQiHS project will be added to the corporate risk register and assurance rframework as appropriate

on the CCG’s Risk Register? Has an Equality Analysis been completed?

Will be completed as part of the programme

Attachments Securing Quality in Health Services- Programme Update Securing Quality in Health Services (SeQIHS) CCG Joint Committee – Draft Terms of Reference




☒

2.


☐

3.


☒


☒

5.




☒


Not required


1. Introduction

In order to secure timely decision making as the SeQIHS programme starts the next phase towards public consultation, a review of the governance arrangements for the programme has been undertaken in order to make decisions and agree documentation in a timely manner. In line with the existing governance CCG arrangements, the form used in other health systems and more recently for co-commissioning is the mechanism of a “Joint Committee of CCGs”.

Legal advice has been provided by Capsticks to produce a scheme of delegation which meets legal and governance requirements and is seen by all CCGs as meeting their needs. Proposed membership of the Joint Committee:

• NHS North Durham CCG • NHS Durham Dales and Sedgefield CCG • NHS Darlington CCG • NHS Hartlepool and Stockton on Tees CCG • NHS South Tees CCG.

2. Actions required to establish the Joint Committee 2.1 Constitutional amendment An amendment will be required to the CCG’s Constitution to include the Joint Committee within the governance arrangements for the CCG. This would be in line with amendments that have already been made to allow for the establishment of joint committees with NHS England for the commissioning of Primary Care.

Draft wording to be added to CCG Constitutions under section 6.11 joint Commissioning Committee is as below:

Joint Commissioning Committee with other CCGs – SeQIHS Joint Committee The Joint Committee is a joint committee of NHS North Durham CCG, NHS Durham Dales, Easington and Sedgefield CCG, NHS Darlington CCG, NHS Hartlepool and Stockton-on-Tees CCG and NHS South Tees CCG. The primary purpose of the Joint Committee is to arrange the formal consultation and undertake the decisions on the issues which are the subject of the consultation in relation to the SeQIHS programme. The Joint Committee will operate in line with the joint arrangements set out in section 6.7 of the Constitution, and the Terms of Reference for the Joint Committee can be found at the following link to the CCG website www.hartlepoolandstocktonccg.nhs.uk The main activities of the Joint Committee include the following:

• Determine the options appraisal process, including agreeing the evaluation criteria and weighting of the criteria

• Determine the method and scope of the consultation process • Act as the formal body in relation to the public consultation with the Joint Overview

and Scrutiny Committees established for it by the relevant Local Authorities • Make any necessary decisions arising from a Pre-Consultation Business Case (and

the decision to run a formal consultation process) • Approve the Consultation Plan

• Approve the text and issues on which the public’s views are sought in the Consultation Document

• Take or arrange for all necessary steps to be taken to enable the CCGs to comply with their public sector equality duties

• Approve the formal report on the outcome of the consultation that incorporates all of the representations received in response to the consultation document in order to reach a decision

• Make decisions about future service configuration and service change, taking into account all of the information collated and representations received in relation to the consultation process. This should include consideration of any recommendations made by the Programme Board or views expressed by the Joint Health Overview and Scrutiny Committee or any other relevant organisations.

The Governing Body of the CCG shall require, in all joint Commissioning arrangements that the lead clinician and lead manager of the CCG, make a quarterly written report to the Governing Body and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives. An amendment will also be needed were Committees of the Governing Body are referenced in section 6.4 of the constitution. 2.2 Amended scheme of delegation In addition to amendments as described in the body of the CCG constitution, amendments to the scheme of delegation to describe the functions that will be delegated to the Joint Committee will also be required to include:.

COMMITTEE DECISIONS/DUTIES DELEGATED BY THE GOVERNING BODY TO COMMITTEES AND BY THE TO ITS SUB COMMITTEES

SeQIHS Joint Committee


• Determine the method and scope of the consultation process • Act as the formal body in relation to the public consultation

with the Joint Overview and Scrutiny Committees established for it by the relevant Local Authorities

• Make any necessary decisions arising from a Pre-Consultation Business Case (and the decision to run a formal consultation process)

• Approve the Consultation Plan • Approve the text and issues on which the public’s views are

sought in the Consultation Document • Take or arrange for all necessary steps to be taken to enable

the CCGs to comply with their public sector equality duties • Approve the formal report on the outcome of the consultation

that incorporates all of the representations received in response to the consultation document in order to reach a decision

• Make decisions about future service configuration and service change, taking into account all of the information collated and representations received in relation to the consultation process. This should include consideration of any recommendations made by the Programme Board or

COMMITTEE DECISIONS/DUTIES DELEGATED BY THE GOVERNING BODY TO COMMITTEES AND BY THE TO ITS SUB COMMITTEES

views expressed by the Joint Health Overview and Scrutiny Committee or any other relevant organisations.

2.3 Ratify the draft terms of reference for the Committee Most of the members CCGs have used the wording that is included in the model wording for amendments to CCG Constitutions in relation to setting up joint committees and this states that the agreement setting out the arrangements for joint working, in this case the terms of reference, will include the following areas:

• How the parties will work together to carry out their commissioning functions • The duties and responsibilities of the parties • How risk will be managed and apportioned between the parties • Financial arrangements, including, if applicable, payments towards a pooled fund

and management of that fund • Contributions from the parties, including details around assets, employees and

equipment to be used under the joint working arrangements The draft terms of reference are therefore provided for the approval of the Governing Body, The terms of reference have been previously discussed at the CCG forum by the Chief Officers of the constituent members of the Committee. 3. Constitutional amendment process As of 1st April 2015, CCG’s are free to apply to NHS England at any point to change their constitution. Amendments to the NHS Darlington CCG constitution require approval by the Governing Body. 4. Recommendation

• To approve the draft Terms of Reference for the Joint Committee

• Approve the proposed constitution amendments

Jon Tomlinson SeQIHS Programme Director 30 October 2015

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Securing Quality in Health Services (SeQIHS) CCG Joint Committee

Draft Terms of Reference

1. Introduction

1.1 The NHS Act 2006 (as amended) (“the NHS Act”) was amended in 2014 to allow Clinical Commissioning Groups (CCGs) to form joint committees. This means that two or more CCGs exercising commissioning functions jointly may form a joint committee. The Legislative Reform Order (“LRO”), which amended section 14Z3 (CCGs working together) of the NHS Act, was passed by Parliament and the reforms took effect from 1 October 2014. The reforms mean that CCGs will no longer find it necessary to operate work-around arrangements such as committees in common, encouraging integration and co-working.

Joint committees are a statutory mechanism which gives CCGs an additional option for undertaking collective strategic decision making.

In addition, the NHS Act provides, at section 13Z, that some of NHS England’s functions may be exercised jointly with a CCG, and that functions exercised jointly in accordance with that section may be exercised by a joint committee of NHS England and the CCG. Section 13Z of the NHS Act further provides that arrangements made under that section may be on such terms and conditions as may be agreed between NHS England and the CCG. Although the SeQIHS Programme will affect services commissioned by the Specialised Commissioning function of NHS England it is not possible for that function to be shared with CCGs. Instead a collaborative commissioning arrangement will be put in place with NHS England’s Specialised Commissioning North East and Cumbria group. Individual CCGs will still remain accountable for meeting their statutory duties. The aim of the LRO is to encourage the development of strong collaborative and integrated relationships and decision making between partners.

1.2 The SeQIHS CCG Joint Committee (hereafter referred to as the Joint Committee) is a joint committee of NHS North Durham CCG, NHS Durham Dales, Easington and Sedgefield CCG, NHS Darlington CCG, NHS Hartlepool and Stockton on Tees CCG and NHS South Tees CCG with the primary purpose of arranging formal public consultation and then making decisions on the issues which are the subject of the consultation in relation to the SeQIHS Programme.

In addition, the Joint Committee will meet collaboratively with those exercising the Specialised Commissioning function of NHS England (NHS England committee or nominated individual) to ensure that integrated decisions are made in respect of the commissioning of Specialised Services and connected health services commissioned by CCGs.

1.3 The SeQIHS Programme - Health leaders across Durham, Darlington and Tees have collectively committed to change the way certain elements of health care is provided to the local population to deliver the highest quality of care possible within the resources available. The work of the SeQIHS programme is designed to deliver key clinical standards consistently across the patch so that all people receive the highest possible care and best outcomes with more care provided Out of Hospital.

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Currently for those people who do need in hospital treatment care can be variable in terms of outcomes because not all hospitals or services can achieve the agreed clinical quality standards. Hospitals are providing the same services in a health system that is constrained by both finance and capacity, particularly certain elements of the workforce, to deliver services at the levels required. From the work carried out to date it is clear that this is not sustainable with the need for some acute and specialist services to be carried out in fewer locations with other services provided in more locations.

1.4 Guiding principles: • The needs of people in Darlington, Durham and Tees will have priority over

organisational interests • NHS and LA Commissioners and providers will work collaboratively and urgently on

system reform and transformation • Costs will be reduced by better co-ordinated proactive care which keeps people well

enough to need less acute, long term and institutional care • Waste will be reduced, duplication avoided and activities stopped which have limited

value. Patients who are no longer acutely unwell will be discharged promptly from hospital and cared for in their own home or a local care facility

• Our health and social care system is made up of many independent and inter-dependent parts which can positively or adversely affect each other. We will develop strong working relationships with clear aims and a shared vision putting the needs of the people we serve first

• There will be partnership with the people of Darlington, Durham and Tees the workforce, voluntary, community and faith based organisations, NHS and LAs

1.5 The SeQIHS Programme established a Programme Board in 2012 which has overseen the development of agreed clinical quality standards, a feasibility analysis looking at the implications of implementing these standards, a clinical case for change, a financial case for change and a model of care. The Programme Board will continue to oversee the continued work of the programme. 2. Statutory Framework The NHS Act which has been amended by Legislative Reform Order 2014/2436, provides at section 14Z3 that where two or more clinical commissioning groups are exercising their commissioning functions jointly, those functions may be exercised by a joint committee of the groups. The CCGs named in paragraph 1.2 above have delegated the functions set out in schedule 1 to the SeQIHS Joint Committee. 3. Role of the SeQIHS Joint Committee The role of the SeQIHS Joint Committee shall be to carry out the functions relating to undertaking formal public consultation and making decisions on the issues which are the subject of the consultation in relation to the SeQIHS Programme.

This includes the following key responsibilities:


• Determine the method and scope of the consultation process • Act as the formal body in relation to the public consultation with the Joint Overview

and Scrutiny Committees established for it by the relevant Local Authorities

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• Make any necessary decisions arising from a Pre-Consultation Business Case (and the decision to run a formal consultation process)

• Approve the Consultation Plan • Approve the text and issues on which the public’s views are sought in the

Consultation Document • Take or arrange for all necessary steps to be taken to enable the CCGs to comply

with their public sector equality duties • Approve the formal report on the outcome of the consultation that incorporates all of

the representations received in response to the consultation document in order to reach a decision

• Make decisions about future service configuration and service change, taking into account all of the information collated and representations received in relation to the consultation process. This should include consideration of any recommendations made by the Programme Board or views expressed by the Joint Health Overview and Scrutiny Committee or any other relevant organisations. It should also include consideration of the implications of the decisions in relation to potential risk to the sustainability and viability of the Foundation Trusts included in the remit of the Programme.

4. Geographical coverage

The Joint Committee will comprise

• NHS North Durham CCG • NHS Durham Dales, Easington and Sedgefield CCG • NHS Darlington CCG • NHS Hartlepool and Stockton on Tees CCG • NHS South Tees CCG

NHS England Specialised Commissioning North East and Cumbria will also be involved through a collaborative commissioning arrangement.

The Joint Committee will have the primary purpose of arranging and undertaking the formal public consultation and then making decisions on the issues which are the subject of the consultation in relation to the SeQIHS Programme.

5. Suggested Membership

• Two senior Governing Body decision makers from each of the member CCGs, including the accountable officer, depending on the management arrangements for each CCG

• Chair and Vice Chair – elected by the members. The Chair and Vice Chair must come from the member CCGs, but both roles cannot be undertaken by members of the same CCG

• The SeQIHS Programme Director will act as Secretary to the Committee to ensure the day to day work of the Joint Committee is proceeding satisfactorily.

6. Meetings and Voting

6.1 The Joint Committee shall adopt the standing orders of Darlington CCG insofar as they relate to the:

• notice of meetings • handling of meetings • agendas

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• circulation of papers • conflicts of interest (together with complying with the statutory guidance issued by NHS

England)

6.2 Voting

All decisions of the joint committee must be unanimous.

6.3 Quorum - at least one full voting member from each CCG must be present for the meeting to be quorate.

6.4 Frequency of meetings – as and when required

6.5 Meetings of the SeQIHS Joint Committee:

Meetings of the Joint Committee shall be held in public unless the Joint Committee considers that it would not be in the public interest to permit members of the public to attend a meeting or part of a meeting. Therefore, the Joint Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

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

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

6.8 The Joint Committee has the power to establish sub groups and working groups and any such groups will be accountable to the Joint Committee.

6.9 Members of the Joint Committee shall respect confidentiality requirements as set out in the Standing Orders referred to above unless separate confidentiality requirements are set out for the joint committee in which event these shall be observed

6.10 Secretariat to be provided by NECS Programme Management Office

The secretariat to the Joint Committee will:

• circulate the minutes and action notes of the committee within three working days of the meeting to all members

• Present the minutes and action notes to the governing bodies of the CCGs set out in 4 above

7. Reporting to CCGs and NHS England

The Joint Committee will make a quarterly written report to the member governing bodies and NHS England and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives.

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8. Withdrawal from the Joint Committee

Should this joint commissioning arrangement prove to be unsatisfactory, the governing body of any of the member CCGs can decide to withdraw from the arrangement. This withdrawal to be on such terms as are agreed between the other CCG members of the JC and the withdrawing CCG member.

9. Decisions

9.1 The Joint Committee will make decisions within the bounds of its remit

9.2 The decisions of the Joint Committee shall be binding on all member CCGs

9.3 Decisions will be published by NHS North Durham CCG, NHS Durham Dales, Easington and Sedgefield CCG, NHS Darlington CCG, NHS Hartlepool and Stockton on Tees CCG and NHS South Tees CCG

10. Review of Terms of Reference

These terms of reference will be formally reviewed by the CCGs named in 4 above in April of each year, following the year in which the joint committee is created and may be amended by mutual agreement between the CCGs at any time to reflect changes in circumstances as they may arise.

10. Signatures:

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Schedule 1 - Delegation by CCGs to Joint Committee

A. The following CCG functions will be delegated to the SeQIHS Joint Committee by the member CCGs in accordance with their statutory powers under s.14Z3 of the NHS Act 2006 (as amended). S.14Z3 allows CCGs to make arrangements in respect of the exercise of their functions and includes the ability for two or more CCGs to create a joint committee to exercise functions. The delegated functions relate to the acute hospital services provided to the five CCG members of the Joint CCG Committee by the three NHS Foundation Trusts, namely:

• South Tees NHS Foundation Trust • North Tees and Hartlepool NHS Foundation Trust • County Durham and Darlington NHS Foundation Trust

The SeQIHS Programme focuses on achieving clinical quality standards in the services listed below provided by the NHS Foundation Trusts named above. As part of this work it is necessary to consider interdependencies between these services and any other services that are affected.

• Acute surgery • Acute medicine • Critical care • Maternity, Paediatrics & Neonatology • Accident & Emergency • Interventional radiology

B. Each member CCG shall also delegate the following functions to the Joint CCG Committee so that it can achieve the purpose set out in (A) above:

1. Acting with a view to securing continuous improvement to the quality of commissioned services in so far as these services are included within the scope of the SeQIHS Programme. This will include outcomes for patients with regard to clinical effectiveness, safety and patient experience to contribute to improved patient outcomes across the NHS Outcomes Framework

2. Promoting innovation in so far as this affects the services included within the scope of the SeQIHS Programme, seeking out and adopting best practice, by supporting research and adopting and diffusing transformative, innovative ideas, products, services and clinical practice within its commissioned services, which add value in relation to quality and productivity.

3. The requirement to comply with various statutory obligations, including to make arrangements for public involvement and consultation throughout the process. That includes any determination on the viability of models of care pre-consultation and during formal consultation processes, as set out in s.13Q, s.14Z2 and s.242 of the NHS Act 2006 (as amended) (‘the Act’)

4. The requirement to ensure process and decisions comply with the four key tests for service change introduced by the last Secretary of State for Health, which are:

• support from GP commissioners • strengthened public and patient engagement

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• clarity on the clinical evidence base • consistency with current and prospective patient choice.

5. The requirement to comply with the statutory duty under s.149 of the Equality Act 2010 i.e. the public sector equality duty. 6. The requirement to have regard to the other statutory obligations set out in the new sections 13 and 14 of the Act. The following are relevant but this is not an exhaustive list:

• 14O - management of conflicts of interest • 14P – Duty to promote NHS Constitution • 14Q – Duty to exercise functions effectively, efficiently and economically • 14R – Duty as to improvement in quality of services • 14T – Duty as to reducing inequalitie • 14V – Duty as to patient choice • 14X - Duty to promote innovation • 14Z1 – Duty as to promoting integration • 14Z2 – Public involvement and consultation by CCGs (see above)

7. The expectation is that CCGs will ensure that clear governance arrangements are put in place so that they can assure themselves that the exercise by the Joint CCG Committee of their functions is compliant with statute. 8. The requirement to comply with the obligation to consult the relevant local authorities under s.244 of the Act and the associated Regulations. 9. To continue to work in partnership with key partners e.g. the local authority and other commissioners and providers to take forward plans so that pathways of care are seamless and integrated within and across organisations

10. The joint committee will be delegated the capacity to propose, consult on and agree future service configurations that will shape the medium and long terms financial plans of the constituent organisations. The joint committee will have no contract negotiation powers meaning that it will not be the body for formal annual contract negotiation between commissioners and providers. These processes will continue to be the responsibility of Clinical Commissioning Groups and NHS England under national guidance, tariffs and contracts during the pre-consultation and consultation periods.

Schedule 2 - List of members

• NHS North Durham CCG • NHS Durham Dales, Easington and Sedgefield CCG • NHS Darlington CCG • NHS Hartlepool and Stockton on Tees CCG • NHS South Tees CCG


Governing Body

Agenda Item: 71

1 December 2015

Title Risk Management December 2015


Category

Strategy &

Planning ☐

Performance &

Operational ☐

Governance &

Assurance ☒


Lisa Tempest

Clinical Sponsor

Andrea Jones


Recommendation(s) The NHS Darlington Clinical Commissioning Group Governing Body is

asked to: • note content of the register • note the progress made in terms of managing the risks

rated as extreme (red). •

Executive Summary

The purpose of this paper is to provide an overview of the Darlington Clinical Commissioning Group (CCG) risk register as of November 2015 and provide assurance to the Governing Body in relation to risk management. Management of risk is a continual activity, which must be performed throughout the organisation. Without on-going and effective risk management processes it is not possible to give confidence that the organisation will meet its objectives. Hence effective risk management is a prerequisite of continued organisational management The risks identified within the CCG risk register have to date been identified from the CCG Clear and Credible Plan 2012-2017, from CCG meetings and also identifies those risks to be inherited from the PCT Cluster as part of the on-going development work related to the Integrated Strategic Operational Plan 2011/12 – 2014/15. The CCG has a Risk Management Policy in place and a process by which all risks are assigned to one of the formal CCG committees (Executive, Finance and Performance or Quality and Innovation) who actively monitor and manage their own risk register. However the Governance, Audit and Risk committee is responsible for the overall CCG register and therefore all committees are required to report into the GAR committee on a bi-monthly basis. Any exceptions

from the CCG risk register (risks with a score over 15) are reported to the Governing Body (via the Executive Management meeting) on a quarterly basis. A summary of the risk register and breakdown by outcome domain is attached. One risk has been escalated to red since the last Governing Body meeting: Risk 1405 – Acute hospital activity exceeds planned levels in 2015/16 leading to a significant cost pressure for the CCG. Escalated to red bu the Finance Committee on 9th November 2015. The following remain red: Risk 1101 –Premises Costs - CCG experiences higher than planned premises costs due to current arrangements for funding void space following the relocation of services - under current NHS England guidance the CCG is responsible for paying NHS Property Services for void space. Risk increased to red (residual rating 16) by Finance Committee in December 2014. Risk 1354 – Quality of Care in Care Homes – concerns identified by the Care Quality Commission and Safeguarding team relating to the quality of care provided to patients in a care home in Darlington. Risk added as red (residual rating 15) by Quality, Performance and Innovation Committee on 28th July 2015 Risk 845- A&E Handovers – The CCGs main provider continues to be a regional outlier in respect of A&E handover delays causing delay in clinical assessment and treatment of patients. Escalated to red (residual rating 16) by Quality, Performance and Innovation Committee on 28th July 2015 The responsible committees and Governance, Audit and Risk committee continue to monitor the above risks and associated action plans closely. The Governance, Audit and Risk Committee met on the 14th July 2015 and reviewed the current risk register, controls and mitigations. No risks were identified for escalation to the Governing Body.

Clinical Engagement

Not required


The report provides evidence of recording, mitigating and monitoring risks.


Not required

Attachments None




☒

2.


☒

3.


☒


☒

5.




☒


Not required


The full CCG risk register is circulated to the Governance Audit and Risk committee on a bi-monthly basis.

Darlington CCG - Overall Summary of Risks - November 15

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DARLINGTON CLINICAL COMMISSIONING GROUP FORMAL EXECUTIVE

Tuesday 8 September 2015

10.30am – 10.40am Ground Floor 1 and 2, Doctor Piper House

CONFIRMED MINUTES

Present: Lisa Tempest Chief Finance and Operating Officer,

(Chair) Andrea Jones Chair, DCCG Richard Harker Quality Lead Jackie Kay Assistant Chief Officer

In attendance: Eileen Carbro Commissioning Manager (Service Planning

and Reform, NECS (Item No. 128)

Darren Boyd Procurement Officer, NECS (item No. 128)

Glenda Lynn Personal Assistant (minute taker)

Action Exec/15/126

Apologies for Absence Murray Rose, Diane Murphy

Exec/15/127 Declarations of Interest There were no declarations of interest.

Exec/15/128 Community Palliative Care Rapid Response Service

The Formal Executive was informed of the proposed procurement and evaluation strategy to be used in the procurement of the County Durham and the Darlington Community Palliative Care Rapid Response Service. As has been previously discussed at Formal Executive that Darlington wished to provide the opportunity for a Darlington only Community Palliative Care Rapid Response Service to be provided. To support this the procurement exercise will be divided into two separate lots to satisfy local needs. A combined Durham and Darlington service will be lot 1 and a Darlington only service will be lot 2. The financial threshold for this service is £436,568 per annum,

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which consists of a provider contribution of up to a maximum of £218,284 per annum, which will be match funded by the CCG if it is below or equal to the maximum affordability threshold. Any bid exceeding the maximum financial affordability limit will be deemed not to be viable and will not be taken any further in the evaluation process. The Formal Executive was informed of the potential procurement risks, being:

• Bids exceeding affordability threshold • Limited interest from potential bidders • Submissions not meeting the minimum quality thresholds

outlined in the evaluation criteria Formal Executive considered the recommendations outlined in the paper and agreed to:

• give the approvals outline, being approval of the proposed procurement and evaluation strategy, procurement timetable, financial threshold and contract terms and note the risks identified

• approve the use of electronic tendering systems and approval for an authorised representative from NECS to open the bids on behalf of the CCG

• note the date for the recommended bidder report and this be added to the agenda for the Formal Executive in December 2015

• provide a copy of the minute, when confirmed.

Exec/15/129

Any New Risks Identified No new risks were identified during the course of this meeting.

Date/Time/Venue of Next Formal Exec Meeting The next Formal Executive meeting due to be held on Tuesday 15th September 2015 commencing at 9am in Gd Floor 1 and 2, Doctor Piper House.

Signed……………………. Chair ……………………… Date……………………….


Tuesday 15th September 2015

9am – 10.40am

Ground Floor 1 and 2, Doctor Piper House

CONFIRMED MINUTES Present: Lisa Tempest Chief Finance Officer, (Chair)

Andrea Jones Chair, DCCG Richard Harker Quality Lead Jackie Kay Assistant Chief Officer Murray Rose Director of Commissioning, DBC In attendance: Liz Dunning Snr Finance Manager, NECS Anne Greenley Head of Clinical Quality, NECS Tracy Doran Adult Safeguarding Lead (Item 138)

DS Paul Goundry Durham Constabulary (Item 136)

Jenny Steel CEO, Primaryhealthcare Darlington (item 135)

Glenda Lynn Personal Assistant (minute taker)

Action Exec/15/126

Apologies for Absence Diane Murphy


Exec/15/128 Minutes of the meeting held on 21 July 2015 and matters

arising The minutes of the meeting held on 21 July 2015 were accepted as a true record.

Exec/15/129 Action Log The action log was discussed and updated accordingly.

Exec/15/130 Clinical Quality Update The Executive considered a report that provided an update of the headline issues relating to clinical quality and assurance and that actions are being taken with providers where necessary.

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In relation to each of the Trusts the following issues have been raised: • The most recent data release of the NHS England Quality

Dashboard for July 2015 shows that County Durham & Darlington NHS Foundation Trust (CDDFT) are showing as a statistical outlier for Central Alerts and Diagnostics over 6 week waits and is below standard for A&E 4 hour waits, Referral To Treatment (RTT) Admitted, and methicillin-resistant Staphylococcus aureus (MRSA).

• South Tees Hospitals NHS Foundation Trust (STHFT) remains a negative outlier for HSMR with a rate of 112.8 (previous position 112.5). It is also a negative outlier for weekend HSMR (non-elective) at 119.8, year to March 2015. NECS Business Intelligence team has identified issues with the accuracy of the Trust’s mortality data and has referred concerns on to the Hospital Evaluation Data Team and the University of Birmingham for investigation.

• STHFT are also showing as a negative outlier for Clostridium Difficile, reporting 4 cases in July 2015, which brings them to 22/50 actual cases this year.

• STHFT continue to hold a Monitor risk rating score of 1 due to financial sustainability and a governance risk rating of red.

• During July 2015, 52 incidents were reported on the Safeguard Incident and Risk Management System (SIRMS) relating to patients or services provided within the Darlington CCG area. Of the 52 incidents, 54% were directly reported by Darlington GP practices, with 13 (25%) reported by CDDFT about primary care providers/contractors. Key themes being Medication incidents, Self-harm, Access, Admission, Transfer or Discharge, Tissue Viability and Clinical Documentation. AG agreed to raise the concerns of RH who said that no feedback is ever received after reporting incidents on SIRMS.

Other issues:

• Nurse revalidation – comes into effect on 1st April2016 – all registered nurses are required to provide evidence they meet revalidation requirements. The CCG is on target and meeting its obligations in this regard.

The Executive received the update and agreed that the necessary actions are being taken forward with the respective organisations to improve quality and experience for patients.

AG

Exec/15/131 Finance Report – Month 4 The Executive considered the report which provided an update on the financial performance of NHS Darlington CCG for 2015/16 financial year.

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The CCG’s financial position is under continual review and the current position shows the organisation to be on track to achieve its key financial targets. The current position shows a year to date underspend of £590k on an allocation of £145,261k. The CCG received non recurrent allocations for Waiting List Validation in month totalling £3k. The CCG has entered into a risk share agreement with TEWV to manage the overall Mental Health and Learning Disabilities budget to ensure breakeven at the end of the financial year – assurances have been requested from the Mental Health Commissioning team that this will actually happen considering the magnitude of the current overspend. Following the preparation of this report, the situation with Continuing Health Care has deteriorated, this is not specific to Darlington CCG but requires explanation from the CHC team. Within Primary Care Services, the prescribing costs relating to a code assigned to Community Nursing have increased significantly, raising concerns that this is an attempt to shift costs. This is currently under investigation. The Executive were advised that based on updated information the financial position of the CCG will deteriorate in M5. The Executive noted the content of the report.

Exec/15/132 Procurement Progress Report The Executive considered the procurement progress report provided and the update was discussed for a number of the areas. Community Palliative Care Rapid Response – agreement at Extraordinary Formal Executive on 8th September to go ahead with the procurement of this service. Audiology – Local tariff has been requested Wheelchairs – Market engagement now complete. Decision to be made on whether to continue with procurement or work with the current provider. Weight Management – Currently going through the process of development work on the draft specification. AJ queried the Community Contract, LT advised a desk top review is being carried out to look at the current contract.

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The Executive noted the report and the update provided.

Exec/15/132 NECS Performance – July 2015 The Executive considered the NECS Performance report provided. Darlington CCG has consistently scored NECS performance 3. It is recognised that some improvement has been made recently particularly since the SPR team and relocated to Dr Piper House. Of particular note was the excellent service provided by the IT Team when Carmel Medical Practice temporarily relocated to Doctor Piper House following a fire at the surgery and the support provided by Andrew Rowlands and his team in preparing for the CCGs Q1 Assurance Meeting with NHS England. The Executive agreed the score now be increased to 4. The Executive noted the report and confirmed the satisfaction score of 4 for the current month.

Exec/15/134 Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework (2015) Gap Analysis The Executive was advised that the purpose of this report was to update on the key requirements of the CCG in relation to safeguarding as outlined in the refreshed Safeguarding Vulnerable People in the NHS – Accountability and Assurance Framework (July 2015). This would indicate if the CCG is compliant, or requires in relation to best practice, development actions or necessitates specific actions or a watching brief because of imminent or new legislative changes or pending guidance. A number of the key requirements within the framework were highlighted to the Executive: Leadership and Accountability – Darlington CCG is aware of the absence of a names GP/Professional and have a plan to respond Policies and Training – Policies for both Safeguarding Children and Safeguarding Adults have been updated and the CCG has a statement outlining its commitment to safeguarding children and adults on the website. Prevention – The CCG and the local authority are working to

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monitor activity, both in relation to the SAB and CCG/LA commissioning discussions and decisions in order to respond appropriately. Co-Commissioning Arrangements – The CCG will implement co-commissioning arrangements in relation to safeguarding and Primary Care in accordance with an agreed MOU between the CCG and NHS England. The Executive noted the content of the briefing document and endorsed the specific or developmental actions required.

Exec/15/135 Female Primary Care Continence Primary Healthcare Darlington asked the Executive to consider the implementation of a twelve month Local Incentive scheme from December 2015 to support practices to deliver a standardised female primary care continence pathway. The Community Continence Service for Darlington is commissioning from CDDFT as part of the Community Services block contract arrangement. Darlington GPs feel the current service offers limited support and disjointed care for patients and their carers. The Executive were advised that this has been set up by some interested clinicians and follows work originally begun through QOF. Some practices have continued to work to these methods other have not. Indications are that those continuing are most cost effective. From a recent audit with three Darlington practices over a six month period, it can be estimates that 60% of female urology secondary care referrals could have been avoided and managed more cost effectively by adopting an integrated female primary care continence pathway. Urology is one of the most expensive disease areas for hospital activity for both men and women. It is recognised that methods need to be developed to allow patients to help themselves. JS explained it is proposed to discuss this subject in detail at the September PLT session. The Executive approved the business case and funding to support the implementation and delivery of a female primary care continence pathway for Darlington.

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Exec/15/136 Funding Contribution Towards the Six Independence Sexual and Domestic Violence Advocate The Executive was advised that Durham Constabulary on behalf of the Safer Durham and Safer Darlington Partnerships manage two budgets. The Sexual Assault Referral Centre budget is funded by Durham County Council, Darlington Borough Council, Durham Constabulary and NHS England. The site at Park Place is considered a centre of excellence. The second, the multi agency risk assessment conference (MARAC) budget is funding by Durham Council Council, Darlington Borough Council, Durham Constabulary and Probation. Expenditure on both budgets is greater than income with a £32,000 shortfall in SARC and £57,000 shortfall in MARAC. Funding is provided on a year by year basis. PG explained that he is tasked with addressing Darlington CCG, and will be meeting with the other CCGs in County Durham to request funding which is proportionate to the size of CCG, in the case of Darlington CCG this will be £10k. PG gave assurance that it is not proposed to reduce the funding provided by Durham Constabulary. The Executive considered the recommendation and agreed to give this due consideration after discussion with colleagues in the other CCGs involved.

Exec/15/137 SRB Bids The Executive was informed that the purpose of this report was to provide an update on system resilience funding as part of winter planning for 2015/16 and secure agreement, including funding allocation, for the SRB schemes for Darlington. The resilience funding for 2015/16 is in the CCG allocations and totals £4,681m for Co Durham and Darlington. For Darlington the funding available to support totals £737k. The Executive discussed the view that this system had not been successful this year and agreed the way forward was to for planning much earlier next year by the Unit of Planning Group. The Executive

• noted the SRG submission templates completed and approved by the SRG

• Approved the funding of the bids agreed specifically relating to Primary Health Care Darlington and Darlington Borough Council

• Approved delegated authority to the Chief Finance Officer

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and Assistant Chief Officer to finalise the allocation of funds in line with the SRG process.

Exec/15/138 Judicial Deprivation of Liberty Safeguards – July 2015

The Executive considered the report which discussed the Mental Capacity Act Deprivation of Liberty Safeguard 2009 and provided information on the CCGs responsibility in relation to the cases that are assessed and funded through the Continuing Healthcare Funded Nursing Care and Jointly Funded packages process. The Executive considered a range of issues outlined in the report and discussed the three options proposed in the recommendation. There is currently a Law Commission Consultation underway, which is expected to conclude in 2017 which will change this to ‘Protective Care’. It was explained to the Executive that a greater understanding is needed of the costs for Darlington and the number of assessments currently. Clarity is also needed of any overlap with Darlington Borough Council.

Exec/15/139


Exec/15/140

Any Other Business No other business was discussed.

Date/Time/Venue of Next Formal Exec Meeting The next Formal Executive meeting will be held on 20th October 2015 commencing at 9am in Ground Floor 1 and 2, Dr Piper House.



Tuesday 20 October 2015

9am – 11am

Ground Floor 1 and 2, Doctor Piper House

CONFIRMED MINUTES Present: Lisa Tempest Chief Finance Officer, (Chair)

Andrea Jones Chair, DCCG Richard Harker Quality Lead Jackie Kay Assistant Chief Officer Murray Rose Director of Commissioning, DBC In attendance: Liz Dunning Snr Finance Manager, NECS Andrew Stainer Head of Transformation Rob Milner Snr Clinical Quality Officer, NECS (Item 145) Donna Owens Commissioning Manager, NECS (Item 154) Glenda Lynn Personal Assistant (minute taker)

Action Exec/15/141

Apologies for Absence Diane Murphy, Ali Wilson


Exec/15/143 Minutes of the meeting held on 8th September and 15

September 2015 and matters arising The minutes of the meeting held on 8th September and 15 September 2015 were accepted as a true record.

Exec/15/144 Action Log The action log was discussed and updated accordingly.

Exec/15/145 Clinical Quality Update The Executive considered a report that provided an update of the headline issues relating to clinical quality and assurance and that actions are being taken with providers where necessary. In relation to each of the Trusts the following issues have been

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raised: CDDFT

• CQC Assessment – the report of the January assessment has now been published with an overall assessment as ‘requires improvement’. A quality summit has been held by CQC, CDDFT and stakeholders and action plans for improvement are being developed and monitored.

• Quality dashboard for August 2015 indicates CDDFT are statistically worse for Maternity FFT % recommended and are below standard for RTT admitted, A&E 4 hour waits, cancer 62 day waits (urgent screening referrals) and diagnostics over six weeks.

• A meeting has been held with CDDFT by DCCG, DDES and NDCCG following gaps being reported in GP cover at urgent care/walk in centres across Durham and Darlington. CDDFT have been asked to provide details of workforce gaps. RM agreed to inform Exec of gaps and likely timescales.

• The 2015 patient led assessments of the care environment (PLACE) were published in August. CDDFT scored below average at all sites with the exception of the Richardson Community Hospital for dementia. UHND scored below average for cleanliness and organisational food, DMH for food and overall condition and appearance, BAGH for privacy and dignity and condition and appearance. Chester le Street and Sedgefield community hospitals scored below average on organisational food.

TEWV

• PLACE – West Park, Lanchester Road and Auckland Park all scored below average for organisational food. West Park. JK asked about the visits, explaining that previously the CCG had been involved in these but this seemed to no longer be the case. RM to ensure DCCG has representation at future visits.

South Tees • Quality dashboard shows STHFT is below standard for

cancer 62 day waits and diagnostics. A&E 4 hour waits, and MRSA and were also a statistical outlier for RTT52+ week waiters, HSMR, weekend HSMR and Monitor, though in August this has improved and no longer an outlier.

• C Difficile – The Trust has reported 29 cases of C Difficile against a target of 50. S. Tees CCG is closely monitoring C Diff performance and has implemented a CCG action plan. It is reported that the rate does seem to have

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RM

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slowed recently. • PLACE – JCUH and Friarage Hospitals scored below

average on organisational food, ward food, privacy and dignity and dementia.

NEAS

• Concern continues in relation to R1 performance. RM advised 8 minute waits are however, coded green this month. Exec expressed some concerns around the level of commitment to actively recruit to vacant posts.

CQC Assessments of GP Practices Positive position overall, however the situation can change between inspections. Some concerns have been raised by GPs regarding Parkgate Practice. A response is awaited from NHS England. A paper from the practice, written by Dr McGarrity, setting out the issues, actions taken and impact is to be considered at the October QP&I Committee. RH expressed his concerns that NHS England are not acknowledging that there is a shortage of GPs across the town, not just at Parkgate Practice. Exec acknowledged the need for a log of issues in primary care. JK to action. South Park Nursing Home The Executive was informed that CQC has informally been back to South Park Nursing Home. No date has yet been set for a formal reassessment. Indications following the recent informal visit were favourable. The Executive received the paper and noted the actions being taken to address the concerns raised.

JK

Exec/15/146 Finance Report – Month 6 The Executive considered the report which provided an update on the financial performance of NHS Darlington CCG for 2015/16 financial year. The CCG’s financial position is under continual review and the current position shows the organisation to be on track to achieve its key financial targets. However, it was reported that there are pressures within the system in all areas. These pressures, if not addressed over the remainder of the year, will potentially impact on the delivery of the planned surplus position. The current position shows a year to date underspend of £884k on an allocation of £145,359k. No allocations were received during the month. CDDFT contract is currently showing a forecast overspend position of £780k net of the impact of an accrual relating to

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2014/15 of £1.2m There still remains a high level of uncoded activity within the data which could affect the reported financial position. The CCG has entered a risk share agreement with TEWV to manage the overall mental health and learning disabilities budget to ensure breakeven at the end of the financial year however it is not anticipated that this will be achieved given the magnitude of the pressure on the mental health budget. A meeting has been held to discuss with TEWV and a proposal as to how TEWV can support mitigation of the in-year pressure is awaited. The forecast overspend for prescribing of £603k has been informed by the forecast information received from the PPD in September. Exec discussed the overspend, citing the additional cost of MDTs and the pressure of the cost of palliative care drugs, previously prescribed by Community Nurse, as a factor in these increased costs. LT had recently met with NHS England to discuss in detail the challenges impacting the CCG and actions being taken to manage them. For information, the Finance Committee originally scheduled for 26th October has been deferred to a future date, yet to be confirmed, due of the number of apologies received. The Executive noted the content of the report.

Exec/15/147 Procurement Progress Report The Executive considered and noted the procurement progress report provided and the update given.

Exec/15/148 NECS Performance – August 2015 The NECS Performance report was not discussed, due to time restrictions.

Exec/15/149 Management of Risks Darlington CCG is required to have robust risk management processes in place to ensure the continuous review and monitoring of organisational risks. The Executive was informed that LT, DM and JK had recently met with representatives from the NECS Governance Team to consider all of the outstanding risks and the register updated. The Executive reviewed the risk register and considered the identified requirements within the recommendations.

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Exec/15/150 Information Governance Strategy The Executive was asked to note and discuss the content of the revised Information Governance Strategy 2015/16, which will also be submitted to the Governance, Audit and Risk Committee for approval on 25th November, followed by Governing Body for final ratification. The Strategy sets out the approach to be taken within the CCG to provide a robust Information Governance Framework and to fulfil its overall objectives. The Information Governance agenda encompasses a number of areas:

• Caldicott • NHS Confidentiality Code of Practice • Data Protection Act 1998 • Freedom of Information act 2000 • Health and Social Care Act 2012 • Human Rights Act 1998 • Care Act 2014 • Records Management (Health, Business and Corporate) • Information Security • Information Quality • Confidentiality • Openness • Legal Compliance • Information Risk

Outlined within the Strategy are the responsibilities of DCCG along with NECS and other organisations. Mandatory training sessions are delivered online to all staff, being key to the successful implementation of the Strategy, embedding a culture of information governance management into the organisation. LT encouraged the Executive Team to ensure their IG training is up to date. JK queried whether the report demonstrates good practice when working with other organisations. LT agreed to contact Lianne Cotterill to establish if any of this can be shared with the Exec. After consideration, the Executive approved the Information Governance Strategy 2015/16.

Exec/15/151 Governance Assurance Report Q2 The Executive was informed that this report brings together intelligence relating to Corporate Governance to provide assurance on governance processes in place to ensure safety and the organisation’s effective management of risk. The report

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focuses on data from 2015/16 Quarter 2 (1st July 2015 – 30th September 2015). LT highlighted a number of areas within the report: Risk Management – A meeting took place between NECS and the CCG to revise and refresh the current risk register. NECS and the CCG continue to work in partnership to support the delivery of SIRMS Risk Management Training. Health and Safety – The CCG has achieved a 4 star H&S Audit rating (94% compliance). The CCG is below target for H&S statutory and mandatory training. Encouragement will be given to staff to complete their training to improve compliant. Equality and Diversity – As of 6th October 2015, the Equality and Diversity figures for the CCG was 75% completed training. Freedom of Information Request – During Q2, 2015/16 68 FOI requests were received by the CCG. All were acknowledged with the recommended 48 hours. 62 had been completed within the statutory 20 working days. 6 requests are outstanding and on schedule to be responded to within the statutory timescales. The Executive reviewed the report, considered the identified requirements and agreed the recommendations. This report will be further discussed at the next Governance, Audit and Risk Committee.

Exec/15/152 National Support and Re-Procurement of Home Oxygen Service Update and Proposal to Extend BOC HOS Delivery Service (part of National Procurement Plan) The Executive was advised that prior to the NHS reforms in April 2013 the regional Home Oxygen Service (HOS) contract was managed by NE Primary Care Services Agency (PCSA) and the Department of Health (DH). Since April 2013 NHS England has continued to host and fund these arrangements on a transitional basis and a new contract oversight and support arrangements were put in place. The contract for home oxygen supply is for five years, ending November 2016, with the option to extend for an additional two years. NECS took over contract management from PCSA for the CCG. As the BOC oxygen delivery service is part of the National Framework Agreement which has been extended for two years until November 2018, it is proposed that this service is also extended. BOC Home Oxygen Supply service has indicated a

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willingness to extend the service. The Executive was informed of the range of benefits to the proposed extension. LT agreed to enquire if patient satisfaction data is available. The Executive noted the content of the report.

LT

Exec/15/153 Winter Planning The Executive was advised that the purpose of this report was to provide an update on winter planning and resilience and to outline the processes being followed to provide assurance and monitor the delivery of approved resilience schemes. County Durham and Darlington System Resilience Group (SRG) has overall responsibility for the capacity planning and operational delivery of urgent and emergency care across the health and social care system. JK explained that the report provided Executive with details of the process in relation to the proposal and approval of resilience schemes for 2015/16 in line with eight high impact interventions developed by NHS England and how providers in receipt of resilience funding will be held accountable for the delivery of approved resilience schemes. The Executive accepted the report for information.

Exec/15/154 Learning Disabilities Fast Track Plan The Executive was informed that on 12 June 2015 NHS England announced that the North East and Cumbria would be one of five national fast track areas for transforming care for people with a learning disability. A joint proposal have been developed with Darlington CCG, North Durham CCG and DDES CCG and the two local authorities, to deliver community based services that will prevent avoidable admission and build safe high quality care. The North East and Cumbria has a baseline of 146 beds which is significantly higher than other parts of the country and on this basis is required to provide a trajectory of bed reductions over the next 5 years. Three proposals have been developed to support the local transformation of learning disability services:

• Community based accommodation • Transitions planning • Enhanced Community Support

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Forecasting information in relation to patients currently within NHS England Specialist Services is being progressed. Assurance meetings have been established and are being used to inform future planning. Supporting the reduction in admissions will be the implementation of the Care and Treatment Review process. The funding being requested is at a level which the Chief Finance Officers from across the region believe is prudent and will support deliverable and cost effective approaches to successfully moving the project forward. There is still a level of uncertainty in relation to how dowries will be applied to people who have been in inpatient settings for more than five year. No specific reserves have been set up for Learning Disability Transformation from within the Mental Health and Learning Disabilities budgets. There are risks in relation to the pace and number of bed closures for the CCG. There does remain uncertainty of the impact of patients stepping down from low and medium secure settings. Workforce requirements are significant and achievement of the proposed trajectories will require transformation of the workforce across the region. The Executive noted the progress against the Transformation agenda and accepted the proposals to deliver sustained community infrastructure.

Exec/15/155 Value Based Clinical Commissioning Policy and Prior Approval Ticket The Value Based Clinical Commissioning Policy VBCCP) was originally approved by the CCG Governing Body in 2013 and a revised policy was approved in 2014. The Durham CCGs have agreed with County Durham and Darlington Foundation Trust (CDDFT) that the VBCCP will be implemented with effect from 1 October 2015 and to support this, it is proposed to introduce the ‘Prior Approval Ticket’ for all referrals for all patients with conditions covered by the policy. It is proposed that Darlington CCG support the implementation of the policy and also introduce the ‘Prior Approval Ticket’. LT informed the Executive that she has recently become a member of a VBCCP Steering Group, established to oversee the VBCCP work.

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There are two main aspects of work associated with VBCCP:

• Part 1 to introduce the ‘Prior Approval Ticket’ • Part 2 to consider further revisions to the VBCCP around

varicose veins and MSK It is anticipated that the existing Individual Funding Request (IFR) system will be used to introduce the ‘Prior Approval Ticket’ in County Durham and Darlington. Some monitoring of the IFR process will take place to ensure the numbers do not increase significantly. LT informed Executive that she would put together a communication to the practices via GPTeamNet. The Executive Committee received and noted the report and agreed the implementation of the ‘Prior Approval ticket’ with CDDFT as of 1st November 2015, and with other providers in due course.

LT

Exec/15/156 Anti Fraud, Bribery and Corruption Policy The Executive was advised that this policy relates to all forms of fraud, bribery and corruption within and against the CCG and is intended to provide direction and help to anyone who may identify suspected fraud. The Executive Committee received, noted and approved the policy ahead of formal ratification at Governance, Audit and Risk Committee.

Exec/15/157


Exec/15/158

Any Other Business St Teresa’s Hospice – Wolfson Foundation Stage 2 Application LT referred to the copy letter received from St Teresa’s Hospice with regard to the Stage 2 application for a grant towards a new in-patient unit. Executive were asked to feed any comments on this to LT

Date/Time/Venue of Next Formal Exec Meeting The next Formal Executive meeting will be held on 17 November 2015 commencing at 9am in the Board Room, Doctor Piper House.


DARLINGTON CLINICAL COMMISSIONING GROUP QUALITY, PERFORMANCE & INNOVATION COMMITTEE

Tuesday 25th August 2015

11.00 – 13.00

Meeting Room 1&2, Dr Piper House

CONFIRMED MINUTES

Present: Richard Harker (Chair) GP Quality Lead Sarah Dodsworth Practice Nurse Representative Vicky Foot GP Clifton Court Medical Centre Andie Mackay Lay Member Finance Adrian Marshall GP Felix House Charles McGarrity GP Parkgate Surgery Tony Shaw GP Moorlands Surgery Michelle Thompson Lay Member Patient & Public Involvement In attendance: Tracey Doran Adult Safeguarding Lead Rob Milner Senior Clinical Quality Officer Andrew Rowlands Commissioning Manager Lisa Tempest Chief Finance & Operations Officer Aimee Tunney Governance & Assurance Manager Rachael White Administration Assistant

Action QPI/15/89

Apologies for Absence Apologies for absence were received from: Carole Atherton Designated Nurse Safeguarding Children Pauline Lax Practice Nurse LiNK Alison McNaughton-Jones GP Rockliffe Court Surgery Diane Murphy Chief Nurse Sue Nuttall Safeguarding Adults Senior Manager Jill Smith Commissioning Support Officer

QPI/15/90 Declarations of Interest No declarations of interest were made.

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QPI/15/91 Minutes of the meeting held on 28th July 2015 and matters arising The minutes of the meeting were agreed as an accurate record.

QPI/15/92 Action Log The action log was discussed and updated accordingly.

QPI/15/93 North East Ambulance Service Quarterly Clinical Quality Update The Quality, Performance and Innovation Committee considered the report which outlined key issues for the North East Ambulance Service (NEAS) and provided assurance that actions were being undertaken where appropriate. In the Annual Clinical Audit Review 2014/15, NEAS were the best in the country for 2 out of the 8 indicators; providing the highest quality of care to STEMI patients and transporting suspected stroke patients within the recommended timeframe. However they were below the national average for survival to discharge as data availability was variable and was reliant upon the Trust that the patient was transported to. Lisa Tempest advised that no communications had been received from Provider Management to advise that Clinical Commissioning Groups (CCG) were taking work forward to resolve this and would check with the contract leads. In April/May 2015, 15 of the patient safety incidents reported had an actual impact of moderate or above where Duty of Candour (DoC) should have been applied, with contact being made in only 4 cases. In the period 27/11/14 - 31/5/15, the Trust had 40 incidents where DoC should be applied with 24 outstanding contacts. This had been escalated within the Trust to apply DoC where/if appropriate. Capacity was still an issue and NEAS continued to pursue opportunities locally, nationally and internationally for paramedics and contact centre staff, with the successful recruitment of a number of paramedics. Despite this, retaining staff and sickness absence was a significant issue. However it was felt that the implementation of the role of the Emergency Care Clinical Manager (ECCM) in April, providing ‘hands on’ support to front-line staff had helped to reduce the sickness absence rate. Rob Milner advised he would compare NEAS’ sickness absence to others ambulance trusts in the area. The Quality, Performance and Innovation Committee noted the contents of the report.

LT

RM

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QPI/15/94 Safeguarding Adults Information Report The Quality, Performance and Innovation Committee considered the report which provided an update on the recently shared paper regarding practice requirements for Deprivation of Liberty Safeguards 2007(DOLS) and compliance with chief coroner’s guidance. The aim of producing the guidance was to address any questions GPs may have under the new process. There had been some confusion early in the year due to how the report from the Coroner’s office had been interpreted and the number of post mortems had increased due to patients not being seen in the required timescale. It was suggested that Nurse Practitioners could be provided with the ability to certify death certificates which would help prevent this and could be linked in with the care home model review work currently being undertaken. Tracey Doran advised that there had been an increase in the number of patients under DOLS which was thought to be as a result of the law change in 2014 which widened the criteria. The Law Commission were now looking to review this. The Quality, Performance and Innovation Group noted the contents of the report and agreed it was to be uploaded to GP TeamNet.

QPI/15/95 Quality & Performance Report The Quality, Performance and Innovation Committee reviewed the information in the Quality and Performance report for August 2015. This report included slides showing performance against the NHS Constitutional Indicators for all main providers. Andrew Rowlands focused on the following key areas: CDDFT ER02 – Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral – County Durham and Darlington Foundation Trust (CDDFT) had now failed this target for 14 consecutive months with July’s data showing that they were still 2% over. The lessons learnt from this were that performance needed to be monitored more closely and if issues were identified, remedial actions were to be put in place immediately. The Committee expressed their concern that the arrangement currently in place may not be effective during the upcoming cancer awareness campaign. Andrew advised that work was still ongoing through the contract meetings and would confirm as to whether the demand plans had been received. CDDFT ER03 - % patients spending 4hrs. or less in A&E minor injury unit – This performance target had been breached from

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December 14 to June 15 however from the data received it was likely that they would soon be achieving it. Despite this there was a risk that they may not be able to withstand the pressures over winter. Work was being undertaken to try and improve patient flow through the hospital which would aid the flow through A&E. CDDFT ER06 - % of patients treated within 62 days of an urgent GP referral for suspected cancer – Of the 9 indictors at CCG level, this was the only target not being achieved. This was a regional issue and both CDDFT and South Tees Hospital Foundation Trust (STHFT) were also not achieving. Recent guidance stated that all providers must comply with an 8 point plan and this would be available for the Committee at the next meeting and would be monitored through contract meetings. It was highlighted that North Tees and Hartlepool Foundation Trust (NTHFT) were achieving the target and it was queried as to whether there were any process/systems in place that could help other providers. Andrew advised he would discuss this with the contract leads for the next meeting. The Quality, Performance and Innovation Committee noted the contents of the report.

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QPI/15/96 GP Variation in Spends The Quality, Performance and Innovation Committee were advised that unfortunately Jill Smith was unable to attend the meeting. However Jill had advised that there were no practices in escalation at this time and the query regarding the budget was still being resolved. Lisa Tempest advised that this had also been discussed at the Finance Committee and there were queries in the finance team as to what figures had been used for 2014/15 as it was still unclear as to why there was such a significant change in the budget. It had also been asked that details be provided of the practices underspending to ensure that there was no impact on the quality of services being provided. The Quality, Performance and Innovation Committee noted the information provided.

QPI/15/97 Research & Development Activity Summary Quarter One 2015/2016 The Quality, Performance and Innovation Committee agreed that the report be deferred to the next meeting and the Ahmet Fuat be asked for his feedback on the content.

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QPI/15/99 Risk Register and Any New Risks Identified The Quality, Performance and Innovation Committee considered the report which provided details of the Risk Management Policy which had been developed for Darlington CCG and a copy of the risk register for the Committee. Lisa Tempest advised that several risks had not been updated since Gill Findley left the organisation and that this would be rectified for the meeting in September. In regards to Risk 1388 – Workforce gaps, the Committee were assured that there was a Practice Manager and practice nurses currently in post at the practice. It was agreed that there were difficulties with recruitment but this was across the area not just in specific practices. The Committee agreed that the Quality in Primary Care Group were to be made aware of these difficulties. Richard Harker and Charles McGarrity were to meet to discuss the issues further. The Committee agreed that the risk regarding Cancer 62 days waits was to be added to the register. The Quality, Performance and Innovation Committee noted the information provided and agreed to the above.

RH

RH&CM

DM

QPI/15/98 Prescribing Sub-Committee Minutes The Quality, Performance and Innovation Committee agreed that the item be deferred to the next meeting.

QPI/15/100 Any other Business No other items were raised.

Date/Time/Venue of Next Meeting Tuesday 22 September 2015, 11-1pm in Meeting Room 1&2 at Dr Piper House, Darlington

Signed………………. Chair.…………………. Date……………………

DARLINGTON CLINICAL COMMISSIONING GROUP QUALITY, PERFORMANCE & INNOVATION COMMITTEE

Tuesday 22nd September 2015

11.00 – 13.00


CONFIRMED MINUTES

Present: Diane Murphy (Chair) Chief Nurse Ahmet Fuat GP, Carmel Medical Practice Vicky Foot GP, Clifton Court Medical Centre Adrian Marshall GP, Felix House Surgery Charles McGarrity GP, Parkgate Surgery Michelle Thompson Lay Member, Patient & Public Involvement In attendance: Carole Atherton Designated Nurse Safeguarding Children Katherine Humby Senior Clinical Quality Officer (Complaints) Kirsty Kitching Senior Commissioning Manager – Provider

Management Heather McFarlane Designated Nurse Safeguarding Children Rob Milner Senior Clinical Quality Officer Barbara Nimmo Medicines Optimisation Pharmacist Sue Nuttall Safeguarding Adults Senior Manager Sarah Perkins Director of Performance (CDDFT) Jill Smith Commissioning Support Officer Aimee Tunney Governance & Assurance Manager Rachael White Admin Assistant

Action

QPI/15/101

Apologies for Absence Apologies were received from: Liane Cotterill Senior Governance Manager Richard Harker GP Quality Lead Pauline Lax Practice Nurse LiNK Alison McNaughton-Jones GP, Rockliffe Court Surgery

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QPI/15/102 Declarations of Interest No declarations of interest were made.

QPI/15/103 Minutes of the meeting held on 25th August 2015 and matters arising The minutes of the meeting were agreed as an accurate record.

QPI/15/104 Action Log The action log was discussed and updated accordingly.

QPI/15/111 Summary of Complaint Activity 1 April 2014–31 March 2015 The Quality, Performance and Innovation Committee reviewed the report which provided a summary of complaints and concerns handled by the North of England Commissioning Support Unit (NECS) Complaints Team. All complaints received by teams within NECS were logged and responded to via the Clinical Quality Team. The report also provided a summary of service improvements identified as a result of complaint investigations and developments within the complaints handling process. A total of 546 cases were dealt with during this time period, 28 of which were from Darlington residents. In 13 cases, the investigation/response was led by the Clinical Commissioning Group (CCG); the remainder were passed to provider organisations for action. Four of the CCG cases were handled under the NHS complaints procedure as formal complaints, 8 were resolved as informal concerns/advice/MP enquiry. All cases were acknowledged by the NECS Complaints Team within the target timescale of 3 working days. The subject raised most frequently in CCG cases was the commissioning of musculo-skeletal and physiotherapy services. The Quality, Performance and Innovation Committee noted the report.

Sarah Perkins and Barbara Nimmo joined the meeting QPI/15/109 County Durham and Darlington Foundation Trust

Performance The Quality, Performance and Innovation Committee were provided with a verbal update from Sarah Perkins, County Durham and Darlington Foundation Trust’s (CDDFT) Director of Performance. Sarah focused on the 3 main areas of concern for the Committee:

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Diagnostics: Performance for diagnostics testing was now on track and the Trust was achieving the performance indicator. Work was being undertaken to establish the impact the new cancer guidelines would have on services. The potential for 6 days services was being investigated and options for recruitment were being reviewed. Echocardiograph tests were in line with performance targets however the Committee were advised that there were pressures in the North of the patch due to a shortage of technicians. It was queried as to whether the result from diagnostics such as this could be uploaded onto ICE and shared with primary care. This would allow a quicker response to the patient from GPs. Sarah advised she would ask if this was possible. Sarah advised that demand plans could be shared with the CCG however they were currently in draft format and subject to change. A&E: CDDFT were currently preparing for their ‘perfect week’ in mid-December. This was through recommendations from the Emergency Care Intensive Support Team (ECIST) with the aim of providing an opportunity to collect data and review where improvements in the system could be made. The Finance Team would be collating this information which would be reviewed and shared with the CCG. The performance target for Darlington was achieved in August and data collated for September looked positive. There had been some changes in processes at the University Hospital of North Durham and it was hoped that some aspects could be introduced at Darlington Memorial Hospital in the near future. Members of the Committee raised issues regarding the information provided in case notes/letters for patients being discharged into a nursing home. In some instances medication additions/ alterations had not been provided which had led to the home requesting incorrect prescriptions etc. Diane Murphy reported that this had been raised at the Quality Review Group. Concern was also expressed regarding GP cover in the Urgent Care Centre as there had been occasions where there had not been a GP on site. Sarah asked that specific examples be provided for both issues so a thorough investigation could take place as to why the information wasn’t provided.

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SP/KK

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Cancer referral waits: Sarah advised that there was a significant amount of pressure around breast referrals. The service had previously been provided across 4 sites and this had been amalgamated into 2 sites, one in Darlington and one in Durham. This was a regional issue and South Tees Hospital were also failing their targets and the service in Sunderland had collapsed. Additional sessions were being held to try and improve the situation and services were also being used in the North of the patch. The 62 day target was breached by ½ a patient in quarter 1. In regards to urology, work was underway with James Cook Hospital to review the service and whether any changes were required. The Quality, Performance and Innovation Committee thanked Sarah for sharing this information and noted the actions being taken.

Sarah Perkins and Adrian Marshall left the meeting QPI/15/114 Prescribing Sub-Committee Minutes

The Quality, Performance and Innovation Committee reviewed and noted the contents of the minutes.

QPI/15/113 Prescribing Update The Quality, Performance and Innovation Committee reviewed the report which provided an update on the current budget forecast for the CCG and the Prescribing Quality Scheme. Based on prescribing data for April – June 2015, the CCG were currently forecasting an overspend of £584,818 on the prescribing budget. Prescribing costs also continued to rise with a high proportion of this being driven by national price increases due to stock shortages. The work plans and budget information for practices was included in the report with a breakdown of what medications were the most prescribed. Members of the Committee reported that there were occasions where secondary care were prescribing high cost medication which could make it difficult to keep in line with practice budgets. It was thought that CDDFT held a meeting to review formulary and that there should be a primary care representative in attendance. Barbara Nimmo to confirm whether this was the case. The Quality, Performance and Innovation Committee noted the information provided.

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Barbara Nimmo left the meeting QPI/15/106 Safeguarding Adults Quarterly Report

The Quality, Performance and Innovation Committee reviewed the report which highlighted key aspects of the strategic and development work undertaken by the Adult Safeguarding Team on behalf of the CCG. The revised Safeguarding Vulnerable People in the NHS: Accountability and Assurance Framework was published in July 2015. Gap analysis against the revised framework had been undertaken and presented to the Governing Body. Compliance against the requirements would be monitored. As part of the Government’s counter terrorism strategy, it was expected that primary care staff were aware of the PREVENT agenda. The Named GP and Designated Nurse had met with the local Police Prevent lead who would attend the safeguarding lead sessions to ensure key staff were updated. Two members of the team were now trained to deliver training and would be preparing a training programme for CCG/Primary Care staff going forward. The Governing Body were to be informed via a session in the near future, Rachael White to advise the administration support for the Governing Body development sessions. The Quality, Performance and Innovation Committee noted the information provided.

QPI/15/107 Safeguarding and Looked After Children Quarterly Report The Quality, Performance and Innovation Committee reviewed the report which provided an update on current development work and key operational issues together with performance information where available. The recent Darlington Borough Council Ofsted inspection in July had deemed that their Children’s Services was inadequate. An action plan had been developed and an Improvement Board was being established. The Local Safeguarding Childrens Board was also included in this review and they were working to resolve the issues identified. Ofsted were retuning in early December as a monitoring visit to review the progress made. Darlington Borough Council was continuing with plans for the gradual introduction of ‘signs of safety’. This was a solution focused approach to assessing children’s needs and actual or potential risks they may be facing. Training sessions for frontline practitioners were underway and dates for October and November had been circulated to practice safeguarding leads.

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The Safeguarding process at CDDFT was under review and in line with all community service budget lines a review of the service had commenced. Diane Murphy advised that there had been recent discussions regarding requirements for special educational needs assessments needing more specific nursing input and designated medical officers. In response to query, Carole Atherton advised that this wasn’t part of the review being undertaken and that Public Health would be considering the nursing and Health Care Assistant aspect. National multi-agency practice guidelines on Female Genital Mutilation (FGM) were being revised and currently out for consultation with a closing date of 30.09.15. Durham Constabulary were looking to work with health colleagues in both acute and primary care to agree a system locally regarding mandatory reporting due to come into place in October 2015. The Quality, Performance and Innovation Committee noted the information provided.

Sue Nuttall, Carole Atherton and Heather McFarlane left the meeting. Jill Smith joined the meeting. QPI/15/108 Quality & Performance Report

The Quality, Performance and Innovation Committee reviewed the information in the Quality and Performance report for September 2015. As significant discussion had taken place earlier in the meeting Kirsty Kitching reported on the following areas: NEAS ER01 – 19 minute response – this target was being met at provider level but the year to target for the CCG was still an issue. A lot of work had been undertaken to recruit new staff to help resolve capacity issues however it was thought that the target may not be met until the new year. A regional divert policy had been put in place which involved penalising trusts if they need to divert patients. However internal diverts e.g. between Darlington Memorial Hospital and University Hospital of North Durham were not included so transfers could be to the nearest hospital rather than a specific organisation. It was asked that details of why patients were being transferred be provided so it could be established if there was an impact in other areas. Kirsty advised this could be provided for Quarter 1. NEAS ER02 – 111 – None of the performance indicators were currently being achieved. Action plans were in place however they were over a long timescale. Further activity to support NHS 111 recovery includes a workstream looking at recruitment and

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retention. The Provider Management Team had requested more details regarding how long it was taking to respond to calls to gage how significant the issues were. Quality Premium – It was forecasted that the CCG would deliver against a number of the indicators. It was expected that more accurate forecast would be produced in October which would allow the CCG to challenge any performance issues. The Quality, Performance and Innovation Committee noted the contents of the report.

QPI/15/110 GP Variation in Spends The Quality, Performance and Innovation Committee were provided with a verbal overview of the GP in Variation in Spends data and escalation process. The most recently data would be published later that day and the quarter 1 report would be produced in the very near future. Meetings were already scheduled with practices to discuss the report and actions plans would be developed accordingly. It was asked that data be provided to show the difference between the weighted size of the practice and the actual performance for the next meeting. The Quality, Performance and Innovation Committee noted the information provided.

QPI/15/105 Clinical Quality Acute and Community Quarterly Update The Quality, Performance and Innovation Committee considered the report which headlined key issues and provided assurance that actions were being undertaken where appropriate. As significant discussion had taken place earlier in the meeting Rob Milner reported on the following areas: CDDFT – The Trust were shown to have a statistically significant higher than expected mortality rate for non-elective admissions. The two primary diagnosis identified as statistically high were pneumonia and syncope. Serious Incident analysis had been undertaken and the most common incident type reported by CDDFT since July 2013 was slips, trips and falls. The Trust were shown to be following a reducing trend in this category despite a rise in the number of slips, trips and falls in August. STHFT - The continuity of services rating from Monitor remained

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at 1 due to a continued material level of financial risk and the governance rating is still red, due to enforcement action. In regards to C.Diff, South Tees Hospital Foundation Trust (STHFT) were above target with 29 cases reported against an expected target of 18. It was expected that the annual target of 39 would be breached late October to early December 2015 unless the number of cases reported dramatically reduced in the coming months. BMI Woodlands – There were currently no concerns regarding the level of care being provided. Members of the Committee expressed concern that on occasions a patient would be referred to BMI Woodlands and then back in the NHS pathway which was causing multiple charges. Jill Smith advised that these instances had been reported via the Safeguard Incident and Risk Management System (SIRMS) however no feedback had been received. Diane Murphy asked that examples be sent to her for follow up. The Quality, Performance and Innovation Committee noted the contents of the report.

JS

QPI/15/112 Research & Development Activity Summary Quarter One 2015/2016 The Quality, Performance and Innovation Committee noted the contents of the report.

QPI/15/115 Parkgate Medical Practice The Quality, Performance and Innovation Committee deferred the item to the next meeting and agreed that the report was to be the first item on the agenda.

QPI/15/116 Risk Register and Any New Risks Identified The Quality, Performance and Innovation Committee considered the report which provided details of the Risk Management Policy which had been developed for Darlington CCG and a copy of the risk register for the Committee. It was agreed that the risk surrounding the Urgent Care Centre not having sufficient GP cover was to be added to the register for monitoring. The Quality, Performance and Innovation Committee noted the contents of the report and agreed to the above action.

DM

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QPI/15/117 Any other Business

- Consultant to Consultant Policy – The CCG had been asked to reinstate the reviewed Consultant to Consultant Referral Policy. It was asked that the clinical representatives of the Committee review the policy and provide feedback to ensure that it was suitable for Darlington from a GP perspective. Diane Murphy would advise Jackie Kay who was leading the review to send it to the relevant Members.

DM

Date/Time/Venue of Next Meeting Tuesday 27 October 2015, 11-1pm in Meeting Room 1&2 at Dr Piper House, Darlington

Signed………………………… Chair.…Diane Murphy..……. Date……………………………

DARLINGTON CLINICAL COMMISSIONING GROUP FINANCE COMMITTEE

Monday 24th August 2015

12.00 – 14.00


CONFIRMED MINUTES

Present: Andie Mackay (Chair) Lay Member Finance Michael Close Practice Manager Representative Richard Stevens GP, Orchard Court Surgery Jayne Turner Practice Manager, Blacketts Medical Practice Lisa Tempest Chief Finance & Operating Officer In attendance: Lis Dunning Senior Commissioning Finance Manager Kirsty Kitching Senior Commissioning Manager – Provider Management Rachael White Administration Assistant

Action

FC/15/58

Apologies for Absence Apologies for absence were received from: Jill Smith Commissioning Support Officer Gomathy Umashankar GP, Blacketts Medical Practice

FC/15/59 Declarations of Interest No declarations were made.

FC/15/60 Minutes of the meeting held on 27th July 2014 and matters arising The minutes of the meeting were agreed as an accurate record.

FC/15/61 Action Log The action log was discussed and updated accordingly.

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FC/15/62 GP Variation in Spends The Finance Committee were advised that unfortunately Jill Smith was unable to attend the meeting however had sent through the latest heat map which was tabled. This would also be circulated after the meeting. Jill had also advised that there were no practice in escalation at this time and the query regarding the budget was still being resolved. Lisa Tempest advised that there were queries in the finance team as to what figures had been used for 2014/15 as it was still unclear as to why there was such a significant change in the budget. The Committee were reassured that this was included in the Activity Management Log and would be monitored closely. It was requested that feedback be sent to Jill, asking for further details of the practices that were underspending to ensure that there was no impact on the quality of service provided to patients. The Finance Committee noted the contents of the report.

RW/JS

FC/15/63 Finance Report The Finance Committee reviewed the report which provided an update on the financial performance of Darlington Clinical Commissioning Group (CCG) for 2015/16 financial year. County Durham and Darlington Foundation Trust (CDDFT) was showing a forecast overspend position of £1,671k which included the application of penalties. A breakdown of the costs was included on slide 16 of the report. Kirsty Kitching advised that CDDFT had made an agreement that that internal diverts between Darlington Memorial Hospital and the University Hospital of North Durham would not be included in the Divert Policy. It was unknown at the point as to how this would affect the region so was suggested that the matter be raised at the escalation meeting being scheduled for Chief Finance Officers and CDDFT. It was agreed that work needed to be undertaken to identify whether there were any shifts in demand across the patch which was contributing to the over performance. For example, BMI Woodlands forecast outturn was already ahead of the position this time last year however they were receiving less subcontracted work from the Hospitals. However there was no obvious reason for this. Lisa Tempest advised that the Clinical Commissioning Group (CCG) were looking to establish and Operations and Delivery meeting which would include Service Planning and Reform, Provider Management and Commissioning Finance to review situations such as this. Lisa

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and Rachael would look to secure a date in the diary as soon as possible. The meeting was to be held monthly roughly one week before the Finance Committee so that updates could be provided. The CCG had entered into a risk share agreement with Tees, Esk and Wear Valley Foundation Trust (TEWV) to manage the overall Mental Health and Learning Disabilities budget to ensure breakeven at the end of the financial year. Review work would be undertaken in conjunction with TEWV to manage the financial position particularly in relation to Northumberland, Tyne and Wear Foundation Trust and Individual Packages of Care. Continuing Healthcare was now forecasting an overspend of £92k which was expected to increase. The main area of overspend was within Children’s Services due to rise the number of eligible children. Work was being undertaken to identify why there had been such an increase. In regards to prescribing costs, from the data provided by the Prescription Pricing Authority (PPA) it was predicated that this would drastically increase towards a £400k overspend in the next month. Historically PPA forecasting hasn’t always been accurate and could be very volatile. The Finance Team were currently looking to develop a form of methodology to predict the forecast internally. Lisa advised she ask for a progress update. Lisa reported that there was also an issue with the Community Nursing budget and Barbara Nimmo was working with CDDFT to identify the reason behind this. There was to be an increase in running costs due to the interim Accountable Officer arrangements which would be included in the next report. The Finance Committee noted the contents of the report.

LT/RW

LT

FC/15/64 QIPP The Finance Committee were provided with a verbal update from Lisa Tempest who advised all schemes were on track to achieve the agreed plan. Lisa presented a detailed scheme overview that was split by programme area with a description of each itemised area. In the current position the Better Care Fund was the highest risk as the CCG did not meet the 2014-15 target. This would be circulated following the meeting and would be submitted to the Governing Body in September. The Finance Committee noted the information provided.

RW

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FC/15/65 CDDFT Contract Negotiation Update The Finance Committee were provided with a verbal update regarding the contract situation with County Durham and Darlington Foundation Trust. The 2015-16 contract had now been signed and work was being undertaken to identify lessons learnt and a chronology of events to identify any significant delays etc. This was essential at this time as work would soon be starting on the 2016-17 contract. Discussion would also take place with CDDFT to understand how the experience was for them and understand the issues they faced. The Finance Committee noted the information provided.

FC/15/66 Risk Register and Any New Risks Identified The Finance Committee considered the report which provided details of the Risk Management Policy which had been developed for Darlington CCG and a copy of the risk register for the Committee. The register had been updated following the previous meeting and the Committee agreed that there were no changes to be made to the residual ratings at this point in time. It was agreed that the pressures surrounding Prescribing costs, running costs and Acute Services contracts be added to the risk register. The Finance Committee agreed to the above changes and noted the contents of the report.

LT

FC/15/67 Any Other Business

No other items were raised.

Date/Time/Venue of Next Meeting Monday 28th September 2015, 12.00 – 14.00 in Meeting Room 1&2, DPH

Signed……………………….. Chair.…Andie Mackay…….

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Date…………………………...

DARLINGTON CLINICAL COMMISSIONING GROUP FINANCE COMMITTEE

Monday 28th September 2015

12.00 – 14.00


CONFIRMED MINUTES

Present: Andie Mackay (Chair) Lay Member Finance Michael Close Practice Manager Representative James Nevison GP, Denmark Street Surgery Richard Stevens GP, Orchard Court Surgery Lisa Tempest Chief Finance & Operating Officer In attendance: Emma Bolton Regional Asset Manager, NHS Property

Services Jo Dea Service Support Officer, NHS Property

Services Lis Dunning Senior Commissioning Finance Manager David Elstob Acquisitions and Disposals Manager, NHS

Property Services Kirsty Kitching Senior Commissioning Manager – Provider Management Andrew Stainer Head of Transformation Rachael White Administration Assistant

Action

FC/15/68

Apologies for Absence No apologies for absence were received.

FC/15/69 Declarations of Interest No declarations were submitted.

FC/15/70 Minutes of the meeting held on 24th August 2015 and matters arising The minutes of the meeting were agreed as an accurate record.

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FC/15/71 Action Log The action log was discussed and updated accordingly.

FC/15/72 NHS Property Services The Finance Committee were given a presentation from Emma Bolton, NHS Property Services outlining the work being undertaken to review estates in Darlington. It had been agreed that all Clinical Commissioning Groups (CCG) would have an estates strategy by December 2015. A Local Estates Group had been established for Darlington with representatives from the CCG, Primary Healthcare Darlington, Darlington Borough Council, County Durham and Darlington Foundation Trust (CDDFT) and Tees Esk and Wear Valley Foundation Trust (TEWV). NHS England had been invited to attend but a representative had not been appointed. The method of billing CCGs was to be changed for the next financial year and would be split into properties. Any void/subsidy costs would continue to be paid by the CCG. Where leases were involved, there would be a clause requiring the costs to move into market rental. The aim of this amendment was to provide clarity of the true costs of services and highlight any opportunity costs. Documented agreements for occupied space would be developed in order to provide all organisations with a clear understanding of what they were paying for. The Vacant Space Policy would encourage efficient use of space and reduce voids for better utilisation of the facilities available. There will be an option for property services to rent out lettable units however there would be a vacating charge depending on the property. The data in the presentation showed that there were 5 properties in Darlington all of which were in use and there wasn’t much void space. Lisa Tempest queried these details as Hundens Lane site B had a significant amount of unutilised space until that week as Carmel Medical Practice Staff were going to be using the facilities and there was a vacant wing in Park Place. Emma advised that she would feed this information back and it would be reviewed. The Committee were advised that the next lease break in the contract for Dr Piper House was 2019. A meeting was scheduled to meet with the Landlord for the building to discuss the lease and a revaluation of the premises was to be undertaken. It was asked that arrangements be put in place to ensure that a reminder was issued to the CCG well in advance of the next

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lease break and that a briefing paper be presented to the Governing Body on the changes. The Finance Committee noted the information provided and thanked NHS Property Services for attending.

LT

FC/15/73 GP Variation in Spends The Finance Committee were provided with a verbal update from Jill Smith. The latest data was due to be released later that day so there was no heat map available for June. Jill advised that from now on 12 month rolling trends would be used for the escalation process and the latest quarterly reports would be reviewed with the practices over the upcoming weeks. In regards to the query at the previous meeting regarding the quality of service provided, Jill advised that the Care Quality Commission (CQC) had found no issues when investigating the practices. In terms of proving whether a patient should have been referred or not, this would not be easy without looking at individual cases. Jill advised she would bring the trends for each practice over the last year to the next meeting. The Finance Committee noted the information provided.

JS

FC/15/74 Finance Report The Finance Committee reviewed the report which provided an update on the financial performance of Darlington Clinical Commissioning Group (CCG) for 2015/16 financial year. There were significant pressures within the system in all areas and the current position had been met by the CCG releasing a benefit from the 2014/15 accruals into its year to date and forecast outturn positions. The current position showed a year to date underspend of £736k on an allocation of £145,359k. The CCG received non recurrent allocation for Eating Disorders in August of £61k and a recurrent allocation for the Neo-natal Audiology Screening at South Tees FT for £37k. BMI Woodlands Hospital was causing significant pressure and the contract lead on Provider Management had been tasked with comparing activity data from 2014/15 to 2015/16. The Committee stressed the need to identify the departments with an increase in activity and if there was reduction in activity elsewhere. Lis Dunning was working with Business Intelligence to gain more detailed information at speciality level across the

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patch and undertaken deep dive reports into the most affected areas. Continuing Care Services were showing a year to date overspend of £175k and forecast outturn underspend of £175k. Included within the forecast outturn was the benefit of an unutilised accrual from 2014/15 of £500k. Without this there would be a projected overspend of £325k for the year. Lisa Tempest advised that a national benchmarking exercise had been undertaken for Continuing Healthcare. This showed that per 50,000 population, the CCG had the highest amount of shared packages with the Local Authority by a significant amount. It had been requested that this be investigated to establish the reason why. NHS England were aware of the CCGs situation and Lisa had sent an additional overview report to them with actions and mitigations for if the position deteriorated. The Finance Committee noted the contents of the report and asked that the next meeting focused solely on the financial position of the CCG.

RW

FC/15/75 Activity Management Action Log The Finance Committee were advised that the activity management reports should be ready for the meeting in October. The report would focus on some of the main pressure areas across the contracts.

FC/15/76 Risk Register and Any New Risks Identified The Finance Committee considered the report which provided details of the Risk Management Policy which had been developed for Darlington CCG and a copy of the risk register for the Committee. The 3 risks mentioned at the previous meeting had been added to the register. It was suggested that Risk 1405 – Acute Hospital activity/costs exceed planned levels in 15/16 – be escalated to red due to the lack of clarity regarding the increase in activity. The Finance Committee noted the contents of the report and agreed to the above.

LT

FC/15/77 Any Other Business No other items were raised.

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Date/Time/Venue of Next Meeting Monday 26th October 2015, 12.00 – 14.00 in Meeting Room 1&2, DPH

Signed………………………. Chair.…Andie Mackay…… Date…………………………..

DARLINGTON CLINICAL COMMISSIONING GROUP GOVERNANCE, AUDIT AND RISK COMMITTEE

Tuesday 14th July 2015

14.30 – 16.30

Emerson Room, Dr Piper House

CONFIRMED MINUTES

Present: John Flook (Chair) Lay Member Governance Richard Harker GP Quality Lead In attendance: Liane Cotterill Senior Governance Manager Kelly Douglas Senior Manager, PwC Stuart Fallowfield Managing Director, Audit North Daniel Houghton Audit Manager, Ernst & Young Stuart Irvine Audit Manager, Audit North Lisa Tempest Chief Finance & Operating Officer Rachael White Administration Assistant

Action

GARC/15/49

Apologies for Absence Apologies were received from Michelle Thompson, Lay Member Patient and Public Involvement.

GARC/15/50 Declarations of Interest No declarations were made.

GARC/15/51 Minutes of the meeting held on 23rd March 2015 and matters arising The minutes of the meeting were agreed as an accurate record subject to minor amendments.

GARC/15/52 Action Log The action log was discussed and updated accordingly.

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GARC/15/53 Internal Audit Progress Report The Governance, Audit and Risk Committee considered the report which provided a summary of internal audit progress in completing the 2014/15 plan and the planned outputs for 2015/16. Three reports were at draft stage and we to be finalised shortly. Three reports had been finalised since the last meeting in May: 1. Practice and Clinical Engagement – significant assurance 2. Information Governance toolkit – significant assurance 3. Continuing Healthcare & Funded Nursing Care – limited assurance. A follow up audit was planned for 2015/16. Since the production of the report, the Data Quality report had been finalised and the Medicines Management Arrangements report was no longer in draft. The Committee requested that in Section 2 – Assignment summaries, the responsible officers also be included. In regards to Continuing Healthcare (CHC), the findings in the report were consistent across the patch and seemed to be a long standing issue. Lisa Tempest advised that there had been difficulties with the CHC Team in terms of how they work and how information was reported back to the CCG. This had been raised through the Service Level Agreement with the North of England Commissioning Support Unit (NECS) and changes had been made. Work was to continue to ensure Darlington was receiving the service it required. There had also been issues regarding capacity and procedure in the Finance Team. Additional resource had now been put in place and a meeting was to be scheduled to review the process for payment of healthcare packages etc. Audit North were liaising with 360 Assurance who had won an award for Governance and Risk Management in relation to a Clinical Commissioning Group (CCG) client elsewhere in the country to see the methodology behind it. Risk Management Workshops were also planned late in the year. There was one outstanding recommendation for Governance and Risk Management regarding having business plans for each Committee. Lisa advised that herself and Rachael White would be developing these and had scheduled a meeting later that week to discuss them. Following the Counter Fraud Annual Report, an annual risk assessment had been undertaken and the draft plan was attached as a separate agenda item. It was highlighted to the Committee that a recent investigation had identified issues regarding false employment and references which had led to

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prosecution. It was felt that this was something to be mindful of what looking at recruitment. The Governance, Audit and Risk Committee noted the contents of the report.

GARC/15/54 Draft Counter Fraud Plan 2015-16 The Governance, Audit and Risk Committee considered the report which set out the proposed counter fraud work plan for 2015/16. NHS Protect define four key areas for counter fraud work Strategic Governance, Inform and Involve, Prevent and Deter and Hold to Account and these are covered within the plan. The main risks identified in the plan were associated with contracting, potential conflicts of interest and low materiality relating to expenses. The CCG would be supported with the completion of the counter fraud self-review toolkit submission and there was small provision for initial investigation of referrals. However if any additional days for detailed investigations were required, they would need to be purchased separately. The Governance, Audit and Risk Committee approved the plan.

GARC/15/55 Annual Audit Letter The Governance, Audit and Risk Committee reviewed and noted the letter which summarised the results of the audit for 2014-15. All work had been undertaken as planned with assurance given and no additional fees.

GARC/15/56 Information Governance Report The Governance, Audit and Risk Committee considered the report which gave an update in relation to statutory compliance with the Freedom of Information (FOI) Act 2000 and Data Protection Act 1998 (DPA). The report also provided an update in regards to the Information Governance (IG) Toolkit. 22 requests were received in April, May and June. All had been responded to within the statutory timescale. As of the end of June there were 11 requests outstanding all of which were on schedule to be completed on time. A selection of request sources and topics were included in the report. Lisa Tempest raised concern that some of the responses were very close to the deadline and there seemed to have been an issue around gaining information from Finance. Liane Cotterill advised that

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this had been raised at Director level and had been agreed that the relevant Director would now be copied into any requests for information. There was an improvement in the 2014/15 IG Toolkit submission to 69% from the 2013/14 submission of 66%.There had been no major changes to the requirements for this year with only minor rewording of some sections. The IG Team were aiming to take some aspects up to Level 3 assurance and were currently working on a gap analysis to clearly identify what was to be provided by the CCG and what by NECS. The Governance, Audit and Risk Committee noted the contents of the report.

GARC/15/57 Risk Management The Governance, Audit and Risk Committee reviewed the full risk register for Darlington Clinical Commissioning Group with appendices providing an overall summary, details of the corporate risks, a distribution matrix and risks closed since the last report. Risk 887 – Children’s Continuing Care – This service was being delivered by County, Durham and Darlington Foundation Trust (CDDFT) and Darlington Borough Council were also heavily involved in the service. As part of the work currently being undertaken by the Members Assembly Task and Finish Group, proposals for a joint Safeguarding Team across the organisations was being considered. This would allow streamlining of services and a better coordination and approach of services. This would be discussed as part of the Task Group feedback at the Members Assembly meeting on the 3rd September. Risk 1199 – Contracting for 2015/16 – Not all contracts had been signed by the end of March 15. A final offer had been drafted and was being sent to CDDFT that day which was based on the agreement made in principle. The North East Ambulance Service (NEAS) contract was also outstanding and discussions were moving into mediation. Risk 970 – Absence of a structured programme for development of the organisation – Lisa Tempest advised that on returning from sick leave, Jackie Kay was working on the Organisational Development plan. Independent support was in the process of interviewing all CCG staff and members in practices which would feed into the plan as well.

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Risk 972 – Delayed location of urgent care with ED at DMH site – The service continued to be split however the long term plan was still to move the service completely to Darlington Memorial Hospital. The move was to be complete in August 2015 however structural work was required which had caused delay. Lisa reassured that despite rumours, there were no plans to shut the A&E department however services could be reviewed under the Securing Quality in Health Care Services work being undertaken. Risk 1136 – Decisions made by the CCG are not clinically informed – There had been a number of issues identified which would be reviewed by the Task Group who were reviewing how to increase engagement. Risk 1339 – CCG Chief Officer absent for extended period of time – Key controls had been added to the register. Formal confirmation from NHS England was yet to be received however verbal approval had been given to the appointed Interim Accountable Officer. Risk 971 – Unable to deliver the HELS review – The contract had been awarded and went live on the 1st July. A steering group was still overseeing the transition and was working with the provider. Risk 1090 – Learning Disabilities and Mental Health patients in Independent Sector hospitals – A number of remedial actions had been put in place which allowed the CCG to oversee any financial costs that may incurred. The possibility of this being monitored jointly with Darlington Borough Council was being discussed. Risk 1102 – CCG experiences financial pressure due to Better Care Fund arrangements – The CCG had been successful in reducing non-elective activity however the results were reviewed quarterly and the target for quarter 4 had not been met. A scorecard system had been developed and was being monitored by the Unit of Planning group. Risk 1101 – CCG experiences higher than planned premises costs due to current arrangements for funding voids space – An estates group had been established and a strategy for Darlington premises was being developed. Discussions were still ongoing regarding how CDDFT were charged and the implications this would have on the CCG but also the amount of funding provided in the CDDFT contract. Risk 7 – Failure to adhere to the Winterbourne View Concordat – All care and treatment reviews had been undertaken and

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plans were in place to move patients to other placements if necessary. If there any patient were to remain in their original placement, they would be monitored closely. Risk 1129 – Insufficient palliative care consultants to meet the required number for population need – Lisa advised that this had not been updated recently and would follow up on the situation. Risk 1128 – Sole provider for Intermediate Care Beds – The situation had improved and more accurate data was being received. The Multi-Disciplinary Team work around the Frail and Elderly could provide a more accurate indication of how many beds would be needed which could lead into where they could be sourced from. Risk 1354 – Quality of care provided to residents of care homes not being of the required standard – A certain care home had failed 9 out of 10 quality standards and the Care Quality Commission (CQC) had served a notice of proposal. However this may be contested by Darlington Borough Council as it was felt that significant improvements had been made. Diane Murphy had established a multi-agency meeting who were working towards a coordinated approach in working with the care home. Through this group, the CCG were assured that all patients were safe and all care plans had been reassessed. It was suggested that Governing Body Members and possibly Members Assembly be notified of the CQC’s notice on the care home and the implications this may have. The Governance, Audit and Risk Committee noted the contents of the report.

LT

DM

GARC/15/58 Losses and Special Payments The Governance, Audit Risk Committee were advised that the CCG had incurred no losses or made any special payments since the last meeting.

GARC/15/59 Governance Assurance Report Quarter 1 2015/16 The Governance, Audit and Risk Committee considered the report which provided intelligence relating to Corporate Governance to provide assurance on the governance processes in place to ensure safety and the organisation’s effective management of risk. An overview of health and safety activity was included in the report with an overview of objective compliance e.g. compliance against health and safety training, % of policies in date and fire

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risk assessments completed for the building. In regards to Equality and Diversity, Liane Cotterill advised that 5 members of CCG staff had completed the Equality Impact Assessment Training. As this contributed towards the CCG fulfilling its legal requirement under the Equality Act 2010 a further session for the remaining staff was to be held later in the year. Work was still ongoing to ensure all policies were up to date and significant progress had been made. The IG Team were using a rag rating system to highlight when a policy is due for review. Section 8 - Claims Management - had been recently added to the report following an incident whereby a patient had been treat by BMI Woodlands Hospital when private providers could gain insurance through the NHS Service Level Agreement which is no longer in existence. As a result the CCG were not aware of the claim and it was agreed that updates would be included in this report for monitoring. The Governance, Audit and Risk Committee noted the contents of the report.

GARC/15/60 Governance Work Programme Quarter 1 2015/16 The Governance, Audit and Risk Committee considered the report which was designed to provide assurance on all Governance work streams. The report did not highlight any new risks to the CCG however the work programme continued to be monitored on a monthly basis. Any risks identified would be highlighted to the Committee in a timely manner. Liane Cotterill confirmed that Lisa Tempest would receive a monthly copy of the work program and the IG team were looking to refine the document so that it aligned to the assurance report. It was agreed that the work programme would be summited to the Executive Committee for monitoring and any exceptions would be report to this Committee. The Governance, Audit and Risk Committee noted the contents of the report.

GARC/15/61 Terms of Reference The Governance, Audit and Risk Committee considered the revised Terms of Reference which now included a statement identifying that this Committee would monitor performance against the annual work programmes for Governance, Health and Safety, Fire Safety, Research Governance and Information Governance.

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It was agreed that ‘Senior Governance Manager’ would be added to the list of officer who would normally be in attendance at meetings. The Governance, Audit and Risk Committee approved the document subject to the addition above.

LT

GARC/15/62 Health and Safety Annual Report 2014-15 The Governance, Audit and Risk Committee considered the report which detailed the work undertaken by the Health and Safety Team in relation to health and safety and fire safety. It was agreed that this Committee would oversee all Health and Safety matters and the Executive Committee would monitor Statutory and Mandatory training. The report was to be updated accordingly. The Governance, Audit and Risk Committee noted the contents of the report.

GARC/15/63 Health and Safety Strategy The Governance, Audit and Risk Committee reviewed and noted the Strategy that had been reviewed and updated with no major changes made.

GARC/15/64 Policies for Ratification: The Governance, Audit and Risk Committee reviewed the Mental Capacity Act policy which outlined how the CCG would fulfil its duties and responsibilities in accordance with the Act. The Committee felt that the policy was more specific to providers and that it was inappropriately detailed. It was asked that future versions be more refined to the CCG. The Governance, Audit and Risk Committee approved the policy.

GARC/15/65 Any Other Business No other items were raised.

GARC/15/66 Private discussions with Internal and External Audit No additional discussions took place.

Date/Time/Venue of Next Meeting 14.30 – 16.30, Tuesday 22nd September 2015, Emerson Room,

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Dr Piper House

Signed………………………. Chair.…John Flook………. Date…………………………..

COMMUNITY COUNCIL OF PATIENTS PUBLIC & CARERS

Thursday 27th August 2015 18:00 – 20:00

Meeting Rooms 1 & 2, Dr Piper House

CONFIRMED MINUTES

Present: Lisa Tempest Chief Finance and Operating Officer, Darlington CCG Stephanie Edge Admin Assistant, Darlington CCG Michelle Thompson Chair, Patient and Public Engagement, Darlington CCG Carole Ferguson Patient, Carmel Medical Practice Betty Hoy Patient, Moorlands Surgery Kath Wall Patient, Denmark Street Surgery Louise Hoggett Practice Manager, Whinfield Surgery Kenneth Frid Patient, Parkgate Surgery Andrea Goldie Healthwatch Darlington John Hodge Patient, Whinfield Surgery Terry Taylor Patient, Neasham Road Surgery Graham Levett Patient, Felix House Surgery Audrey Lax Patient, Blacketts Medical Practice In attendance: Greg Burke Chief Officer, County Durham and Darlington LPC

Item No. Agenda Item

Action

CCM/15/126 Welcome & Introductions As above.

CCM/15/127 Apologies for Absence Jackie Kay

CCM/15/128 Minutes from meeting held Thursday 25th June 2015 Audrey Lax apologies to be added. Amendments were made to the minutes regarding the comments from Denmark Street Surgery. Matters Arising Sally Hutchinson asked for the Community Council to be aware of how bitterly disappointed she was by the comments made regarding Denmark Street PPG group. To Sally’s knowledge, Kenneth Brown did not attend any PPG meetings held.

Sally Hutchinson and Denmark Street surgery have confirmed PPG Meetings are held quarterly and have taken place in June 2015, March 2015, November 2014, July 2014, March 2014 notices were placed in the waiting room, website and emailed out to the 20-25 PPG members. At the last meeting Denmark Street PPG were encouraged to be more proactive in setting their own agenda, chairing their own meetings with help and assistance from the Practice. GL queried why was KB was so mistaken. KW has spoken to KB and he will not be attending meetings in the foreseeable future.

CCM/15/129 Update on Community Council TOR and Membership Michelle Thompson MT advised that the CCG are looking at ways of engaging more of a cross section of people across Darlington. NECS are supporting the CCG in enhancing membership. The CCG are looking at individuals and the groups that they feed into rather than just PPG groups, there will be a move away from practice membership and a focus on community involvement. There will be a number of ‘Community Champions’ rather than practice leads. New members will not necessarily be part of PPGs and will be CCG volunteers. Messages will not be going back and forth to practices, the patient voice will be going out to the community. This could mean that not all PPGs will have a representative. The PPG will no longer be an agenda item, this will be covered under ‘feedback from the community’. There was a concern about the number of new members there would be, MT confirmed this will depend on applications received. The TOR for the group need refreshing. MT questioned, is the Community Council group still effective and asked the members to reflect on this. GL commented that members should not be bringing personal health issues to the table. There will be an application process and informal interview, where CCG expectations are explained. The recruitment drive will open to everyone. Originally, practices were asked by the CCG to nominate a PPG member to attend the Community Council group. MT confirmed that all members will be encouraged to reapply. Advertisements will be distributed by Healthwatch Darlington, online and across the Darlington networks.

CCM/15/130 Community Pharmacy Greg Burke from the LPC presented on Community Pharmacies and their roles and responsibilities. There are 23 community pharmacies in Darlington, independent and multiples. 5 out of the 23 are 100 hours, access is very good. These 5 pharmacies are: Cockerton, Sainsbury’s, Clifton co-op, Asda, Denmark St. GB described those services that are essential to provide i.e. dispensing and enhanced services i.e. the minor ailment scheme. Enhanced services are locally commissioned by DBC, the Minor Ailment Scheme is funded by the CCG. Pharmacies should all have a private consultation room. GL was concerned that a Medicines Use Review (MUR) is done without knowledge of medical conditions. If there is a course of action following the MUR, then a form will be returned to GP with recommendations. PERMSS – Pharmacy Emergency Repeat Medication Supply Service: Patients were taking up appointments at A&E and the Urgent Care Centre (UCC). The Northern CCG forum decided to recommission on permanent basis for ‘Out of Hours’ services. This is just local, not currently national. The scheme is only for pharmacies open ‘Out of Hours’. Transfer of Patient Care, North of Tyne, this is run on the Pharma Outcomes system. The system will be in all wards in hospitals and staff will securely transit information from the ward to community pharmacy. This is to ensure pharmacist knows patients have been in hospital. The information is sent in real-time. LH felt there should be more of a focus on GPs getting information. Minor Ailments Scheme: items are free to any patient who receives free prescriptions. The members were concerned that people did not know about the scheme. The Pharma Outcomes system would stop abuse of minor ailments, i.e. people going to multiple pharmacies to acquire free medicines. Action: GB and LT to meet to discuss.

CCM/15/131 Urgent Care Strategy Anita Porter There is a National focus on urgent and emergency care services. In line with the national vision, the local vision for urgent and emergency care includes the whole urgent and emergency care system from

pharmacies, GP practices and other primary care services, community services and acute hospital services. In County Durham and Darlington that vision is that: ‘Patients are seen by the right health professional, in the right setting, at the right time, to the highest quality and in the most efficient way providing the best outcome for the patient.’ The Systems Resilience team are working to ensure the objectives of the strategy are developed. The strategy outlines plans in terms of how services are developed going forward. The CCG are responsible for working with our providers to implement change to pathways to meet strategy and improve services for patients. The strategy considers expanding 111, 7 day working, diagnostics, consultants and community pharmacy. This is a complete redevelopment to increase capacity for A&E and avoid unnecessary or inappropriate ambulances. Ambulance handover must be improved, CDDFT have a poor performance rate. Patients will be signposted for care depending on severity of symptoms and those whose life is threatened will be treated within acute hospital. BH queried where the co-location of A&E and Urgent Care is up to. The Trust were not able to keep to timescales because of the significant changes to building. The timeline is for completion November 2016. The feedback on the strategy was that it was very County Durham focussed and although it was stated that Healthwatch Darlington were involved in the System Resilience Group, this is not the case at the moment. The way forward arrow for direction of travel in the diagram looks like it is going nowhere. There is an overarching strategy but local strategies are up to each individual CCG.

CCM/15/132 CCG Update

CCM/15/133 PPG Updates

CCM/15/134 VCS Update • Andrea gave an update on Healthwatch activities. • 6 surveys have taken place across Darlington • Social media campaigns are ongoing

• Healthwatch continue to facilitate the Mental Health Network, Learning Impairment, Darlington Organisations Together (DOT) and the Darlington Ageing Well Network as well as supporting the Children and Young People Network.

• VCS Strategy and Development meetings are taking place due to the dissolution of Evolution. Discussions include how organisations can work more collaboratively together as well as sharing information.

• There are Access Points across Darlington for people to attend and give their views.

• Macmillan Information & Support Centre Survey undertaken on what’s going well, what’s not?

• CCG Backpain and MSK surveys due to take place. • Continue CDDFT Engagement, recent update on Breast Services,

Bishop Auckland. • BME Health Connectors have received training in in order to

enhance the signposting of services between communities... • Continue to engage with the working population, hard to reach by

nature of the fact they are working. Healthwatch are going into the work place.

• Jodie Craggs continues to work with Children and Young People. • HWD are currently managing room bookings for Church Row,

since Evolution dissolved. This will continue until end of December 2015.

• Concerns from Whessoe Parish Council regarding plans to build 450 new houses in the area. Concerns around GP practice availability and capacity. More information is needed. NHS England providing a formal response to proposed development. Otherwise ensure GP provision there.

• Ingenious Darlington – the town is the quickest economic growth in the country. The scheme is about celebrating how good we are and reminding people about all the good things we have done.

CCM/15/135 Update on Darlington CCG Financial Health

Due to time constraints, the Financial Report was distributed to members and all were asked to feedback any questions arising to LT via email.

CCM/15/136 Any Other Business 2 items outstanding feedback:

1. Blocked phone calls and DNAs. Calls from withheld number. Not all followed up with letter and don’t leave a voicemail. The call barring is causing issues.

2. Central Booking and cancellation of appointments because of overbooking. Central booking needs looking at.

Date and time of next meeting Thursday 24th September 2015 – 18:00 to 20:00 Meeting Rooms 1 & 2, Dr Piper House