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Meeting in Public of the Camden CCG Governing Body Wednesday 9 May 2018 14:00 - 16.00
PART I
AGENDA
Item Title Presenter Action Paper Time Page 1. Introduction 1.1 Apologies for Absence Dr Neel Gupta Note Verbal 14.00 -
1.2 Declarations of Interest Dr Neel Gupta Note 1.2 14.01 4
1.3 Declarations of Gifts and Hospitality Dr Neel Gupta Note 1.3 14.03 -
1.4 Minutes of the Previous Meeting Dr Neel Gupta Approve 1.4 14.05 9
1.5 Action Log
Dr Neel Gupta Note 1.5 14.07 19
2. Questions from the Public -
Members of the public have the opportunity to ask questions. These must relate to items that are on the agenda for this meeting and should take no longer than three minutes per person.
3. Chair, Accountable Officer, Patient and Quality Reports 3.1 Chair’s Report
Dr Neel Gupta Note 3.1 14.15 22
3.2 Accountable Officer’s Report
Helen Pettersen
Approve 3.2 14.25 26
3.3 The Patient Voice Report
Kathy Elliott Note 3.3 14.35 30
3.4 Quality and Clinical Effectiveness Report
Charlotte Cooley
Note 3.4 14.40 39
4. Strategy 4.1 4.2 4.3 4.4
PMS Update Business Plan 2017/18 Update Report Business Plan 2018/19 St Pancras Estates Redevelopment Pre-consultation Business Case
Sally MacKinnon Sally MacKinnon Sally MacKinnon Richard Lewin
Note Note Approve Approve
4.1
4.2
4.3
4.4
14.45 14.55 15.05 15.10
50
58
80
93
Page 1 of 422
5. Finance and Performance 5.1 Finance Report Simon
Goodwin
Note 5.1 15.25 309
5.2 Integrated Performance Report
Richard Cartwright
Note 5.2 15.35 318
6. Governance
6.1 6.2
Camden CCG 2017/18 Draft Annual Report and Accounts Board Assurance Framework
Ian Porter Richard Strang
Approve Note
6.1
6.2
15.40 15.45
336
340
6.3 6.4
NCL Audit Committee in Common and Individual CCG’s Audit Committees Revised Terms of Reference Integrated Commissioning Committee
Ian Porter Matthew Clarke
Approve Approve
6.3
6.3
15.50 15.55
352
376
7. Committee Reports – For information
only 15.58
7.1 Finance, Performance and QIPP Committee
Dr Birgit Curtis Note 7.1 389
7.2 Integrated Commissioning Committee
Dr Matthew Clark
Note 7.2 392
7.3 Localities Report
Dr Jonathan Levy
Note 7.3 396
7.4 7.5 7.6
Audit Committee NCL Joint Commissioning Committee NCL Primary Care Commissioning Committee
Richard Strang Paul Sinden Paul Sinden
Note Note Note
7.4
7.5
7.6
399
403
413
8. Any other Business
9. Date of Next Meeting: 11 July 2018
REGISTER OF INTERESTS A register of members’ interests is available on the Camden CCG website
http://www.camdenccg.nhs.uk
A conflict of interest is defined as “a set of circumstances by which a reasonable person would consider that an individual’s ability to apply judgement or act, in the context of delivering, commissioning, or
assuring taxpayer funded health and care services is, or could be, impaired or influenced by another interest they hold”.
Managing conflicts of interests in the NHS: Guidance for staff and organisations 2017.
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Camden Clinical Commissioning Group Governing Body Members' Register of Interests 2018/19
Declared From Updated
Fina
ncia
l Int
eres
ts
Non
-Fin
anci
al
Prof
essi
onal
Inte
rest
s
Non
-Fin
anci
al
Pers
onal
Inte
rest
s
Swiss Cottage Surgery Yes Yes No Direct Owner and GP Partner 16/12/2016 01/07/2007 13/6/2017Haverstock Healthcare Ltd Yes Yes No Direct Swiss Cottage Surgery is a shareholder 16/12/2016 01/07/2007 13/6/2017Swiss Cottage Private General Practice Yes Yes No Direct Owner and Shareholder 16/12/2016 01/01/2016 13/6/2017CHE Neighbourhood Yes Yes No Direct Swiss Cottage Surgery is affiliated to this neighbourhood 16/12/2016 01/08/2016 13/6/2017Cadence Minerals PLC Yes No No Direct Shareholder 16/12/2016 01/07/2014 13/6/2017Docmartin Residential Yes No No Direct Owner shareholder of property investment company 18/02/2017 13/6/2017Children's Trust Partnership No Yes No Indirect CCG Representative 16/12/2016 01/07/2014 13/6/2017North Camden Zone No Yes No Indirect CCG Representative 16/12/2016 01/07/2015 13/6/2017Camden Youth Foundation No Yes No Indirect CCG Representative 16/12/2016 01/08/2016 13/6/2017Central Health Evolution Limited Yes Yes No Direct Shareholder and Founding Member 22/03/2017 13/6/2017Hampstead Group Practice Yes Yes No Direct Nurse Practitioner 18/07/2017Haverstock Healthcare Limited Yes Yes No Direct Works at out of hours hub at weekend 18/07/2017Camden LMC No Yes No Direct Practice Nurse Representative, Not voting, observer role 18/07/2017Royal College of Nursing No Yes No Direct Member 18/07/2017City University Yes Yes No Direct Honourary lecturer for nursing and midwifery 29/09/2017West Hampstead Medical Centre Yes Yes No Direct GP Partner 14/12/2016 01/11/2012 05/07/2017Haverstock Healthcare Ltd Yes Yes No Direct West Hampstead Medical Centre is a shareholder 14/12/2016 01/11/2012 05/07/2017KCA Architects No No Yes Indirect Company Secretary and husband is a Director 14/12/2016 01/01/1998 05/07/2017Central Health Evolution Limited Yes Yes No Direct Shareholder 22/03/2017 05/07/2017Prince of Wales Group Practice Yes Yes No Direct Practice Manager 13/12/2016 12/06/2017SanKtus Welfare Project - Welfare Charity No No Yes Direct Treasurer 13/12/2016 12/06/2017
Dr Neel Gupta Elected GP and GB Chair The Keats Group Practice Yes Yes No Direct Salaried Employee 15/11/2016 01/08/2011 14/8/2017
James Wigg and Queens Crescent Practices Yes Yes No Direct GP Partner 15/11/2016 01/09/2015 12/06/2017Haverstock Healthcare Ltd Yes Yes No Direct Shareholder in GP Federation 15/11/2016 01/09/2015 12/06/2017Hampstead Group Partner Yes Yes No Direct Partner 29/11/2016 14/06/2017Haverstock Healthcare Ltd Yes Yes No Direct Shareholder in GP Federation 29/11/2016 14/06/2017CCAS Assessor Yes Yes No Direct GP Assessor 29/11/2016 14/06/2017UCLH Council of Governors No Yes No Indirect Camden CCG rep on UCLH Council of Governers 01/03/2018 13/06/2017Bloomsbury Surgery Yes Yes No Direct GP Partner 13/06/2017 13/06/2017Central Health Evolution Limited Yes Yes No Direct GP Practice is a Member 13/06/2017 13/06/2017CCAS Assessor Yes Yes No Direct 2-4 sessions per month 13/06/2017 23/8/2017
Parliament Hill Medical Centre Yes Yes No DirectSalaried Employee. The partners at Parliament Hill Medical Centre are shareholders of Haverstock Health. 11/07/2017
Care UK, HMP Pentonville Yes Yes No Direct Salaried GP (1 day per week) 11/07/2017
Public Health England No No Yes IndirectPartner, Mr Peter Graham is a civil servant and works at Public Health England as a partnership marketing manager. 11/07/2017
Nature of InterestDeclared Interest- (Name of the organisation and nature of business)Name
Position (s) held- i.e. Governing Body, Member practice,
Employee or other
Date of InterestType of Interest
Is the interest direct or indirect?
Elected Voting Members
Jonathan Duffy Elected Practice Manager
Dr Jonathan Levy Elected GP Representative
Dr Sarah Morgan
Dr Kevan Ritchie Elected GP Representative
Dr Martin Abbas Elected GP Representative
Dr Birgit Curtis Elected GP Representative
Elected GP Representative
Elected Practice NurseCharlotte Cooley
Dr Philip Taylor Elected GP Representative
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Camden Clinical Commissioning Group Governing Body Members' Register of Interests 2018/19
Director of Public Health Camden and IslingtonYes Yes No Direct Salaried Employee 15/11/2016 01/02/2013 12/06/2017Vice-chair of London Association of Directors of Public Health No Yes No Direct 15/11/2016 01/01/2014 12/06/2017Lewisham and Greenwich NHS Trust Yes Yes No Direct Paediatric Registrar 15/11/2016 01/03/2013 12/06/2017Welbodi Partnership - registered UK Charity No No Yes Direct Board Member 15/11/2016 08/08/2008 12/06/2017
Kings College London No No No Indirect
Wife is a research fellow which is funded by the NHS National Institute of Health Research and Tommy's Charitable Trust 15/11/2016 01/10/2014 12/06/2017
Nursing and Midwifery Council No Yes No Direct Registrant Panellist for the Conduct and Competence Panels 16/11/2016 01/02/2013 12/06/2017The Order of St John Priory Group for Greater London No No Yes Direct Member 29/03/2017 12/06/2017Caversham Group Practice No Yes No Direct Member of the Patient Participation Group 12/12/2016 13/06/2017Kaeconsulting - independent consultancy Yes No No Direct Owner/Director 12/12/2016 13/06/2017UK Public Health Register (UKPHR) No Yes No Direct Assessor and Chair of the Registration Panel 12/12/2016 13/06/2017Faculty of Public Health No Yes No Direct Member 12/12/2016 13/06/2017PHAST - public health consultancy No Yes No Direct Associate 12/12/2016 13/06/2017
Simon Goodwin Chief Finance Officer, NCL CCGs East London NHS Foundation Trust Yes No No Indirect Wife is a senior manager 14/06/2017 14/06/2017
Helen PettersenAccountable Officer, NCL CCGs and NCL STP Convenor No declared interests Nil return 05/04/2017
Richard Strang Lay Member Tavistock and Portman NHS Foundation Trust No Yes Yes Direct Former Non-Executive Director 31/07/2017
Young Foundation Yes Yes No Direct Chief Executive Officer 09/08/2017
Member of the House of Lords Yes Yes No DirectBaroness Thornton - Labour and Co-operative Member From 1.11.2017: Opposition spokesperson for Health 09/08/2017 23/07/1998 1/11/2017
London School of Economics No Yes Yes Direct Emeritus Governor 09/08/2017
Social Enterprise UK No Yes Yes Direct Patron 09/08/2017
Healthcare and Assistive Technology Society No Yes Yes Direct Chair of the Advisory Panel and Patron 09/08/2017
Cabinet Member for Health and Adult Social Care Yes Yes No Direct Councillor, Camden Borough Council 02/10/2017St Michael's Primary School No Yes No Direct Governor of St Michael's Primary School 02/10.2017Unison No Yes No Direct Union Member 02/10/2017Camden LMC No Yes No Direct Chair 20/09/2016 18/06/2017
Camden, Barnet and Brent GP Practices Yes Yes No DirectLocum GP working across multiple GP practices and GP Appraiser (paid work) 18/01/2017 18/06/2017
Medical Women's Federation No Yes No Direct Trustee - unpaid 18/01/2017 18/06/2017UK General Practitioners Committee Yes Yes No Direct Elected Member - paid honoraria for attendance 18/01/2017 18/06/2017
NHS Digital Yes Yes No Indirect
Husband is a member of an advisory panel for e-Consult and is currently seconded to NHS Digital as a national medical director clinical fellow 18/01/2017 18/06/2017
Pulse Live Conferences Yes Yes No Direct Speaker - paid honoraria 18/01/2017 18/06/2017
Medical Student OSCE examiner Yes Yes No Direct Paid for work completed 18/01/2017 18/06/2017
Simone Hensby Voluntary Sector Representative Voluntary Action Camden Yes Yes No Direct Executive Director 19/12/2016 18/06/2017
Camden Patient & Public Engagement Group No Yes Yes Direct Chair 16/08/2017 14/08/2017
Non-Voting Members
Appointed Voting Members
Julie Billett Public Health Representative
Dr Mathew Clark Secondary Care Doctor
Kathy Elliott
Glenys Thornton Lay Member
Dr Farah Jameel LMC Observer
Patricia Callaghan Health and Wellbeing Board Observer
Lay Member
Jane Davis OBE Registered Nurse
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Camden Clinical Commissioning Group Governing Body Members' Register of Interests 2018/19
Adelaide Medical Centre No Yes Yes Direct Chair of Patient Participation Group 16/08/2017
Universal Offer Delivery Group No Yes Yes Direct CPPEG Patient Representative 27/09/2017London Borough of Camden Yes Yes No Direct Director of Integrated Commissioning 23/11/2016 13/06/2017Camden Schools Project Ltd Yes Yes No Direct Director 23/11/2016 13/06/2017Camden BSF SPV Ltd Yes Yes No Direct Director 23/11/2016 13/06/2017Camden SPV Holdings Ltd Yes Yes No Direct Director 23/11/2016 13/06/2017Camden Healthwatch No Yes No Direct Chair 29/06/2017 12/07/2017Chomley Garden Surgery Practice No Yes No Direct Patient Participation Group Representative 06/01/2016 12/07/2017UK National Thalassemia and Sickle Cell Group (NHS England) No Yes No Direct Lay Member 06/01/2016 12/07/2017Ambassador Little Village Charity No No Yes Direct 12/07/2017 12/07/2017Camden Reach Pregnancy Project Yes Yes No Direct Project Coordinator 12/07/2017 12/07/2017London Antenatal Screening Programme No Yes No Direct Lay Member representative 12/07/2017 12/07/2017
Rebecca Booker Deputy Chief Finance Officer No interests declared Nil return 18/10/2017Mike Cooke Chief Executive No interests declared Nil return 21/11/2016 28/06/2017Sally MacKinnon Transformation Programme Director Change the Record Management Consultancy No No Yes Indirect Executive Director. Company owned by husband David
MacKinnon 25/11/2016 01/10/2014 20/06/2017Meena Mahil Interim Director of Primary Care
and Community CommissioningOptologie Ltd Yes No No Direct
Director 02/02/2018 02/02/2018 02/02/2018Sarah Mansuralli Chief Operating Officer No interests declared Nil return 12/06/2017 12/06/2017Jennifer Murray-Robertson
Director of Commissioning and Contracting
No interests declared Nil return 02/02/2018 02/02/2018 02/02/2018
Ian Porter Director of Corporate Services No interests declared Nil return 14/11/2016 16/06/2017Neeshma Shah Director of Quality and Clinical
EffectivenessIndependent consultant Yes Yes No Direct Occasional ad hoc consultancy work on sole trader basis on
subject matter relating to medicine, the pharmacy profession and the health and social care landscape 25/11/2016 24/04/2013 18/06/2017
Saloni Thakrar Healthwatch Representative
Richard Lewin Local Authority Representative
Patient RepresentativeHilary Lance
Attendees
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Page 6 of 422
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CAMDEN CLINICAL COMMISSIONING GROUP GOVERNING BODYDraft Minutes of the Meeting held on Wednesday, 14 March 2018 at 2 pm
At BMA House, Tavistock Square, London WC1H 9JP.
Present:
Elected Voting Members:Dr Neel Gupta ChairDr Martin Abbas Elected GP RepresentativeCharlotte Cooley Elected Nurse RepresentativeDr Birgit Curtis Elected GP RepresentativeMr Jonathan Duffy Elected Practice ManagerDr Jonathan Levy Elected GP RepresentativeDr Sarah Morgan Elected GP RepresentativeDr Kevan Ritchie Elected GP RepresentativeDr Philip Taylor Elected GP Representative
Appointed Voting Members:Julie Billett Director of Public Health Camden and Islington CouncilsDr Matthew Clark Secondary Care DoctorJane Davis OBE Registered NurseKathy Elliott Lay MemberSimon Goodwin Chief Finance Officer, NCL CCGsHelen Pettersen Accountable Officer, NCL CCGsRichard Strang Lay MemberGlenys Thornton Lay Member
Non-Voting Members:Simone Hensby Executive Director, Voluntary Action CamdenHillary Lance CPPEG ChairRichard Lewin Director of Integrated Commissioning,
London Borough of Camden (LBC)Councillor Richard Olszewski Health and Wellbeing Board Representative,
London Borough of CamdenSaloni Thackar Chair Healthwatch Camden
In Attendance:
Sarah Mansuralli Chief Operating Officer, Camden CCGDr Tom Aslan MSK Clinical Lead, Camden CCG (Item 4.2 only)Rebecca Booker Deputy Chief Finance Officer, Camden CCGRichard Cartwright Head of Performance, Camden CCG (Item 5.3 only)Carolyn Cullen Interim Board Secretary, Camden CCG (Minutes)Delyth Ford Head of Insights, Camden CCG (Item 4.3 only)Jennifer Murray-Robertson Director of Commissioning and ContractingIan Porter Director of Corporate Services, NCL CCGs
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1. Introduction 1.1 Apologies for Absence 1.1.1
Apologies were received from Simone Hensby and Farah Jameel.
1.2 Declaration of Interest 1.2.1
The Register of Interests was considered. There were no new declarations of interest.
1.3 Declarations of Gifts and Hospitality 1.3.1
There were no declarations of gifts and hospitality.
1.4 Minutes of the Meeting held on 15 January 2018 1.4.1
The Governing Body considered the minutes of the meeting held on 15 January 2018 and no points of accuracy were raised.
1.4.2 The Governing Body agreed that the minutes of the meeting held on 15 January 2018 were a true record.
1.5 Action Log
1.5.1 The Governing Body considered the updates on the actions arising from the previous meeting:
Item 4 (15 January 2018): Sally MacKinnon gave a verbal update on why the Royal Free London was not meeting its diagnostic targets at present. This has been raised with Barnet CCG who are the lead commissioners for the Royal Free London. Item 4 (8 November 2018) Dr Neel Gupta updated the Committee on information received from Hammersmith and Fulham CCG regarding GP at Hand. There are now 20,000 patients registered with this service, but less than a thousand have a registered post code in the Camden area. Hammersmith & Fulham CCG have shared concerns regarding equalities in how this service is operating and has commissioned a detailed review.
1.5.2 The Governing Body noted the Action Log
2. Questions from Members of the Public
2.1 There were no members of the public present and no questions from members of the public had been received
3. Chair, Accountable Officer, Patient and Quality Reports 3.1 Chair’s Report 3.1.1 The Chair highlighted that the transfer of adult community commissioning from the Council to
the CCG has successfully been concluded. An early benefit of the new arrangements was that the Continuing Healthcare team and the Delayed Transfers of Care team had enabled the CCG to better support UCLH in managing winter demand over the holiday period. Joint CCG and
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Council management of Mental Health/Learning Disabilities and Children’s Integrated Commissioning teams will begin in March 2018. A small number of CCG Governing Body Members had attended an informal Board to Board with representatives from Islington CCG. The meeting was very positive and a further meeting is planned in three months. The Chair informed the meeting that following the departure of Charlotte Mullins, Hasib Aftab will lead the Sustainable Insights Directorate for the time being and Meena Mahil will act as interim Director of Primary and Community Commissioning until Sarah McDonnell takes up the substantive role at the end of May 2018.
3.1.2 The Governing Body noted the Chair’s Report 3.2 Accountable Officer’s Report
3.2.1 Helen Pettersen stated that the procurement process had now concluded for internal audit and
counter fraud services and the contract had been awarded to RSM Risk Assurance Services (the current provider). This contract is for 3 years with an optional extension for a further two years. Helen Pettersen requested that the Governing Body ratify this decision. With the departure of Charlotte Mullins, Director of Sustainable Insights, in February 2018 the role of SIRO (Senior Information Risk Owner) will transfer to Ian Porter, Director of Corporate Services NCL. Camden CCG is on track to achieve “Level Two” for its Information Governance IG Toolkit submission. The final submission will be submitted by the 31 March 2018 deadline and will be signed off by Neel Gupta (in his capacity as Caldicott Guardian) and Ian Porter Camden CCG SIRO.
3.2.2 The Chair invited comments:
Ian Porter stated that NHS England had sent out on-line training on conflicts of interest; this training is mandatory for all Governing Body members. Action 1: Board Secretary to ensure that GB members have access to online training packages via the ESR system and to consider arranging face to face and group sessions for some mandatory training elements possibly utilising the Governing Body Breakfast meetings.
3.2.3 The Chair asked for a vote; and the following was approved with no votes against or
abstentions.
3.2.4 The Governing Body ratified Chair’s Action to appoint RSM Risk Assurance Service to provide internal audit and counter fraud services for a period of three years with an optional extension for a further two years The Governing Body approved the Director of Corporate Services (Ian Porter) as the Camden CCG SIRO (Senior Information Risk Owner)
3.3 The Patient Voice Report
3.3.1 Kathy Elliott presented the report, stating that the CCG had engaged and consulted on a wide
range of issues since the last Governing Body including Annual Health Checks for patients with learning disabilities whose conditions are managed in general practice and also consultation on
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End of Life Care. There has also been intensive engagement regarding acute mental health day units. In response to feedback, the patient and public feedback report will describe the difference that feedback and engagement with patients is making. A part-time Patient Director has been appointed as part of the new Musculoskeletal (MSK) service.
3.3.2 Hillary Lance followed on with two short patient stories, both regarding social media.
The first patient story concerned a mother concerned about her sixteen month toddler’s long term episode of salmonella. Both the surgery staff and doctor were, in her eyes, not responsive or reassuring to the point that the mother sought help via social media and also changed practice. The lesson to be learnt is that social media can set a trail of bad news running but equally the responses received by the mother were on the most part practical and balanced.
The second patient story also concerned local mothers reinforcing messages via social media. The issue raised was NHS health checks and whether they were worth it. Again the responses were positive and balanced. The concluding point being that practices need to be aware that social media is how patients exchange information and more focus needs to be given to what information is on practice websites and how web communities can be used to support patients positively.
3.3.3 The Chair invited comments:
Councillor Richard Olszewski stated that the Camden CCG Communications and Engagement team is supporting the Council in raising awareness of the Camden 2025 plan. Kathy Elliott stated that, as a resident, she had received a short synopsis of the 2025 and asked that this synopsis be circulated to all Governing Body members. This was agreed. Action 2: Board Secretary to circulate Camden Council’s four page synopsis of their 2025 plan to all Governing Body members.
3.3.4 The Governing Body noted the Patient Voice Report 3.4 Quality and Clinical Effectiveness Report 3.4.1 Neeshma Shah presented the report, highlighting the following:
Three more never events at the Royal Free London have been reported since the last
Governing Body meeting. Barnet CCG, as Lead Commissioner, in conjunction with NHSE/NHSI have undertaken a review of surgical never events
The CQC has undertaken a re-inspection of the Camden and Islington Foundation Trust; initial feedback has been positive with no enforcement notices and the CQC had commented positively on cultural change and improvements at the Trust
UCLH have provided assurance that ISBARD a communication tool to assist clinical staff to make clear and effective escalations and handovers has been successfully implemented and UCLH are undertaking an initiative, Improving Care Rounds (ICRs),
Concerns have been raised regarding the lack of compliance with adult safeguarding training and the lack of safeguarding referrals at the Tavistock and Portman NHS Foundation Trust. This has been escalated and is being actively monitored.
3.4.2 The Chair invited comments:
a) Hillary Lance expressed her concern regarding the lack of compliance with adult
safeguarding training at the Tavistock and Portman NHS Foundation Trust. This concern
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was echoed by the whole Governing Body.b) Dr Matthew Clark stated that some of the Never Events at the Royal Free London seemed
similar to previously occurring incidents and asked whether the Action Plans followingSerious Incidents (SI) are rigorously followed up. The Chair concurred and summed updiscussion by stating that the Governing Body was not assured as to whether certainfailings had continued to recur and asked that there be a further report back to the MayGoverning Body.
Action 3: Neeshma Shah to report back to the May Governing Body on an update on theactions and learnings associated with the Royal Free Hampstead site surgical NeverEvents
3.4.3 The Governing Body agreed to note the Quality and Clinical Effectiveness Report
4. Strategy4.1 PMS Update
4.1.1 Sally MacKinnon explained that following an extensive review, a process for transferring thePMS premium from the current 15 PMS practices to all 34 practices in Camden via an agreedspecification for service delivery had been agreed by the NCL Primary Care Co-CommissioningCommittee. The total value of this investment is approximately £3.4 million and this will beredistributed according to list size over the next four years, using a recent weighted list sizefigure of 274,082 patients, which provides approximately £12.60 per patient.
4.1.2 The Chair thanked Sally MacKinnon and her team for their excellent work in progressing thePMS review.
4.1.3 The Governing Body noted the report.
4.2 Musculoskeletal (MSK) Service Update
4.2.1 Dr Tom Aslan presented the report, stating that the report is intended to give the GoverningBody an update on progress made to date by UCLH, the lead provider, during year one of thenew MSK contract. The new clinical model aims to provide:
A single point of access, triage, referral and case management for patients, carers andreferrers
A full range of integrated services, including ambulatory care, imaging and specialistinpatient services
Patient choice for specialist services Resources for patient self-management and education (including digital services)
Dr Tom Alsan asked the Governing Body to note in particular that a part-time patient directorhad been appointed to help improve communication and engagement with patients and UCLHhave launched a website for patients regarding MSK conditions and services.
4.2.2 The Chair invited comments:
a) Dr Sarah Morgan commented that feedback from patients regarding the quality ofcommunity physiotherapy services was not positive and sought assurance that the newservice would address this feedback
b) Hillary Lance stated that patients’ feedback is that they are passed round the system and
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that care is still not co-ordinated.
The Chair stated that the new contract is a major change to how services are contracted anddelivered. Over the next year there should be significant changes to how MSK services areactually provided and experienced by patients. The Chair thanked the MSK team for theirinnovative work in mobilising this contract.
Action 4: Dr Matthew Clark to provide a six month update on the performance of thenew MSK service; this will be considered at the September Governing Body meeting
4.2.3 The Governing Body noted the report.
4.3 Insights around Non-Electives
4.3.1 Delyth Ford presented the analysis which gives a detailed picture of the non-elective pressuresfacing Camden. Overall, increases in activity for the over 60 population is significantly higherthan population growth. The value of over performance (as at Month 9) is £6.3m. Feedbackfrom main acute providers is that this extra cost relates to the increased acuity of the patientsreceiving treatment. The conversation rate of patients being admitted from A&E for non-electiveconditions is 22% at UCLH, 20.7% at the Royal Free London against the London average of17.4%. A further factor to be considered is that the introduction of HRG4+ coding requirementswhich has had the effect of increasing unit costs for non-elective activity.
4.3.2 The Chair invited comments:
a) Dr Matthew Clark suggested a clinical audit by acute trusts to better understand why nonelective admissions were increasing. Sarah Mansuralli suggested taking this forwardthrough the STP admission avoidance work stream.
b) Kathy Elliott thought the analysis was very useful and that it should be made available tomembers of the NCL Joint Commissioning Committee for their consideration. This wasagreed.
Action 5: Helen Pettersen to make the Camden Analysis of Non-Elective Admissionsavailable members of the NCL Joint Commissioning Committee
4.3.3 The Governing Body noted the report
5. Finance and Performance5.1 Budget 2018/19 Report
5.1.1 Simon Goodwin summarised NHSE’s planning guidelines, informing the Governing Body of thekey dates for submission of the financial plan and Operating Plan for 2018/19 as well as asummary of the 2018/19 QIPP and potential budget risks in 2018/19.
5.1.2 Simon Goodwin advised the Governing Body that the 2018/19 Operating Plan needed to beagreed and submitted by 30 April 2018. As there is not a Governing Body meeting until May,Simon Goodwin suggested that the Finance, Performance and QIPP meeting in April shouldhave delegated authority to approve the Financial Plan and Operating Plan for 2018/19. TheChair requested that all Governing Body members be invited to this meeting.
Action 6: Simon Goodwin to advise Board Secretary on whether an increased GoverningBody attendance at the April Finance, Performance and QIPP Committee, or a speciallyconvened Governing Body meeting, is required to ratify the 2018/19 Budget and
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Operating Plan.
5.1.3 The Governing Body noted the report.
5.2 Finance Report
5.2.1 Rebecca Booker introduced the Finance report, which set out the CCG’s financial position as atthe end of January 2018, Month 10, and provides the latest position with regarding delivery ofthe 2017/18 QIPP.
5.2.2 Rebecca Booker highlighted that:
The projected acute over performance is £3.2m, with over performance of £1.4m at theRoyal Free London, £0.8m at Imperial Healthcare and £0.7m at UCLH
The main driver for over performance in the acute sector is non-elective expenditure The non-acute sector is forecasting a year-end over performance of £2.5m as at Month 10 The main areas of over performance in the non-acute sector are: Continuing Health Care
(CHC) £1.1m, Primary Care prescribing £0.5m, Children Services £0.4m and Mental HealthServices £0.2m
The control total will be met by the use of reserves and contingencies.
5.2.3 The Chair invited comments:
a) Dr Matthew Clark asked why there was such a significant upward variance on DiagnosticImaging; and asked if costs had risen or the volume of images required had gone up
b) The Chair concurred and asked that analysis be done to understand what was going on
Action 7: Rebecca Booker to provide an in-depth analysis of the increase in diagnosticimaging expenditure referred to in Table 4 Page 99 of the Finance Report and reportback to the May Governing Body meeting.
5.2.4
5.3
5.3.1
5.3.2
The Governing Body noted the Finance Report
Performance Report
Richard Cartwright introduced the performance report; the main areas of concern as at March2018 are performance against the four hour target, 62 day cancer targets and the RTT waitingtime standards.
Dr Martin Abbas suggested that there needed to be more focus on what impact the Royal FreeLondon missing its RTT targets is having on Camden patients and requested a breakdown ofRTT performance by site at the Royal Free London. Helen Pettersen stated that Barnet CCGhad recruited to the Director of Commissioning post and monitoring and follow up will beimproved.
5.3.3 The Governing Body noted the Performance Report.
6. Governance6.1 Board Assurance Framework
6.1.1 Richard Strang introduced the Board Assurance Framework (BAF). Currently there are 13 riskson the BAF of which five are Camden specific and eight are NCL-wide. The five Camden risks
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relate to: system resilience, failure to deliver QIPP savings identified in the 2017/18 plan, failureto meet the Cancer 62 day target at UCLH, increased costs due to acute over-performance,failure to agree and deliver a robust QIPP savings plan for 2018/19.
6.1.2 The Governing Body reviewed the risks and noted the Board Assurance Framework
6.2 NCL Joint Commissioning Committee Terms of Reference
6.2.1 Helen Pettersen explained that the proposed changes allow for the Committee Chair to beappointed from either a CCG Lay Member representative or through the appointment of anIndependent Chair should the Committee wish to pursue that option. The proposed changesalso allow for the appointment of a Vice Chair from the remaining CCG Lay Memberrepresentatives.
6.2.2 The Chair asked for a vote; and the following was approved with no votes against orabstentions.
6.2.3 The Governing Body approved the revised NCL Joint Commissioning Committee Termsof Reference.
7. Committee Reports7.1 Finance, Performance and QIPP Committee
7.1.1 The Governing Body agreed to note the Finance, Performance and QIPP CommitteeReport.
7.2 Integrated Commissioning Committee
7.2.1 The Governing Body agreed to note the Integrated Commissioning Committee Report.
7.3 Localities Report
7.3. The Governing Body agreed to note the Localities Report.
7.4 Procurement Committee
7.4.2 The Governing Body agreed to note the Procurement Committee Report.
7.5 Health and Wellbeing Board
7.5.1 The Governing Body agreed to note the Health and Wellbeing Board Report.
8. Any Other Business
8.1.1 The Chair asked if there was any other business:
a) Saloni Thacker raised the recent press articles on the Focus mental health service forhomeless people and stated that it had been reported that the funding for this service isbeing reduced. The Chair replied that this is the case, but that a detailed commissioningreview had been undertaken alongside a detailed equality and quality impact assessmentconducted jointly with Camden &Islington Foundation Trust’s (service provider) MedicalDirector. These reviews had helped determine that the service could be delivered more
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efficiently with no impact on those homeless patients with the most complex needs who theservice is specifically intended to help. Mechanisms to monitor impact of the change havebeen put in place.
b) Glenys Thornton stated that she had been part of the commissioning review as a memberof the integrated commissioning committee and agreed with the conclusions, but the CCGneeded to better consider how decisions to de-commission or reduce funding for servicesare communicated.
8.1.2 The Governing Body agreed to note the planned agenda items for the May 2018Governing Body meeting.
8.1.3 There was no further business and the Chair closed the meeting at 15.55 pm.
These minutes are agreed to be a correct record of the Governing Body meeting of Camden ClinicalCommissioning Group held on 14 March 2018
Signed ………………………………………….. Date …………………………………
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Agenda Item: 1.5
CAMDEN CLINICAL COMMISSIONING GROUP GOVERNING BODY 2017/18 ACTION LOG - PART 1
Meeting Date
Action No.
Action Lead Deadline Update
14 March 1 Accountable Officers Report Board Secretary to ensure that GB members have access to online training packages via the ESR system and to consider arranging face to face and group sessions for some mandatory training elements possibly utilising the GB Breakfast meeting.
Kofo Abayomi March 2018 This action is in progress.
14 March 2 The Patient Voice Report Board Secretary to circulate a summary of Camden Council’s 2025 plan to all Governing Body members.
Kofo Abayomi March 2018 The Board Secretary is awaiting the 4 page synopsis relating to the Camden Council’s 2025 plan from Council colleagues. The synopsis will be circulated prior to the May GB meeting.
14 March 3 Quality and Clinical Effectiveness Report Neeshma Shah to report back to May Governing Body on whether the Royal Free London had acted on previous action plans resulting from Never Events as the GB was not assured as to whether certain failings had continued to recur.
Neeshma Shah May 2018 This is captured in the quality and clinical effectiveness May GB report.
14 March 4 Musculoskeletal Services Update Dr Matthew Clark to provide a six month update on the performance of MSK services which will be considered at the September 2018 Governing Body
Matthew Clark September 2018
Update to be provided at September meeting.
14 March 5 Budget 2018/19 Report Simon Goodwin to advise Board Secretary on whether an increased GB attendance at April FPQ Committee or a special GB meeting is needed to ratify the 2018/19 Budget and Operating Plan.
Simon Godwin March 2018 Governing Body members invited to April FPQ Committee meeting to approve the Budget. Budget 2018/19 was noted at the FPQ April meeting with an update on May Governing Body meeting agenda.
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Agenda Item: 1.5 14 March 6 Finance Report
Jennifer Murray-Robertson to provide an analysis of the increase in diagnostic imaging expenditure (Table 4, Page 99) and report back to the GB in May 2018.
Jennifer Murray-
Robertson
May 2018 As at month 10 the Diagnostic Imaging Point of Delivery (POD) 2017-18 forecast over-performance of £1.5m. This reported over-performance on this POD is driven by Royal Free (£1.7m) offset by small underspends elsewhere.
At Royal Free the majority of this over-performance relates to ‘chemical pathology’. A contractual challenge on this was raised in quarter 1 and a value agreed. As the quarter 1 challenges where agreed in aggregate and not at individual service level the forecast over-performance has not been adjusted in 2017/18.
15 January 2 Quality and Clinical Effectiveness Report GB Members to receive the results of Barnet CCG’s deep dive into the Never Events at the Royal Free London
Neeshma Shah May 2018 This information is captured in the quality and clinical effectiveness May GB report.
8 November 1 Healthy London Partnership GB to receive an update on the link with the STP in the next HLP report. Board Secretary to add to annual cycle of business.
Board Secretary
May 2018 Work to develop new 2018/19 plans for HLP work streams is in progress. A report to the GB will be provided once this is available.
13 September
5 STP Programme Spend GB to consider detailed STP programme spend and evidence of delivery/value for money at May 2018 meeting.
Helen Pettersen
May 2018 This item has been deferred to the July GB meeting and will be provided by Will Huxter, Director of Strategy for NCL.
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Chair’s Report Agenda Item 3.1 Date 09.05.18
Committee Chair (where applicable) Lead Director Dr Neel Gupta, Chair Tel/Email [email protected]
Report Author Tel/Email GB Sponsor(s) (where applicable)
Tel/Email
Report Summary The purpose of this report is to highlight the Chair’s business activities and to provide an update on key areas of work.
Purpose Information Approval To note √
Decision
Recommendation The Governing Body is asked to note the content of this report.
Strategic Objectives Links
The Chair’s business activities are linked to all the CCG’s strategic objectives.
Identified Risks and Risk Management Actions
Where applicable any risks are identified within the report.
Conflicts of Interest
None
Resource Implications
Not applicable
Engagement Engagement activities are contained within the report.
Equality Impact Analysis
There are no equality impacts arising from this report.
Report History and Key Decisions
The Chair’s Report is a standing item on the Governing Body agenda.
Next Steps None
Appendices None
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Chair’s report March to May 2018
1. Introduction
This is my regular written report to the Governing Body, updating on the business that I undertake on behalf of the CCG and highlighting key areas of work being progressed in the CCG.
2. Primary and Community Plan
Following the transfer of adults’ community commissioning back to the CCG which concluded at the end of January, the Primary and Community Services Directorate have been developing a Primary and Community Plan, which builds on the strategic review of primary care undertaken at the end of 2017. The aim of this plan is to accelerate integrated care service delivery at neighbourhood level.
To develop the initial scope of this work there has been engagement with partners and practices to start to develop a shared vision for integrated services in 2020/21. Key next steps include co-production of the model of care with patients and professionals as well as mapping of contracts that need to be changed in order to realise the vision.
During this period there has also been extensive engagement with practices, neighbourhood and federation leads as well as the Camden Local Medical Committee (LMC) regarding minor changes to the Universal Offer. Many elements of the Universal Offer investment have resulted in significant improvements in patient care and patient outcomes in 2017-18; the changes are designed to help sustain investment in primary care by ensuring that the entirety of the Universal Offer investment represents maximal value for money.
3. Service Developments
Musculoskeletal Services (MSK)
The new integrated MSK service which includes a Single Point of Access (SPoA) went live on the 3rd April 2018. This is a significant and very positive milestone and is the culmination of several years of work in response to feedback from patients, in particular frustration about disjointed MSK services. The integrated service operates under a lead provider contract model led by UCLH which requires all MSK providers within North Central London to work together in order to provide the full range of MSK services in a joined up way. Patients can also self-refer directly into the service. The integrated service offers the full range of care from preventative/self-help support through to specialist intervention in the hospitals; a major part of the provision is based in the community e.g. community based physiotherapy.
Dermatology
The transformation of dermatology services is progressing well and a model of delivery has been agreed across NCL. The key changes are the introduction of a new Teledermatology service whereby GPs can take a good quality photograph of a skin condition or lesion and send this electronically to a specialist for timely treatment advice (excluding suspected cancer) and the mobilisation of the minor surgery Directed Enhanced Service (DES) more effectively across Camden to allow more consistent access to minor surgical procedures in the community.
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4. Integration of health and care in North Central London
An event, bringing together leaders from across North London Partners to debate how we take forward integration was held on 8th March. The event was well attended by senior leaders and there was a lot of positive energy, in particular around the development of neighbourhoods/CHINs. The workshop provided an opportunity for valuable discussion about principles for working together, maintaining focus on transformation and on outcomes as part of a long term strategic approach to improving the health and well-being of our population.
The event resulted in a number of actions to improve our approach to integration across organisations and is work in progress. Governing Body members will be kept updated about progress in due course.
5. Chairs Action – Interpreting Services
Chair’s action was utilised to approve a decision to progress a one year contract award for interpreting services through the NHS Shared Business Service. NHS Shared Business Service operates a London Framework with a range of providers who have already been through the procurement process and are compliant with UK and EU procurement regulations. The contract award using Chair’s action will allow timely and seamless provision of this essential service within a 3 week timeframe in May 2018 with a minimum one month’s mobilisation period during June 2018.
Neel Gupta Chair
Camden Clinical Commissioning Group
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Accountable Officer’s Report Agenda Item 3.2 Date 09.05.18
Lead Director N/A Tel/Email
Report Author Helen Pettersen, NCL Accountable Officer
Tel/Email [email protected]
GB Sponsor(s) (where applicable)
Tel/Email
Report Summary The Accountable Officer’s Report highlights key issues for the Governing Body’s consideration that are not covered elsewhere on the agenda.
Purpose (tick oneonly)
Information Approval To note
Decision
Recommendation The Governing Body is asked to note the contents of this report.
Strategic Objectives Links
The Accountable Officer highlights a variety of issues within the report and these may link with all strategic objectives.
Identified Risks and Risk Management Actions
Where applicable any risks are identified within the report.
Conflicts of Interest
There are no conflicts of interest arising from this report.
Resource Implications
No direct implications, although each area described has resource implications for the CCG.
Engagement Engagement activities are highlighted as appropriate.
Equality Impact Analysis
There are no equality impacts arising from this report.
Report History This report is a standing item on the Governing Body agenda.
Next Steps None
Appendices None
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Accountable Officers Report
1 Introduction
1.1 This report focuses on the key activities that the senior team and I have been involved in since the last Governing Body meeting and work progressed.
2 Contracting
2.1 The focus of our commissioning and finance teams has been on the 2018/19 contracting round with our acute, community and mental health provider organisations.
2.1 This is due to be concluded by the end of April, with mediation meetings required for The Whittington Hospital NHS Trust, Royal Free London NHS Foundation Trust (RFL), North Middlesex Hospital NHS Trust and Central London Community Healthcare Trust (CLCH).
2.2 The main issue for the acute providers was the financial value of QIPP plans. A process is therefore being followed during April where clinicians from both parties review these plans again. The aim of this is to ensure all plans have been signed off as clinically appropriate and able to be delivered in year. This will be concluded by the end of April. All other areas, including growth, service developments and planning assumptions for the Referral to Treatment target (RTT) have been agreed, subject to reaching overall contract agreement.
2.2 A lessons learnt exercise for the 2018/19 contracting round is underway. In addition to this, Camden CCG has initiated an internal work stream looking at alternative forms of commissioning for 2019/20 onwards.
3 Finance
3.1 The focus of the CCG finance team has been year end accounts which have now closed. Subject to audit process, the CCG has been able to achieve our financial control target for 2017/18.
3.2 I would like to acknowledge the hard work and effort of CCG staff during this year of substantial financial challenge for maintaining financial grip and focusing on delivery of the Quality, Innovation, Productivity and Prevention Plan (QIPP).
3.3 The Executive Management team and Governing Body members have been involved with a substantial amount of planning for transformational priorities in 2018/19 and this work very much continues to be the focus of the CCG at present.
4 Operating Plan
4.1 The announcement of the November 2018 Budget included additional NHS funding of £1.6bn for 2018-19, which increases funding for emergency and urgent care and elective surgery. In addition, for other core frontline services such as mental health and primary care, the Department of Health and Social Care (DHSC) is making a further £540 million available through the Mandate over the coming financial year.
4.2 NHS England and NHS Improvement has issued guidance on how the funds will be distributed. The CCG has refreshed its operating plan for 2018-19 to align with this guidance, which will be submitted to the Finance, Performance and QIPP Committee on the 25th April 2018 for approval, ahead of the submission date of 30th April 2018.
5 Information Governance
5.1 The IG toolkit process for 2017-18 has been submitted with a self-assessment rating of satisfactory. This reflects the CCGs ongoing performance of all IG related matters and includes staff training.
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5.2 The new ‘General Data Protection Regulation’ (GDPR) comes into force on 25th May 2018 and we are working with the CSU and NCL Corporate Services to ensure we meet the required standards and we will be providing governing Body members with some clear information and guidance on this.
5.3 In addition, we are also liaising closely with our member practices to provide support and guidance to aid their preparation in relation to GDPR.
6 CSU Transfer Update
6.1 Governing Body members will recall that we are in the process of transferring a number of staff from NEL Commissioning Support Unit (NEL CSU) into the NCL CCGs. These staff work mainly on contracts with NHS Trusts (contract monitoring, finance, analytics, clinical quality, performance monitoring etc.). This work is progressing well. Having previously gained Governing Body approval to proceed with this project, and give notice to NEL CSU for some services, we are required to submit a Business Case to NHS England as part of the staff transfer approval process.
6.2 The business case was submitted the week of 9th April 2018 and we await feedback on it. We have NCL CCGs’ Governing Body members on the oversight group for this project, and we will continue to keep all Governing Body members updated on progress and confirm the precise transfer date when it is finalised.
7 Additional NCL Post
7.1 At its meeting on 1 March 2018, a recommendation was put forward to the Remuneration Committee in Common for Barnet, Camden, Haringey, Enfield and Islington CCGs to split the role of the Director of Performance and Acute Commissioning, NCL CCGs into two roles. These are a Director of Performance, Planning and Primary Care and a Director of Acute Commissioning.
7.2 The Governing Body is asked to note that the Remuneration Committees in Common approved the split of this role into two new posts. Paul Sinden will be the Director of Performance, Planning and Primary Care for the NCL CCGs.
7.3 I am pleased to announce the appointment of Eileen Fiori to the post of Director of Acute Commissioning, NCL CCGs. Eileen has a strong provider and contracting background and is a qualified nurse. Eileen has most recently been working at NEL CSU as a CSU POD Director and is experienced in leading transformational change. Eileen will start her new role on the 1st May 2018.
7.4 I am also pleased to announce the appointment and commencement of Alex Faulkes, Programme Director for NCL STP Urgent and Emergency Care. Alex brings a wealth of experience in urgent and emergency care and previously worked as Director of Performance and Planning where he worked with a number of challenged health economies to improve urgent and emergency care provision. Alex will be work across the STP and be a member of the Camden Executive Management team with Sarah Mansuralli as the SRO for Urgent and Emergency Care.
Helen Pettersen Accountable Officer, 09 May 2018
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Patient Voice Report Agenda Item 3.3 Date 09.05.18
Committee Chair (where applicable)
Not Applicable
Lead Director Ian Porter, Director of Corporate Services
Tel/Email [email protected]
Report Author Martin Emery & Simeon Baker, Head of Communications and Engagement
Tel/Email [email protected]
[email protected] GB Sponsor(s) (where applicable)
Kathy Elliott, Lay Governing Body member responsible for Patient and Public Engagement
Tel/Email [email protected]
Report Summary This paper gives a synopsis of the patient and public engagement activity undertaken since the previous Governing Body meeting.
Purpose (tick one boxonly) [See note 6]
Information Approval To note X
Decision
Recommendation The Governing Body is asked to note the content of the report.
Strategic Objectives Links
Objective E: Work jointly with the people and patients of Camden to shape the services we commission
Identified Risks and Risk Management Actions
Not Applicable
Conflicts of Interest
Not Applicable
Resource Implications
Not Applicable
Engagement Engagement documented in report.
Equality Impact Analysis
No equality impact assessment is required for this report.
Report History and Key Decisions
The Patient Voice is reported to the Governing Body on a Bi-monthly basis
Next Steps Not Applicable
Appendices Not Applicable
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The Patient Voice Report (May 2018)
This paper covers work undertaken over the past two months, relating to: 1. Camden Patient and Public Engagement Group (CPPEG)2. Business Plan Objective E: Work jointly with the people and patients of Camden to shape the serviceswe commission.
1. Camden Patient & Public Engagement Group (CPPEG)Since the last Governing Body meeting the CCG has held one CPPEG operational meeting and a bi-annual Patient Participation Group (PPG) forum meeting. Key themes and issues arising are describedbelow.
1.1 CPPEG operational meeting (06/03/2018) CCG Committee reports CPPEG committee representative reports and the Governing Body Patient Voice report were discussed, approved and disseminated to PPGs for information, which can be accessed here.
Quality, Innovation, Productivity and Prevention (QIPP) Programme update Sally Mackinnon, Transformation Programme Director and Dr Birgit Curtis, GP and CCG Governing Body Member gave an overview of the QIPP programme detailing progress made in relation to the main work streams (Incl. STP – planned care, urgent & emergency, care close to home, local Camden acute QIPP, mental health, prescribing, community-better care fund, corporate & budget and new schemes (mitigations)). The key messages highlighted was that the CCG is expecting to deliver 90% of its QIPP targets in 17/18 at month 10. Although performance has varied by work stream, an approach of adopting mitigating actions / efficiencies was required to deliver this position for assured delivery by NHS England. Moving forward the main lessons learnt suggest a focus on greater provider engagement and implementation is necessary in the first quarter of 18/19 to ensure achievement of the QIPP targets.
CPPEG members welcomed the update and thanked Sally and Birgit. An outcome of the discussions will result in the CCG producing materials to help communicate with local residents about the work to deliver financial savings next year (linked to both the local care strategy and QIPP plan). It was agreed that a representative from the CCG would attend CPPEG later in the year to update members on QIPP. The presentation will be made available to the public following the local council elections (3rd May).
EMIS Web Local Record Sharing in Camden Presenter: Hasib Aftab, Assistant Director – IT Systems presented plans for introducing EMIS Web local record sharing across Camden and North Central London (NCL). The presentation is here. In summary, CPPEG members were informed of the benefits of local NHS providers in Camden sharing records (not just the patient’s GP surgery), which means that patient records will also be updated across local providers which clinical staff can access and ensure better and safer care.
CPPEG members welcomed the presentation and the opportunity to assist in ensuring that the information made available to the public helps them understand the purpose of local record sharing and the option for opting out. CPPEG members expressed hope that lessons would be learnt from the development of CIDR in raising the profile of the service and patients right to opt out. It was also agreed that a representative from the CCG would attend a future CPPEG meeting to update members on progress made.
CPPEG Elections (North & West Localities) Martin Emery – from the Communications and Engagement Team gave an update on progress made in relation to elections for the West and North Localities. In the West, the election was not contested with 3 people standing for the 3 vacant positions. For the North there were 5 people standing for the 4 positions. An election was not required for the South locality as PPG member terms had not come to an end. Following the ballot the current PPG membership for CPPEG is as follows:
North Locality West Locality South Locality Hilary Lance (2nd term),
Adelaide PPG John Levite (2nd term), Keats
PPG
Ivy Johnson (1st term), AbbeyPPG
Irene Fuchs (1st term),Brondesbury PPG
Christopher Morgan (1stterm), Museum PPG
Elie Collis (1st term),Brunswick PPG
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Joanna Macrae (1st term) &Ruth Appleton (2nd term),Caversham PPG
David Richards (2nd term) &Leon Douglas (2nd term) WestHampstead PPG
Gill Walt (1st term) & KathyGraham Harrison (1st term),James Wigg PPG
You Said We Did CPPEG committee reports: Approved.
QIPP Programme: CPPEG members welcomed the update and asked for public friendly information to be disseminated to local people informing them of the plan to deliver financial savings during 18/19 (linked to STP and QIPP plan).
EMIS Web Local Record Sharing in Camden: CPPEG members welcomed the update and being given the opportunity to contribute to the drafting of information to inform patients of the purpose of record sharing and opting out.
CPPEG Elections (North & West Localities): Kathy Elliott, Vice Chair of CCG welcomed the outcome of the election.
Camden CCG has: Disseminated reports to PPGs via the monthly newsletter and made available on the public website.
Camden will: Disseminate the approved presentation to PPGs following the local election via the public website and PPG newsletter. A representative from Camden CCG will also return to CPPEG later in the year to give an update on progress made for 18/19.
Invite members from CPPEG to assist the communications & engagement team to provide public friendly information on the CCG plans to deliver financial savings.
The difference that this will make is ensuring that the public are informed of the CCG plans to deliver financial savings in plain English.
Camden has: Disseminated the presentation to patients via the PPG newsletter and made available on the public website. A representative from the IT team will also attend a future CPPEG meeting to update members on the promotion and implementation of EMIS across Camden.
The difference that this will make is ensuring that the information given to patients is checked by patients to ensure that the benefits and opt out are easy to follow.
Camden CCG will: Kathy Elliott & Martin Emery (Camden CCG) with Hilary Lance - Chair of CPPEG will review the election system to vote for a PPG member. The current system stands at 1 PPG member 1 Vote. Feedback received from some voters have said that wished they would have had the opportunity to vote for more than 1 candidate.
1.2 PPG Forum meeting (10/04/2018) CPPEG hosted the fifth bi-annual PPG forum meeting with 42 PPG forum members attending. The forum agenda reflected what PPG members requested and the programme for the forum is here.
Presentation 1: Camden GP Hubs The presentation by Amanda Rimington, Senior Commissioning Manager – Primary Care and Pal Bhambra, AT Medics Senior Manager can be viewed here. The main messages were as follows:
The hubs offer evening and weekend NHS GP and nurse appointments to Camden residents andthose registered with a Camden-based GP. The service is open seven days a week, 365 days a year:6.30-8pm, Monday to Friday and 8am-8pm, Saturday, Sunday and bank holidays
The hubs are staffed by experienced GPs and nurses and offer routine assessment and treatment forboth adults and children. For example, minor injuries and infections, immunisations, vaccinations, urinetests and cervical screening.
The service, which is funded by Camden CCG and run by AT Medics, will provide around 34,840additional appointments a year in Camden (70% with a GP and 30% with a nurse).
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o Appointments are available at four local locations: (Brondesbury Medical Centre, CavershamGroup Practice, Somers Town Medical Centre & Swiss Cottage Surgery).
Attendees welcomed the presentation and the increased opportunity for patients to be cared for in general practice. PPG members also expressed an interest in whether their practices referred patients to the service and were willing to encourage practices where the referral rate could be higher.
Presentation 2: PPG success stories: Caversham Group Practice, the Listening Space - Garden Project The presentation by Roderick Allison, PPG Chair and Sheetal Shah, Practice Manager can be viewed here. The main messages were as follows:
Kings Fund report ‘Gardens and Health’ – outlines the case for the importance of gardening in fosteringwellbeing & collects evidence for garden/horticultural therapy projects & their link to better healthoutcomes.
Opened May 2017 - courtyard into internal garden. Patient volunteers from the PPG helped in the work& continue to help maintain the garden; promoting awareness to registered patients and localresidents.
The garden is like an imaginary village hall in the centre of Kentish Town, away from the stresses andstrains of everyday life, where patients and staff grow flowers and food that is shared; and whereseasonal celebratory gatherings are held "It's a gentle way to come together as a community: a baseto connect with people in a simple way”.
The majority of attendees welcomed the success of the garden project and the opportunity that different approaches bring to build relationships between a local practice and the community in which it is based. Two attendees felt that it was best for PPGs to focus on other matters such as local NHS plans for changing services in Camden. Roderick recognised the importance of local NHS plans but stressed that one model should not fit all PPGs and it was important to link with local communities in a variety of ways as this would build relationships between practices, PPGs and the local community in which they are based.
Presentation 3: Building effective PPGs The presentation given by Kathy Elliott, Vice Chair Camden CCG can be viewed here. The main messages were as follows:
What PPGs can contribute (user experience, patients as experts, range of skills and experience, localnetworks and links with the wider community)
What does a good PPG look like (active, making a difference to patients and the practice, visible topatients and the practice, achieving results, meeting the needs of the community, connects with otherPPGs, local community groups and other relevant organisations).
Attendees welcomed the presentation and the National Association Patient Participation Resource Pack for supporting practices in developing PPGs.
Presentation 4: Improving the Health and Wellbeing of Children and Young People The presentation given by Julia Mills (Head of Children's Joint Commissioning Team), Harriet Clarke (Children's Commissioning Project Manager) and parents from the Parents Advisory Board can be viewed here. The main message was as follows:
5 objectives of the commissioning team were explained in relation to improving health and wellbeingof children and young people in relation to mental health, universal health services, special educationalneeds and disabilities, ill health and long term conditions and supporting families and safeguarding.
Attendees welcomed the presentation, health quiz and the work of the Parents Advisory Board who supported and challenged the work of the commissioning team.
Presentation 5: Accessible Information Standard (AIS) in General Practice (Healthwatch Camden) Anna Wright, Policy Director Healthwatch Camden presented the outcome of the support visits. The presentation can be viewed here. The main messages were: One of the aims of the AIS is for public sector organisations to take steps to ensure that people receive
information which they can access and understand, and receive communication support if they needit.
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Healthwatch talked to the LMC and the CCG about these challenges and the CCG set up a smallaction group to make sure things got done.
Healthwatch with the support of the CCG have visited 20 of 34 GP practices so far and will visit therest over the coming weeks. The practices have been very grateful for the help. 100% of those visitedhave reported that the visit was “very helpful” and that they would recommend it to other practices.Healthwatch in collaboration with the clinical lead for learning disabilities have tailored easy read andlarge print annual health check letters and registration forms.
PPG members welcomed the presentation and reviewed the list of practices that have been visited to date and agreed to contact their practices to encourage visits if a date has not already been scheduled.
Presentation 6: PPG member survey feedback (future topics for forum meetings) Martin Emery, Communications and Engagement Team presented the interim survey feedback from PPG members. The presentation can be viewed here. The main messages were as follows:
Ranking of proposals from PPG members to date (GP Neighbourhoods, Social Prescribing & SelfCare, Performance of Local Care Providers (acute, community & mental health) and then the LocalCare Strategy / Sustainability & Transformation Partnerships (STPs) work.
You Said We Did Camden GP Hubs: PPG members welcomed the presentation and offered to help promote the service within their PPGs.
PPG success stories and building effective PPGs: PPG members welcomed the refresh on building effective PPGs and the success story as it helped people think beyond meetings in relation to supporting practices and connecting to local communities.
Improving the Health and Wellbeing of Children and Young People: PPG members welcomed the update and projects that the commissioning team were undertaking to improve the health and wellbeing of children and young people in Camden.
Accessible Information Standard (AIS) in General Practice: PPG members welcomed the practice support visits and offered to support Healthwatch and the remaining practices to tailor the annual health check letters and registration forms in easy read and large print.
PPG member survey feedback (future topics for forum meetings): Attendees asked that the survey is disseminated to PPGS again to improve the response rate.
Camden CCG have: Disseminated the presentation to PPGs and the public via the PPG newsletter and website.
Camden CCG will: Continue to promote the service and encourage PPGs to support practices in raising awareness of the service.
Camden CCG have: Disseminated the NAPP resource pack and raised awareness of the Garden Project with PPGs via the public website and PPG newsletter.
The difference this will make is bring to people’s attention that there is more than one way that a PPG can operate and connect to its local community.
Camden CCG has: Disseminated the presentation to PPGs and the public via the PPG newsletter and public website.
The commissioning team will: Think about how PPGs can engage with families to promote health and wellbeing with the support of clinical lead for children and young people.
The difference that this will make is getting the commissioning team and PPGs to work together to access families who would benefit from the work of the programmes to improve health and wellbeing.
Camden CCG will: Continue to support Healthwatch Camden and PPGs schedule support visits for the remaining practices (N=14).
The difference this will make is ensuring that PPGS become more aware of AIS and be able to support practices in meeting its standards.
Camden CCG has: Disseminated the survey to PPG members and will schedule the topics into PPG forum and open meeting schedule with the approval of CPPEG.
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2. Business Plan Objective E: Work jointly with the people and patients of Camden to shape theservices we commissionThe following summarises other key engagement activity undertaken by the CCG over the last two monthsto support Objective E:
Mental health The communications and engagement team supported the mental health commissioning team in organising a focus group of service users to review content of the mentalhealthcamden website to ensure that it has the right content and functionality (the website can be viewed here) on 1 February. In addition to this the communications and engagement team are also supporting the forthcoming roll out of mental health teams aligned to primary care neighbourhoods, including Mental Health staff and Voluntary Community Sector (VCS) staff.
Medicines management The communications and engagement team are supporting the Medicine Management team in responding to the national NHSE guidance on reducing prescribing of over-the-counter (OTC) medicine for minor and short-term health concerns. Published on 29 March 2018, it lists 33 minor health concerns, identified by a national joint clinical working group, which are either self-limiting or suitable for self-care. Vitamins/minerals and probiotics have also been included as items of low clinical effectiveness which are of high cost to the NHS. Camden CCG are currently considering whether to follow the guidance which could result in a public consultation.
Local care strategy The communications and engagement team are supporting commissioners in the publication of tendering specifications for new social prescribing services to be appointed to run services from autumn 2018.
Citizens Panel The contract for MES (Service Provider) has been extended for an additional 12 months and the membership (1,200) is currently being refreshed to ensure that the panel reflects as best as possible the demographics of the Camden population. The panel is currently being consulted and asked to return a self-care survey. The purpose of the survey is to measure a person’s level of activation to ascertain individual’s levels of knowledge, skills and confidence to assume responsibility for their own health and well-being. Once the response have been received the CCG will use the Patient Activation Measure (PAM) and the results will be presented at CPPEG. Panel members have also received a survey from MES asking for feedback on their experiences of sitting as a panel member over the previous 12 months.
Patient self-care workshops being delivered in Camden The communications and engagement team supported Dr Sarah Morgan in promoting workshops via social media, local networks and the PPG newsletter. The workshops were delivered to support reducing pressure in General Practice and A+E by:
encouraging patients to self-manage minor ailments promoting Thinking Pharmacist first educating patients about when to see their GP /use A+E advising on the impact of lifestyle on health and local resources to support showing patients what role pharmacists can play to improve health
Collaboration with Healthwatch Camden – patient feedback The communications and engagement team has supported Sally MacKinnon, Transformation Programme Director in commissioning Healthwatch Camden to collate patient feedback in (a) to ascertain the effectiveness of the Admissions Avoidance (Rapids) service and (b) to ascertain the effectiveness of the Discharge to Assess service (supporting patients to avoid hospital admission or come out of hospital without delay once they are medically fit to do).
Universal Offer The communications and engagement team are supporting commissioners in the development of the universal offer contract across Camden general practice, comprising Post-Operative Wound Care, Planned Care (including End of Life Care), Asthma Service for Children, Immunisation, High-Risk Drug Monitoring, Anticoagulation, IUCD/IUS and Homelessness.
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National General Practice Survey The communications & engagement team supported the Primary Care team by raising public awareness of the national survey via our website, social media and PPG newsletter which ended on the 31 March.
Camden Council & St Pancras & Somers Town Living Centre drop in sessions The communications and engagement team supported the local council in raising awareness offering residents of all ages’ practical support on dealing with hearing loss over the last 2 months.
Voluntary Community Sector (VCS) In the feedback from NHSE to the CCG on our compliance with statutory guidance standards of patient and public participation in commissioning health care, the CCG was asked to consider how the CCG can engage and collaborate in different ways with the VCS and in specific networks. To address the guidance the communications and engagement team and vice chair of the CCG are meeting with local representatives from the VCS to grow our understanding of the voluntary sector in Camden.
Part of the work involves getting a better understanding of the Centre for Independent Living (CIL) (click here for additional information). CIL is a network of organisations, which is run and managed by people with disabilities to provide a range of services and activities that will offer a range of services and activities that support independence, inclusion, health and wellbeing. The work of CIL will be presented to CPPEG and CCG staff later in 2018/19 focusing on four elements of the work (information, advice, signposting and a new model of engagement).
Camden Carers Service Annual General Meeting The communications and engagement team supported Dr Sarah Morgan, elected GP representative in raising awareness of the CCG’s contribution to supporting carers in the local community (for example, improvements in identifying and supporting carers in general practice, consulting with local carers in improving end of life care for patients, working with carers to reduce admission to hospital settings, carer health and lifestyle consultations and Camden Carers Service involvement in supporting integrated care teams.
University College London Hospital NHS Foundation Trust (UCLH) Kathy Elliott, Vice Chair Camden CCG met with the Non-executive UCLH Board member, with responsibility for patient involvement (Altheae Funshile) to discuss patient experience. It was agreed that representatives from UCLH will return to CPPEG to report progress with implementation of the patient experience strategy. Key areas of concern that remain relates to patient experience of waiting times in A&E, outpatient appointments and discharge from hospital, as well as concerns raised by CPPEG about improving patient letters (both the content and timeliness in being sent to general practices and between providers when patients are transferred). Representatives from UCLH will return to a CPPEG open meeting to update and follow up on past presentations and actions.
The Francis Crick Living Centre and Somers Town Medical Centre The communications and engagement team supported Hilary Lance, Chair of CPPEG in connecting the Lead Director for the Living Centre and clinical staff from Somers Town general practice to improve the health and wellbeing of local residents in Camden.
Citizens Space Training Citizens Space provides software for Camden CCG to design and disseminate patient surveys and a training workshop was held for CCG and general practice staff in April. Attendees were trained on how to create online surveys, how to use online surveys effectively with social media and how to best design surveys with analysis in mind.
3.0 Looking ahead The following activity is currently planned for May/June 2018: Tuesday 12th June – CPPEG open meeting The communications and engagement team are working with Camden & Islington Foundation Trust
and Islington CCG to undertake a public consultation on the redevelopment of St Pancras Hospital siteover the summer 2018
General Practice AIS support visits by Healthwatch Camden (May/June 2018).
Throughout 2018, the Communications and Engagement team will look at how we:
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Can best support commissioners to share information transparently with residents about servicechanges or consultations under consideration
Link commissioning decisions being taken at a North Central London (STP or Joint CommissioningCommittee) level into our local Camden patent and public engagement activity and communicationchannels.
Include examples of the impact that patient and public engagement work has on commissioning plansand decisions in future Patient Voice reports, which Lay Member Kathy Elliott will highlight (linked toNHS England Assurance Rating feedback on Domain D).
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Camden Clinical Commissioning Governing Body 09 May 2018
Report title Quality and Clinical Effectiveness Report Agenda item 3.4 Date 09.05.18
CCG Clinical Lead
Charlotte Cooley Tel/Email [email protected]
Lead director Neeshma Shah Tel/Email [email protected]
Report author Quality and Safety team Tel/Email [email protected]
Report summary This report provides a summary of key quality, safety and clinical effectiveness information for Camden CCG.
Areas to highlight to the Governing Body are:
UCLH UCLH provided assurances to the Clinical Quality Review Group (CQRG) regarding the implementation of learning at the Eastman Dental Hospital (EDH), following six Never Events (NE) that occurred in dental surgery between 2014 -2017. A review of indicators in the quality improvement plan for Hyper Acute Stroke Unit (HASU) and Stroke Unit (SU) showed significant improvement in transfer times to the SU, the door to needle time to receive thrombolysis was at a median time of 26 minutes. The Quality Account priorities for 2018-19 were agreed.
RFL Concerns were raised at the Governing Body meeting in March that ‘retained foreign object’ has been cited in previous incidents, and that perhaps previous action plans were either not implemented or did not identify the necessary mitigating solutions. Assurances were provided to CQRG that these have been isolated incidents some of which have occurred in other areas outside of the theatre suite, where invasive procedures are undertaken, e.g. Interventional Radiology.
CIFT Following a CQC inspection in December 2017 the trust was rated outstanding for being effective, good for being caring, responsive and well-led and requires improvement for being safe. Overall the Trust rating was upgraded from “requires improvement” in 2016 to “good”. A Quality Summit was held on 08 March 2018.
T&P The Trust have informed commissioners that they will not meet the NHS England Prevent requirements of compliance by the end of March 2018.
NCL quarter 3 Serious Incidents The themes and trends identified within investigation reports for Serious Incidents (SI) which occurred within NCL Trusts during Q3 were discussed, together with the mitigating actions being undertaken by Trusts with their lead commissioner.
Purpose Information Approval To note Decision
Recommendation The Governing Body is asked to NOTE the content of this report.
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Strategic objectives links
Objective A: Commission the delivery of NHS Constitutional rights and pledges Objective B: Improve the quality and safety of commissioned services Objective C: Improve health outcomes, address inequalities and achieve parity of esteem
Identified risks and risk management actions
Provider management of quality and safety issues affecting patient care and experience. These are being managed through regular clinical quality review (CQR) meetings and regular liaison with respective provider leads.
Resource implications
Competent and appropriately resourced CCG teams
Equality impact analysis
An equality impact assessment has not been conducted on this document as it is a summary report and record of the key outcomes of the Quality and Safety Committee meeting.
Report history This report is a summary report of the work of the QSC. Next steps None. Appendices None.
Glossary
CIFT Camden and Islington NHS Foundation Trust CHIP Camden Health Improvement Practice CHR Clinical Harm Review CPR Cardiopulmonary resuscitation CQC Care Quality Commission CQRG Clinical Quality Review Group CRG Clinical review Group CSCB Camden Safeguarding Children’s Board DNA Did Not Attend ED Emergency Department EDH Eastman Dental Hospital ITU Intensive Theatre Unit LCW London Central West Unscheduled Care Collaborative LD Learning Disability LSCB Local Safeguarding Children Boards MCA Mental Capacity Act MDT Multidisciplinary Team NRM National Referral Mechanism NCL North Central London NE Never Event NEWS National Early Warning Scores NHSE NHS England NHSI NHS Improvement QSC Quality and Safety Committee RFL Royal Free London Foundation Trust RTT Referral to Treatment SI Serious incidents STP Sustainability & Transformation Partnership T&P Tavistock and Portman NHS Foundation Trust UCLH University College London Hospital NHS Foundation Trust WHO World Health Organisation WRAP Workshop to Raise Awareness of Prevent
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Executive summary
This report provides an update on Provider quality and safety, medicines management and the CCG’s statutory duties under safeguarding children and vulnerable adults.
The CCG’s Quality and Safety Committee (QSC) received additional reports relating to Integrated Urgent Care and London Ambulance Service, InHealth, NCL Providers’ Serious Incidents and Never Events, Safeguarding Adults, Safeguarding Children, Quality Surveillance Group, the Camden Medicines Management Committee, Improving Access to Psychological Therapies (IAPT), Team Around the Practice (TAP), Diabetes Integrated Practice Unit, and Camden Children and Young People Atopy services.
Key points and actions from these reports and discussions are noted below. The Quality and Clinical Effectiveness Risk Register is reviewed monthly.
University College Hospital London (UCLH)
UCLH provided assurances regarding the implementation of learning at the Eastman Dental Hospital (EDH), following six Never Events (NE) that occurred during dental surgery between 2014 - 2017. This is captured in an internal publication for the staff At the Sharp End. UCLH have adopted the approach used by the aviation industry, referred to as the ‘dirty dozen’, which identifies the most frequently recurring factors. Key points to note;
1. Simulated training has been developed and delivered by the Consultant Oral Surgeons, using casesstudies and role play.
2. Implementation of the EDH Safer Dental Surgery Policy, which places an emphasis on thoseprocedures which are classified within the National Safety Standards for Invasive Procedures(NatSSiPs).
3. The implementation of customised checklist, modelled on the World Health Organisation (WHO)Surgical Checklist used within theatres for all invasive dentistry in the ambulatory setting.
4. The Dental Outpatients Department have developed a bespoke audit tool, which focuses onindividual and team behaviours.
Feedback and learning from incidents is embedded within lectures, audit and governance days.
A review of indicators in the quality improvement plan for Hyper Acute Stroke Unit (HASU) and Stroke Unit (SU) showed significant improvement in transfer times to the SU, and the door to needle time to receive thrombolysis was at a median time of 26 minutes (target of 90% within 45 minutes). The HASU is now running a 7-day clot retrieval service. Improvements still need to be made in the provision of psychology services within the HASU, though there is better provision in the brain injury unit. UCLH did not achieve the standard of 95% of patients receiving swallow screening within the first four hours. An e-learning swallow screening tool has been designed and is being rolled out to the HASU doctors and is now mandatory training for the role. This is being observed by Speech and Language Therapists.
Clinical Harm Reviews (CHRs) continue to be undertaken by the Trust on patients who have breached the Referral to Treatment (RTT), and 62-day cancer targets. There have been no incidents of harm associated with waiting times reported to date. UCLH has struggled to meet some of the national cancer standards. Clinical cancer discussions challenged UCLH to reduce delays in patients who have co-morbidities to ensure that any assessment of the co-morbidity is given sufficient urgency, to improve reporting of the cancer staging data and tackling capacity issues in urology.
Assurances were provided to the CQRG by the maternity subgroup of the reduction in the numbers of women sustaining 3rd and 4th degree tears following the implementation of a number of measures. This includes the provision of a training room on the labour ward enabling training to be delivered in the clinical area and creating opportunities for a multidisciplinary approach to learning from incidents. The division has good compliance with mandatory training, and have successfully secured funding from Health Education England (HEE) to introduce a new midwifery role of Advanced Midwifery Practitioner,
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to support the professional development of midwives whilst enhancing the care and experience of women. As part of this UCLH have launched a “restorative approach to managing challenging situations” for doctors and midwives to improve patient experience. The division’s focus on identifying root causes of incidents and learning from these was evident in their report to the CQRG. The Trust has undertaken a gap analysis against the ten actions within the NHS Resolution Clinical Negligence Scheme for Trusts (CNST) incentive scheme.
Analysis of patient experience data showed that the main areas of concern continue to be cancellations and waits, communication and patient transport. A report on workforce and capacity indicated that nursing and midwifery staffing was not an issue during the winter pressures period. UCLH relayed the challenges of recruiting theatre nurses and are considering setting up a theatre training school in order to meet this gap as existing theatre nurses leave.
Royal Free London (RFL)
The Trust advised the CQRG that there have been ten Never Events (seven at the Hampstead site and three at the Barnet site) since 01 April 2017, and not eleven as reported to this committee in March. The investigation into this case concluded that the retained swab identified during an outpatient appointment, was a gauze pack inserted by the community nursing team, as part of their on-going care for the patient.
Concerns were raised at the GB meeting in March that ‘retained foreign object’ has been cited in previous incidents, and that perhaps previous action plans were either not implemented, or did not identify the necessary mitigating solutions. Assurances were provided to CQRG that these have been isolated incidents, some of which have occurred in other areas outside of the theatre suite, where carry invasive procedures are undertaken e.g. Interventional Radiology. Due to the individual nature of these incidents that could lead to patients being identified, the event details are not provided in this report.
Barnet CCG, in their role as lead commissioner, had requested a review of all Surgical Never Events. The Trust have taken immediate actions in response to these incidents and oversight will be maintained through the monthly CQRG meetings. At a meeting with representatives from Barnet CCG, NHS England and NHS Improvement, the Trust presented a wide range of information about their improvement programmes, human factors reviews, and evidence of implementation of actions from previous NEs, results of relevant clinical audits and how the learning and governance approach has been shared across divisional, hospital and group level. The regulators and commissioners were satisfied that there was engagement from clinicians at all levels and that there was a clear improvement plan in place.
• A Task and Finish Group has been established, chaired by Clinical Lead for Safer Surgery andMedical Director for Chase Farm Hospital. This group are reviewing all Never Events which haveoccurred over the previous two years to identify trends, themes and further learning. It is anticipatedthat this review will help to establish whether learning identified in the earlier Never Events had beenembedded.
• Local Safety Standards for Invasive Procedures (LocSSIPs), where invasive devices are inserted inenvironments outside of operating theatres e.g. ITU and radiology, have been developed by theTrust.
• The Trust have also enlisted external peer support from the Association of Perioperative Practice(AfPP), to review processes within theatres.
• Work is underway to explore Human Factors within theatres; the Trust are working with a PhDstudent from Loughborough University to support this work.
• There is a culture of openness and transparency within the Trust in identifying and reporting whenthings go wrong. The Trust acknowledge that they need to review data relating to “Near misses” tounderstand why these events almost occurred, and what learning and changes resulted from these.
• Once the final SI investigation report is submitted in May, another quality visit will be undertaken byNHSE, NHSI and Barnet CCG to review the implementation of all actions to date.
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• Oversight and governance in relation to all SIs and NE will continue through CQRG, where these arestanding agenda items.
Clinical Harm Reviews (CHRs) continue to be undertaken by the Trust on patients who have breached the Referral to Treatment (RTT), and 62-day cancer targets. There have been no incidents of harm associated with waiting times reported since the last update to this committee.
Camden and Islington Foundation Trust (CIFT)
The Care Quality Commission (CQC) completed a full inspection of services provided by the Trust in December 2017. Following this inspection in December 2017 the trust was rated outstanding for being effective, good for being caring, responsive and well-led and requires improvement for being safe.
The Trust hosted a Quality Summit on 08 March 2018, where the CQC were complimentary of the work undertaken by the Trust to make the necessary improvements following the findings of the previous inspection in 2016.
Positive findings:
• The trust had made good progress in ensuring that patients had their physical health care needsmet. For adults being supported by the community recovery and rehabilitation teams, weekly physicalhealth clinics were being developed. These had a particular focus on supporting patients who werehard to engage or not registered with a GP to ensure their physical health needs were addressed.
• Existing Executive team has been strengthened and has supported the Trust to make the necessaryimprovements as identified during the previous inspection.
• The inspectors complimented the Trust on their Clinical Strategy, which was co-produced withpatients and carers, and focused on the needs of the local population.
• Evidence that governance processes in the Trust had been strengthened in relation to, Risk management. Management of incidents and complaints.
The CQC and stakeholders attending this Quality Summit, recognised the work undertaken by the Trust to be rated as Good. The inspectors recognised that the Trust still faced many challenges and were not assured of the safety of services provided by the Trust for the following reasons:
• On the acute wards records of restraint did not always include details of the type of restraint used,the names of the staff involved and the length of time that staff restrained the patient.
• Staff were not always ensuring patients were aware of the need for close physical health monitoringpost rapid tranquilisation.
• In circumstances where patients initially refused observations, staff did not always return to askagain.
• At the time of inspection, 63% of staff had completed their Mandatory Training. Mandatory Trainingcompliance for Cardiopulmonary resuscitation (CPR) was identified as an area of concern. The Trusthave explained that although the position is improving, it recognised that was impacted by a changeover from Basic Life Support (BLS) to Intermediate Life Support (ILS) part way through the year. TheTrust have now increased the training compliance percentage rate to 80% trust wide.
• Vacancy rates were highlighted as a concern area. During November 2017, eight out of elevenwards were reported as having vacancy rates of 20%.
• Within the long stay / rehabilitation wards, staff were aware of the Safeguarding processes within theTrust. However, individual services did not keep a record of safeguarding concerns which had beenreported to the local authority and the relevant outcomes.
The CQC have served three requirement notices to the Trust as detailed below.
1. Regulation 9 HSCA (RA) Regulations 2014 Person-centred Care.2. Regulation 12 HSCA (RA) Regulations 2014 Safe care and Treatment.3. Regulation 18 HSCA (RA) Regulations 2014 Staffing.
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Areas where the Trust must make improvements include:
• Ensuring that the completion of mandatory training relating to patient safety reaches the Trust targetas a priority.
• On acute wards for adults of a working age and psychiatric intensive care units the Trust mustemploy sufficient staff to ensure that the shifts are covered. The service must ensure that staffconsistently complete comprehensive records after all incidents that involve staff restraining patients.
• On long-stay wards the Trust must ensure that patients on inpatient rehabilitation wards have accessto sufficient occupational therapy input.
• The Trust must take action to address high caseloads, and individual workloads for staff in theIslington Crisis Resolution and Home Treatment Team (CRHT), and the high turnover of staff acrossthe CRHTs.
The Trust have developed a CQC compliance schedule and action plan to be presented to the Trust Board in March 2018, progress against this will be monitored through CQRG.
Tavistock and Portman NHS Foundation Trust (T&P)
The substantive post for Adult Safeguarding commenced work in April.
The Trust informed CQRG in March that while there has been an improvement in training compliance for Workshop to Raise Awareness of Prevent (WRAP), they will not meet the NHS England requirements of compliance by the end of March 2018. This has been added to the Trust’s Risk Register.
North Central London (NCL) Quarter 3 Serious Incident Trend Report
The QSC considered the themes and trends identified within investigation reports for Serious Incidents (SI), which occurred within NCL Trusts during Q3.
The top themes identified from the SI reports across all the NCL Providers reviewed during Q3 are:
1. Communication - Improving Communication within teams and in the wider multidisciplinary team(MDT).
2. Staff knowledge and training - ensuring that all staff have completed statutory and mandatorytraining and are up to date with role specific training.
3. Deviation from policy / protocol - to ensure that protocols are current and that staff are aware oftheir existence and content. Staff need to know how to access the documents and they should bereadily available and accessible to staff.
4. Human Error - ensure that all staff are aware of the factors influencing human error.5. Gaps in protocol - to ensure that protocols are current and that staff are aware of their existence
and content. Staff need to know how to access the documents and they should be readilyavailable and accessible to staff.
Assurances regarding the implementation of learning from SI actions plans is obtained through lead commissioners and their respective providers.
Integrated Urgent Care and London Ambulance Service (LAS)
The 2017 media SI external review report was shared with commissioners at an extraordinary clinical quality review meeting on 16 February 2018. The review confirmed LCW’s Serious Incident Investigation findings, that there was no patient harm, and some care and service delivery issues were identified. The external review team made recommendations for consideration by commissioners and the provider, which are being taken forward by Enfield CCG, as lead Commissioner for the service on behalf of NCL CCGs.
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LCW was inspected by the CQC during the week 22 to 26 January 2018. Initial feedback given to the provider was largely positive. No immediate actions were required or warning notices issued. The full CQC report is expected to be by published in May 2018.
The CQC inspected LAS on the 21 – 22 March 2018, focusing on the ‘Well Led’ domain. In addition there will be one unannounced and one short notice focused inspection of at least one core service. The outcome of these inspections was not known at the time of writing this report.
Diabetes Integrated Practice Unit (IPU)
NHS England rated Diabetes Care as “outstanding” in Camden during the 2016/17 Improving and Assessment Framework (IAF), which was published in January 2018. A quality schedule specific to the IPU is being agreed as part of the 2018-19 contract with Royal Free London.
InHealth Diagnostics Services
Camden CCG is the lead commissioner for this service on behalf of NCL CCGs. There were 37 incidents reported in Q3 2017/18 and none met the threshold for a serious incident (SI).
The QSC requested further detail relating to these incidents to be assured that themes were being identified and lessons learnt. The Provider has also shared information relating to complaints, and will be asked to separate patient complaints from the alerts raised by referrers as currently InHealth is capturing the data and learning all under “complaints”.
A meeting is due to take place to discuss how the report from InHealth is strengthened to provide this assurance going forward. The CCG has oversight of referrer concerns and feedback through the quality and safety team’s Quality Alert System (QAS).
Q3 2017/18 Safeguarding Adults Report
Safeguarding Professionals The Designated Nurse for Safeguarding Adults provided Safeguarding training for new Governing Body members during Q3. The mandatory training compliance target for CCG staff is 95%, Safeguarding adults training is at 78%, while Basic Prevent Awareness has increased from 14% to 53%. The Named GP and Designated Nurse facilitated the first of the Practice Safeguarding Adults Leads Network which was attended by 27 practices and well evaluated.
Prevent The Designated Nurse for Safeguarding Adults, as Prevent Lead, represents the CCG on the Camden Channel Panel and regional forums. NHS Trusts and Foundation Trusts are required to demonstrate 85% of staff requiring specialist Prevent training have received it by March 2018. Providers have either reached this or are close to achieving this and development of this area of safeguarding continues. Member practices have access to prevent training through a new e-learning package on the intranet or from the Designated Nurse and Named GP.
The Learning Disability Mortality Review Programme (LeDeR) The LeDeR Programme supports local reviews by health and social care professionals of deaths of people with learning disabilities (LD) aged four years and over in England. The Designated Nurse for Safeguarding Adults fulfils the CCG Coordinator role for LeDeR in Camden, where reviews are either completed or in progress with one referred for Safeguarding Adults Review. Learning is reported to the STP Lead, NHS England, the CCG and the Safeguarding Adults Board with an action plan for Camden in development.
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Statutory Reviews
Safeguarding Adult Reviews (SAR) Learning from the YY SAR has been shared with practices through the Practice Safeguarding Adults Leads Network. The CCG has an action plan in response to the SAR which will be monitored through the Safeguarding Adults Partnership Board (SAPB) and updated by the Named GP and Designated Nurse.
A SAR for Adult D, has been commissioned by Brent Safeguarding Adults Board. Adult D was known to a number of agencies at the time of his death and was registered at a Camden CCG practice. The Named GP is producing an analysis of clinical practice and the Designated Nurse will provide panel membership.
Domestic Homicide Reviews (DHR) A DHR was commissioned by the Community Safety Partnership Board (CSPB) following the murder of a woman in Camden by her partner. The CCG have completed their actions from the review and disseminated the learning points through the Practice Safeguarding Adults Lead Network. The DHR report was approved by the Community Safeguarding Partnership Board (CSPB) in Q2 and is awaiting approval from the Home Office for publication.
Care Homes There is an expectation from partner agencies that the CCGs, as commissioners of health care, will oversee arrangements or directly contribute expertise regarding clinical support for safeguarding and quality in care homes ranging from individual cases of abuse and neglect through to organisational abuse and quality assurance and monitoring of providers. The Quality and Safety Assurance Lead provides support to the local authority care homes quality team and the Designated Nurse and Named GP provide safeguarding advice and support where appropriate
Q3 2017/18 Safeguarding Children Report
Assurances were provided to the committee regarding the arrangements for safeguarding children in Camden: • Training Compliancy reports for CCG Staff and Governing Body Members, demonstrate compliancy.• The “Child Protection Case Conference Support Scheme for GPs” is continuing to demonstrate
improvement which is being maintained. Compliancy during Q3 is at 90%.• Camden providers provide safeguarding assurance through their quarterly safeguarding metric
reports. These reports include data in regards to structures, supervision, compliancy with training andchild protection case conference participation.
• The Named GP lead, with support from the Designated Nurse, continues to support the learning anddevelopment within GP practices through regular planned GP Forum meetings. A safeguardingtraining programme has been developed in conjunction with the CNWL Named Nurse for GPs,Health Visitors and School Nurses, focusing on neglect, promoting joint working and informationsharing with a ‘Think Family’ approach.
UCLH have not provided data in regards to their maternity domestic abuse screening. The Named Nurse and new Named Midwife investigated this and report that screening has been embedded within maternity and that the data reports are being collected by the Maternity Matrons, but not being shared with the safeguarding team. The Designated Nurse has escalated this issue to the Director of Midwifery and an update will be provided within the next safeguarding report to the QSC in June.
T&P have improved their internal mechanisms to record participation with child protection case conferences. However, commissioners are not assured that the Trust have a robust mechanism for recording supervision. The Trust were requested to review their current processes by the CCG designated nurse for Safeguarding Children.
The Safeguarding Team at London Central West Unscheduled Care Collaborative (LCW) have not provided any safeguarding training data for Q3. This has been raised with their lead commissioner (Enfield CCG) and the Designated Nurse, who will action this. LWC’s Safeguarding Team report that all GPs have to evidence compliancy with safeguarding training before they commence employment. The
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Designated Nurse for Enfield has joined LCW’s safeguarding committee and plans to raise safeguarding training assurance reporting.
Brook, Brandon and the Homerton University Hospital NHS Foundation Trust Young People’s Sexual Health Services
The safeguarding assurances monitoring arrangements for this service have changed for 2018. Previously these services were monitored in in conjunction with the designate team at Islington, but they have now incorporated the review of this service in their internal safeguarding commissioning committee. The new arrangements for Camden are for the Designated Nurse to review the quarterly safeguarding commissioning reports and she will attend the commissioning monitoring meetings bi-annually. Their safeguarding lead will continue to engage in the Camden Safeguarding Children’s Board (CSCB) Health Committee.
Child Death Overview Panel (CDOP)
In February the CDOP received notification of death of a young male who had died as a result from a stabbing incident. This death is being reviewed as part of Camden Safeguarding Children Board Child Death Overview Processes and police investigations are in process. A CDOP Rapid Response Meeting has taken place and a second follow up meeting has been arranged.
CSCB Peer Learning Event
Local Safeguarding Children Boards (LSCBs) are required to hold learning reviews as part of their improvement framework. A Peer Learning Event was arranged and facilitated jointly by Camden’s Children’s Social Care Quality Assurance Lead and the Designate Nurse. The case chosen involved a young baby who sustained a physical abuse injury. Practitioners who were directly involved in this case took part in this review.
The learning themes identified from this review were; 1. The need to increase awareness of the CSCB Escalation process.2. The need to improve communication processes (for health agencies it was evident that they
needed to strengthen their reporting on how potential parental health risks can impact onparenting.)
3. The need to improve safer discharge planning.
The evaluations from this event were positive and practitioners were able to reflect on their practice.
Camden Medicines Management Committee (CMMC)
The CMMC considered guidelines that support various elements of the STP prescribing work streams and the QIPP programme for prescribing for 2018/19. The guidelines comprising either local Camden prescribing recommendations or approval of NCL guidance were assessed by the Committee with regards to quality, safety, clinical effectiveness, cost efficiency and evidence base. The guidelines assist with fulfilment of the twin aims of managing clinical variation and managing financial risk.
The documents approved by the Committee included new indicators and updates for some of last year’s indicators. One of the new review documents focuses on repeat prescribing, with the aims of ensuring that practices have robust governance arrangements in place that includes clinical authorisation of repeat lists and request processes optimising use of GP Online. This review should also assist in identifying any potential areas of medicines waste.
The Committee discussed the differences between guidelines produced by NICE and by the British Thoracic Society / Scottish Intercollegiate Guideline Network (BTS/SIGN) on the management of asthma. The Committee suggested recommendations for making prescribers aware of the differences.
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The Committee approved updates to the home oxygen guidance and referral pathways. The updates include details for referring to the Camden Home Oxygen Assessment and Review (HOS-AR) service, which is now operational and accepting patient referrals.
An update to a patient information leaflet on self-monitoring blood glucose levels was also approved. The leaflet includes information on when self-monitoring is essential, when it is recommended, and when it is not necessary. The leaflet has been updated to signpost those who drive and have diabetes to the Driver & Vehicle Licensing Agency (DVLA). The DVLA has further information on what drivers with different types of diabetes need to tell DVLA by law. The leaflet incorporates suggestions kindly made by the Camden Reader Panel Group to improve its accessibility.
To uphold transparency the Committee was reminded of the “Sunshine Rule”, which requires CCGs staff to declare gifts and hospitality received from any suppliers including pharmaceutical companies. Conflict of Interest (CoI) declarations apply to GP Practice (staff) in their role as membership practices of the CCG and all practice staff should be made aware of the respective CoI, its impact, and consequences.
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title PMS Contracts and Reinvestment contracts Agenda Item 4.1 Date 09.05.18
Committee Chair N/A
Lead Director Sally MacKinnon Tel/Email [email protected]
Report Author Sally MacKinnon Tel/Email [email protected]
GB Sponsor(s) Sarah Mansuralli Tel/Email [email protected]
Report Summary The report presents some late feedback from practices on the PMS contract and the LES Reinvestment contract. The feedback covers a wide range of areas and each area is addressed in the report with an associated recommendation.
Purpose Information Approval X
To note Decision
Recommendation Camden CCG Governing Body are asked to approve the following recommendations:
1. Seniority factor payments for PMS practices in Camden is agreed as a2 year process to be concluded in 2020 but that there is no adjustmentto the actual payment in recognition that this change should have beenagreed on a phased basis from 2015.
2. Practices are informed about how baseline payments will be alignedover time
3. Amend the title of the ‘Camden CCG PMS Premium Locally EnhancedService Contract’ to ‘Camden CCG PMS Premium ReinvestmentContract.’
4. Inform practices about the NCL proposal and the commitment that PMSpremium is invested in practices is embedded in the PMS reviewprinciples notably principle 7 (see appendix 1)
5. Confirm that the CCG will start discussions about the future use of theinvestment 6 months before the end of the contracted period or theextended contract period whichever is in place.
Strategic Objectives Links
• Improve the quality and safety of commissioned services• Improve health outcomes, address inequalities
Identified Risks and Risk Management Actions
Please see section 3 of main report
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Conflicts of Interest
GPs on Governing Body all have a potential conflict of interest on this item as all practices stand to benefit from the PMS premium reinvestment therefore GPs will not be allowed to vote on this item.
Resource Implications
None associated with these changes
Engagement Discussions with representative form the Local PMS Reinvestment group and the NCL PMS reinvestment group both of which included GPs
Equality Impact Analysis
These matters have been fully considered as part of the development and agreement of the service specification which is not being changed in the current proposals
Report History and Key Decisions
GB agreed the PMS reinvestment on 1st December 2017 Procurement committee considered the reinvestment on 15th Nov 2017
Next Steps CCG to announce decision to the PMS negotiating team and members of the Local PMS reinvestment group.
Appendices Appendix 1 PMS Review Principles
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1
PMS CONTRACTS & PMS PREMIUM REINVESTMENT CONTRACTS
FOR CAMDEN CCG GOVERNING BODY FORUM – 25TH APRIL 2018
1. Introduction
This paper is seeking approval from the Governing Body on final changes to the agreed PMS reinvestment proposal in response to some late feedback given by PMS Representatives (Camden GPs) on the contract documents that have been issued by the CCG.
The key decisions already taken as part of the governance of the PMS proposals have included:
• CCG Procurement Committee approved the specification and contract proposal on 15thNovember 2017
• NCL Primary Care Committee in Common approved the specification and proposal on17th November 2017
• NHSE/LMC Assurance panel assured the specification and proposal on 28th November2017
• Camden Governing Body noted the specification, proposal and associated risks in part 2of meeting on 6th December 2017
Camden CCG submitted draft contract documents in December 2017 and practice letters in January 2018 to the London-wide LMC for comments. These were agreed in February and March 2018 respectively. The relevant documents were issued to practices on the following dates:
• 9th February 2018 - PMS contract offer letter issued • 8th March 2018 - Final PMS and LES contract pack issued
The final date for signing of the PMS and LES contracts was agreed as the 31st May 2018 but it was also agreed with NHSE that the contract start date would be back dated to the 1st April 2018.
2. Feedback from PMS Representatives
Following the issuing of the contract pack on 8th March, PMS Representatives have raised the following concerns with regards to the PMS (Core) Contract and the PMS Premium Locally Enhanced Service Contract following advice from their lawyer:
PMS (Core Contract)
1. Seniority payments – asking for agreement on how these will be paid to be agreedbefore signature of PMS contracts
2. Contract baseline changes – query on how these will be applied to the PMS contractover the period of the transition
Camden CCG PMS Premium Locally Enhanced Service Contract 3. The title – ‘Camden CCG PMS Premium Locally Enhanced Service Contract’ to
remove the LES reference4. Contract length - proposed extended to 5 years to allow for full effect of transition within
the contract period
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2
5. End of contract term arrangements – indicating they would like agreement on what willhappen at the end of the contract term
The key issues and recommendations on each of these matters are summarised below:
PMS (CORE) CONTRACT
1. Seniority payments
PMS Representatives have suggested that these payments have been specified separately in the finance documentation and PMS practices will require written confirmation that NHSE will continue to make these payments to practices in addition to the PMS transition and other payments. PMS representatives have indicated that they expect the CCG to obtain this confirmation prior to signing the contract.
RESPONSE: Seniority factor payments were introduced as part of the new General Medical Services (GMS) contract in 2004. Payments are part of an individual GP’s pay in recognition of length of service and related to qualifying income, although they are paid to the practice. Seniority payments are currently paid to PMS practices in Camden as part of their baseline payments. There have been no adjustments to date. The total value of Seniority payments made to the 15 PMS practices across the whole of Camden is currently £280,954 per annum.
It has been agreed nationally that seniority payments will cease altogether on 31 March 2020, with the total amount reinvested into the global sum. The first reductions and reinvestment took place elsewhere in October 2015 and will last for a 6 year period, ending in March 2020. Seniority payments to Camden’s GMS practices are also being phased out in this way.
There are 3 other boroughs in London that have seniority for PMS practices paid into the baseline they are: Tower Hamlets who cease payments in the second year of transition of their PMS contract (2018/19), Waltham Forest and Barking and Dagenham who we understand have also made a phased exit in line with the national timetable.
Seniority payments are not related to the PMS contract issues and therefore the linking of this with the PMS premium contracting process is misleading. However, the PMS practices are in a different position to other local practices on seniority and it is part of the CCG’s responsibilities to come to a local arrangements to phase out seniority in the absence of NHSE having undertaken this in 2015. The three options available to the CCG include:
1. Decouple the seniority payment issue from the PMS premium contract work and deal withthis separately from the PMS negotiations
2. Make an agreement to reduce payments over a 2 year period (end by March 2020) in linewith other practices nationally and our GMS practices locally (under a separateagreement) but agree this upfront now to avoid the risk that the practices fail to sign thePMS contracts on the basis of this not being resolved.
3. Agree to pay the seniority payments for the 2 remaining years at the existing level inrecognition that NHSE could reasonably have been expected to make a suitablearrangement for phasing out seniority from 2015 and that this would have cushioned theimpact for PMS practices who will also be getting a reduced PMS premium during thisperiod.
It is recommended that seniority payments for PMS practices in Camden are phased out in line with the timetable for GMS practices locally and nationally which gives a 2 year transition period to March 2020 but that there is no reduction in the amount they are paid in recognition
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3
that this should have been organised at an earlier date. From March 2020 PMS practices along with their GMS and APMS colleagues will receive no further seniority payments.
2. Contract baseline changes
PMS Representatives have stated that it is not clear how contract baseline changes in April and future years will be applied to the PMS practices and how these will equalise over time.
RESPONSE: It has previously been confirmed that in future all baseline changes for practices will be the same e.g. MPIG adjustments, annual uplift, new patient payments etc. therefore as the PMS premium is extracted over the transition period the PMS practices gradually move towards the GMS position and practice incomes are equalised at the end of their transition period.
CAMDEN CCG PMS PREMIUM LOCALLY ENHANCED SERVICE (LES) CONTRACT.
3. The title - ‘Camden CCG PMS Premium Locally Enhanced Service Contract’
PMS Representatives have suggested removing the words ‘Locally Enhanced Service’ they believe that by including this as part of a range of LES contracts it may not be seen as the separate funding mechanism that it is, specifically to reinvest PMS premium money in local general practices.
RESPONSE: It is recommended that the CCG amends the title to ‘PMS Premium Reinvestment Contract’, which has no material impact on the contract terms and conditions.
4. Contract length
PMS Representatives have suggested that the contract length is for five years because in year 4 only 80% of the PMS Premium funding would have been invested in the service (as the last 20% is released from PMS practices in April 2022 which is technically year 5).
• RESPONSE: Further to the advice of the NCL PMS group it is recommended that theCCG confirm to practices that the NCL group will be making a representation to thePrimary Care Committee in Common that: implementing the contract extension clausefor 2 years at the end of year 4 would be consistent with the key principles of the PMSreview agreed by NCL, notably the principle 7 - PMS premium investment will bedistributed in-year to general practice (individual practices or Federations).
5. End of the contract term
PMS representatives have suggested that the contract does not indicate how the funds will be reinvested at the end of the term of the contract and seems to suggest that the service will end unless the commissioner decides to continue, rather than the other way round. They are also concerned that there is a fixed two-year restriction on the length of time it can continue for. There are concerns that practices will have significantly invested in providing this service for patients and it could be withdrawn without it being clear what the consultation process around this will be.
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RESPONSE: The contract terms are NHS standard and in that sense the CCG would not normally include any clauses that guarantees any particular action or income beyond the lifetime of the contract being awarded.
The CCG will have to be explicit about the fact that they can give no further guarantees beyond the lifetime of the contract but that they would make a firm commitment to start discussions about the future of the contract at the end of year 4 and/or the end of year 6 should a contract extension be granted for 2 years.
3. Risks
RISK DESCRIPTION MITIGATION RESIDUAL RATING
1. Failure to agree the position onseniority payments couldprevent final agreement andsigning of the PMSreinvestment contract
Proposal that an agreement on seniority is made alongside the PMS agreement this May 2018. Seek views of the negotiating team before the proposal is considered by GB.
Medium
2. Failure to agree an extendedperiod may result in the contractnot being signed by both PMSand GMS/APMS practices
Seek further feedback from the negotiating team before proposal presented to GB but present and confirm the NCL position which will provide significant reassurance.
Medium
3. Future proofing the contractmay prevent conclusion of thecontracting process
Seek further feedback from the negotiating team before proposal presented to GB but ensure present the CCGs position re relative term of other major contracts and reconfirm the PMS review principles agreed across NCL as advised by the NCL PMS board.
Medium
4. Summary of Recommendations
Camden CCG Governing Body are asked to approve the following recommendations:
1. Seniority factor payments for PMS practices in Camden is agreed as a 2 year processto be concluded in 2020 but that there is no adjustment to the actual payment inrecognition that this change should have been agreed on a phased basis from 2015.
2. Practices are informed about how baseline payments will be aligned over time3. Amend the title of the ‘Camden CCG PMS Premium Locally Enhanced Service
Contract’ to ‘Camden CCG PMS Premium Reinvestment Contract.’4. Inform practices about the NCL proposal and the commitment that PMS premium is
invested in practices is embedded in the PMS review principles notably principle 7 (seeappendix 1)
5. Confirm that the CCG will start discussions about the future use of the investment 6months before the end of the contracted period or the extended contract periodwhichever is in place.
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APPENDIX 1 - NCL PMS REVIEW PRINCIPLES
• Principle 1: Fairer distribution of funding - Within a 2 – 4 year (to be locally agreed) period the baseline per weighted patient (pwp) funding for each PMS practice in a CCG is the same asthe GMS pwp funding in that CCG.
• Principle 2: Equality of opportunity for all practices (GMS, PMS, APMS) - Within a 2 - 4year period the PMS premiums and the LCS funds are combined within each CCG to form onering fenced and protected budget to pay for local general practices to deliver services over andabove “core” general practices services.
• Principle 3: Help reduce inequalities in health
• Principle 4: Local teams empowered to respond to local need - PMS/LCS funds to be retained within each CCG – no cross subsidies between CCGs. The investment plan, based on local need, will include new models of care. Commissioners to proactively support, review and test the development and implementation of at-scale delivery.
• Principle 5: Local accountability and transparency for use of resources
• Principle 6: A supportive and collaborative approach adopted by all
• Principle 7: PMS premium investment will be distributed in-year to general practice (individual practices or Federations)
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Camden Clinical Commissioning Group Governing Body 9 May 2018
Report Title Business Plan 2017/18 Update Report
Agenda Item 4.2 Date 09.05.18
Committee Chair (where applicable)
N/A
Lead Director Sally Mackinnon, Director of Transformation, Planning and Delivery
Email [email protected]
Report Author Debbie Hawkins, Head of PMO Graham McLaurin, PMO Business Manager
Email [email protected] [email protected]
GB Sponsor(s) (where applicable)
Sarah Mansuralli, Chief Operating Officer
Email [email protected]
Report Summary The Business Plan 2017/18 sets out the CCG’s key priorities for 2017/18. Progress is monitored through the year with bi-annual reports to Governing Body. This is the second and final report to Governing Body for the 2017/18 plan.
This is primarily an exception report focusing on those initiatives which have a RAG status of either red or amber, whilst also highlighting some key updates.
In terms of achievements during 2017/18, a number of priorities within the Business Plan are Local Care Strategy priorities, for which a review of progress is currently underway. This will be reported to Governing Body later in the year and will provide more insight into what has been achieved in 2017/18.
Overall progress Progress continues to be made across all eight objectives with over half of the initiatives either complete or progressing to plan with no material issues. Of the 41 initiatives, 19 are progressing to plan (RAG status - green); 4 have been completed (RAG status - blue); 15 have some risks/issues impacting on delivery and/or timescales (RAG status - amber); and 3 initiatives have risks/issues significantly impacting on delivery and/or timescales (RAG status - red).Many of the amber and red status rated initiatives are reflective of the inherent challenges involved in delivering transformation initiatives, as well as some of the wider challenges in the system, both in acute and primary care. In some instances these are also related to the transition which occurred during 2017/18 whilst new arrangements for North Central London, adults’ community commissioning and the Sustainability and Transformation Plan were being embedded.
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Issues and risks for amber and red schemes are being actively managed and positive progress is expected over the next six months. The attached Update Report provides detail of the actions being taken.
Key issues / risks There are a number of risks on the Board Assurance Framework relating to the Business Plan, summarised below. Further information is provided in the separate Board Assurance Framework paper to Governing Body.
• Poor performance against constitutional targets (Threat)o relates to initiative ‘A1 ‘Constitutional standards and targets’
• Delivery of Cancer 62-day waiting time standard (Threat)o relates to initiative ‘A1 ‘Constitutional standards and targets’
• Delivery of four-hour waiting time standard for A&E (Threat)o relates to initiative ‘A1 ‘ Constitutional standards and targets’
• Mobilisation of STP and QIPP plans (Threat)o relates to initiative ‘A1 Constitutional standards and targets’ and
‘G1 Financial Strategy and QIPP’• Managing acute contracts within contract baselines (Threat)
o relates to initiative ‘G1 Financial Strategy and QIPP’• PMS Review (Threat)
o relates to initiative ‘D4 PMS review’• Failure to produce a deliverable and robust QIPP plan for 17/18 (Threat)
o relates to initiative ‘G1 Financial Strategy and QIPP’
Purpose (tick one box only)
Information Approval To note √
Decision
Recommendations Governing Body is asked to
1. Note the contents of this update
Strategic Objectives Links
The Business Plan makes a contribution to all of the CCG Strategic Objectives. The majority of the initiatives are in objectives C and D which are: Objective C: Improve health outcomes, address inequalities and achieve parity of esteem. Objective D: Integrate and enable local services to deliver the right care in the right setting at the right time.
Identified Risks and Risk Management Actions
Issues and risks for each objective are included in the main report and the key risks are noted above in the report summary. Relevant risks relating to Business Plan initiatives are monitored through the Board Assurance Framework and Committee Risk Registers.
Conflicts of Interest Where conflicts of interest arise in relation to specific Business Plan initiatives, these will be addressed accordingly.
Resource Implications
Resource implications of the Business Plan are addressed as part of implementation planning and mobilisation.
Engagement This report has been prepared with the involvement of the CCG Executive Team and senior managers involved in delivering the Business Plan.
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Equality Impact Analysis
There are no equality issues arising from this report. Equality impact assessments for individual initiatives are undertaken as appropriate in line with the CCG’s policies.
Report History Updates are presented every six months to Governing Body, after review by the Executive Management Team.
Next Steps The Business Plan for 2018/19 has been refreshed to reflect the CCG’s current priorities and is reported separately to Governing Body. Any 2017/18 priorities which remain priorities in 2018/19 are reflected in the refreshed plan for 2018/19. The CCG will continue to prioritise the implementation of the Business Plan and provide regular updates to Executive Management Team and Governing Body.
Appendices Business Plan Update Report
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Business Plan Update Report
Governing Body – 9th May 2018
1Page 59 of 422
Title Slide No.Business Plan Objectives 3Overview of Business Plan Initiatives 4 - 5Highlights from 2017/18 6 - 7 Initiatives with Green or Blue Status 8 - 9
Objective A: Commission the delivery of NHS constitutional rights and pledges
10 - 11
Objective C: Improve health outcomes, address inequalities and achieve parity of esteem
12 - 14
Objective D: Integrate and enable local services to deliver the right care in the right setting at the right time
15 - 16
Objective F: Involve member practices and commissioning partners in key commissioning decisions
17
Objective G: Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for-money services
18
Table of Contents
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Commission the delivery of NHS constitutional rights and pledges
Improve the quality and safety of commissioned services
Improve health outcomes, address inequalities and achieve parity of esteem
Integrate and enable local services to deliver the right care in the right setting at the right time
Work jointly with the people and patients of Camden to shape the services we commission
Involve member practices and commissioning partners in key commissioning decisions
Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for-money services
Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce
Population segment addressed
Enablers
Children Adults Mental Health
Learning Disabilities
Eight Objectives in Camden CCG Business Plan
A
B
C
D
E
F
G
H3
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Overview of Business Plan Progress
Summary
4
4
3
15
19
Summary of RAG Status - May'18
Progress continues to be made across all eight strategic objectives with over half of the initiatives either complete or progressing to plan.
Of the 41 initiatives
• 19 are progressing to plan (RAG status - green)• See slides 8-9
• 4 have been completed (RAG status - blue)• See slide 9
• 15 have some risks/issues impacting on delivery and/ortimescales (RAG status – amber)
• See slides 10-18
• 3 initiatives have risks/issues significantly impacting ondelivery and/or timescales (RAG status – red)
• See slide 10-18
Many of the amber and red status rated initiatives are reflective of the inherent challenges involved in delivering transformation, as well as some of the wider challenges in the system, both in acute and primary care. In some instances these are also related to the transition which occurred during 2017/18 whilst new arrangements for North Central London and the Sustainability and Transformation Plan were being embedded.
Issues and risks for amber and red schemes are being actively managed and positive progress is expected over the next six months.
KeyRed – Issues/risks having a significant impact on delivery and/or timescalesAmber – Issues/risks having a moderate impact on delivery and/or timescalesGreen – No Issues, progressing according to planBlue – Initiative has been completed
The Business Plan sets out the key CCG priorities for the year, taking into account the Sustainability and Transformation Plan, the Local Care Strategy
and the QIPP Plan to ensure strong alignment between these plans.
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Objectives Key
Objective A: Commission the delivery of NHS constitutional rights and pledges
Objective B: Improve the quality and safety of commissioned services
Objective C: Improve health outcomes, address inequalities and achieve parity of esteem
Objective D: Integrate and enable local services to deliver the right care in the right setting at the right time
Objective E: Work jointly with the people and patients of Camden to shape the services we commission.
Objective F: Involve member practices and commissioning partners in key commissioning decisions
Objective G: Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for-money services.
Objective H: Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce.
Overview of Business Plan Progress (cont’d)
5
KeyRed – Issues/risks having a significant impact on delivery and/or timescalesAmber – Issues/risks having a moderate impact on delivery and/or timescalesGreen – No Issues, progressing according to planBlue – Initiative has been completed
1 1 1 1
21
2
7
4
1
1
1
8
5
21
1
1
5
10
15
20
Obj A Obj B Obj C Obj D Obj E Obj F Obj G Obj H
RAG Status of Initiatives by Objective
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Highlights from 2017/18 (1)
A&EBoth UCLH and Royal Free are currently (Feb’18) in the top half of London Trusts for performance against the four hour standard, and London is the best performing region in England.
CancerStronger performance against cancer standards across NCL reflecting significant work undertaken across the system in delivering action plans and improving the flow of patients between trusts.
Local Care Delivery Board and associated groups have continued to bring together health and social care organisations and the voluntary sector in Camden to implement the whole system model for integrated health and social care services agreed in the Local Care Strategy.
NCL Quality and Safety collaborationJoint NCL review of A&E Safety undertaken; A&E Delivery Boards in place where safety concerns can be raised. Work on Care Homes hasprogressed, intention to apply for pharmacist support to conduct a review of governance relating to managing patients' medicines in Care Homes.
Children and Adolescent Mental Health Service (CAMHS)Waiting times continue to be reduced, with Camden currently having the third lowest waiting time in the country.
Managing long-term childhood conditions in primary careAsthma Nurse pilot is now a substantive service and has been extended to include eczema management and other related atopic conditions.
Camden Diabetes Integrated Practice Unit (IPU)Ranked 'outstanding' in the national assessment for diabetes by NHS England; shortlisted in two categories at the prestigious Health Service Journal Value Awards 2018 - ‘Improving the value of primary care services’ and ‘Improving value through better diabetes care’.
Integrated Musculoskeletal (MSK) Service went live in April’18.
Discharge to assessAll pathways implemented, helping to reduce length of patients’ hospital stays and delays in discharge
Annual health checks for those with learning disabilitiesCamden is on track to maintain its trajectory of meeting NHS England’s target of annual health checks for 79% of those with learning disabilities.
Enhanced mental health liaison servicesSuccessful bid enabled enhanced service in A&E at UCLH in 2017/18, with an independent evaluation identifying that the service shortenedpatients’ lengths of stay on wards. 6
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Highlights from 2017/18 (2)
7
Perinatal mental health serviceNew specialist service was launched in Jul’17.
Extended AccessNew service successfully implemented from four general practice sites or ‘hubs’, with current hub utilisation of 82%.
Neighbourhood developmentCamden practices have worked together to develop neighbourhood structures in 2017/18. Practices are now grouped in five neighbourhoods, aligned to two GP Federations and are meeting regularly as neighbourhood groups.
Primary Care Quality ImprovementCCG investment in neighbourhoods to deliver quality improvement linked to the long term conditions element of a local agreement with GPs. This has supported collaborative working and has had a significant impact on the achievement of clinical outcome targets.
Universal OfferGP Practices have successfully delivered the Universal Offer in 2017/18. The new model for locally commissioned services has ensured that patient access to all services in the Universal Offer has improved.
Care Integrated Digital Record (CIDR)CIDR, which enables patients to share their information with all the health and care professionals looking after them, was named Tech Project of the Year at the Health Technology Newspaper Awards.
Camden CCG’s Personal Medical Services (PMS) PremiumLocal service specification has been developed in consultation with GPS and approved by NHS England and the LMC. Contracts have been issued to practices for their consideration and signatures by the end of May.
Patient and community engagementCamden CCG were rated as ‘good’, achieving Outstanding in two domains – ‘ Governance’ and ‘Day to Day Practice’; Good in two – ‘Annual Reporting’ and ‘Equalities and Health Inequalities’; and Requiring improvement in only one area – ‘Feedback and Evaluation’.
QIPPThe CCG has been successful in delivering 2017/18 QIPP plan, with an outturn delivery rate of circa 90% against the target of £18.1m.
Financial positionThe CCG has met its 2017/18 financial control total. Robust financial monitoring is in place for managing the medium term financial strategy (MTFS), including identification of cost pressures, financial risks and mitigations, monitoring of investment and QIPP.
Healthy Work Place CharterCommitment level 1 achieved.
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8
Initiatives with Green or Blue RAG status (1)
Ref Initiative Name RAG Accountable Director
B1 NCL Quality and Safety collaboration - Optimise the new North London CCGs collaboration to enable improved quality and safety of jointly commissioned contracts
Quality and Clinical Effectiveness
C1 CAMHS - Procure mental health peer education and support for perinatal, children and young people; reduce service wait times and implement the new service structure which incorporates the THRIVE approach
Integrated Commissioning / Commissioning & Contracting
C5.3 Simplified Discharge - Implement an end to end pathway for reducing length of stay, delayed discharge and discharge to assess
Commissioning & Contracting
C6.1 Social Prescribing and Self-care - Develop an integrated approach and new model of social prescribing which improves access to services and enables people to retain independence for longer. Alongside this,develop a self-care programme which allows people to effectively manage their long term conditions
Primary Care & Community
C6.2 Prevention - Develop an integrated approach to prevention and wellbeing, reviewing our current service provision to ensure patients and residents are able to access early intervention and prevention services
Transformation, Planning &Delivery
C7 Primary care mental health - Develop a primary care mental health service through the provision of multidisciplinary teams at the front door aligned to neighbourhoods
Integrated Commissioning/ Commissioning & Contracting
C10 Co-ordinated resilience network - Develop VCS services providing mental health support into a resilience network. Develop network of providers delivering against community resilience priorities to develop collaborative approach; align outcomes with activity, ensure best use resources
Integrated Commissioning/Commissioning & Contracting
C11 Transforming Care - Enable more people with learning disabilities and/or autism to live in the community, with the right support
Integrated Commissioning
C12 Learning Disabilities Annual Health Checks - Meeting target of annual health checks for 79% (TBC) of those with learning disabilities
Integrated Commissioning/ Commissioning & Contracting
D3 Primary Care strategy and vision - Develop a vision and strategy for Primary Care, including the future model for Camden
Primary Care & Community
D4 PMS Review - Reach agreement on the PMS review plans and recontract with GPs Transformation, Planning &Delivery
D5 Extended Access - Successfully implement the new contract and ensure the service is fully up and running
Primary Care & Community
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9
Ref Initiative Name RAG Accountable Director
D7 Estates Strategy - Develop an estates strategy for the health system in Camden, including Primary Care, Mental Health and Community services, incorporating strategic sites proposals and opportunities for efficiencies
Primary Care & Community
D9 Workforce Planning - The initiative will: baseline workforce pressures on the system; develop plan to address workforce challenges; and provide multi-agency learning and development plans to support workforce strategy.
Transformation, Planning &Delivery
E1 Local Care Strategy communications - Participate effectively in the Local Care Strategy communications group with other Camden organisations, and ensure the CCG delivers communication and engagement activity that meets our CCG duties
Transformation, Planning &Delivery
E2 Communications, engagement and consultation activity for Camden priorities - Deliver communications, engagement and consultation activity for Camden priorities – incl. IVF, POLCE, PMS, Neighbourhoods, primary care mental health, mental health day units, planned care pathways, MSK
Corporate Services
F2 Member engagement in planning - Maintain engagement with members in planning and prioritisation for 2018/19
Corporate Services
G4 Data Handling - Ensure that providers are handling data in line with national guidance and making adjustments where necessary for new models of care. This will be through a long term data assurance piece which will be routinely discussed at Finance, Performance & QIPP Committee
Commissioning & Contracting
H2 Relocate the CCG’s headquarters - Successfully relocate the CCG’s headquarters by October 2018 Corporate Services
C2 Asthma nurse pilot – Embed the asthma nurse pilot across all localities in Camden, to increase coordination between primary and secondary care
Integrated Commissioning/ Commissioning & Contracting
D6 Primary Care Delegated Commissioning – Implement effective management and monitoring arrangements for primary care delegated commissioning
Primary Care & Community
G3 QIPP Systems and processes – Put in place systems and processes to delivery QIPP governance and support to effectively support delivery and remove barriers to the delivery of QIPP
Transformation, Planning & Delivery
H1 Staff Survey – Implement an action plan following 2016 staff survey results, including achievement of Level 1 commitment of the Healthy Workplace Charter
Corporate Services
Initiatives with Green or Blue RAG status (2)
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Objective A: Commission the delivery of NHS constitutional rights and pledges
Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
A1 Achievement of remedial action plans, improvement trajectories and maintenance of compliance with standards
Through the NCL Joint Commissioning Committee, improve the delivery of constitutional standards and pledges, where required. This includes, for UCLH, achievement of remedial action plans and improvement trajectories for: • cancer 62-day waits• the A&E 4-hour standardand maintenance ofcompliance of the followingstandards;• cancer 14 day waits• diagnostic targets• improvement of specialty-specific Referral toTreatment (RTT) deliverychallenges
• UCLH has not met the 90% threshold setout in the FYFV (five year forward view).
• UCLH is not currently meeting the RTTtarget (referral to treatment) and iscurrently forecasting a return tocompliance in Mar’18. While at a Trustlevel UCLH are not meeting thestandard, performance for Camdenpatients at UCLH is above the 92%target.
• Although improvements have beenmade, cancer 62 day performance isbelow target at UCLH
A&E• Strengthened governance to the
Camden/UCLH system through the newA&E Delivery Board
• Regular joint meetings with UCLH, NHSEngland and NHS Improvement. Highpriority actions agreed, progress reviewed atthe A&E Delivery Board and a localperformance meeting with the aim of drivingperformance above 90%, and achieving thenational ambition of 95% by Mar’19.
Cancer• The cancer Recovery Action Plan was
refreshed and is having a positive impact onthe Trust's internal performance.
• System wide cancer issues, including highvolumes of late referrals from referringproviders is being managed at the NCLCancer Performance Leadership Forum.
RTT• UCLH RTT recovery plan created, including
specialty level trajectories. The plan will bemonitored at the monthly performancemeeting with escalation to Contract ReviewGroup where necessary, and GoverningBody updated via the IntegratedPerformance Report.
• The Royal Free’s plan is being agreed withBarnet CCG and Camden have beeninputting in to this. Camden CCG is askingBarnet for assurances from the Trustparticularly around patients being booked inchronological order and that the reportingissues have been fully resolved.
Chief OperatingOfficer
Director of NCL Planning, Performanceand Primary Care
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Objective A (cont’d): Commission the delivery of NHS constitutional rights and pledges
Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
A2 Local Care DeliveryImprove the delivery of constitutional standards and pledges using the following STP and LCS work streams as an enabler to improving performance:• Urgent and EmergencyCare (including admissionsavoidance)• Care Closer to Home• Planned Care• Prevention
The initiative is Amber as there has been significant slippage against the original STP and LCS timescales, and the work required to validate the QIPP has in some cases delayed business cases and implementation. Those schemes that require extensive involvement of the five CCGs tend to be taking longer than local initiatives, as the five NCL CCGs seek to agree a framework for implementation first.
The Transformation and QIPP teams continue to support the implementation of the programme, working alongside commissioners and sometimes leading new initiatives until they become established.The partnership is seeking to establish a Quality Improvement approach locally that will support the implementation of local care/STP initiatives.
Director of Transformation,Planning and Delivery
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Objective C: Improve health outcomes, address inequalities and achieve parity of esteem
Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
C3. Paediatric specialism in primary care pilotOperationalise the pilot across Camden; resolve IT and governance issues to enable the operationalisation and sign-off tariff changes with RFH.
The model for the Integrated Paediatric Service was approved by the Integrated Commissioning Committee (ICC) in Jul’17 subject to further scrutiny of the financial modelling. Roll out of this initiative is subject to identification of investment funding, implementation plans will resume from next month if funding can be identified.
Through negotiation with acute providers and repurposed funding, the investment is expected to be identified to support rollout in 2018/19.
Director of Integrated CommissioningandDirector of Commissioning and Contracting
C4.1 Planned care -Dermatology, GastroenterologyDevelop new pathways, models and commissioning arrangements with a view to implement these in the first half of 2018
Tele-dermatology - the implementation for 2018/19 is proceeding although behind the original timeframe. The PID has been approved by STP and shared with providers.
Gastroenterology - Locally, the initial focus has been on the updated faecal calprotectin pathway, which will reduce unnecessary referrals to secondary care. The pathway has been reviewed and updated. Additional work was undertaken with UCLH and RF to take forward the development of the Gastro-nurse and development of the business case and pathway.
Tele-dermatology – the service specification was signed off by all providers at an NCL-wide meeting in March. The next step is NCL STP tariff negotiation.
Gastroenterology - Development of the business case and pathway to be shared with the providers.
Director of Transformation,Planning and DeliveryandDirector of Commissioning and Contracting
C4.2 Planned care -PoLCE, IVF, Integrated MedicineAddress PoLCE (Procedures of Limited Clinical Evidence) compliance, and implement IVF (In Vitro Fertilisation) policy changes informed through consultation
PoLCE – An updated STP PoLCE policy scheduled for Dec’17 will now be ready in May’18 due to lack of resources. The UCLH PoLCE audit is still awaiting sign-off from the trust. This work will identify if the CCG should allow UCLH to continue self-regulation of PoLCE.
Integrated Medicine - Good progress has been made with the RLHIM audit.
IVF policy – The public consultation on revising Camden CCG's IVF offer, in line with NICE guidance, is currently on hold due to the local election purdah period.
PoLCE - A new PoLCE STP lead is being recruited. The policy criteria are being updated by clinicians in line with recent changes to national guidance by Apr’18.PoLCE audit proposal has been submitted to UCLH.
Integrated Medicine - RLHIM homeopathy rebate from the audit was achieved, and a new agreement reached on robust management.
Director of Commissioning and Contracting
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Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
C4.3 Planned care – MSKEnsure the integrated MSK service is fully implemented by March’18
The MSK integrated service went live on the 3rd
April’18 and teething issues are expected. The implementation is being closely monitored to enable learning from any issues and to make practical adjustments as required.
Camden CCG continues to support UCLH in rolling out this contract so that full benefits can be realised as soon as possible. Progress is being monitored via UCLH’s Strategic Board and Operational Delivery meeting and the CCG’s monthly contract meeting.
Director of Commissioning and ContractingandDirector of Transformation,Planning and Delivery
C4.4 Planned care - LTCDevelop a strategy for managing Long Term Conditions in Camden, including linkages to the Primary Care UniversalOffer
Work on the Long Term Conditions (LTC) strategy has been paused as the Primary Care and Community team is currently undertaking a stocktake to work on a forward plan for the services.
Further work to be carried out on the Primary Care and Community Plan in 18/19 which will incorporate the LTCs strategy.
Director of Primary Care and Community
C5.1 Admissions AvoidanceAdmissions avoidance –enhance the Rapids service to keep more people out of hospital
Although progress has been made, there is further work to do before realising the ambition set out in the business case. A whole system approach is being taken to increase referrals from primary and acute care to the service.
Camden CCG is actively engaging actively with CNWL to agree an ambitious and achievable admission avoidance plan for 18/19: building on the existing engagement programme with primary care, the existing workplan to increase UCLH Emergency Department referrals, and further opportunities both to increase referrals (e.g. direct referral pathway for London Ambulance Service) and to identify additional cohorts of patients that could be supported through rapids.
Director of Commissioning and Contracting
Objective C (cont’d): Improve health outcomes, address inequalities and achieve parity of esteem
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Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
Mental Health
C5.2 Integrated Care Teams (ICT)Develop and implement a new model for Integrated Care teams aligned with Primary Care neighbourhoods to achieve better and more integrated support for people in the home
Delivery of this initiative has been delayed in 2017/18 due to lack of resources and transfer of the initiative from the local authority to the CCG. However, progress has been made to implement the changes agreed in Sept’17, and the integrated home care and reablement delivery model has been aligned with GP neighbourhoods.
Further work is required to agree district nursing team alignment with GP neighbourhoods. A new business case will be presented to ICC that builds on the initial business case for this work. The focus will be on clarifying what the ICT is, defining the patient cohort and the processes required to ensure patients are identified and supported by the ICT.
Director of Primary Care and Community
C8 Perinatal Mental HealthDevelop a specialist community perinatal mental health team so that more Camden residents have access to evidence based specialist perinatal mental health care. This is a NCL project as part of the STP
While NCL was successful in receiving Wave 2 funding for a community perinatal mental health service, the funding for the service would not be sufficient to meet the needs of the population.
A further bid has been prepared for Wave 3 funding in order to increase the provision to meet the needs of 5% of the population (as found in the NCL needs assessment).
Director of Integrated CommissioningandDirector of Commissioning and Contracting
C9 Crisis Care (Core 24 Liaison Services)Scale up 24/7 comprehensive liaison service to UCLH. To support University College London Hospital (UCLH) to develop mental health liaison services that meet Core 24 NHS England bid criteria
This is currently Amber as the NHS funding for extra staff in the psychiatric liaison team is only available until Mar’18, with the expectation that it will produce cashable savings that UCLH will reinvest in the team going forward. Mental Health Strategies evaluated the project and it identified thatthe service shortened patients’ lengths of stay on wards with associated savings. There is a risk that these savings are not realised and/or that UCLH does not fund services in the future, which would cause a £0.5M cost pressure to the CCG.
The risk has been added to the ICC risk register. Currently working to identify possible solutions across the partnership.
Director of Integrated CommissioningandDirector of Commissioning and Contracting
Objective C (cont’d): Improve health outcomes, address inequalities and achieve parity of esteem
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Objective D: Integrate and enable local services to deliver the right care in the right setting at the right time
Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
D1.1 Neighbourhoods -Service DeliveryGain approval for two service delivery proposals, and ensure service delivery is fully underway
The neighbourhood service proposals have been delayed. At the end of November mobilisation of the service was paused after one neighbourhood felt changes were required. The three neighbourhoods are revising plans for investment of the GPFV funding and are now working with the Primary Care team to agree any changes.
Neighbourhood leads and the Primary Care team are developing a proposal for the investment of the remaining GPFV funding. A proposal for investment will be taken to ICC in May’18. The mental health service was approved at the end of November. The service is now mobilising and will be delivered from May.
Director ofPrimary Care and Community
D1.2 Neighbourhoods –Quality Improvement Support Teams (QISTs)Develop and agreed the QISTs business case, and deliver quality improvement support to practices, linked to the Universal Offer
This initiative is rated Amber because QIPP savings have not been delivered in 2017/18.However, work is progressing and each neighbourhood has a QIST lead who is responsible for delivering the current QIST specification during 2017/18. The business case for investment in QISTs in 2018/19 and 2019/20 was approved by ICC in Feb’18
The CCG will work with both federations to ensure smooth transition to QIST delivery in 2018/19.
Director of Primary Care and Community
D2 Universal Offer Ensure all practices successfully deliver the Universal Offer, and refine for 2018/19
This initiative is broadly on schedule. The delivery RAG is Amber to reflect that the target savings against the Universal Offer services will not be fully delivered in 2017/18.Delivery of some services linked to projected savings did not start until Q3 and this has impacted on savings achieved in 2017/18.
The CCG QIPP / Finance team and the Primary Care team are meeting regularly to review delivery of the services against the savings targets. The savings targets and achievement will also be reviewed each month by the Universal Offer Delivery Group.
Director of Primary Care and Community
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Objective D (cont’d): Integrate and enable local services to deliver the right care in the right setting at the right time
Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
D8 Digital programme Implement the following workstreams of the ‘Towards Digital’ strategy, to enable LCS:• CIDR enhancements for111, radiology,documentation, and singlesign-on betweensecondary and council ITsystems• Enabling other key LCSwork streams such asTele-Dermatology pilot• 111/OOH servicesintegration with GP Hubsand GPs• Produce monthly digitaldashboards on the activityand quality of primary careservices, for GP servicesand the CCG, forassurance and informationpurposes• Enable patients to bookand access GP/primary care professionals through alternative means such as e-consultation, telephonetriage and Patient Online
CIDR - Ongoing delays re the ULCH Admission Discharge Transfer (ADT) interface with CIDR, due to infrastructure issues at UCLH. RFH radiology interface complete but has been delayed at the final testing phase due to internal issues on the provider side.
All other work streams are on track:• Tele-Dermatology - technical kit has been
successfully tested and will be procured forroll-out to all Camden GP practices
• 111/OOH - Urgent and Emergency Boardhas agreed funding for NCL to connectLCW with GPs, urgent care centres andGP hubs. Roll-out will be within 6-12months
• Mobilisation of MSK Contract - use ofEMIS on track
• Online booking - increase in onlineappointment and e-consultation bookings.NHS England has agreed funding for anNCL-wide implementation.
Online services:• Online consultation – aim to start pilot in
Jun’18.• Enabling GP practices Wi-Fi connectivity
to be completed across 34 practices.
CIDR• Continue to offer support and apply
pressure to UCLH, exploring allopportunities for leverage
• RFH radiology work is underway andescalated, aim to be completed June’18
• New mental health data set for careplanning has been agreed and developmentwork to be mapped during Apr’18.
LCS:• Working up social prescribing and self care
specification for IT and Systems• Primary care mobile working – all 34
Camden practices have been issued EMISanywhere devices to enable remoteworking
• Working closely with CNWL on migrationplan to move from SystmOne to EMIS toalign with integrated care teams - funding tobe agreed.
Assistant Director of IT and Systems
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Objective F: Involve member practices and commissioning partners in key commissioning decisions
Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
F1 Stakeholder Feedback - Respond to feedbackfrom stakeholders throughthe 360 degree survey, anddemonstrate improvementsmeasured through nextyear’s survey
During 2017/18 active work has been underway to address areas of improvement signposted in 2017 stakeholder survey results. This initiative is however marked amber in recognition that there are still further improvements needed.
In light of the results of the most recent survey, the Communications team is analysing the results and will work on a plan, in addition to the established Communications and Engagement strategy. The plan will address any areas of weakness and put in place actions to continue improving our engagement with stakeholders.
NCL Director ofCorporate Services
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Objective G: Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for-money services
Initiative Reason for Amber and Red Status Red or Amber
Key Actions being taken Accountable
G1 Financial Strategy and QIPP Develop and implement Camden’s medium-term financial strategy in line with the revised financial allocation, taking into account cost pressures, investment plans, QIPP plans, demographic growth and other adjustments, and deliver 17/18 QIPP and develop plans for 18/19 QIPP
Although positive progress has been made during 2017/18 (see below), the status is red due to the challenging financial position for 18/19.
Re 2017/18, the CCG has met its financial control total. Robust financial monitoring is in place for managing the medium term financial strategy (MTFS), including the identification of cost pressures, financial risks and mitigations, monitoring of investment and QIPP. A recovery plan was implemented in Oct’17 and cost saving actions are being delivered.
During this year the CCG has been successful at identifying and delivering the QIPP plan, with delivery rate of circa 90% against a targetof £18.1m. This plan has been delivered by a combination of transformational, transactional and non-recurrent initiatives.
For 2018/19 in line with national trends the CCG continues to face increasing costs and higher demand for services which may impact on the medium term financial strategy. The 2018/19 QIPP target, required to deliver a balanced budget, is an ambitious £26m.
The CCG is proactively managing this QIPP requirement and has received positive assurance on the governance arrangement in place to support this. However, it is worth noting that the 18/19 QIPP target is ambitious and is not without some delivery risk. Robust financial management and reporting will be critical to ensure that financial risks are identified at an early stage and that mitigating actions to contain cost pressure are implemented.
Deputy Director of FinanceandDirector of TransformationPlanning and Delivery
G2 Alternative contracting forms Through the NCL Joint Commissioning Committee, work with providers to further develop system incentives and options for alternative contract forms that better support the new models of care in the STP and ensure financial sustainability
Discussions regarding further changes to contract form are at an early stage of option appraisal. Significant changes are already in place for 2017/19, with a move away from PbR (payment by results) towards marginal rates, and a revised set of contract incentives.
The working group with NCL providers looking at alternative contractual forms for 2019/20 contracts is planned to be re-launched in June, once 2018/19 contract discussions have been concluded.
NCL Director of AcuteCommissioning
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Camden Clinical Commissioning Group Governing Body 9 May 2018
Report Title 2018/19 Business Plan Agenda Item 4.3 Date 09.05.18
Lead Director Sally MacKinnon, Director of Transformation, Planning and Delivery
Email [email protected]
Report Author Debbie Hawkins, Head of PMO
Email [email protected]
GB Sponsor(s) (where applicable)
Sarah Mansuralli, Chief Operating Officer
Email [email protected]
Report Summary This report presents Camden CCG’s Business Plan for 2018/19.
The Business Plan sets out the key priorities for the year ahead, taking into account the Sustainability and Transformation Plan, the Local Care Strategy and the QIPP Plan to ensure strong alignment between these plans.
The Business Plan is intended to provide a clear focus for the organisation to concentrate its efforts on the achievement of these priorities. The plan also provides clarity for partners and the public in understanding the CCG’s priorities.
The CCG will monitor delivery against the plan during the year and provide bi-annual updates to Governing Body.
Purpose (tick one box only) Information Approval
√ To note Decision
Recommendations Governing Body is asked to 1. Approve the 2018/19 Business Plan
Strategic Objectives Links
The Business Plan sets out the key priorities for how the organisation will contribute to all of the CCG’s eight Strategic Objectives.
Identified Risks and Risk Management Actions
Relevant risks relating to Business Plan initiatives will be monitored individually and through the Board Assurance Framework and Committee Risk Registers.
Conflicts of Interest Where conflicts of interest arise in relation to specific Business Plan initiatives, these will be addressed accordingly.
Resource Implications
Resource implications have been considered as part of the work on the CCG’s operating model, which is currently being embedded to ensure there is sufficient commissioning and contracting capacity to deliver the strategic priorities set out in the Business Plan.
Engagement This report has been prepared with the involvement of the Governing Body members and the CCG Executive Team.
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Equality Impact Analysis
There are no equality issues arising from this report. Equality impacts of individual Business plan priorities will be considered as part of implementation.
Report History The CCG’s first Business Plan was a three year plan developed for 2015/16 – 2017/18. This plan was refreshed twice to reflect the CCG’s priorities. The 2018/19 Business Plan was considered at two Governing Body workshops in October 17 and January 18.
Next Steps The Business Plan will be presented to May Governing Body for information.
Appendices Appendix A: 2018/19 Business Plan
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Camden Business Plan 2018/19
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p. 1 of 11
Eight Objectives in the Business Plan
The Business Plan sets out the key CCG priorities for the year, taking into account the Sustainability and Transformation Plan, the Local Care Strategy and the QIPP Plan to ensure strong alignment between these plans. Page 81 of 422
Objective A. Commission the delivery of NHS constitutional rights and pledges
PRIORITIES Ref Priorities 18/19 Accountable
A1 Through the NCL Joint Commissioning Committee and local CCG activity, improve the delivery of constitutional standards and pledges, where required. This includes, for University College London Hospital (UCLH), achievement of remedial action plans and improvement trajectories for:
• cancer 62-day waits• the A&E 4-hour standard
and maintenance of compliance of the following standards: • cancer 14 day waits• diagnostic targets• improvement of specialty-specific Referral to Treatment (RTT) delivery challenges
SRO: Chief Operating Officer / NCL Director of Planning, Performance and Primary Care
CRO: Dr Birgit Curtis Dr Matthew Clark (A&E)
A2 Deliver the following priorities under the Urgent and Emergency Care workstream in the Sustainability and Transformation Plan (STP) and Local Care Strategy (LCS) to support the achievement of constitutional targets through managing acute demand:
A2.1 • Ambulatory Care – work with UCLH to maximise the opportunities to increaseambulatory care
SRO: Director of Commissioning & Contracting CRO: Dr Matthew Clark
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A2.2 • Simplified Discharge – implement Discharge to Assess Pathways across all acutehospital sites for Camden patients to ensure patients, once medically optimised, canreturn home sooner and have better outcomes and experience; also resulting inreduced unnecessary acute lengths of stay and occupied bed days
SRO: Director of Commissioning & Contracting CRO: Dr Sarah Morgan
A2.3 • Admissions Avoidance (RAPIDS) – enhance the use of the community RapidResponse service to avoid admissions into hospital and ensure that patients receivehigh quality care within their own home
SRO: Director of Commissioning & Contracting CRO: Dr Sarah Morgan
A2.4 • Falls Admission – reduce falls related hospital admissions through the use of amultifactorial intervention combining regular exercise (including strength andbalance), modifications to people’s homes and regular review of medications,delivered in collaboration across the local public sector organisations and with thevoluntary and community sector
SRO: Director of Commissioning & Contracting CRO: Dr Sarah Morgan
A2.5 • Last Phase of Life – develop enhanced end of life care in care homes through theintroduction of last phase of life facilitators to work with care home staff; develop asingle point of access for specialist palliative care; and address inequity in specialistpalliative care provision
SRO: Director of Commissioning & Contracting CRO: Dr Sarah Morgan
A3 Integrated Urgent Care (111/OOH) – implement the Memorandum of Understanding to shift appointments from out of hours (OOH) provider to extended access services to maximise the OOH GP offer and reduce unattended appointments (DNA)
SRO: Director of Primary Care and Community CRO: Dr Kevan Ritchie
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Objective B. Improve the quality and safety of commissioned services PRIORITIES Quality and safety is at the heart of our commissioning approaches and is embedded through Objectives A, B, C and D.
Objective C. Improve health outcomes, address inequalities and achieve parity of esteem PRIORITIES Ref Priorities 18/19 Accountable
C1 Deliver the following priorities, informed by RightCare, under the Planned Care workstream in the Sustainability and Transformation Plan (STP) and Local Care Strategy (LCS) to improve health outcomes
C1.1 • MSK – successfully implement lead provider arrangements with associated pathwayimprovements
SRO: Director of Commissioning & Contracting / Director of Transformation, Planning & Delivery CRO: Dr Matthew Clark
C1.2 • Dermatology – implement a new model for both Camden and NCL, incorporating tele-dermatology; increase minor surgery in primary care and appropriate onward treatment
SRO: Director of Transformation, Planning & Delivery / Director of Commissioning & Contracting CRO: Dr Sarah Morgan
C1.3 • Gastroenterology – develop and implement new pathways, models and commissioningarrangements
SRO: Director of Transformation, Planning & Delivery / Director of Commissioning & Contracting CRO: Dr Kevan Ritchie
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C1.4
C1.5
C1.6
• Pathology – implement GP direct access pathology protocols to reduce duplication ofdiagnostics, and as improve diagnostic pathways in pathology
• Urology – develop and implement a new urology service model and associated pathwaysacross all NCL CCGs and providers to reduce variation across primary and acute care
• Demand Management – ensure patients are appropriately referred through- CCAS Demand management – extend the scope of Camden’s Clinical Assessment
Service (CCAS) to receive all GP referrals and thus reduce variation and inappropriatereferrals to secondary care
- PoLCE – contribute to this STP initiative to strengthen current policy criteria and introducenew procedures to improve clinical effectiveness and patient outcomes
- IVF – consult on the proposal to reduce to 1 cycle, in tandem with Islington CCG- Consultant to Consultant referral (C2C) – implement a programme of clinical work in
tandem with UCLH to reduce inappropriate C2C referrals- Integrated Medicine – work with RLHIM to understand their provision and ensure robust
clinical effectiveness is applied across all of their services- Clinical Advice Network (CAN) – contribute to this STP initiative to which will improve the
quality and response times of advice and guidance and increase current levels of usage byGPs in Camden, therefore reducing inappropriate referrals to secondary care
SRO: Director of Commissioning & Contracting CRO: Dr Philip Taylor SRO: Director of Commissioning & Contracting CRO: Dr Sarah Morgan SRO: Director of Commissioning & Contracting CRO: Dr Kevan Ritchie
C2 Enable more people with learning disabilities and/or autism to live in the community, with the right support (Transforming Care)
SRO: Director of Integrated Commissioning / Director of Commissioning & Contracting CRO: Charlotte Cooley
C3 Learning disabilities health checks - meet the proposed target of annual health checks for 79% of those with learning disabilities
SRO: Director of Integrated Commissioning / Director of Commissioning & Contracting CRO: Charlotte Cooley
C4 Develop a future plan for Community and Primary Care for how we bring together community and primary care services over the next five years, building on the principles outlined in the Local Care Strategy; this will include care for long term conditions.
SRO: Director of Primary Care and Community CRO: Dr Kevan Ritchie / Dr Sarah Morgan
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Objective D. Integrate and enable local services to deliver the right care in the right setting at the right time
PRIORITIES Ref Priorities 18/19 Accountable D1 Deliver the following Local Care priorities linked to the Health and Care Closer to Home
workstream in the Sustainability and Transformation Plan (STP) and the Primary Care vision by developing Camden GP neighbourhoods to deliver the following services and outcomes
D1.1 • Integrated Care Teams – ensure primary care, community health services & socialcare teams work together to deliver more effective care for the most complex patients;to include the alignment of services around GP neighbourhoods, the delivery ofeffective multi-disciplinary teams (MDTs) and achievement of significant activity shift inthe system
SRO: Director of Primary Care and Community CRO: Dr Sarah Morgan
D1.2 • Universal Offer – successfully implement changes to the Universal Offer includingchanges to existing services and the introduction of new services focused on deliveryof system efficiencies (services to be confirmed following approvals in February 2018)
SRO: Director of Primary Care and Community CRO: Dr Kevan Ritchie
D1.3 • Neighbourhood Development and Quality Improvement Support Teams (QISTS)– ensure the two Camden federations are funded and have resource in place to deliverneighbourhood priorities in 2018/19 including: delivery of neighbourhood proposedservices; expansion of quality improvement work within neighbourhoods; achievementof neighbourhood clinical and financial outcome targets; and successful establishmentof neighbourhood MDTs
SRO: Director of Primary Care and Community CRO: Dr Kevan Ritchie
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D1.4
D1.5
• Primary Care Mental Health – implement a primary care mental health servicethrough the provision of multidisciplinary teams (MDTs) aligned to neighbourhoods
• Integrated Paediatric Services – embed paediatric specialist integrated outreachclinics in primary care comprising of referral triage, integrated paediatric clinics inprimary care and a monthly MDT for each Neighbourhood facilitated by a paediatrician.
SRO: Director of Integrated Commissioning / Director of Commissioning & Contracting CRO: Dr Jonathan Levy
SRO: Director of Integrated Commissioning CRO: Dr Martin Abbas
D2 PMS Review – all practices to plan for transition (over four years) to deliver the agreed services based on the redistribution of PMS premium monies agreed with NHSE and LMC
SRO: Director of Transformation, Planning & Delivery CRO: Dr Kevan Ritchie
D3 Self-care and Prevention – implement the self-care action plan including: embedding self-care in the Local Care Strategy/Sustainability and Transformation Plan initiatives and existing contracts; ensuring consistency of approach across information advice services; developing a new model for Care Navigation and Social Prescribing; mapping community assets at neighbourhood level; and delivering a survey on self-care through the Citizens’ Panel.
SRO: Director of Transformation, Planning & Delivery CRO: Kathy Elliott
D4 Workforce – through Camden’s Community Education Providers Network (CEPN), deliver priorities which enable the health and social care workforce to meet the requirements of the transformation agenda, including: deliver apprenticeships and traineeships, and further develop career pathways for new roles as well as retention of ‘at risk’ groups; deliver locally prioritised multi-disciplinary education and training; and support quality improvement activities by facilitating North Central London (NCL) networks and coordinating Quality Improvement training
SRO: Director of Transformation, Planning & Delivery CRO: Dr Sarah Morgan
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D5 Digital Strategy - Improving Interoperability of Systems within Camden Health and Care economy: Stage 1: Primary Care and Community Services system – enable GPs and CNWL services to use the same IT system (EMIS) to share real time data, referrals, prescribing and care planning Stage 2: Primary Care and Mental Health Services – enable GPs and C&I services to use the same IT system (EMIS) to share real time data, referrals, prescribing and care planning Stage 3: Shared care record across the whole health economy – share real time data and population health management (extends to 2020)
SRO: Assistant Director of IT CRO: Dr Neel Gupta
D6 Estates Strategy – Complete the space utilisation review to identify premises which may be under-utilised and implement plans to improve utilisation, and implement solutions for all leases due to expire
SRO: Director of Primary Care and Community CRO: Dr Kevan Ritchie
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p. 9 of 11
Objective E. Work jointly with the people and patients of Camden to shape the services we commission
PRIORITIES Working closely with patients, service users and other members of the public is an integral part of our commissioning arrangements and is embedded within the commissioning priorities in Objectives A, C and D.
Objective F. Involve member practices and commissioning partners in key commissioning decisions PRIORITIES Engaging with member practices and commissioning partners is an integral part of our commissioning arrangements and is embedded within the commissioning priorities in Objectives A, C and D.
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Objective G. Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for-money services
PRIORITIES Ref Priorities 18/19 Accountable
G1 Financial Strategy and QIPP – develop and implement Camden’s medium-term financial strategy in line with the revised financial allocation, taking into account cost pressures, investment plans, QIPP plans, demographic growth and other adjustments, and deliver the 18/19 QIPP Plan
SRO: Deputy Director of Finance / Director of Transformation, Planning & Delivery CRO: Dr Birgit Curtis
G2 New Contracting Forms – through the North London Joint Commissioning Committee and Local Care Delivery Board, work with providers to further develop system incentives and options for alternative contract forms that better support the new models of care in the Local Care Strategy/Sustainability and Transformation Plan to ensure financial sustainability and achieve the relevant transformation of the health and care system
SRO: NCL Director of Acute Commissioning CRO: Dr Neel Gupta
G3 Contracts Review – analyse all contracts/investments listed in the Commissioned Services Register with a view to identify and realise potential savings through revision of terms of arrangements or decommissioning
SRO: Director of Transformation, Planning and Delivery CRO: Dr Neel Gupta
G4 Provider Data Handling and Assurance – ensure that providers are handling data in line with national guidance and making adjustments where necessary for new models of care. This will be through a long term data assurance piece which will be routinely discussed at Finance, Performance and QIPP Committee
SRO: Director of Commissioning & Contracting CRO: Dr Birgit Curtis
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Objective H. Build a high performing organisation that attracts, develops and retains a skilled and motivated workforce
PRIORITIES Ref Priorities 18/19 Accountable
H1 Embed the CCG’s operating model, including Adults Community services and the relevant Commissioning Support Unit (CSU) teams, to ensure sufficient commissioning and contracting capacity to deliver strategic priorities, and further strengthen alignment with North Central London (NCL)
SRO: Chief Operating Officer CRO: Dr Neel Gupta
H2 Successfully relocate the CCG’s headquarters by October 2018 SRO: NCL Director of Corporate Services CRO: Dr Neel Gupta
H3 Develop and implement an organisational development plan to ensure a resilient workforce measured through improved workforce indicators and the results of the staff survey
SRO: Chief Operating Officer / NCL Director of Corporate Services CRO: Dr Neel Gupta
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title St Pancras Estates Redevelopment Pre-consultation Business Case
Agenda Item 4.4 Date 09.05.18
Committee Chair (where applicable)
Dr Neel Gupta
Lead Director Richard Lewin Director Integrated Commissioning
Tel/Email [email protected]
Report Author Jill Britton, Associate Director Joint Commissioning, Islington CCG
Tel/Email [email protected]
GB Sponsor(s) (where applicable)
Jonathan Levy Tel/Email [email protected]
Report Summary Camden CCG is proposing a change to some services currently delivered on the St Pancras Hospital site, to modernise and improve the quality of care provided to local people. The changes will affect all inpatient services at St Pancras and some community services based both at St Pancras and other C&I Foundation Trust sites.
The Pre-Consultation Business Case (“PCBC”) assesses the opportunity to deliver better outcomes for users of mental health services across Camden and Islington through the development of a high quality and accessible estate. It sets out a way forward for formal consultation on a preferred option which is demonstrably the best solution in terms of benefits and value for money. The objectives of the PCBC are to:
• Make the case for change for transformation and modernisation of themental health services, delivered by Camden and Islington NHSFoundation Trust (“the Trust”) across its community estates, andspecifically at the St Pancras Hospital (“SPH”) site, to set out proposalsfor the redevelopment of the estates required to enable thetransformation;
• Describe how the transformation of mental health services contributestowards the STP objectives of improving overall mental healthoutcomes across North London and reducing inequalities for those withmental ill health;
• Describe the clinically developed model of care and specification for themovement of community services into community hubs and themovements of in-patient services from SPH to another site.
• Detail the process undertaken to engage the public, staff and otherstakeholders in the pre-consultation phase and demonstrate how theirfeedback has shaped the development of the options as well as theproposed option to take forward;
• Set out how the development of the preferred options is compliant withthe Secretary of State for Health and Social Care’s (“SoS” or “Secretaryof State”) four tests of service reconfiguration and NHSE’s other tests;
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• Make the case to NHS Islington Clinical Commissioning Group (CCG),NHS Camden CCG and NHS England (“NHSE”) to commence publicconsultation on the preferred option.
The Governing Body are asked to approve the pre-consultation business case. If the Governing Body approve the PCBC, then the final version of the consultation documents will come to the Board in June for approval to proceed to formal consultation.
Purpose (tick one boxonly) [See note 6]
Information Approval
To note Decision
Recommendation The Governing Body is asked to approve the pre-consultation business case
Strategic Objectives Links
The proposals set out in these papers contribute to the following strategic objectives: Objective B – Improve the quality and safety of commissioned services Objective C – Improve health outcomes, address inequalities and achieve
parity of esteem Objective D – Integrate and enable local services to deliver the right care, in
the right setting, at the right time. Identified Risks and Risk Management Actions
The major risk relating to this project is that the required consultation programme is not adequate or has not followed the prescribed process, which might lead to a Judicial Review or Independent Panel Review. To mitigate against this the following has been undertaken:
• A Steering group has been established to oversee the process, whichhas membership from all key stakeholders including David Mallett,Head of Service Reconfiguration at NHS England, who is providingexpert advice and assurance.
• Engagement with the Camden and Islington Overview and ScrutinyCommittees;
• Expert advice commissioned for the consultation methodology anddocumentation
• Pre-consultation engagement with patients and carers (CIFT)• Legal advice has been commissioned to ensure that the process is
technically accurate.• Additional management resources have been sourced to ensure that
there is capacity to undertake the consultation effectively.
Conflicts of Interest
There are no known conflicts of interest
Resource Implications
There are no financial implications for the capital development for NHS Camden CCG
Engagement A range of patient and public involvement activities have been undertaken in the development of the proposals, which has influenced the proposals and options appraisal. This includes meetings with HealthWatch in Camden and Islington, which have surveyed the inpatients units about the proposed developments. A wide range of community and voluntary organisations have also been engaged about the proposals, as well as service user and carer groups.
Equality Impact Analysis
The EIA has been completed in two parts, with the initial phase completed prior to consultation and a second stage to be completed following the consultation outcomes. The majority of vulnerable or protected groups identified as part of the EIA have been judged as achieving greater equality, improved outcomes or increased accessibility through the proposal. For example, both inpatient and
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community developments will provide improved disabled access for service users, staff and visitors. For many other groups, the purpose built facilities offer an improvement in therapeutic environment, access to outdoor space and care delivered closer to home.
At this stage, the EIA has identified the potential increased travel time for some disabled service users as the only vulnerable group that may experience a reduction in accessibility. In order to minimise this risk, route planning to the new site will be provided and shared with local community groups for individuals with disabilities.
Report History and Key Decisions
The pre-consultation business case and the consultation documents were considered by Board members at the Islington CCG Governing Body seminar on 11th April.
The pre-consultation business case and the consultation documents were considered by Board members at the Camden CCG Governing Body breakfast meeting on 25th April.
Next Steps The documents will be presented to: • the London Clinical Senate on 15th May• Camden and Islington Overview and Scrutiny Committees – 14th June• Camden and Islington CCGs Governing Bodies - June
Appendices Draft pre-consultation business case
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Pre-Consultation Business Case for the Redevelopment of the St Pancras Hospital site and Mental Health Community Hubs
Version 4.2 20 April 2018
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Glossary of Terms
5YFV Five Year Forward View A&E Accidents & Emergency ALoS Average Length of Stay CAMHS Child and Adolescents Mental Health Services Capex Capital Expenditure CBT Cognitive Behavioural Therapy CCCG Camden Clinical Commissioning Group CCG Clinical Commissioning Group CIM Capital Investment Manual CIP Cost Improvement Plan CMH Community Mental Health CNWL Central and North West London NHS Foundation Trust COIL Certificate Of Immunity from Listing COO Chief Operating Officer CQC Care Quality Commission CSF Critical Success Factors DHSC Department of Health and Social Care DMBC Decision-Making Business Case DQI Design Quality Indicator EAV Equivalent Annual Value EBITDA Earnings before Interest, Tax, Depreciation and Amortisation EA10 Equalities Act 2010 EIA Equality Impact Assessment FBC Full Business Case FSRR Financial Sustainability Risk Rating GB Green Book GEM General Economic Model GPs General Practitioner HMHC Highgate Mental Health Centre HMT HM Treasury HOSC Health Oversight and Scrutiny Committee HR & OD Human Resources & Organisational Development I&E Income and Expenditure IAPT Improved Access to Psychological Services ICCG Islington Clinical Commissioning Group ICT Information & Communication Technology IoMH Institute of Mental Health
Term / Abbreviation Definition
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IT Information Technology ITFF Independent Trust Financing Facility JHOSC Joint Health and Overview Scrutiny Committee JHWS Joint Health and Wellbeing Strategies JSNA Joint Strategic Needs Assessment LCS London Clinical Senate LoS Length of Stay LTFM Long Term Financial Model Moorfields Moorfields Eye Hospital NHS Foundation Trust NCL North Central London NHS FT NHS Foundation Trust NHSE NHS England NHSI NHS Improvement NPC Net Present Cost OBC Outline Business Case OSC Overview Scrutiny Committee PBMH Practice Based Mental Health PCBC Pre-Consultation Business Case PDC Public Dividend Capital PIA Privacy Impact Assessment PICU Psychiatric Intensive Care Unit PID Patient Identifiable Data PLACE Patient Led Assessment of the Care Environment PPE Property Plant and Equipment QIA Quality Impact Assessment R&R Rehabilitation and Recovery SAMH Services for Ageing and Mental Health SMS Substance Misuse Service SOC Strategic Outline Case SoS Secretary of State SPH St Pancras Hospital STF Sustainability and Transformation Fund STP Sustainability and Transformation Partnerships the Trust Camden and Islington NHS Foundation Trust the Trust Camden and Islington NHS Foundation Trust; the “Trust” Two boroughs The London Boroughs of Camden and Islington
UCL University College London UCLH University College London Hospital UCLP University College London Partners VAT Value Added Tax
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ContentsPre-Consultation Business Case for the Redevelopment of the St Pancras Hospital site and Mental Health Community Hubs 1
Foreword 7
Executive summary 9
1.1 Introduction 9
1.2 Case for change and care model 10
1.3 Governance 12
1.4 Stakeholder engagement 12
1.5 Finance case 14
1.6 Implementation 14
1.7 The SoS’s four tests and NHSE’s other test 15
1.8 Decision making and next steps 15
2 Introduction 17
2.1 Overview 17
2.2 PCBC objectives 17
2.3 Background 18
2.4 PCBC scope 18
2.5 Parties involved in the production of this PCBC 19
2.6 Proposal Development 20
2.7 PCBC structure 21
3 Context 23
3.1 The Population and Healthcare challenges 23
3.2 Background to the Trust and CCGs 24
4 Case for Change 27
4.1 Local Policy Framework 27
4.2 National Policy Framework 30
4.3 Regional Policy Framework 34
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4.4 Quality of Existing Estate 39
4.5 Limitations of Current Service Provision 41
5 Care model and expected benefit 42
5.1 Care Model 42
5.2 Expected benefit 54
5.3 Impact on service users and benefits 54
5.4 Changes to travelling times and distances 57
5.5 Public Sector Equality Duty 57
6 Governance 59
6.1 Governance structure for the consultation process 59
6.2 Roles and Responsibilities 61
6.3 Information Governance Issues 61
7 Stakeholder engagement 62
7.1 Legal Context 62
7.2 Pre-consultation engagement on the case for change 63
7.3 Options appraisal engagement 65
7.4 Applying pre-consultation engagement findings to options appraisal 68
7.5 Other pre-consultation engagement activity 69
7.6 Consultation Plan 69
8 Options development, analysis and evaluation process 74
8.1 Option development 74
8.2 Appraisal 1: Feasibility Study 75
8.3 Appraisal 2: Hurdle CSF 76
8.4 Appraisal 3: Qualitative CSF 77
8.5 Appraisal 4: Value for Money evaluation of options 79
8.6 Combined appraisal 82
8.7 Impact of the preferred option 82
9 Finance case 84
9.1 Introduction 84
9.2 Basis of preparation 85
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9.3 Financial projections 85
9.4 Impact on financial sustainability risk rating (FSRR) 98
9.5 Sensitivities 98
9.6 Conclusions 99
10 Implementation 100
10.1 Post consultation process 100
10.2 Programme management arrangements 100
10.3 Project implementation plan 105
10.4 Post project evaluation 106
10.5 Approvals process for investment by the Trust 107
11 The SoS’s Four Tests 109
11.1 Test 1: Strong public and patient engagement 109
11.2 Test 2: Consistency with current and prospective need for patient choice 112
11.3 Test 3: A clear clinical evidence base 113
11.4 Test 4: Support for proposals from clinical commissioners. 114
11.5 NHSE’s Bed Closures Test 115
12 Decision making and next steps 117
Appendix Contents 118
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Foreword
North London Partners in Care share a vision for our community to be happier, healthier and to live longer in good health. We have a collective agenda and a commitment to transform the health and care services of North London. Our community has told us they want a more joined up and integrated health and care system, they want care closer to where they live and work, delivered by professional and compassionate health and care workforce.
We are united in our commitment to transforming care to deliver the best possible health outcomes for our local population. This will be done by shifting our model of care so that more people are cared for in ‘out of hospital’ settings, and through prevention, more proactive care, and new models of care delivery, we can reduce the reliance on secondary care and improve the way people access and receive care.
We want to improve overall mental health outcomes across North London and reduce inequalities for those with mental ill health; enable more people to live well and receive services closer to home and ensure that we are treating both physical and mental ill health equally.
Our ambition is that unless someone requires highly specialised care, they will be able to receive the care they need within North London, and not require an out of area placement. By investing in community based care, we aim to reduce demand on the acute sector and mitigate the need for additional mental health inpatient beds.
To deliver our vision, we have designed a programme of transformation for mental health services based around these fundamental elements:
Supporting people with mental ill health to live well, enabling them to receive care in theleast restrictive setting for their needs;
Raise mental health awareness to reduce stigma, ensuring that mental health isconsidered equally with physical health;
Reduce reliance on inpatient care and expand community provision to support morepeople to spend more time at home, rather than in hospital;
Ensuring more accessible and extensive mental health support is delivered locally withinprimary care services.
We are developing our services in the community to make sure that health and care will be available closer to home for all, ensuring that people receive care in the best possible setting at a local level and with local accountability. At the heart of the care closer to home model is a ‘place-based’ population health system of care delivery which draws together social, community, primary and specialist services underpinned by a systematic focus on prevention and supported self-care, with the aim of reducing unplanned hospital admissions.
We believe that the changes proposed in this document provide an exciting opportunity to deliver on our ambition to improve the mental health and reduce the health inequalities of our communities. By delivering more care in community settings and working in a more joined up and integrated way with our health, social care and voluntary sector partners, we believe that we will be able to deliver better outcomes for our patients. By supporting people closer to their homes and embedding services in the community, our teams can help prevent
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people becoming unwell, or help them earlier so that they require fewer hospital referrals and less crisis care.
We know that services provided in the community for people who experience mental ill health bring many benefits and better health outcomes. Community service are less stigmatising and easier to access. People receiving their health care close to their homes can continue to receive the support of their families, friends and local community, which we know is vital to recovery. In order to realise our vision we need to be able to provide more specialist mental health services for all forms of mental health in the community, supporting the work of our GPs and community teams, so that we can support earlier discharge and reduce admissions and re-admissions.
Sometimes people will need specialist support provided in a hospital environment and it is our aim that this is provided in environments that are safe, therapeutic and maintain individual privacy. Where care is underpinned by strong, integrated community services, people will be referred to hospital less often and will be discharged earlier following periods of illness. By providing treatment in the least restrictive environment possible, fewer people will be detained under the Mental Health Act and those that do can step down from a hospital environment as soon as possible.
The community estate is key to delivering our vision. It can be brought together to help achieve these synergies between services and sectors, supporting joint and multi-agency working. The exact details of how all services may work together in the future is still to be developed through co-production with service users and carers and creating the space in Community Hubs is an enabler for this.
The care that we provide to patients must be underpinned by the best practice and we want to be at the forefront of research developments to ensure that people who experience mental ill-health are receiving the best care possible. By working with our academic partners, we can ensure that every intervention is evidence based and so will be the least restrictive as possible.
Helen Petterson Angela McNab
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Executive summary
1.1 Introduction The local health organisations are united in the commitment to transforming care to deliver the best possible health outcomes for the population of Camden and Islington. The local communities have voiced a need for a more joined up and integrated health and care systems. This will be done by shifting the model of care so that more people are cared for in ‘out of hospital’ settings, and through prevention, more proactive care, and new models of care delivery, reliance on secondary care can be reduced and improve the way people access and receive care.
This Pre-Consultation Business Case (“PCBC”) assesses the opportunity to deliver better outcomes for users of mental health services across Camden and Islington through the development of a high quality and accessible estate. It sets out a way forward for formal consultation on a preferred option which is demonstrably the best solution in terms of benefits and value for money. The objectives of the PCBC are to:
Make the case for change for transformation and modernisation of the mental healthservices, delivered by Camden and Islington NHS Foundation Trust (“the Trust”) acrossits community estates, and specifically at the St Pancras Hospital (“SPH”) site, to set outproposals for the redevelopment of the estates required to enable the transformation;
Describe the clinically developed model of care and specification for:
The movement of community services into community hubs; and
The movements of in-patient services from SPH to another site.
Detail the process undertaken to engage the public, staff and other stakeholders in thepre-consultation phase and demonstrate how their feedback has shaped thedevelopment of the options as well as the proposed option to take forward;
Set out how the development of the preferred options is compliant with the Secretary ofState for Health and Social Care’s (“SoS” or “Secretary of State”) four tests of servicereconfiguration and NHSE’s other tests;
Make the case to Camden NHS Clinical Commissioning Group (“CCG”) (“CamdenCCG”), Islington NHS CCG (“Islington CCG”), and NHS England (“NHSE”) to commencepublic consultation on the preferred option.
The proposal set out in this document is to move the following:
Services being provided from SPH that are moving into the community hubs
Inpatient services being provided from SPH that are moving to another site that is 2.5miles away from the current location; and
A limited range of other NHS services that are currently delivered from a variety of Trustsites which will move as part of proposals.
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1.2 Case for change and care model 1.2.1 Context The current Joint Strategic Needs Assessments (“JSNAs”) for Camden and Islington produced by the respective Health and Wellbeing Boards outline a clear requirement for sustainable and high quality mental health service in the area. Both Camden and Islington have significantly higher rates of mental health diagnosis than other London Boroughs. Islington has the highest proportion of its population diagnosed with a psychotic disorder, with Camden third highest nationally. The proposed reconfigurations reflect Health and Well Being Board Strategies to achieve this goal.
The Trust provides mental health services for people in the area. Almost 98% of services are commissioned by Islington CCG in their role as lead commissioner with Camden CCG as an associate commissioner.
The SPH redevelopment programme and development of mental health Community Hubs enables an overarching transformation of the estate to enable effective delivery of the Trust’s Clinical Strategy along with national and local health strategies through the development of a range of health services and research facilities. It puts service users at the centre, recognising there is a once in a lifetime opportunity to transform services across the London Boroughs of Camden and Islington, building more visible, more accessible and more integrated services for people locally alongside world class research driving the very best practice.The vision for the community hubs is that service users and carers will have a familiar, non-stigmatising, easily accessible place where they can access a variety of services that promote holistic care.
Community services are being developed to make sure that health and care will be available closer to home for all, ensuring that people receive care in the best possible setting at a local level and with local accountability. At the heart of the care closer to home model is a ‘place-based’ population health system of care delivery which draws together social, community, primary and specialist services underpinned by a systematic focus on prevention and supported self-care, with the aim of reducing unplanned hospital admissions.
Parity of esteem for mental health through modern estate and integration of care with physical health is widely supported through national initiatives and within the local health system. This is a rare opportunity to make a step change in converting that concept into reality for service users in North Central London and is aligned to the wider Model of Care and goals in the local Sustainability and Transformation Plan (“STP”).
To deliver the STP vision and the aims of the Five Year Forward View, a programme of transformation has been designed with four aspects: Prevention, Service transformation, Productivity and Enablers. The STP identifies the need to redevelop the estate at SPH, in conjunction with other redevelopments, in order to enable a range of initiatives across North Central London. Progress has been made against the STP plans through improving community resilience, increasing access to primary care mental health services, developing a women’s psychiatric Intensive Care Unit (“PICU”), investing in a community perinatal service, investing mental health services delivered in A&E and increasing access to psychological therapies.
The Trust’s sites vary widely in terms of their distribution, age, condition and suitability and these “extensive differences” were noted in the 2016 Care Quality Commission (“CQC”)
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inspection and whilst the 2018 inspection noted mitigations in place to address the concerns raised previously the overall rating for Safety remained as “Required Improvement”. Part of this is due to the inherent challenges of the estate such as visibility within the buildings. There is a potential time constraint on the ability to deliver the SPH transformation insofar as August 2015 the Trust were successful in their application for a Certificate of Immunity from Listing (“COIL”) that prevents the SPH site from becoming a listed building for five years.
1.2.2 Current and future care model The Trust’s Care Model forms part of the broader NCL STP ‘stepped’ model of care for mental health with goals around improved access to mental health services, improving the acute mental health pathway and improving patient pathways through practice based mental health teams and specialist care pathways. Following changes to the current care model, the workforce requirement will change in line with the NCL STP under this proposal to achieve portability, staff experience and career planning/development. Several initiatives have been developed that are specific to mental health, in conjunction with other NCL STP programmes, which include recruitment initiatives, rental initiatives development, and use of new roles and up-skilling current staff.
The commercial structure around the payments to the Trust from the CCGs is such that there would be no negative financial impact on the CCGs as a direct result of the proposed service changes. The Trust currently has 235 beds (84 on the SPH site) used for acute admissions, treatment of adults and older people. Over the last couple of years the Trust has experienced consistent pressure on its remaining beds and an increase in numbers of people admitted and those treated by the Crisis system. The STP mental health work stream is to a large extent based on reducing the demand for in-patient beds and meeting people’s needs in the community. The Trust has undertaken a range of changes to bed management that has reduced admissions, reduced bed utilisation so reduce private sector admissions, and reduced length of stay. Consequently the CCGs are confident that maintaining the current bed base at 235, will be sufficient to meet demand in 2025, the new build will actually allow one additional bed to 236 due to the removal of the estate compromise that saw one bed close in 2017.
1.2.3 Expected benefit The service user benefits depend on the service they access:
Community based care: The relocation of some services to the Camden hub offers the opportunity to access services at a welcoming community based, non-acute setting.
Improved therapeutic environment: For inpatients at SPH, moving to a new facility ensures they receive care in a high quality, specialised building with modern facilities.
Improved access: Relocating to a newly built site that meets modern accessibility requirements, this will increase equality of access for users, staff and visitors. There will need to be a focus on supporting disabled service users with accessibility to the new site as identified in the Equality Impact Assessment.
Parity of esteem for mental and physical health: By co-locating the new purpose built facility alongside the Whittington Acute Hospital, service users are able to receive specialist mental health treatment from the same site as users of the acute service.
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Improved integration between acute and mental health services: It is expected that users transferring between mental health inpatient and acute facilities on the same site will receive a quicker and more streamlined transition.
Better working initiatives for staff: By developing new facilities and implementing the workforce plan as per the STP, the local health organisations are more likely to attract a higher quality staff by providing a high level of staff support.
Improved research opportunities: Leading to long term improvements in mental health care and outcomes.
1.3 Governance The consultation phase of the redevelopment of the St Pancras site is being overseen by the St Pancras Hospital Redevelopment Oversight Group and led by the Chief Operating Officer of Islington CCG. This group is reporting to both of the CCGs, in addition to providing assurances to NHS England and be supported by three sub-groups: Clinical Senate Liaison Group, Public Consultation Working Group and Financial Modelling Group.
In order to proceed to public consultation, the process requires approval from the CCGs Governing Bodies and NHS England. Camden and Islington Health and Overview Scrutiny Committees will be also be provided an opportunity to review and comment on the consultation prior to launch.
As a part of the proposed relocation, the Trust is not proposing to change the use, storage or accessibility of any Patient Identifiable Data it holds.
1.4 Stakeholder engagement Under section 242 of the NHS Act 2006 and section 142Z of the Health and Social Care Act 2012, NHS Trusts and CCGs have a legal duty to make arrangements for individuals to whom the services are being or may be provided, to be involved throughout the process. All public consultations should adhere to the Gunning Principles.
1.4.1 Pre-consultation engagement on the case for change
The local health organisations have engaged with inpatient service users, community service users, carers, staff and other stakeholders as part of pre-consultation engagement work for the development of the plans. Pre-consultation engagement including as part of the STP included service users and carers, employees, GPs, the JHOSC and other local stakeholders.
1.4.2 Options appraisal engagement As part of the options development a series of meetings were held to get input and understand the needs of stakeholders. The following options appraisal engagement was incorporated into the options appraisal process up to the point of selecting the preferred option. Shortlisted options for inpatients included:
A1 – Do minimum - The Trust would carry out the minimum works necessary to improve the quality of their existing estate to enable the Trust to deliver a higher quality of care.
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A2 – Re-provide inpatients at SPH - A new mental health inpatient facility would be built on the existing SPH site.
A3 – Re-provide inpatients at Whittington Hospital - The Whittington Hospital is located in Islington but on the border road between Camden and Islington to the North of both Borough’s. It is an acute hospital with land available for the Trust to build a new inpatient facility.
A4 – Re-provide inpatients at St Ann’s Hospital - St Ann’s Hospital was identified during the Strategic Outline Case (“SOC”) stage as having the potential to host a new inpatient facility for the Trust.
Each option had the same proposal for community services and other services which is why they are not explicitly mentioned under each option above. A summary of the areas considered following this engagement included:
The need for adequate consultation with service users, which would include the formal consultation process itself;
Preference for inpatient beds to remain within or close to Camden;
Preference for inpatient beds not to shift to the St Ann’s site due to travel and accessibility issues;
Noting the proposal land disposal of the SPH site; and
Preference the provision of appropriate services from the community hubs. Following this the preferred option was agreed to be to move inpatient beds from SPH to a site in Camden and Islington, invest in community services through the two community hubs and bring researchers and academics together on a single site at SPH. The Whittington site was selected as the preferred option for inpatients and there has since been further engagement undertaken in the form of regular meetings with service users, carers, Trust staff, JHOSC updates and meetings with NHS Improvement (“NHSI”) and NHSE by the local health organisations.
1.4.3 Consultation Plan In light of the service changes under this proposal, Islington CCG is proposing to run a public consultation for 12 weeks starting from July 2018 to September 2018.
As part of the formal consultation process, the group of stakeholders who will be engaged will be widened. Accordingly the range of methodologies will also be expanded to cover targeted and ongoing engagement, across a range of channels. The concerns raised through the pre-consultation engagements will be incorporated in the consultation as follows:
Consulting with current and ex-service users;
Keeping the provision of services within Islington or Camden;
Undertaking further travel time analysis;
Be clear about strategy of sale of NHS Resources; and
Opportunity to input on which services are provided in the Community Hubs. The channels used to share the consultation and gather as many views as possible will include website/online media, paper copies, public meetings, focus groups, staff engagement, NHS provider roadshows, targeted interventions and local networks.
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The CCGs will appoint an independent partner to evaluate the consultation responses and analyse the results of the consultation. This will inform proposals in a Decision-Making Business Case (“DMBC”) that will validate the consultation outcomes.
Following the closure of the consultation on 30th September 2018, the evaluation team will have a period to analyse the results and present these to both of the CCG Governing Bodies (“CCG CBs”). Islington CCG will then make a recommendation on the redevelopment proposals to NHSE and both of the Overview and Scrutiny Committees (“OSCs”) for Islington and Camden.
1.5 Finance case As previously detailed, the amount of spending planned by both CCGs with the Trust will not negatively change as a direct result of these proposals because of the contract arrangements in place, whereby the Trust receive a negotiated fixed amount per period from CCGs to provide services to the local population – this is not directly linked to volume of service users unlike Payment by Results approaches for many physical care services. The Chief Financial Officer for both Camden CCG and Islington CCG corroborated the financial information presented below with the Director of Finance for the Trust and both individuals have reached an agreed position. As a result the main impact of the proposals is on the Trust.
The preferred option does provides a sustainable solution for the SPH site, eliminates backlog maintenance and enables the Trust to procure alternative accommodation which will directly support and enable implementation of the Trust’s Clinical Strategy.
Due to the high value of estate at St Pancras, the capital receipt from the redevelopment of the SPH site is expected to be greater than the total capital cost of the transformation. In the Trust’s Outline Business Case (“OBC”), a red book valuation has been undertaken as per NHSI and HM Treasury guidance which presents a prudent value. Therefore, the risk of not achieving a level of capital receipt to cover the costs of the redevelopment is low. As above, there is no request for funding associated with this programme of work, with any shortfall from land sales being initially met through the Trust’s internally generated reserves and to be recovered through the benefits in future periods. There will, however, likely be a requirement for interim financing arrangements for the Trust to manage the timing of cash flows.
1.6 Implementation Following the close of the consultation and decision-making process the CCGs will hand back decision making responsibility to the Trust. The Trust will implement the proposal, having already factoring in considerations from the consultation process.
The Trust has developed a robust programme management and governance structure which ensures accountability through clear allocation of responsibilities, and provides assurance through regular reporting, enabling quick identification and addressing any issues as they arise. The Trust implementation team will comprise approximately 4-6 people on a whole time equivalents (“WTE”) basis to be engaged at various points during the implementation. The function requirements during the implementation include: Programme Director; Project
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Director; Project Managers: Finance Support; HR and Workforce Support; Clinical Support; and Administration.
A detailed project plan exists that sets out milestones which will be updated on a regular basis as more information becomes available and the project develops. There is also an existing risk management process in place for the Programme, and this process will continue throughout the implementation and delivery phase of the programme to ensure that risks are identified, monitored and where possible, mitigated.
NHSI also require Trusts to submit a SOC, OBC and Final Business Case (“FBC”) for approval for capital investment proposals of this value.
1.7 The SoS’s four tests and NHSE’s other test The 2014/15 mandate from the Secretary of State to NHS England, outlines that proposed service changes should be able to demonstrate evidence to meet four tests before they can proceed:
1) Strong public and patient engagement: There has been extensive stakeholder engagement to date as described in Section 7 of this document including presentations, discussions, surveys, meetings and emails. This will continue during the Consultation.
2) Patient choice: There will no change in the number of providers serving the local area, whilst choice will be improved through the offer of a fit for purpose mental health facilities for local service users.
3) Clinical evidence base: There is a clear case for change insofar as the existing estate is ageing and inflexible with multiple ligature points and blind spots where staff cannot easily observe service users. A wide range of clinicians have been engaged and consulted throughout to ensure patient outcomes are central to plans with feedback showing a strong level of support. The Clinical Senate will also provide feedback prior to formal consultation commencing.
4) Support from clinical commissioners: Both CCGs support and have helped to develop the proposals in this document. CCG Governing Body leads have been involved in the process throughout alongside member GPs.
It is also noted that NHS England have also introduced an additional test but as it only relates to circumstances where there are proposals to reduce bed numbers it is not applicable here.
1.8 Decision making and next steps Following consultation, the St Pancras Hospital Redevelopment Oversight Group will review consultation responses received from members of the public and organisations. The committee will then consider the views of the participants and the effect these may have on the decision-making process.
However, to give an indicative timeline, the programme expects the following milestones for this process. These may be subject to change, as described above:
Formal public consultation –5th July 2018 to 30th September 2018 (12 weeks).
External analysis of consultation responses – October 2018.
Final business case preparation – November 2018
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Each CCG GB to consider the final business case document – November 2018
Each CCG GB make a decision on the final business case – November 2018
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2 Introduction
This section provides an overview of the purpose and development of the Pre-Consultation Business Case (”PCBC”), as well as a description of the contents of the PCBC.
2.1 Overview The local health organisations are united in the commitment to transforming care to deliver the best possible health outcomes for the population of Camden and Islington. The local communities have voiced a need for a more joined up and integrated health and care systems. This will be done by shifting the model of care so that more people are cared for in ‘out of hospital’ settings, and through prevention, more proactive care, and new models of care delivery, reliance on secondary care can be reduced and improve the way people access and receive care.
This PCBC sets out the proposal to develop a fit for purpose and cost-effective service transformation that delivers a high quality and accessible estate for patients with mental health needs across the London Boroughs of Camden and Islington. The new estate, combined with the service transformation, will enable Camden and Islington NHS Foundation Trust (“the Trust”) to deliver high quality integrated health and social care services, whilst supporting the Trust’s research objectives.
As set out in the Trust’s Estates Strategy, it is necessary to release value from the St Pancras Hospital (“SPH”) site to enable the delivery of the broader transformation of mental health facilities in the area.
This PCBC sets out a way forward for full public consultation on a preferred option which is demonstrably the best solution in terms of benefits and value for money.
2.2 PCBC objectives The objectives of this PCBC are to:
Make the case for change for transformation and modernisation of the current services delivered at the SPH site and the community sites of Greenland Road and Lowther Road and detail the proposal for redevelopment that enable these changes to happen;
Describe the clinically developed model of care and specification for the re-provision of:
Inpatient services from SPH to a new site;
The re-provision and alignment of some community services into newly developed community settings; and
Detail the services that are remaining on SPH, albeit in new facilities.
Detail the process undertaken with stakeholders to inform, develop and evaluate viable options for the redevelopment of the SPH site and re-provision of services elsewhere;
Detail the process undertaken to engage the public, staff and other stakeholders in the pre-consultation phase and demonstrate how their feedback has shaped the development and selection of the preferred option;
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Set out how the development of the preferred options is compliant with the Secretary of State for Health and Social Care’s (“SoS” or “Secretary of State”) four tests of service reconfiguration and NHSE’s other tests;
Make the case to Camden NHS Clinical Commissioning Group (“CCG”) (“Camden CCG”), Islington NHS CCG (“Islington CCG”), and NHS England (“NHSE”) to commence public consultation on the preferred option.
2.3 Background The existing mental healthcare estate at SPH is not fit for purpose – it is in part converted from Victorian workhouses and was simply not designed to meet modern health and safety requirements or provide an optimal environment for delivering healthcare. The latest Care Quality Commission (“CQC”) inspection published in March 2018 noted that the Trust had sufficient mitigations in place to address the concerns raised previously. However the overall rating for Safety remained as “Required Improvement”. The previous The CQC report (June 2016) highlighted that the Trust’s acute wards (for adults of working age) and psychiatric intensive care units require significant improvement. This judgement was based in part on the breach of guidance on single sex accommodation, the physical ward layout which prevented staff observation of all areas and the presence of a number of ligature risks that were insufficiently managed; with the risk either not consistently recognised or mitigated or the unavailability of ligature cutters.
As well as failing to meet modern standards, the location itself is no longer fit for purpose as it does not provide therapeutic value for people who may be resident for many weeks or months. For example, the estate lacks space for physical activity, monitoring of service user wellbeing is impeded by the layouts, and there are significant commercial developments in the area surrounding St Pancras that infringe on the privacy and therapeutic environment of service users.
Significant investment would be required to maintain and upgrade the current premises to meet modern standards, and it would require significant disruption to services during a transition period with several stages of decanting services from one site to another. Even then, in some cases, the Trust would still be unable to satisfy the standards prescribed by Department of Health best practice guidance (Health Building Notes).
The Trust has, however, identified an opportunity to transform the estate to provide a fit for purpose, cost-effective, integrated, accessible estate to enable the delivery of high quality health and social care services. This is set out in subsequent sections of this document.
2.4 PCBC scope Islington CCG, Camden CCG and the Trust have carefully considered what needs to be consulted on. It has been decided that the following services will be publicly consulted on:
Inpatient services being provided from SPH that are moving to another site that is 2.5 miles away from the current location;
Services being provided from SPH that are moving into the community hubs; and
A limited range of other mental health services that are currently delivered from a variety of sites which will move as part of proposals.
A complete list of the Trust’s services that are moving can be found in Appendix [1].
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Services that are not moving will not form part of this consultation, but for completeness this document does set out the NHS services that will be staying on the SPH site. The following NHS organisations who are currently providing services on SPH will continue to do so in new buildings:
Royal Free NHS Foundation Trust; and
King’s Cross Surgery and London Central and West Unscheduled Care Collaborative. Central North West London NHS Foundation Trust and University College London Hospital, who are currently providing services out of the South Wing building at SPH, will continue to do so from existing facilities: All of these organisations have been consulted with as part of the production of PCBC and will have the opportunity to feed into the consultation.
It is not currently envisaged that services will have to move off the SPH site during the redevelopment process. However, there is a possibility that the GP out of Hours service and GP practice may need to temporarily move within the SPH site. If this is the case, every effort will be made to reduce disruption and inconvenience to patients, staff and the public. Furthermore, during this redevelopment period every effort will be made to ensure disruption is kept to a minimum for users of the site and surrounding area. Where development is required alongside existing services, all regulatory processes will be followed to ensure development areas are sectioned off and safe for public passage in line with best practice for construction contractors. In particular, current plans for access for contractors will be through the eastern end of the SPH site, away from South Wing and residential areas of Somerfield, thereby not obstructing access, limiting noise impacts and retaining ambulance access. Trust services that are not provided on SPH site and are not moving, as well as back office support services will not form part of the consultation. A complete list of other provider services that are staying at SPH can be found in Appendix [2].
2.5 Parties involved in the production of this PCBC The PCBC has been produced following engagement throughout the process with the following parties:
NHS England (“NHSE”);
The local CCGs, specifically Camden NHS CCG and Islington NHS CCG;
The local Health Trusts, specifically Camden & Islington NHS Foundation Trust (“the Trust”);
London Health and Care Devolution;
Other primary care providers; including those on site (King’s Cross Surgery and London Central and West Unscheduled Care Collaborative); and
Local Authorities, specifically Islington London Borough Council and Camden London Borough Council including through the Joint Health Oversight and Scrutiny Committee (“JHOSC”), as set out in Section [7].
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2.6 Proposal Development The Trust proposal set out in this document is to invest in new facilities for community services provided on the SPH site, plus one site in Islington and one in Camden, whilst re-providing the working age acute and rehabilitation inpatient facilities at SPH to a site adjacent to HMHC. These new facilities in Camden and Islington are described as community hubs. The new facilities provided at the SPH site will also accommodate a new Institute for Mental Health (“IoMH”) on behalf of Universities College London (“UCL”).
Development of the proposed changes has been ongoing since early 2016 by the local health organisations. This includes work on the pre-consultation activities, stakeholder engagement and options development. Further detail of the options development is set out in Section [8].
The SPH redevelopment programme and development of mental health Community Hubs enables an overarching transformation of the estate to enable effective delivery of the Trust’s Clinical Strategy along with national and local health strategies through the development of a range of health services and research facilities. It puts service users at the centre, recognising there is a once in a lifetime opportunity to transform services across the London Boroughs of Camden and Islington, building more visible, more accessible and more integrated services for people locally alongside world class research driving the very best practice. The opportunity is time limited because of the Certificate of Immunity from Listing (“COIL”) that is set out in more detail in Section [4.1.3].
The SPH redevelopment programme is an opportunity to reshape the services themselves delivering high class local, integrated care, meet leading 21st century standards in facilities and develop a world class research institute.
As part of this transformation, the Trust will:
Build the community hubs, as part of the wider SPH transformation programme, where people can access local integrated health and social care;
Deliver innovative wellbeing and recovery services, with improved visibility with the local population, colleges, universities, and employers; and
Create an attractive setting that combines physical and mental health provision alongside a vibrant new development of residential, restaurant and leisure uses.
The SPH and Community Hubs programme will deliver:
1) Community hubs that support integrated care The vision for the community hubs is that service users and carers’ will have a familiar, non-stigmatising, easily accessible place where they can access a variety of services that promote holistic care. There is a programme of transformation for mental health services based around these fundamental elements:
Supporting people with mental ill health to live well, enabling them to receive care in the least restrictive setting for their needs;
Raise mental health awareness to reduce stigma, ensuring that mental health is considered equally with physical health;
Reduce reliance on inpatient care and expand community provision to support more people to spend more time at home, rather than in hospital;
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Ensuring more accessible and extensive mental health support is delivered locally within primary care and other community services.
Community services are being developed to make sure that health and care will be available closer to home for all, ensuring that people receive care in the best possible setting at a local level and with local accountability. At the heart of the care closer to home model is a ‘place-based’ population health system of care delivery which draws together social, community, primary and specialist services underpinned by a systematic focus on prevention and supported self-care, with the aim of reducing unplanned hospital admissions.
The plan is to develop community hubs as follows:
A 4 storey community hub at the Trust’s existing site in Greenland Road, in the London Borough of Camden; and
A 4 storey community hub at the Trust’s existing site at Lowther Road in the London Borough of Islington, replacing the existing building.
What this means for residents is that some services will move from their current locations the final details for some of these services are yet to be fully determined. However, the local health organisations are confident that by co-locating clinical teams, giving access to joined-up care will have significant benefits for residents.
2) The SPH Site The St Pancras Hospital site will be redeveloped to provide a total of 2,187m2 of accommodation for the Trust including, out of a total current Trust occupied area of 12,117m2:
New community facilities that will include consulting rooms, meeting rooms, training facilities and the Recovery College. The Recovery College includes space for both clinical delivery and support facilities for the clinical teams;
In addition, a new Institute of Mental Health (“IoMH”) in partnership with University College London will provide an opportunity to improve mental health outcomes over the long term; and
New facilities for the other NHS services. 3) High quality inpatient facilities
A new build inpatient facility – located at Whittington Hospital (“the Whittington”). The inpatient facility will be a three storey new build surrounded by landscaped gardens with car parking available at our neighbouring Highgate Mental Health Centre (“HMHC”);
The new facility will have 84 single bed rooms, supported by 606 m2 of support space, an
external courtyard or garden space and consulting rooms for each ward;
The new facility will be fully accessible, and present an attractive, therapeutic and welcoming environment for staff and service users; and
The facility will be designed to be future proof allowing reconfiguration in use as requirements change over the next decades.
2.7 PCBC structure This PCBC was developed in line with the NHSE guidance “Planning, assuring and delivering service change for patients” published on 1 November 2015 and the update in
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March 2018, and HM Treasury Green Book guidance in relation to the capital investment decisions involved to support that service change. It includes the following sections:
Executive summary: Summarises the key findings from the PCBC.
Introduction (this section): Provides an overview of the project’s objectives, background, scope, parties involved in the production and the proposal.
Context: This section sets the background of the parties involved, the current healthcare challenges faced by the commissioners and providers, and the commissioning arrangements between the CCGs and Trust.
Case for change: This section details the rationale and key drivers for changing the way services are delivered including from a national and local strategic context.
Care model: This section sets out the model of care and details how the model of care is changing and the proposal facilitates delivery of this. It highlights the expected benefits and also how the model meets the needs identified in the Case for Change section.
Governance: This section documents the governance structure that has been put in place to ensure the consultation process is robust, accommodates relevant stakeholder views and who is responsible for making decisions and who is responsible for approvals.
Stakeholder engagement: This section sets out the engagement undertaken to date, how this has informed the consultation proposed and how the consultation will be run.
Options for consultation: This section documents the process for options generation and evaluation.
Finance case: This section sets out the financial impact of the selected option on the CCGs, Trust and any other relevant parties.
Implementation: This section sets out the practice steps needed to deliver the option identified in the Options for consultation, including project team, governance, risk management and timelines.
The SoS’s Four Tests: This section sets out how the consultation process has met the Secretary of State’s four tests and NHSE’s other tests.
Decision making and next steps: This section identifies next steps for the consultation process and wider development programme.
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3 Context
3.1 The Population and Healthcare challenges The healthcare challenges set out below are in line with those presented in each of the borough’s Joint Strategic Needs Assessments (JSNAs) and latest published Annual Report and Accounts.
3.1.1 Health and well-being challenges in the borough of Islington
Islington borough is London’s fifth most deprived borough and the fourteenth most deprived in England, which contributes to poor health and wellbeing outcomes.
The borough is one of London’s most mobile populations with approximately 20% of residents entering and leaving the borough each year. This results with challenges in identifying health issues and monitoring improvement in health outcomes.
At least 44,000 registered service users have one long term condition such as diabetes. It is also assumed that many more long term conditions may be undiagnosed.
Islington has the highest prevalence of psychotic disorders in England, nearly double the national average. In addition, 10% of registered service users has a diagnosis of depression which is amongst the highest in London.
It is estimated that about 31,000 people in Islington suffer with depression or anxiety. The suicide rate has been reducing since 2001 and in 2011-2013 it was below the national average and slightly above the London average. The relatively younger population explains a lower prevalence of dementia.
Islington is the 14th most deprived Local Authority in England. The borough has a few small pockets of higher financial capability, with the rest of the population having low financial capability.
3.1.2 Health and well-being challenges in the borough of Camden
Camden is ranked the 15th most deprived borough in London (out of 33). Within Camden there are areas that are within the 10% most deprived areas in England. Poverty is a key determinant of poor outcomes in health and wellbeing and higher levels of deprivation are linked to numerous health problems such as chronic illness.
Camden has the third highest diagnosed prevalence of serious mental illness in the country and the 8th highest diagnosed prevalence of depression in London. One in seven GP registered adults in Camden have been diagnosed with one or more mental health conditions.
Camden experience a higher rate of alcohol specific hospital admissions than England and London. Three quarters of the adult population in Camden drink alcohol and of those who drink an estimated 34% drink at levels that cause risk of harm to physical and mental health.
Life expectancy in the borough of Camden is higher than the average life expectancy in London and England. While the life expectancy is higher, on average the last 20 years of
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their life is spent in poor health. There is also a stark difference in the life expectancy between the most and least deprived boroughs.
The JSNA’s published in October 2016 estimate that the population is due to rise by 9% over 10 years. Although older people make up a relatively small proportion of Camden’s population (approximately 11.5% are aged 65 and over), the highest percentage growth (41%) in the 10 years commencing 2016 will be seen in those aged 75 years and older, resulting with exacerbation of health challenges1.
3.2 Background to the Trust and CCGs The services provided by the Trust are primarily commissioned by Islington CCG in their role as lead commissioner for mental health services, with Camden CCG as a significant Associate commissioner to the Islington CCG contract. This account for 98% of services commissioned. As such, the Chief Accountable Officer for both organisations will be the decision maker for this proposal; this position is held by the same person across both organisations.
3.2.1 Islington NHS CCG Islington CCG is the lead commissioner for mental health services provided by the Trust, accounting for 98% of services commissioned.
Islington CCG has 33 member GP practices, serving a population of nearly 250,000. The CCG spent a total of £329.6 million in 2016/17 and achieved an in year surplus of £9.7 million2.
The majority of the CCG’s services are provided by local NHS organisations such as Whittington Health, Moorfields NHS Foundation Trust, Camden and Islington NHS Foundation Trust, University College London Hospital NHS Foundation Trust and Royal Free London NHS Foundation Trust. Services are also commissioned from not-for-profit organisations based in the local community and other providers.
As part of taking forward the Haringey and Islington Wellbeing Partnership, the executive management team of the CCG operates jointly with neighboring Haringey CCG. The two CCGs are led by a single Chief Operating Officer. Islington CCG received a “Good” rating at the 2016/17 annual assessment.
3.2.2 Camden NHS CCG Camden CCG is a significant Associate to the Islington CCG contract.
Camden CCG has 35 member GP practices and serves a slightly smaller population than Islington of 280,000 residents. The CCG spent £371.7 million in 2016/17 and achieved an in-year surplus of £476k3.
Similarly for Camden CCG, the majority of services commissioned are provided by local NHS organisations, including Camden and Islington NHS Foundation Trust, University College London Hospital NHS Foundation Trust and Royal Free London NHS Foundation Trust, Whittington Health and Moorfields NHS Foundation Trust. Camden CCG also 1 Camden JSNA 2015/16 (October 2016) 2 Islington CCG Annual Report and Accounts 2016/17 3 Camden CCG Annual Report and Accounts 2016/17
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commissions services from not-for-profit organisations based in the local community and other providers.
3.2.3 Background to the Trust The Trust provides mental health services for people with psychoses, complex psychological conditions such as personality disorders, substance misuse, acute and crisis care, common mental health disorders and dementia care. In addition, the Trust has a number of specialist programmes such as mental health care for veterans living in London which is commissioned by NHSE, this will not form part of this consultation as these services are not moving, as set out in Section [2.4]. The Trust is the main provider of mental health services for people living in Camden and Islington and also provides statutory social work and social care services on behalf of the London Boroughs of Islington and Camden.
Services are provided for adults of working age, adults with learning difficulties and older people in the London area, either in a community or inpatient setting. The Trust has approximately 1,700 staff and provides services to approximately 30,000 people per year. This includes a significant minority of people who are not local residents, but are temporarily based here, such as students, asylum seekers and visitors to the capital.
Services at the Trust are managed in the following five operational divisions:
Acute and Crisis Care (Urgent care);
Recovery and Rehabilitation (Psychosis);
Services for Ageing and Mental Health (Older people and Dementia);
Substance Misuse Services (Alcohol and drugs);
Community Mental Health (Complex psychological and common mental health conditions).
The Trust does not provide child and adolescent mental health services (which is provided by the Tavistock and Portman in Camden and Whittington Health in Islington) and has relatively few specialist services.
The Trust is a member of University College London Partners (“UCLP”), one of the world’s leading academic health science partnerships, and has a strong reputation for supporting world-class quality research in to mental health.
The Trust has around 30 sites across Camden and Islington, as follows:
Inpatient beds are accommodated at two significant hospital sites in Camden (SPH and HMHC) providing 235 beds;
Community beds (residential) are provided across several sites, accommodating 78 beds;
Community clinical services are delivered from a number of buildings, spread across Camden and Islington.
The Trust’s Head Office is located at SPH, located within Camden. This occupies the former St Pancras Workhouse and Infirmary and comprises 17 separate buildings and structures. The site is located north of Kings Cross and St Pancras Station and west of the mainline railway tracks. The Grand Union Canal is located just to the north and east of the site. St
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Pancras Gardens forms the southern boundary to the site. In addition, the South Wing of the hospital is located just to the south fronting onto St Pancras Way.
Adjacent developments around Kings Cross and St Pancras have transformed the area and attracted significant inward investment. A number of large-scale housing developments, a feature of the regeneration of the area, overlook the site which is not seen as conductive to mental health recovery.
The proposal is in line with the Trust’s 2016-2021 clinical strategy, which highlights some particular demands on the estates of the Trust.
The focus of the Trust’s Clinical Strategy is to promote recovery, resilience and independence via easy to access community-based services and specialist care-pathways. This is based on:
Expanding capacity by integrating more staff into primary care and community settings;
Integrating physical and mental health;
Reducing the physical and psychological barriers to entry (through more local provision, better access for those with disabilities and more generally through greater awareness in the community);
Improving lives and wellbeing through wider integration of social and mental health support.
The Clinical Strategy is consistent with national policy and the North Central London (“NCL”) Sustainability and Transformation Plan (“STP”), which aims to increase early intervention and support through primary care, join up social care and health services and ensure mental health has parity with physical health. This is outlined in further detail in the regional policy case for change in Section [4] below.
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4 Case for Change
There are five categories of drivers for change to the current service delivery:
The local policy framework drivers for change – delivering on the objectives set out in the Trust’s clinical and estates strategies by providing more care in the community, developing research capabilities and leading on equality and diversity;
The national policy framework drivers for change – focusing on prevention, achieving parity for mental health and physical health care provision and integration of physical and mental care;
The regional policy drivers for changes – implementing the NCL STP plan;
The poor quality of existing estate at SPH; and
The limitations on the current service provision at SPH;
4.1 Local Policy Framework 4.1.1 The Trust’s Clinical Strategy This proposal is in line with the Trust’s 2016-2021 clinical strategy, which highlights some particular demands on the estates of the Trust.
The Trust’s Clinical Strategy represents a vision for the transformation of mental health and substance misuse services. It is aimed at addressing the challenges for mental health services of:
Increasing demand;
Historic underfunding in comparison with physical health services;
Difficulties with accessing timely interventions due to stigma; and
Poor awareness and services often not being joined up or accessible particularly for vulnerable communities.
The strategic priorities of the Trust are:
Early and effective intervention;
Helping people to live well; and
Research and innovation.
It focuses on increasing services based in primary care and the community, improving access to services and integrating physical and mental health. The Clinical Strategy recognises that health and wellbeing are shaped by individual characteristics, lifestyle choices and environmental influences. So instead of attempting to ‘fix’ people and their problems, or do things to them rather than with them, recovery-orientated services look at individual needs and help people reach their potential. The Trust aims to provide services that are accessible, person-centred and responsive to the often complex needs of individuals. It is also recognised that the main determinants of health are socio-economic. In order to promote good health, prevent ill health and reduce inequalities in health, the Clinical
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Strategy promotes ongoing joint working with our partner organisations to act on the social determinants that are likely to impair people’s health.
A key component of the Clinical Strategy is the development of Practice Based Mental Health. Practice-based teams work locally with GPs and other services in primary care. Offering rapid assessments near to where people live, by senior clinicians who can make decisions about treatments, access services in the community or, if needed, refer to our specialist care-pathways. They will link people into the local community resources and services as they are better placed to see people who won’t engage with secondary care mental health services. They will support GPs in managing people with chronic mental illnesses who are stable. Along with acute services, the practice-based teams are the entry point into our specialist care-pathways.
Development of specialist care-pathways that deliver treatment and support to people with similar needs due to mental illness is another priority. The focus of these services is to help people achieve their recovery goals and link into their local social networks and community resources. Access to these pathways is based on risk, intensity and the need for specialist treatment.
The Trust has won awards for the development of an Integrated Practice Unit for people with psychosis, which brings together partner organisations to improve the physical health of those with psychosis. This is done with an aim to close the health inequality and lost years of life for people with this condition experience. Bringing together all the providers who deliver care to people with psychosis and coordinate their treatment and support will deliver a better quality service and better outcomes, especially physical health outcomes.
Through community teams, and work with partners the Clinical Strategy sets out the vision to offer high quality and comprehensive care and treatment. This is to ensure that service users have access to high quality supported housing and are helped where necessary into education and employment, and to develop social networks. Community services and support help people to continue their recovery and maintain their independence locally, and help reduce the length of time people need to spend in hospital, when they are very unwell, to a minimum. The Trust is committed to offering world class, safe inpatient services in therapeutic environments.
The focus of the Trust’s Clinical Strategy is to promote recovery, resilience and independence via easy to access community-based services and specialist care-pathways.
It is clear that in order to meet this clinical vision, the Trust needs an estate that enables Practice Based Mental Health to work locally and effectively with GPs and other services in primary care. It also needs an estate that allows the early successes of Integrated Practice Units to expand and bring physical health and mental health services together to meet health in-equalities. The development of Community Hubs, rather than multiple sites for small teams, allows a bringing together of services and providers to enable the coordination of treatment to deliver care closer to people’s homes, a better quality service and better outcomes. Finally, the Trust needs an estate that can provide a safe and therapeutic environment to those requiring inpatient care.
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The Clinical Strategy was approved and adopted by the Trust Board in November 2015. The Clinical Strategy Programme Board was set up to oversee and monitor the delivery of the Clinical Strategy.
The Clinical Strategy is in line with the NCL STP, which aims to increase early intervention and support through primary care, joined up social care and health services and ensure mental health has parity with physical health.
4.1.2 The Trust’s Estate Strategy The overarching aims of the Estate Strategy are to:
Provide modern, therapeutic mental health facilities across Camden and Islington;
Move more of our services into the community;
Build high quality, up-to-date, warm and welcoming inpatient facilities; and
Create world-class research facilities to help us deliver the very best care.
The Estates Strategy sets out the Trust’s vision for an overarching transformation of the estate to enable effective delivery of national and local health strategies. It covers the period 2017 to 2022 and it is based on the Trust’s assessment of the present estate to establish the scale of investment required to achieve the desired transformation. It has been developed in consultation with Trust Clinicians and the Estates Team, and was approved by the Board in April 2017.
In summary, the Estates strategy:
Highlights the significant shortcomings of the present Trust estate and the need for wholesale estate change to meet service transformation;
Sets out an estate transformation strategy for the next five years that enables the intentions of the Trust’s Clinical Strategy to be delivered;
Illustrates the opportunity that exists through a comprehensive approach to the St Pancras site and wider estate to enable the creation of community hubs (buildings that bring together a range of services for mental and physical health and social care) in local settings across both boroughs, supporting the local CCGs’ and Local Authorities’ strategies for locally based services in defined geographical patches;
Creating centralised high quality clinical, education and research, facilities, integrated primary care and the development of key worker and social housing for staff and local communities;
Improving access for all to services both through the location of services and by addressing EA10 compliance – both of which are currently difficult to achieve within the existing estate; and
Improving the efficiency and environmental impact of buildings alongside critically ensuring we create environments that are therapeutic – supporting people’s wellbeing and recovery.
The Trust’s vision is:
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“Our vision is to provide a fit for purpose, therapeutic, cost-effective, integrated and accessible estate which enables the delivery of high quality health and social care
services for our local population”
4.1.3 Equality and Diversity Policy The Trust’s Equality and Diversity Policy sets out how the Trust will demonstrate that it is planning and delivering services in a fair and equitable manner to all sections of the community, free from discrimination, and with dignity and respect.
Tackling health inequalities and social exclusion is an important priority for the Trust and it is committed to taking positive steps to ensure fair and equitable access to services for all. As a major provider of services, the Trust recognises the need to be pro-active so that it can meet the changing needs of diverse communities, and provide fair access for all in an environment where dignity, equality, diversity and human rights are respected and promoted.
In this respect, the proposed redevelopment will provide fit for purpose, accessible facilities and support improved access to services for all users.
4.1.4 Global Leader in research The SPH site has a strategic importance due to its proximity to Kings Cross Station, Euston Station and St Pancras Station representing a major national and international transport hub. There is also a Health and Life Sciences Cluster around Euston and Kings Cross that already includes The Trust, UCL, University College London Hospital NHS FT, the Francis Crick Institute, the Wellcome Trust and the London BioScience Innovation Centre.
The Trust already has one of the strongest records and reputations in UK mental health research. That is why the vision for the SPH site includes the establishment of an IoMH – in partnership with UCL who have the highest number of mental health academic citations in the UK – so that the Trust can build on this strength and be a world leader. For every £1 invested in mental health research, economic benefits are estimated to be 37p4 per year in perpetuity, so this is an initiative that supports not only better care for service users but also the Mental Health Taskforce 5YFW (2016) objectives and broader economic sustainability.
4.2 National Policy Framework Figure [4.1] summarises a number of relevant national policies and guidelines for mental health and also for healthcare more broadly. These policies and guidelines have guided and informed the proposal in a number of ways;
Services should be delivered to a local population footprint, rather than an organisational footprint;
Access to mental health must be improved to meet the rising demand for services;
Mental health must have parity of esteem to physical health to improve outcomes;
4 Health Economics Research Group, Office of Health Economics, RAND Europe. Medical Research: What’s it worth? Estimating the economic benefits from medical research in the UK. London: UK Evaluation Forum; 2008
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The barriers between primary and secondary care must be reduced to improve outcomes and reduce costs;
Services should be delivered as close to user’s homes as possible and supporting primary care;
The NHS Estate Policy highlights the importance of ‘the estate’ as an enabler to these changes.
Figure [4.1]: Key National Policy Frameworks
5 Year Forward View and New Models of Care
Improving mental health provision is a central theme in NHS England’s 2014 Five Year Forward View (“5YFV”) alongside mental health specific policies, such as the Mental Health Growth Strategy and the NHS Mental Health Policy, which sets out the need for change in how the NHS delivers services in the future. The strategy includes a focus on prevention, allowing people more control over their care, better use of technology and so-called triple integration: between primary and secondary care, between mental health and physical health and between health and social care. The 5YFV suggests that mental health outcomes can improve by better prevention, increasing early access to effective treatments and crisis care and integrating care to reduce mortality. It challenges the NHS to develop new models of care to better provide for the needs of people and the increasing demand on health services.
North London Partners in Health and Care (NLP) has produced a five year Sustainability and Transformation Plan (STP) which drives the implementation of the 5YFV. This focuses on planning by place for local populations rather than individual organisations.
Incorporating the STP plans, the Trust has developed an ambitious, innovative and robust Clinical Strategy in line with the 5YFV, evidencing the Trust’s willingness to adopt new models of care to transform outcomes. This includes using Practice-Based Mental Health Teams to provide mental health services from local GP Surgeries; allowing service users to be seen directly in Primary Care and facilitating early diagnosis and intervention. Having Multidisciplinary Teams removes organisational and specialty barriers between primary and secondary care and also any perceived divisions between mental and physical health. The Trust have developed an ambitious, innovative and robust Clinical Strategy in line with these principles from the 5YFV, evidencing the Trust’s willingness to adopt new models of care to transform outcomes. This not only aligns local planning to national policy, but supports mental health specific guidance around increasing access to services by reducing stigma, putting mental health within reach of local communities and allowing access through primary care. This is often
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referred to as getting ‘parity’ for mental health services and is important to this case for change, as that is precisely what the SPH redevelopment facilitates.
5YFV for Mental Health
In January 2016 the UK Prime Minister announced proposals to increase spending on mental health by £1bn. This was followed by the publication of the ‘Five Year Forward View for Mental Health’ in February 2016 from an independent national taskforce. Relevant areas of growth for the Trust include:
Access – New access targets to reduce waiting lists and address the pressures between demand and current capacity. This has been announced in Early Intervention in psychosis and will extend into other areas.
Integration of physical health and mental health – Services which support integration with physical health care and acute Trust efficiencies such as comprehensive liaison services, specifically in A&E, but also including areas such as support to people with dementia to reduce Average Length of Stay (ALoS).
The Trust already provides services in these areas, and has evaluated pilot projects to expand them in new models of delivery. It is therefore expected that the Trust will be successful in extending its services in this area in the next few years and this has formed part of the service reconfiguration plans.
NHS Mental Health Policy
The government plans to continue to prioritise improvements to mental health services, building on the policy priorities of the last coalition government. This was further reinforced by the Prime Minister’s statement on 9 January 2017. The government wants public services to reflect the importance of mental health in their planning, putting it on a par with physical health. This is often referred to as getting ‘parity’ for mental health services and is important to this case for change as that is precisely what the SPH redevelopment will allow, particularly in enabling better access to mental health services. The key priorities that are relevant to this PCBC are:
Enabling better access to mental health services and shorter waiting times a priority for NHS England;
Making reducing mental health problems a priority for Public Health England, the new national public health service;
Making mental health part of the new national measure of wellbeing, so it is more likely to be taken into account when government creates policy;
Providing £400m between 2011 and 2015 to give more people access to psychological therapies - including adults with depression, and children and young people; and
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Providing up to £16m of funding over four years for Time to Change, the campaign against mental health stigma and discrimination.
Other policies and frameworks that would affect the strategic decision making of the Trust are:
The current national strategy for mental health in England: No Health without Mental Health.
A new national strategy up to 2020 for mental health in England is currently being developed by the Crisis Care Concordat, which the Trust signed up to in 2014 together with many of its partners in the two boroughs (Camden and Islington).
The CQC 2015 Report – Right Here Right Now.
Recent reports such as Transforming Care (2012) and the Confidential Inquiry into the Premature Deaths of People with Learning Disabilities (2013).
The Care Act 2014. Guidance from The Department of Health states “the environment provided by acute mental health services is a crucial element in the delivery of positive therapeutic outcomes for service users, their safety and the safety of staff and the wider community.” The environment in which care is delivered is a dynamic of the care itself and plays a crucial role in supporting the delivery of higher-quality and more cost-effective care. In particular for mental health facilities, a superior and sympathetically designed therapeutic environment has the power to alleviate stress and provide comfort to peoples at times of acute distress and vulnerability. By continuing to deliver services in sub-par facilities, the Trust is failing to deliver an optimal service and the projected improvements to quality as laid out in the STP are unlikely to be achieved. By moving a number of services currently provided at the SPH site to facilities in the community, the Trust will be able to increase access and provision to the local population. The associated reduction in cost of delivering services in the community also supports this strategy, allowing the CCGs to deliver better value services.
NHS Estates Policy
The Trust is required to reach an agreement on an outcome that works in the interests of all interested providers, commissioners (local CCGs and NHSE) and regulators (NHS Improvement). As above, the Trust has already started this process through its bilateral agreements as described in Section [4.5].
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4.3 Regional Policy Framework 4.3.1 NCL STP (January 2017) background The Camden and Islington CCGs are part of the grouping of commissioners and providers in the North Central London region, which incorporates Barnet, Enfield, Haringey, Camden and Islington health, social care and public health commissioners, as well as all NHS Providers in the sub-region. This group is now referred to as North London Partners in Health and Care (NLP).
North London Partners in Health and Care has worked together to develop an North Central London (NCL) wide STP which sets out how local health and care services will transform and over the next five years, build and strengthen local relationships and ultimately deliver the Five Year Forward View vision. The STP Vision is as follows:
“Our vision is for North Central London to be a place with the best possible health and wellbeing, where no-one gets left behind”
A set of core principles to support delivery of the vision has been developed, along four themes.
1. Prevention: increased efforts on prevention and early intervention to improve health and wellbeing outcomes for the whole population, to reduce health inequalities, and help prevent demand for more expensive health and care services in the longer term.
2. Service transformation: service transformation to meet the changing needs of the population and bring care into the community, closer to home. This includes taking a “population health” approach by strengthening the offering in the community by closely integrating with primary care.
3. Productivity: identifying areas to drive down unit costs, remove unnecessary costs and achieve efficiencies to ensure sustainability. For providers, this includes implementing recommendations from the Carter Review and working together across organisations to identify opportunities to deliver better productivity at scale.
4. Enablers: a focus on delivering capacity in key areas that will support the delivery of transformed care across NLP. This includes digital, workforce, estates, and new commissioning and delivery models.
4.3.2 NCL STP: Plan for Mental Health The STP proposes a ‘stepped’ model of care supporting people with mental ill health to live well, enabling them to receive care in the least restrictive setting for their needs. The aim is to reduce demand on the acute sector and mitigate the need for additional mental health inpatient beds.
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Figure [4.2]: Stepped Model of Care for Mental Health, NCL STP
Initiatives include:
Improving community resilience through specific initiatives supported by NHSE, such as helping service users get back into work, which have been shown to reduce cost and activity;
Increasing access to primary care mental health services: ensuring more accessible mental health support is delivered locally within primary care services;
Improving the acute mental health pathway: developing alternatives to admission by strengthening crisis and home treatment teams;
Developing a Woman’s Psychiatric Intensive Care Unit (“PICU”): ensure local provision of inpatient services to female service users requiring psychiatric intensive care, where currently there is none;
Investing in mental health liaison services: scaling up 24/7 all-age comprehensive liaison to more wards and Emergency Departments;
Investing in a dementia friendly NCL: looking at prevention and early intervention, supporting people to remain at home longer and supporting carers to ensure that we meet national standards around dementia.
In addition to the alignment with the STP plan indicated in Section [4.1], the reconfiguration of services directly addresses the building of community resilience, improving access to primary care mental health services and the development of a women’s PICU. The subsequent section set out the current model of care at the Trust and its relation to the STP model of care in more detail.
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4.3.3 Progress on STP mental health initiatives in Camden and Islington
There has been significant progress made in Camden and Islington since the STP was written with the boroughs on track to deliver the STP mental health vision. The mental health STP was driven by care models to improve patient outcomes, care and treat people in the least restrictive environment, thus mitigating the need to expand the in-patient facilities.
4.3.3.1 Improving community resilience Camden and Islington have implemented new employment schemes based on Integrated Personal Support which is an evidence based type of employment support to help those with mental health conditions back into work. These initiatives are specifically supported by NHS England and have been shown to reduce activity, and also cost to, health services as people gain employment.
Mental Health First aid is also widely rolled out to Camden and Islington Council and voluntary sector services. This initiative is aimed at non-specialist front line services helping them identify mental health concerns and support people to access mental health services. Similarly suicide prevention training is also being commissioned to support early identification and intervention with people who may be at risk of suicide but not in contact with mental health services.
4.3.3.2 Increasing access to primary care mental health services
The rollout and increased access to Practice Based Mental Health (“PBMH”) has been mentioned as a part of the health organisation’s vision and transformation strategy – specifically “ensuring more accessible and extensive mental health support is delivered locally within primary care services”. This will help the population get local care with local accountability that is integrated with social, community and specialist services underpinned by a systematic focus on prevention and supported self-care, with the aim of reducing unplanned hospital admissions. In addition Camden and Islington CCG are on target to increase access to IAPT services to 25% by 2021. Islington CCG has also invested in ‘integrated IAPT’ which specifically targets people with long-term physical health conditions who may otherwise not recognise and come forward for help with depression and anxiety associated with their conditions, but which nevertheless make their condition more difficult to live with. Initially this is targeted at those with diabetes and chronic pulmonary respiratory disorder.
4.3.3.2.1 Improving the acute mental health pathway Camden and Islington both have Crisis Home Recovery Teams that can respond to individuals in the community who feel in crisis and without immediate support would need to attend an Emergency Department. All acute admissions for mental health are agreed by the Crisis Team to ensure that no one who could be supported at home or in a Crisis House is admitted. There is also a 24-hour crisis line that the public and professionals can call to get
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advice and support over the phone. Camden and Islington residents can also access Crisis Houses across the boroughs to help avoid inpatient admissions where possible. These teams will be reviewed in 18/19 to ensure that they are being efficiently used and working to ensure that they are working to fully support people in the community, able to respond in a timely way, working closely with voluntary sector and social care; in order to support people’s needs in the least restrictive setting.
Islington and Camden CCGs are early implementers of the Serenity Integrated Mentoring (“SIM”) programme, which brings together police and care co-ordinators around a specific cohort of patients who are repeatedly admitted to Health Based Paces of Safety under S136 of the Mental Health Act. In pilots elsewhere, this has resulted in a 50% decline in attendance at Health Based Places of Safety and impacted on subsequent admissions.
4.3.3.3 Developing a Woman’s Psychiatric Intensive Care Unit (“PICU”)
In November 2017 the Trust launched an 11 bed Women’s PICU, which is a shared resource for North London Partners; however the majority of admissions will be from Camden and Islington due to the higher acuity of need in these boroughs. The service is already demonstrating significant improvement to patient care, not only are patients now able to be provided with services in the NHS and within their local area enabling visits from relatives and better joined up care, but length of stay has also reduced to an average of 27 days from previous average in the private sector of 45 days. It is too early to say but it is hoped that this locally provided more joined up care, as well as reduced length of stay on the PICU, will impact on the overall length of stay in in-patient care for these women.
4.3.3.4 Investing in mental health liaison services The Trust provides mental health liaison services in UCLH, Royal Free London and Whittington Hospitals which are the main Emergency Departments attended by Camden and Islington residents. The services there operate 24/7 and provide in-reach to the wards to support training of staff, early discharge and reduced re-admission. The services provided at these hospitals can be described at meeting many of the Core 24 requirements. In addition a new mental health suite is being implemented in Whittington Hospital, which will provide a safe and therapeutic environment for patients who have attended Emergency Departments to be assessed and cared for prior to admission or discharge. It is expected that the mental health suite will provide a calming environment which will support more people to be able to access services at Crisis Houses, or in the community with support from community teams and thereby reduce admissions to acute inpatient mental health settings.
4.3.3.5 New model of care for Child and Adolescents Mental Health Services (“CAMHS”) and perinatal services
The Trust does not provide CAMHS services and therefore this proposal will not impact on CAMHS services. However in 2016 the Trust launched a new Community Specialist Perinatal Service. This service is a NLP resource and builds upon the small services that
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were already operating in Islington, Camden and Haringey. The new service works across maternity units and peripatetically in the community to support the needs of pregnant women and those with babies under one year old. This multi-disciplinary specialist service ensures that the top 3-5% of women with severe mental health needs are provided with specialist care and support, to better anticipate potential decompensation of mental health and to support better treatment in the community.
4.3.3.6 Investing in a dementia friendly NCL Islington and Camden achieve high rates of dementia diagnosis for their estimated dementia population; the NHSE target is for two-thirds of those estimated to have dementia to have received a diagnosis. As of March 2017 Camden’s diagnosis rate was 75.4% and Islington’s 96.8%. This means that people in Camden and Islington can access support and services early in their diagnosis thus reducing crisis and inpatient care and supporting more people in their homes. The mental health for older people pathway will also be reviewed in 18/19 to ensure that services are best supporting people’s needs.
4.3.4 The Health Estate as an Enabler The STP states that:
“An important enabler of a number the initiatives is the redevelopment of both the Barnet, Enfield and Haringey Mental Health Trust St Ann’s site and the Camden and Islington Foundation Trust St Pancras site.” Furthermore, the STP confirms that the proposed developments at the St Ann’s and St Pancras sites would:
Transform the current inadequate acute mental health inpatient environments on both sites;
Provide more therapeutic and recovery-focused surroundings for service users and staff;
Improve clinical efficiency and greater integration of physical and mental health care;
Release estate across the Trusts, to enable development of community-based integrated physical and mental health facilities;
Develop world class research facilities for mental health and ophthalmology enabling practice to reflect the best evidence; and
Provide land for both private and affordable housing, as well as supported housing for service users and housing for key workers.
At a local level there is also alignment towards the health estate as an enabler for broader transformation. Both Islington CCG and Camden CCG, have overarching visions to improve access to appropriate and effective mental health services and to ensure services are integrated to enable a much more seamless experience for service users. This vision will be enabled through the provision of fit for purpose, cost-effective, integrated, accessible estate which enables the delivery of high quality services. This is covered in more detail in Section [4.5].
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4.3.5 Links to Joint Strategic Needs Assessments (“JSNA”)
The current JSNAs for Camden and Islington produced by the respective Health and Wellbeing Boards with input from the local authorities, CCGs and other public sector parties further outline the requirements for a sustainable and high quality mental health service in the area. Both Camden and Islington have significantly higher rates of mental health diagnosis than other London Boroughs, with Islington holding the highest percentage of psychotic disorder diagnoses and Camden 3rd on that list. This has significant impacts for the overall health and wellbeing of residents across the boroughs; the Camden JSNA (2016) reveals that of those receiving incapacity benefits in Camden, mental ill health and behavioural disorders accounts for the largest proportion of claims. Consequently, the proposals to dramatically improve the quality of services to promote recovery and outcomes alongside improved access for users in the community are essential to meeting local needs.
“…a service model that systematically promotes integration of physical and mental health across primary and secondary care services and including self-management is required.” Additionally, as articulated in the extract above from the Camden JSNA (2016) and, as stated in the most recent Islington JSNA (2016) the strong link between mental and physical health warrants a more joined up model of care that addresses mental and physical health together; providing further support for a model that aligns these services.
4.3.6 Joint Health and Wellbeing Strategies (“JHWS”) Both the Camden JHWS (2016) and the Islington JHWS (2017) identify mental health as one of their key priorities to improve health and wellbeing in their Borough over the next few years. There are similar strategies proposed in these documents to deliver this goal, such as improving access to community based interventions and improving attitudes towards mental health by developing understanding and reducing stigma. The proposed reconfigurations reflect these broader strategies.
4.4 Quality of Existing Estate 4.4.1 CQC reports The Trust delivers the majority of its care to residents in the London Boroughs of Camden and Islington, including from its two acute sites at St Pancras Hospital (SPH) and the HMHC. The sites vary widely in terms of their distribution, age, condition and suitability and these “extensive differences” were noted in the June 2016 CQC report.
The report highlighted that the SPH acute wards and psychiatric intensive care units required significant improvement. Therefore, it is a priority for the Trust to update the facilities within which these services are delivered to enable better outcomes for service users.
The latest CQC inspection published in March 2018 it was noted that the Trust had sufficient mitigations in place to address the concerns raised previously. However the overall rating for Safety remained as “Required Improvement”. Furthermore this most recent report highlights the staffing difficulties facing the St Pancras site, with the vacancy rate of over 20% on all
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wards. This not only increases workload for staff but also increases the reliance on agency and bank staff, which increases the likelihood of protocol not being followed and staff training shortfalls.
4.4.2 Backlog maintenance As may be expected, there is a considerable amount of backlog maintenance, particularly at SPH, to the value of £10 million. Many of the buildings are inefficient, do not provide a therapeutic inpatient environment, lack modern safety features and make it difficult to bring together a full range of services (physical and mental health, and social care).
Beyond the £10 million of backlog maintenance, an estimate of approximately £175 million has been quoted to re-provide services at the St Pancras site that meet modern standards. A significant proportion (c.73%) of the Trust’s backlog maintenance requirement relates to the SPH site.
4.4.3 Time bound opportunity Critically, the opportunity to transform the mental health services in the area through the St Pancras redevelopment is potentially time bound insofar as the Trust were successful in their application for a Certificate of Immunity from Listing (COIL) and this is valid for a 5-year period running to 2020. The importance of this to the scheme is that it means that no further buildings on the site can become listed in this period, enabling the Trust to consider alternative uses for the current site.
4.4.4 Accessibility In addition, whilst SPH does meet the Disability access requirements under Equalities Act 2010 (“EA10)”) compliance, the issues highlighted above, due to the age and consequent design of the estate, leave room for improvement as they do not inherently meet the requirements.
4.4.5 Patient assessment The 2016 Patient Led Assessment of the Care Environment (PLACE) scores, shown in Figure [4.3], demonstrates the challenges the Trust has on the SPH site. This clearly evidences that SPH needs improvements within the ‘Condition, Appearance and Maintenance’ section and is a significant outlier on both the ‘Dementia Friendly’ and Disability Access’ sections.
Figure [4.3]: 2016 PLACE assessment scores for SPH
Site Assessed Cleanliness 2016
Food & Hydration (Ward) 2016
Privacy, Dignity & Wellbeing 2016
Condition, Appearance & Maintenance 2016
Dementia Friendly 2016
Disability Access 2016
St Pancras Hospital
99.51% 86.26% 87.28% 91.4% 68.28% 65.57%
Average score C&I
99.51% 93.54% 89.43% 96.35% 82.07% 83.87%
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National average 98.1% 89% 84.2% 93.4% 75.3% 78.8%
Comparative MH Trusts
99.6% 84.83% 96.24% 97.84%* 94.96% 93.32%
*SLAM spent a considerable sum in environmental works prior to the PLACE inspections
4.5 Limitations of Current Service Provision 4.5.1 Parity of esteem for mental health Parity of esteem for mental health is widely supported as a concept across the health and social care system, reflecting the fact that mental health can be more debilitating than most physical conditions as well as the enormous social and economic costs of untreated conditions (only 25% of those with depression are diagnosed).
Similarly, for inpatients that are admitted to the service at SPH, there is an associated stigmatism with the facility which could be addressed through moving to a new, modern site rather than staying at SPH. By exploring options to deliver inpatient facilities at a site that also has physical health acute wards, there is an opportunity to develop closer collaboration in meeting mental and physical health needs. This supports the wider new Model of Care as set out in Section [5] and STP goals for mental health provision that is integrated and viewed as equal to physical health provisions.
4.5.2 Integration of care This is a rare opportunity to make a step change in converting that concept into reality for service users in North Central London. The proposal for the development of community hubs brings the potential for significant strategic benefit for the broader health and social care system as this hub will allow service users to have their physical and mental health conditions considered on a single site through cross organisational working. The local health organisations know that those living with psychosis on average die 20 years earlier than average, but often this is due to poor management of preventable physical health and wellbeing such as weight, diabetes and substance abuse. So this will enhance the delivery of whole health and social care system transformation that is already underway.
As this way of working is embedded across the community, there may also be opportunities for workforce diversification, allowing staff to work more holistically than ever before with service users. By bringing facilities and workforce together, collaborative working and smoother transitions between services can achieved, which could not be achieved at SPH. For example an inpatient on a mental health ward could be visited on-site by a cardiologist or diabetic nurse without significant travel or time delays. Similarly, an individual receiving treatment on an acute ward may be recommended for swift assessment by a member of the mental health team to best meet their needs.
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5 Care model and expected benefit
5.1 Care Model The Trust’s Clinical Strategy 2016-2021 sets out the clinical model for services provided at the Trust, both currently and in the future. This model has been designed to keep community teams at the heart of service delivery; ensuring care is provided as close to patients’ homes as possible. This model and its constituent parts are unchanged by the proposed relocations, however its delivery will be greatly enhanced by the improved quality and location of services, as evidenced below.
As described in the previous section, the Trust’s Care Model forms part of the broader NCL STP ‘stepped’ model of care for mental health. This overarching model supports the focus of services wrapped around individuals within their communities, with increasing levels of more intensive, specialist care provided according to increasing need.
The development of a new inpatient facility 2.5 miles away from the existing site, alongside new community facilities on the existing site and development of two new community hubs, supports the improved delivery of the North Central London STP in a number of ways:
5.1.1 Improving facilities Due to current inadequacy of the facilities at the St Pancras site, and the location of some community services at this site, the Trust is unable to sufficiently deliver on a number of aspects of the STP Model. This includes the delivery of high quality specialist services close to home (Step 3) and elements of the more intensive levels that stipulate services should support recovery at home and in the community (Step 4).
Furthermore, one of the enablers of the STP is the estates strategy, which lists the redevelopment as key to delivering more therapeutic and recovery focussed surroundings.
5.1.2 Increasing access to mental health services The STP’s focus on delivering more accessible and extensive mental health support within primary care services is aligned to the planned roll out of the practice-based mental health (PBMH) to all practices and increased access to Improved Access to Psychological Services (IAPT) to 25% of the indicated population by 2021.
All Islington CCG registered patients are now able to access PBMH service. However some patients need to be seen at an alternative venue to their GP practice due to the limitations of this estate. Camden CCG will expand their residents’ access to PBMH by building on their current Team Around the Practice model from 18/19, which too will add pressure on the primary care estate.
Currently there are a high number of secondary care community teams located across multiple sites, which includes some teams based on the St Pancras site. The development of Community Hubs will allow the re-location of some of these services into more accessible local sites for residents, away from hospital and closer to home. It also brings teams from the same Division onto a single site which improves closer working between professionals. Community delivered services are expected to increase in levels of contact time with
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patients as care is re-directed away from inpatient services, this requires a larger community estate to accommodate additional activity.
Community Hubs may also be able to bring opportunities for a wider range of in-reach work for physical health services to patients with mental health to help improve accessibility to physical health services.
5.1.2.1 Improvements to access within Camden South Camden iCope (IAPT) and Assessment and Advice Team moving from St
Pancras to Greenland Road;
South Camden Recovery Team to move into Greenland Road;
Community Recovery Service for Older People to Lowther Road in Islington (most patients are seen at home).
5.1.2.2 Improvements to access within Islington Islington Practice Mental Health Team (where there is no capacity for patients to be seen
at their GP practice) to move to Lowther Road;
Islington Assertive Outreach Team to move to Lowther Road;
Islington North iCope Team to move to Lowther Road;
Community Recovery Service for Older People to Lowther Road (most patients are seen at home).
5.1.2.3 Moves from St Pancras to sites other than the community hubs
Rivers Crisis House is likely to be moved off the St Pancras site, however plans for where this will be located are not finalised;
Pharmacy services to move to HMHC to support inpatients at both inpatient sites.
5.1.3 Improving the acute mental health pathway The proposed relocation and development of Community Hubs does not involve the provision of any extra inpatient beds, which aligns with the STP vision to develop alternatives to hospital admission by strengthening crisis and home treatment teams. As part of the acute pathway improvements, the STP also identifies the investment needed in supported living arrangements, providing users with a supported, and longer term arrangement for effective discharge.
5.1.4 Patient pathways 5.1.4.1 Practice Based Mental Health Teams PBMH based in primary care is a key component of the NCL STP, the Trust’s Clinical Strategy and the CCG commissioning intentions. PBMH was piloted in Barnet and found to reduce the need for referral to specialist care pathways by 60-65%. Subsequently it has been operating across nine of the 34 practices in Islington for two years and has been rolled out to all practices in 17/18, and across Camden from 18/19.
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Service users are able to access locality based services, which include consultant psychiatrists, psychologists, social workers and nurses. These services aim to:
Increase access to high quality assessment and early intervention;
Provide a supporting role to GPs and primary care staff to help manage patients at the primary care level, avoiding deterioration of health and the need to refer to secondary services; and
Reduce demands on a range of secondary services including Crisis Teams, secondary care teams, and acute inpatient admissions.
Healthy London Partnership has commissioned an economic evaluation of PBMH models used across London. Islington PBMH service will be one of the sites which is expected to deliver its findings in summer of 2018. The economic evaluation will look at a range of factors including the impact of the service on secondary care and acute bed utilisation.
PBMH also helps to reduce the stigma of accessing services specifically for mental health and they have been found to be effective in managing mental health in Primary Care settings. By continuing to invest in PBMH, more individuals requiring mental health services can be identified and supported early on, thereby reducing the impact of undiagnosed and untreated conditions on long term health and wellbeing. For the majority of service users, PBMH will be the entry point to more specialist support, however other entry points include the Urgent Care/Acute pathway and A&E.
PBMH complements IAPT services where people with common mental health services can access care and support without the need to meet secondary care thresholds of care.
5.1.4.2 Specialist Care Pathways Service user access to specialist care pathways depends on a number of factors, including; risk level, intensity of interventions required and the need for a specialist treatment only available via these pathways. There are four divisions currently in place focused on particular user cohorts and providing specialised, tailored support depending on user need and these continue to be developed by the Trust.
Community Mental Health (CMH) Division;
Rehabilitation and Recovery (R&R) Division;
Services for Ageing and Mental Health (SAMH) Division;
Substance Misuse Service (SMS) Division. In addition to these four divisions, the Trust also provides an Urgent Care/Acute Pathway (Figure [5.1]) that service users may enter if they are experiencing a crisis in their mental health. For some service users this may be their initial entry pathway to services. However service users on this pathway are moved as soon as possible onto less intensive and more tailored pathways.
A service user will often move among or between pathways and specialist sub-divisions as part of their therapeutic journey and teams work collaboratively across pathways to ensure users are supported throughout by a team that knows and understands their needs.
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Figure [5.1] The Trust’s Clinical Model
5.1.5 Workforce Following changes to the current care model, the workforce requirement will change in line with the NCL STP; under this proposal this is related to greater expansion of community staff. The NCL STP Mental Health Workforce programme recognises that all NCL mental health providers will face the following key issues:
Portability to enable staff to work across traditional boundaries (organisational and health and care settings);
Improving staff experience of providing care; and
Career planning/development to support a lifetime career in NCL. To address these issues, there is a dependency on two other NCL, STP programmes:
Care closer to Home: to provide more care from integrated primary and community settings; and
Workforce: to ensure the workforce can meet the above expectations. The aims of the programme are:
To provide analytical support in designing the workforce elements across workstreams to address the key issues above, including providing an understanding of the impacts and benefits of introducing new roles and ways of working;
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To provide a common approach to recruitment across the 10 NHS Trusts in NLP which will cover common recruitment policy and processes that will support collaborative recruitment and retention initiatives for provider trusts; and
Enable ‘portability’ of staff between providers and into primary and community care settings.
To deliver these aims and address the issues, the NCL STP proposes a range of measures which will impact the workforce considered as a part of this proposal: Recruitment initiatives General STP workforce recruitment initiatives are:
The CapitalNurse (CN) programme is trialling a joint approach across NCL and NEL by giving an employment guarantee to all locally educated student nurses in September 2018. This will provide a core offer to all students including access to a CN branded preceptor ship programme. The NLP are keen to understand whether this approach would be of value to other staff groups.
There will be a joint approach and a common policy to facilitate collaboration in NCL to training Nursing Associates, and using apprenticeships to grow the workforce.
NCL has led the way in identifying overseas educated nurses who do not have a UK registration but are working in support roles in the NHS and social care in NCL. Whilst the new funding arrangements at HEE mean that the funding approach will change this is a great route to identifying more new nurses.
The development of a shared staff bank in NCL. Some mental health specific initiatives that are directly applicable to the Trust are:
International nurse recruitment from the Philippines.
Participating in local, London-wide and national careers fairs as well as engaging with local schools.
Streamlined recruitment process has improved time to hire and had a positive impact on our vacancy rate.
Retention initiatives: A Retention Study is being conducted across the STP by IPSOS Mori, with the results
available in May 2018. Once the retention issues have been identified initiatives can be designed and delivered to tackle those problems.
Reviewing flexible working and flexible retirement options and introducing new package of non-pay benefits for staff.
Buddy scheme for new starters.
Current action planning to address issues identified in staff survey.
Over 30 Quality Improvement projects focussing on staff wellbeing, reducing violence and aggression in wards, improving patient experience.
Identifying training needs across NCL in order to inform a programme of joint training that can be utilised across the STP. This has recently been done with Dialectical Behaviour Training running across NCL.
Training to be provided for adult MH colleagues in CAMHS and vice versa in order to enhance skills and enable a more joined up workforce across the sectors.
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Development and use of new roles: Piloted nursing associates in 2017/18 and seeking to expand cohort in 18/19.
Working with Skills for Health to identify new roles/existing roles suitable to be adapted to our workforce and activities (e.g. advanced practitioner)
Working in partnership with Inclusion Barnet to identify roles, which benefit from being held by people with lived experience of mental health issues. This follows a two year experience of employing community engagement workers who all have lived experience.
The development of Children and Young People crisis services that will work across NCL – a children and young people’s Out of Hours crisis team and bid to develop a new Health Based Place of Safety at HMHC – will create new roles and posts.
The potential devolution of Tier 4 CAMHS and the development of the acute care pathway across NCL will result in further enhancement of the workforce and create new roles by 2020/21.
Expansion of IAPT services is seeing a growing workforce that requires better career development and support.
Up-skilling current staff: Recruited Physical Health Leads to improve skills of our mental health workforce.
Apprenticeship programme to enhance technical and management skills of staff.
Nursing associate and nurse degree apprenticeships commencing autumn 2018.
Dialectical behaviour therapy (“DBT”) training is being undertaken by 23 staff across NCL to further enhance the acute care pathway.
The development of a CAMHs Out of Hours crisis team will create opportunities for staff to work in different settings and developing their skill set.
Opportunities are being explored to develop joint training across adult mental health and CAMHS in order to upskill staff in both sectors.
Mental Health First Aid Training for 200 non-mental health staff and current Peer Support Workers to be delivered by June 2018.
200 Primary Care and Social Care Staff to receive Suicide Prevention Training
A further 250 primary care and community staff will receive training through integrated IAPT programme.
In accordance with the care model, many staff at the Trust are already more community based than they have been previously, and the preferred option does not call for any staff to transfer out of the Boroughs of Camden and Islington.
These proposals are not expected to have negative impacts on the workforce. Any workforce changes will be consulted on in-line with the Trust’s agreed Change Management Policy and sufficient time will be allowed to ensure appropriate notice is given of any changes. Furthermore, the Trust’s devolved structure encourages clinically led divisional autonomy, within the Trust’s overarching policies, procedures and values. Each division will be responsible for managing their workforce changes, supported by the Human Resources & Organisational Development Team. The Trust Strategic Development Committee will have oversight of workforce plans, with ultimate accountability being held by the Trust Board.
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5.1.6 Commercial principles There is no activity shift expected between the different providers of the services being consulted on.
In fact, the commercial structure around the payments to the Trust from the CCGs is such that there would be no negative financial impact on the CCGs as a result of the proposed service changes. This is because of the block grant payment mechanism which is set out in more detail in Section [9].
As a result, the CCGs will not be conducting any further consideration of impact on other providers.
5.1.7 Activity, Volume and Capacity Modelling The table below sets out the overarching activity figures for the Trust over the period April 2014 to March 2017.
Figure [5.2]: Trust Total Activity and Admissions April 2012 to March 2017
2012/13 2013/14 2014/15 2015/16 2016/17
Admissions 1,216 1,316 1,315 1,397 1,363
Inpatient and Community Episode Caseload (Total distinct patients)
20,020 21,567 22,584 23,274 23,823
The Trust currently has 235 beds (84 on the St Pancras Hospital site) used for acute admissions, treatment of adults and older people.
Over the past decade or more, changes in the way mental health services are delivered have consistently reduced the use of inpatient beds. The Trust has closed approximately 130 beds (acute and continuing care) in the past 10 years, through the development of increased alternatives to hospital care and improvements to the arrangements and working practices in inpatient care.
Over the last couple of years the Trust has experienced consistent pressure on its remaining beds and an increase in numbers of people admitted and those treated by the Crisis system. This reflects both demographic growth and the nature of the local demographic, which is highly transient and includes many people accessing mental health services for the first time (and who therefore often require greater support). There has been an increasing number of Overseas Visitors to the UK who require urgent and emergency care, often resulting in an inpatient admission, before they can be re-patriated to their home country.
In 2016, commercial advisors were commissioned by NCL STP to undertake bed modelling for the area. The advisors predicted an increase in the overall requirement of inpatient beds to increase from 236 to 268 in the Trust by 2021, an increase of 32 beds based on an 8% demographic growth if services remained as they were with no operational efficiencies or clinical improvements. The advisors also suggested that if the STP mental health work stream was delivered, it would remove the need for many of the additional inpatient beds
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required estimating that the Trust bed base would need to increase to 246, a much smaller growth of 10 beds.
The STP mental health work stream and progress on it in Camden and Islington is detailed in section [4.4.2], these are to a large extent based on reducing the demand for inpatient beds and meeting people’s needs in the community. In addition to this there have been a range of changes to the Trust bed utilisation since the commercial advisors’ modelling as the STP initiatives and Trust initiatives have advanced.
5.1.8 Trust initiatives on inpatient beds usage In 2017, the bed situation specifically length of stay had worsened for Male PICU and acute wards. Due to this and the already high length of stay for older people and rehabilitation wards, the Trust embarked on an ambitious plan to reduce the length of stay of all of its wards which is showing real progress and has enabled some significant changes.
The commercial advisors’ review detailed that the average length of stay in 2015 for acute wards was around 49 days, and 55 for male PICU. The Trust acknowledged that they were an outlier compared to other Trusts for length of stay, which contributed to high occupancy levels and meant that they often had to use private beds to accommodate needs; this included a length of stay for older adults of 135 days. The commercial advisor found that bed occupancy was at 97-98% for acute and 99% for older adults, the Trust’s ambition is to achieve 95% by March 2018.
To achieve the overall aim of 95% bed occupancy by March 2018 the Trust programme was to:
Free up 12 beds across the system by 31 July 2017 to enable the opening of a Women’s PICU by 1 November 2017;
Fully utilise new community resource to step down some long staying rehabilitation patients by September 2017;
Reduce the number of people staying beyond the agreed median Length of Stay (LoS) by 50% by the end of 2017;
Convert 4 older people’s continuing care beds to acute beds by 31 March 2018.
This was achieved in a range of ways including:
Re-assessment of number of patients who were outliers in terms of LoS;
Closer links with Islington’s voluntary sector Crisis House to better utilise this service, the Trust is a partner in the newly re-commissioned service which started in April 2018;
Greater social care presence in acute wards to strengthen links to the community and supported accommodation to facilitate move on;
Senior clinical review of patients to support reduction in LoS, including older adults with a target of reducing stays to 60 days;
Introduction of Red to Green which is a daily analysis of the treatment and care delivered to inpatients; red days being days where the treatment given could have been provided in the community. Therefore working towards ensuring that every inpatient day is fully utilised and that patients are supported to discharge ensuring that they are treated in the least restrictive setting.
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The Trust has made significant progress on these targets with the following having been achieved:
Reconfiguration of bed base to allow the opening of an 11 bed women’s PICU (this included one bed closure due to the restrictions of the SPH estate);
Reduction in Continuing Health Care beds by four as planned, but increases acute bed base to support demand;
Increased flow to rehabilitation beds which in turn supports reduction in length of stay in acute beds;
Utilisation of all types of beds has reduced in the last year (Appendix [25])
Utilisation of acute beds has reduced from 99% to 96% in the last year, a reduction of 3%;
Length of stay for acute beds for 17/18 is 67 days including PICU wards;
Utilisation of older adult beds has reduced from a high of 648 bed days in June 2017 to 502 in March 2018, a reduction of 33%
Length of stay for older adult for 17/18 is 118 days;
Utilisation of rehabilitation beds has reduced from 99% to 97% over the last year a reduction of 2%;
Length of stay for rehabilitation for 17/18 is 721 days;
Occupied bed days (OBD) for private sector placement for acute care and PICU are now on a significant downward trajectory, following sharp peaks between July – Dec 20175, and are now on a zero trajectory by March 2021 (submission to NHSE) (Appendix [25])6;
Total OBDs for private sector placement acute and PICU placements fell from a high of 2065 in quarter three of 2017/18 to 330 in the following quarter;
New admissions have reduced from 591 to 474 between 15/16 and 17/18 representing a 20% reduction.
5.1.9 Refreshed bed modelling Further bed modelling has been developed for the Trust which forecasts further in to the future. In this updated bed modelling local demographic trends have been extrapolated into short term and long term growth scenarios. The forecast suggests population growth of 8.29% in the years 2017 to 2025 with the population of Camden and Islington rising from 509,594 in 2017 to 551,855 in 2025.
Growth in Islington is forecast to be higher that Camden over this period (9.24% compared to 7.43%). The trajectory of demographic growth from 2017 – 2025 on the projected bed requirement in would be 254 beds from the current bed base of 235, with no mitigation of efficiency or service development. In short there would be a requirement of 19 additional beds.
5 This was due to closure of a 12 bedded acute ward during the re-configuration to women’s PICU, since opening of the PICU
(November 2017) both PICU and acute bed admissions to private sector have fallen to under 100 per month, compared with highs of 500 (PICU) and 400 (acute) per month.
6 STP trajectory is not zero but C&I trajectory is and this is likely to be achieved ahead of schedule.
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The Trust has the second highest number of acute beds per head of population, and is within the upper quartile of mental health trusts for acute admissions and length of stay (Appendix [24]). The Trust has around 70 beds more than the crude arithmetic mean. 40 of these beds result from a higher than average propensity to admit. 30 of these beds result from a higher than average length of stay.
There are some local factors that account for a proportion of this higher admission and length of stay, such as the need for higher dependency bed usage, and for admissions of people with a diagnosis of psychosis (above upper quartile for Cluster 10-16, and near to it for Cluster 17). London similarly has much higher proportion of psychosis patients. However, figures suggest that this may account for as many as 29 beds. There are high relative levels of homelessness in Camden that analysis suggests could account for 8 beds, plus the ongoing need of high levels of funded overseas visitors, again an additional 8 beds.
Thus 45 excess beds can be explained by clinical need, (from the identified 70), leaving opportunity for improving bed utilisation that could result in bed savings of 25. This reflects the difference between the existing and remodel of care figures, and mitigates against the 19 forecast additional beds demographic change suggest should the care model not change.
The Trust has around the median number of older adult beds per head of population, and is in the lowest quartile of mental health trusts for older adult admissions (Appendix [24]). Both Camden and Islington have relatively young populations compared to London and England. Length of stay in the Trust is fifth highest nationally and the longest in London. The Trust has a much lower propensity to admit but a higher length of stay, with overall fewer than average beds (c. 2 beds) per head of relevant population. Analysis suggests that the lower propensity to admit accounts for 12 beds fewer than the mean, whilst the higher than average length of stay accounts for about 10 beds. There is little to suggest any capacity to reduce the bed base in this area7 and would need to reflect demographic growth in the future.
With regard to rehabilitation beds there is a predicted growth of eight beds. However, significant work has been done to reduce the length of stay for these patients including the opening of a new resource which has allowed the opportunity for patients to step out of rehabilitation that had previously had very long stays. Thus the need for additional beds is mitigated, and a further review of rehabilitation across inpatient and community wards’ will be undertaken in 2018/19 to ensure optimised care pathway to reduce length of stay where possible.
The evidence above with regard to the progress made so far both in terms of delivery of the STP and Trust initiatives suggests that this requirement will not be needed. For example, through earlier diagnosis and intervention; and greater support and capacity to enable patients to receive care in the community, as well as continuation of the Length of Stay project to absorb demand as admission and treatment length are reduced. Some of these initiatives are difficult to quantify exactly, for example, there is yet to be an established evidence base on the impact of PBMH on inpatient beds. However this, combined with
7 Source: 2016 NHS Mental Health providers’ benchmarking club
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initiatives in crisis services, is the prevailing good practice model and one being followed by all mental health Trusts.
Consequently the CCGs are confident that maintaining the current bed base at 235, will be sufficient to meet demand in 2025, and the new build will actually allow one additional bed to 236 due to the removal of the estate compromise that saw one bed close in 2017. CCG believe that this is a conservative proposal based on the clinical efficiencies postulated within the STP, the service development being delivered in the Trust’s Clinical Strategy and improved practice that is already in track. These movements are set out in more detail in Figure [5.3].
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Figure [5.3]: Bed modelling
Type of Bed Current Location No of Beds (Feb 16)
No of Beds Predicted by STP
due to demographic
growth and no service
developments (Feb 21) McKinsey
No of Beds Predicted in STP
with demographic growth and Service Developments (Feb
21) McKinsey Mitigation
Current No of beds (Feb 18)
No of Beds Predicted in
OBC due to 8% demographic
growth and no community
developments (Feb 25 )
No of Beds Predicted in OBC due to
demographic growth with Clinical Strategy
implemented community
developments (Feb 25)
Service Developments Assumed / Delivered
(15/16) full year data available
to McKinsey
Assumptions are 13.3% demographic growth from 15/16 -
20/21 (5 years) steady length of
stay and occupancy
As detailed in the STP Increased CRHT Teams /
Perinatal/Primary Care
Service Developments
from Feb 17 include: Women's
PICU
N/A As detailed in the Clinical Strategy
Men’s PICU Total 12 13 13 12 13 12 Length of stay MPICU 55 89 Women PICU Total 0 0 10 11 12 11 Length of stay WPICU 36 Acute Total 152 173 140 140 151 130 Length of stay Acute 49 38 67 Older Adult Total 28 32 27 28 30 30 Length of stay Older Adult 135 37 118 Rehabilitation Total 44 51 66 44 48 52 Length of stay Rehab 1103 721
Total number of beds 236 269 246 235 254 235
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5.2 Expected benefit The benefit impact of the proposed development of facilities is focused around the improved therapeutic environment for service users. This is in line with the current clinical strategy to promote recovery, resilience and independence via easy access to community-based services and specialist care-pathways.
The main benefits that have been identified are as follows:
Improve quality of care by enabling transformation of service models;
Support the delivery of the Trust’s clinical strategy and STP by increasing accessibility to community services;
To create fit for purpose, therapeutic inpatient wards;
Enable the Trust to fully comply with CQC requirements without the need for high numbers of adaptations – both hospital regulations and standards and statutory regulations;
Improve the Trust’s status as a research and development centre of excellence through e.g. better facilities and partnerships with other organisations;
Promote equality through improved access to ‘disability friendly’ facilities;
Improve sustainability through improved efficiency of facilities and enablement of better and more efficient care models;
Enable greater alignment of Trust services with the needs of service users through improved access to safer facilities;
Reduce stigmatisation of Mental Health service users by facilitating easy access to new facilities and open spaces;
Improve service user experience with the ability to access integrated physical and mental health services in line with the 5YFV and national NHS Mental Health strategy “No Health without Mental Health”;
Enable greater proximity to services for a high proportion of service users by locating services in Camden and Islington;
Attract and retain high quality staff by providing a high level of staff support including improved engagement and facilities;
Contribute to the local community by promoting community health services and improving staff’s workplace;
Support the movement or maintenance of the current location of others Trusts as set out in the STP; and
To allow the development of joint Mental and Physical health care by the proximity of the Whittington health site.
5.3 Impact on service users and benefits Of the 25,000-30,000 people seen by the Trust on average per year, just under 9,000 were seen at the St Pancras site last year. Of these 9,000 users, over half were visiting services that will remain at the St Pancras site and so the number of users expected to be affected is around 3,100 (see Figures below).
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Figure [5.3]: Affected service users by service - Inpatients
Name of service Proposed new location Number of service users affected (based on attendances 1 Jan-31Dec 2017)
Dunkley Ward (mixed sex with 4 learning disability beds) New in-patient facility 165
Laffan Ward (mixed acute mental health)
New in-patient facility 168
Ruby Ward (female PICU)8 New in-patient facility 20
Rosewood Ward (female acute mental health) New in-patient facility 115
Montague Ward (mixed high dependency rehab ward) New in-patient facility 32
Sutherland Ward (mixed long-term complex care ward) New in-patient facility 27
Total number of service users 527 Note: The Approved Mental Health Professional Service and Pharmacy services are addition to those listed above that form part of the proposal (see Appendix [1]). However, these two services support services listed above and are therefore covered in their numbers of service users.
Figure [5.4]: Affected service users by service - Community
Name of service Proposed new location Number of service users affected (based on attendances 1 Jan-31Dec 2017)
Camden Mental Health Assessment and Advice Team Camden Hub 720
Islington Practice Mental Health Team9 Islington Hub 15
Islington Assertive Outreach Islington Hub 101 South Camden Recovery Team Camden Hub 720 iCope North Islington Team Islington Hub 2,179 Community Recovery Service for Older People (Camden and Islington)
Islington Hub 99
South Camden iCope Camden Hub 2,450 Total number of service users 6,284
These users will see a number of significant benefits depending on the service they access:
5.3.1.1 Community based care Over two-thirds of the users likely to be impacted are attributed to the South Camden iCope service, which is a low intensity service providing guided self-help interventions alongside psychological interventions such as Cognitive Behavioural Therapy (CBT). For these users,
8 Part year effect opened in November 2017 9 Those not able to be seen in GP surgeries – figure based on March 18 only when full roll-out was achieved.
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the relocation of this service to the Camden hub offers the opportunity to access services at a more welcoming community based, non-acute setting. This will not only provide easier, more direct access to services but also reduce the stigma attached with accessing mental health services.
5.3.1.2 Improved therapeutic environment For inpatients at the St Pancras site, moving to a newly built facility ensures they receive care in a high quality, specialised building with state of the art facilities. The current site was deemed unfit for purpose following a CQC report in June 2016, with some wards having serious health and safety concerns, including ligature points and blind spots. The latest CQC inspection published in March 2018 noted that the Trust had sufficient mitigations in place, however the overall rating for Safety remained as “Required Improvement”. Furthermore this most recent report highlights the staffing difficulties facing the St Pancras site, with the vacancy rate over 20% on all wards. This not only increases workload for staff but also increases the reliance on agency and bank staff, which increases the likelihood of protocol not being followed and staff training shortfalls.
By transferring these services to a purpose-built facility, critical safety improvements will be seen alongside drastic improvements to the general therapeutic environment. For example, the new site will improve on the poor quality of available outside space at the St Pancras site and improve lines of sight for monitoring of patients.
5.3.1.3 Improved access When rated for disability access, the current site’s 2016 PLACE rating is a significant outlier at only 65.57% accessible when compared to the national average of 78.8%, and the even higher rating for comparative MH Trusts at 93.32% accessible. By relocating to a newly built site that meets modern accessibility requirements, this will increase equality of access for users, staff and visitors.
5.3.1.4 Parity of esteem for mental and physical health By co-locating the new purpose built facility alongside the Whittington Acute Hospital, service users are able to receive specialist mental health treatment from the same site as users of the acute physical health care service. This helps reduce the stigma attached to mental health facilities and is a key aim of both the Trust and the STP clinical aims.
5.3.1.5 Improved integration between acute and mental health services
In addition to the reduced stigma, by having mental health inpatient and acute facilities on the same site, it is expected that users transferring between the two services will receive a quicker and more streamlined transition. For service users being ‘stepped-up or stepped-down’ from the acute pathway, there will be a minimal physical transfer required and this will be able to occur more quickly between the two providers, improving treatment and service user experience.
By continuing to deliver a model of care that is primary care and community focused, the proposed relocation of some services does not impact upon the majority of service users’ access to services. The ongoing roll out of practice-based teams ensures all service users are able to access mental health professionals and receive treatment and support close to their homes.
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5.3.1.6 Better working initiatives for staff: By developing new facilities and implementing the workforce plan as per the STP, it is expected that the local health organisations are more likely to attract a higher quality staff by providing a high level of staff support including improved engagement and facilities. There will also be a naturally higher retention rate due to the higher quality buildings.
5.4 Changes to travelling times and distances The travel time analysis and presentation is being developed into maps. It sets out lower super output areas using the Transport for London travel tool. Analysis and maps will be presented in the form of heat maps and demonstrate the impact on services users and populations for the change in travel times by differing modes of transport for the following scenarios:
For all postcodes - a map showing the change in time due to relocation of beds fromSt Pancras to the Whittington. For those showing an improvement (meaning areduction in travel time) of greater than 5 minutes a shading of green. For thoseshowing an improvement reduction of 5 minutes or less or an increased time up toand including 5 minutes, a shading of Amber. For those postcodes where there is anincrease in time of over 5 minutes a shading or red.
For Islington Postcodes – a map showing change in time due to relocation ofcommunity services from St Pancras to Lowther Rd For those showing animprovement (meaning a reduction in travel time) of greater than 5 minutes a shadingof green. For those showing an improvement reduction of 5 minutes or less or anincreased time up to and including 5 minutes, a shading of Amber. For thosepostcodes where there is an increase in time of over 5 minutes a shading or red.
For Camden Postcodes - Map showing change in time due to relocation ofcommunity services from St Pancras to Greenland Rd For those showing animprovement (meaning a reduction in travel time) of greater than 5 minutes a shadingof green. For those showing an improvement reduction of 5 minutes or less or anincreased time up to and including 5 minutes, a shading of Amber. For thosepostcodes where there is an increase in time of over 5 minutes a shading or red.]
The Figure below provides a summary of this analysis, with supporting information in Appendix [3].
Figure [5.5]: Summary of travel time analysis
[x]
5.5 Public Sector Equality Duty The Equality Impact Assessment (EIA) process is designed to ensure that a project, policy or scheme does not discriminate against any disadvantaged or vulnerable people or groups. This ensures CCGs pay ‘due regard’ to the Public Sector Equality Duty. The EIA will be completed in two parts, with the initial phase completed prior to consultation and a second stage to be completed following the consultation outcomes.
The initial phase EIA focused on:
How the services will impact on protected and vulnerable groups in the community;
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How the CCGs and providers must ensure equality and fairness in terms of access to these services- and appropriate provision for all patients based on their clinical, personal, cultural and religious needs; and
How the CCGs will work together with local providers and patients and carers to ensure a high quality of services that all patients can experience.
The majority of vulnerable or protected groups identified as part of the EIA have been judged as achieving greater equality, improved outcomes or increased accessibility through the proposal. For example, both inpatient and community developments will provide improved disabled access for service users, staff and visitors. For many other groups, the purpose built facilities offer an improvement in therapeutic environment, access to outdoor space and care delivered closer to home.
At this stage, the EIA has identified the potential increased travel time for some disabled service users as the only vulnerable group that may experience a reduction in accessibility. In order to minimise this risk, route planning to the new site will be provided and shared with local community groups for individuals with disabilities.
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6 Governance
6.1 Governance structure for the consultation process The consultation phase of the redevelopment of the St Pancras site is being overseen by the St Pancras Hospital Redevelopment Oversight Group and led by the Chief Operating Officer of ICCG (Figure [6.1]). This group is reporting to both of the CCGs in addition to providing assurances to NHS England. NHSE representatives also have positions within a number of the groups relevant to the redevelopment to ensure adherence to rigorous NHSE guidelines for consultation. These arrangements are for the consultation phase only, with full project governance details being set out in Section [9].
In order to proceed to public consultation, the process requires approval from the CCGs Governing Bodies and NHSE. To support this decision, the CCG Governing Bodies will review the proposed consultation document, consultation methodology (including the Equality Impact Assessment (EIA) and Quality Impact Assessment (QIA)), financial modelling and consider the response from the Clinical Senate. Camden and Islington Local Authority’s Heath and Care Overview and Scrutiny Committees will be also be provided an opportunity to review and comment on the consultation prior to launch.
Figure [6.1] Public Consultation Governance Structure
A full break down of these consultation groups is provided below.
Figure [6.2] Membership of consultation groups
Group Lead Members Reporting to St Pancras Hospital Redevelopment Oversight Group
Chief Operating Officer, Islington CCG
Transformation Programme Director, the Trust Islington CCG Camden CCG NHSE
CCG Governing Bodies and NHSE
Clinical Senate Liaison
Associate Director of Joint Commissioning for Islington CCG
Camden CCG Islington CCG Medical Director, the Trust NHSE
St Pancras Hospital Redevelopment Oversight Group
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Public Consultation Working Group
Senior Engagement Manager, Islington and Haringey CCGs
Camden CCG Engagement Lead Head of Communications and Engagement, the Trust HealthWatch Camden and Islington Service users
St Pancras Hospital Redevelopment Oversight Group
Financial Modelling Workstream
Chief Finance Officer, North Central London CCGs
Trust Director of Finance –NHSE Finance lead
St Pancras Hospital Redevelopment Oversight Group
6.1.1 St Pancras Hospital Redevelopment Oversight Group
The overall redevelopment programme is managed by the St Pancras Hospital Redevelopment Oversight Group and chaired by the Chief Operating Officer for Haringey and Islington CCGs. This group has representation from the Trust, the CCGs (including Engagement leads from each CCG) and NHSE. This group reports to CCG Governing Bodies and in turn to NHSE.
6.1.2 Clinical Senate Liaison The Clinical Senate Liaison group is led by the Associate Director of Joint Commissioning for Islington CCG and is responsible for co-ordinating activities with the London Clinical Senate (LCS). This group includes the CCG GP leads for Mental Health from Camden and Islington and clinical representatives from CCGs, the Trust and NHSE. This group reports to the St Pancras Hospital Redevelopment Oversight Group which in-turn reports to the NHSE locally established Clinical Senate panel.
6.1.3 Public Consultation Working Group The primary purpose of this group is to facilitate strong public engagement and ensure a thorough and rigorous consultation is undertaken. All public consultation activities are being managed by this group. The group is led by the Senior Engagement Manager for Islington and Haringey CCGs and has support from the Camden CCG Engagement lead and the Trust. Members from Healthwatch Camden and Healthwatch Islington and two service users are members of this group. This group has inputted into the consultation document itself and methodology.
6.1.4 Financial Modelling Work stream This small working group consists of representatives from the Trust and NHSE and is led by the Chief Financial Officer for the North Central London CCGs. This group is responsible for providing financial insight and recommendations for funding of the redevelopment and also report to the St Pancras Hospital Redevelopment Oversight Group.
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6.2 Roles and Responsibilities 6.2.1 The CCGs Approximately 98% of services provided at the St Pancras site are commissioned by Islington CCG in their role as lead commissioner, with Camden CCG being a significant Associate to the Islington CCG contract. As such, these CCGs will be the ultimate decision making authority for the programme.
6.2.2 The Trust The Trust is leading on the SPH redevelopment proposal and working with stakeholders such as NHSI, London Devo, NHSE, the Local Authorities, Service Users, staff and other interested public bodies, including the CCGs to ensure plans are in line with individual commissioner intentions and fit for purpose.
6.2.3 NHS England NHSE are providing assurances and support at all levels of the programme, including representation on many of the programme working groups.
6.3 Information Governance Issues The Trust stores data about its patients that could identify each patient. This Patient Identifiable Data (PID) can be classed as any information, electronic or paper format that would allow a third party to identify the patient.
As a part of the proposed relocation, the Trust is not proposing to change the use, storage or accessibility of any PID it holds. A Privacy Impact Assessment (PIA) screening questions form was completed by the Trust (Appendix [4]) whereby the result indicated that a PIA was not required.
The principal reasons include:
1. Trust staff will still be able to access data in the usual way via Carenotes and N3 secure connection to digital records
2. Trust staff will still be able to access paper records through the Iron Mountain procedures
Should there be any changes to information privacy as a part of this proposal in the future; the Trust will re-complete the PIA screening questions form to determine whether a PIA is needed. The Trust’s Head of Information Governance and Security will be consulted closer to the relocation to discuss shredding bins, privacy displays, and photocopier / scanner / medical device locations.
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7 Stakeholder engagement
This section sets out the engagement that has been undertaken to date regarding the relocation of some services away from the St Pancras site and the development of community hubs. This includes the stakeholder groups who have been included as a part of the pre-consultation process, engagement activities undertaken and the findings from those activities. Moreover, it explains how this feedback has been used to develop the options detailed in Section [8] of this PCBC.
7.1 Legal Context Under section 242 of the NHS Act 2006 and section 142Z of the Health and Social Care Act 2012, NHS Trusts and CCGs have a legal duty to make arrangements for individuals to whom the services are being or may be provided, to be involved. Individual involvement includes participation in consultation, information sharing, or in other ways, such as:
Planning of the provision of those services;
Developing and considering proposals for changes to the way services are provided; and
Influencing decisions which affect operation of those services. In order to meet these legislative requirements and the ‘four tests’ outlined in the Mandate from the Secretary of State to NHS England and NHSE’s other tests, public involvement must be an integral part of the service change process. Engagement should be early and on-going throughout the process using a broad range of engagement activities.
The Clinical Commissioning Group (CCG) must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways):
In the planning of the commissioning arrangements by the group;
In the development and consideration of proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them; and
In decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.
All public consultations should adhere to the Gunning Principles, which are:
Consultation must take place when the proposal is still at a formative stage;
Sufficient reasons must be put forward for the proposal to allow for intelligent consideration and response;
Adequate time must be given for consideration and response; and
The product of consultation must be conscientiously taken in to account.
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7.2 Pre-consultation engagement on the case for change The local health organisations have engaged with inpatient service users, community service users, carers and staff as part of pre-consultation engagement work for the development of the plans.
The local health organisations have met regularly as part of the Stakeholder Reference Group, which is made up of senior representatives from the Trust, both CCGs and both Councils. This group provides oversight and maintains responsibility for the pre-consultation activities, consultation programme and implementation programme, including the review and approval of business cases developed by member organisations. See Appendix [5] for a full list of meetings conducted and pre-consultation engagement activities undertaken to date.
7.2.1 Pre-consultation engagement with service users and carers
The local health organisations have held a number of pre-consultation engagement events to listen to the views of existing and previous service users and carer representation groups.
This has included:
The Trust’s medical director attending existing service user meetings to explain proposals and take questions;
The Nubian Service Users’ Forum and the Women’s Strategy Group are among the existing groups the Trust has engaged with;
A two borough community hubs event in March 2018, which attracted a diverse audience;
A Service User Alliance meeting on 31 March 2017; and
A Service User Conference on 13 April 2017. At these meetings, senior leaders from the Trust provided information on the outline plan and long list of options. Time was allocated for full debate, questions and feedback and this has been logged and passed on for consideration. In addition, a survey was developed to better understand the clinical and service priorities of service users in both the community and inpatient settings. This was sent to all service users via email and copies were made available in paper form at key meetings. Feedback from this survey is set out in Section [7.3] below.
Some groups were asked to feedback on the positive aspects of the community services they currently use, what could be improved, if they envisaged any problems if some community services were based in the new hubs and if any problems were identified, what the Trust could do to mitigate or minimise impact.
Carers in both Camden and Islington have been given opportunities to hear more about the proposals, to provide feedback and ask questions through a number of meetings throughout 2018. This includes the Islington Carers’ Hub and Camden Carers’ Hub. Healthwatch Camden was also commissioned to attend the Camden and Islington carers meetings to engage carers and listen to feedback.
Healthwatch interviewed 55 individuals comprised of current and former inpatients at SPH, Highgate, staff and carers during February and March 2018.
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7.2.2 Pre-consultation engagement with employees Due to the potential workforce implications, the Trust have also completed initial consultations with their staff and governors. This includes meetings with trade union representatives and Governors and staff at key sites including St Pancras, HMHC, Lowther Road and the Peckwater Centre.
Five clinical and technical design review workshops were also held to secure input from approximately 30 clinicians on the optimal design of the estate in terms of both community and inpatient facilities. See Appendix [5] for a full list of these meetings.
7.2.3 Pre-consultation engagement undertaken as a part of the STP
As a part of the STP process, a wide array of stakeholders were engaged that included CCG Chairs, CCG Members, Clinical Cabinet, GPs, LINKs Local Healthwatch, Local Authorities – Health and Wellbeing Boards, Local Authorities – Lead Officers and Members, Provider Trusts, OSC/JHOSCs and voluntary and community groups. Appendix [6] sets out how these parties were engaged with and continue to contribute to the development and implementation of the STP.
7.2.4 Pre-consultation engagement with GPs The Trust’s Clinical Director and SPH programme director presented at a Camden CCG GB seminar on 26 July 2017 and to Islington GB in July 2017. The Camden GB included the GP chair of the locality meetings and an elected GP representative. The Islington GB includes the GB Clinical Lead for Mental Health.
A written briefing was shared with Camden GPs in November 2017 and the medical director is scheduled to present the Trust’s proposals at the CCG’s April 2018 locality meetings.
In March 2018 proposals were presented to the Islington GP Forum by the CCGs Clinical Lead for Mental Health.
7.2.5 Pre-consultation engagement with the JHOSC The London Boroughs of Camden and Islington are on the same committee of the North Central London Joint Health and Overview Scrutiny Committee (“JHOSC”). The JHOSC undertook a review of the SPH proposal in April 2017, September 2017 and March 2018.
At the 19 September 2017 JHOSC meeting, the redevelopment at the St Pancras site was discussed, as part of the wider NHS Estates strategy. This meeting provided an opportunity for the JHOSC to question and challenge current plans. A copy of the full minutes from this meeting is in Appendix [7]. A summary of the points raised at this meeting includes:
Overall members welcomed the proposal to move inpatient facilities to the Whittington and agreed with the suitability of this site;
Councillors would appreciate the opportunity to view the current site to assess the opportunities for Social Housing development and this was agreed at the meeting;
Following concerns raised that sale proceeds would be used for revenue spending, members were assured this would not happen;
The opportunity for surplus land to be used for GP surgery sites was raised as desirable;
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Concerns were raise that the number of inpatient beds was not increasing. The Trust should ensure the justification for this is clear in the consultation; and
It was agreed that the Full Business Case would be presented to the JHOSC when appropriate.
The SPH Project Director presented at the JHOSC on 23 March 2018 with an update on the SPH redevelopment project. The following was noted in the minutes which are yet to be formally agreed:
It was agreed that further information would be provided at the June 2018 Camden and Islington OSCs by the Trust;
The London Estates Devolution team have been engaged and are being consulted but the SPH redevelopment would not require their approval;
It was agreed that the Chair of the Camden HOSC would be invited to the next SPH redevelopment programme board meeting, which for the first time would combine the separate boards of stakeholders and providers; and
There were no further concerns or issues raised about the proposal. All review points raised by the JHOSC have been addressed and it should be noted that the SPH redevelopment is implementing the STP plan, to which the JHOSC contributed to.
7.2.6 Pre-consultation engagement with local people The Trust has shared its proposals with local people through the St Pancras Community Association and the Somers Town Neighbourhood Forum. Local people asked that consideration is paid to what young people may need and the provision of jobs.
7.2.7 Pre-consultation engagement with other local stakeholders
The Trust has engaged with a number of local organisations including Healthwatch, Citizen’s Advice Bureau, Voluntary Action Camden, the Old St Pancras Church, Octopus Communities and the Holy Cross Centre Trust who provide support for people who are socially excluded, for example, homeless.
7.3 Options appraisal engagement As part of the options development (Section [8]), a series of meeting were held to get input and understand the needs of stakeholders. The following options appraisal engagement was incorporated into the options appraisal process, as set out in the next section, up to the point of selecting the preferred option.
A brief summary of the options are set out below:
Re-provide inpatients at SPH;
Re-provide inpatients at Whittington site; or
Re-provide inpatients at St Ann’s Hospital. Each option had the same proposal for community services and other services as set out in Appendix [10] which is why they are not explicitly mentioned under each option above.
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7.3.1 Overview Key findings included:
Concerns over adequate consultation with service users;
Concerns over inpatient beds moving out of Camden;
Concerns over inpatient beds moving to St Ann’s site due to travel and accessibilityissues;
Concerns over land disposal proposals of the SPH site; and
Concerns over the provision of appropriate services from the community hubs.However, a consensus was reached on the preferred option: Moving the inpatient beds from St Pancras to a site in Camden or Islington, invest in community services through the two community hubs, build new facilities, and bring researchers and academics together on a single site at SPH. Specifically, the Healthwatch feedback indicated a unanimous agreement that the existing facilities at St Pancras Hospital are not fit for the purpose and the majority were in favour of the proposal.
7.3.2 Consulting with the service users Local Healthwatch teams identified that service users felt strongly that there needed to be a focus on consulting with current and ex-service users as part of the consultation.
7.3.3 Inpatient beds moving out of Camden Concerns were raised in some service user groups about inpatient beds being moved away from St Pancras and out of Camden – whether that be to Whittington Hospital or to St Ann’s Hospital.
The ‘trade-off’, which reached a general consensus to be accepted by the majority of service users, is that to resource the building of new warm, welcoming and therapeutic inpatient spaces, beds would need to move from the high cost St Pancras site to one where a new inpatient facility could be affordably built with additional revenue being directed towards improving community services.
The Healthwatch engagement found a small minority said they would prefer to retain the existing St Pancras Hospital. The central location and good transport links at St Pancras are highly valued by many. However, depending on the specific circumstances for the individual, a roughly equal number of respondents said a Whittington location would be easier for them personally. Many people said they thought that the potential benefits of a new purpose built hospital would outweigh any disadvantages associated with the re-location of the new site to Whittington. The concerns about the Whittington location are almost exclusively related to transport links and the walking distance to shops which in both cases are less convenient than for St Pancras.
7.3.4 Inpatient beds moving to St Ann’s Some service users with direct experience of the St Ann’s site raised concerns about the possibility of inpatient beds moving there. There was concern mainly focused on the travel challenges and general accessibility of the St Ann’s site. This concern is analysed in more detail through the travel analysis undertaken in Section [5.4] and also factored into the options evaluation process in Section [8.4].
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It was explained that the Trust would create its own buildings and deliver its own services. It was also emphasised that the purchase of land at St Ann’s would be cheaper, enabling more resources to be channelled into our community services. Relocating inpatient beds to St Ann’s next to Barnet, Enfield and Haringey’s mental health inpatient site might allow for the sharing of some facilities, such as an on-site gymnasium for example.
7.3.5 Land disposal proposal for SPH Concerns were raised over the irreversible selling-off of ‘precious’ NHS resources, namely the St Pancras site.
The mitigation includes the plan to offer some of the land to another NHS provider, as well as sell a portion of the estate for the creation of affordable accommodation – with an element being key-worker staff, potentially including Trust staff. It was explained that all existing services remaining on the St Pancras site would no longer be viable beyond a certain point in time, because without a substantial additional and continuing stream of finance it would become unaffordable to either maintain and or replace existing St Pancras facilities to ensure they were safe and fit-for-purpose.
7.3.6 Community care delivery Service users highlighted confusion at the term “community hub”, confusing it with a community centre. Part of the session was used to identify more suitable terms for the new hubs. Going forwards, further engagement will be sought to define the community hubs in a clear and consistent manner.
A need for a non-stigmatising and respectful environment that is considerate to different cultures was highlighted. It was generally felt that more interventional services were required to prevent a mental health crisis, namely a drop-in facility that is accessible to service users so they have a place to go when they begin to feel unwell. It was felt that A&Es are inappropriate and terrifying when suffering a mental health crisis with a preference for a different “first port of call” option.
Equally, it was felt that more support is needed when an individual is out of crisis – which the Trust needed to be more proactive rather than reactive. Although one service user stated that some of the Trust’s proposed new locations could be more difficult for those with mobility issues, if they did have to travel further, the majority view was that location was less of an issue if services were good, improved and inclusive.
Some group members were particularly interested in the design of the buildings – asking that they are Obsessive Compulsive Disorder friendly, not anxiety provoking in terms of design or layout and present a more therapeutic environment with the right colours and plants. Others said that there was a need to ensure the Trust had staff to support these new buildings – people who have experience of the issues to talk to service users.
Most service users were generally positive about the proposed new facilities. The strongest views were based on wanting services that were inclusive, resourced with knowledgeable and compassionate staff and a non-stigmatising and welcoming environment. One service user said: “Buildings need to feel more vibrant, don’t want to feel that we’re going to that place”.
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7.4 Applying pre-consultation engagement findings to options appraisal
As part of the formal consultation process, the group of stakeholders who will be engaged will be widened to include commentators and influencers such as local media, ward councillors, NHS pressure groups and heritage bodies, as well as the wider local community, including residents and businesses. Furthermore, Camden Healthwatch and Islington Healthwatch will be commissioned to engage local people covering the nine protected characteristics and other vulnerabilities. Accordingly the range of methodologies will also be expanded to cover targeted and ongoing engagement, across a range of channels, as shown in Section [7.5.3]. Stakeholder mapping has been completed to ensure all interested and relevant groups are captured.
The concerns raised through the pre-consultation engagement highlight the requirement for full and contextual information to be provided alongside the options when undertaking the formal consultation. Specific concerns raised will be incorporated in the consultation as follows:
7.4.1 Consulting with current and ex-service users The Trust’s Clinical Director will speak at all of the Trust’s service users groups to introduce the consultation, taking questions and letting people know how to fill it in (along with taking some hard copies). Further targeted engagement using the consultation survey with service users across all five of the Trust’s divisions – Acute, Services for Ageing and Mental Health, Recovery and Rehabilitation, Substance Misuse Services and Community Mental Health. This will include both current service users of inpatient services and community services.
7.4.2 Moving services out of Camden This stresses the importance of ensuring the case for change is clear in all consultation materials; emphasising not only the inadequate provision currently at the St Pancras site and the premium paid on land here, but also the added value of the public pound when looking at the alternative sites. The strategic case must be accessible to all stakeholders to ensure this message is understood thoroughly.
Moving inpatient beds to the St Ann’s Hospital site in Tottenham, would mean moving them out of the boroughs of Camden and Islington. The majority of pre-consultation engagement activity points to individuals being not in favour of St Ann’s, saying it is a harder-to-reach location for most people than the HMHC. We are therefore proposing we move our inpatient beds to a new site at Whittington opposite the HMHC. This is consistent with the qualitative scoring undertaken in Section [8] of the St Ann’s option and therefore will not form part of the consultation.
7.4.3 Travel challenges The concerns raised around travel times and access highlights the need for clear distance and travel time information. To this end, travel analysis has been completed (see Section [5.3]) and provides interested parties the opportunity to understand the direct impact of a move. This information will also be included in the consultation document and materials, including publication on the CCGs and Trust’s websites.
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7.4.4 Sale of NHS Resources This common concern is particularly emotive, and this issue must be handled sensitively during the wider consultation to ensure the underlying strategy behind the move of some services is clear. This also highlights that there should be some emphasis placed on the number of services that will remain at the St Pancras site, alongside the proposed use of the redeveloped space for NHS use; such as supported living accommodation, the Institute of Mental Health and any space that will be utilised by other NHS healthcare providers.
7.4.5 Services in the Community Hubs There will be opportunities for broader input on a range of issues. For example, to agree a new name for the community hubs, ideas to generate this include a board where service users can post suggestions and vote on a range of names. It will be a number of years before community hubs opened, should the proposal go ahead, so there is ample time to develop this with services users.
7.5 Other pre-consultation engagement activity Following on from the above engagement activity, the Whittington site was selected as the preferred option as set out in Section [8].
There has since been further engagement undertaken in the form of regular meetings with service users, carers, Trust staff, JHOSC updates and meetings with NHSI and NHSE by the local health organisations.
7.6 Consultation Plan This section provides an outline of the plan for public consultation on the proposal. This plan is in the process of review and is subject to change. The full consultation plan can be found in Appendix [8].
7.6.1 Overview of the consultation plan In line with statutory duties, both CCGs are required to consult on the redevelopment proposals, ensuring local people are given the opportunity to share their views on the redevelopment of the St Pancras Hospital site and all of the services affected. The redevelopment of the site will affect the inpatient facility, the community services both on the site and on additional Trust sites, along with NHS services which are delivered on the St Pancras Site by other NHS Providers such as the Royal Free Hospital. A summary of service changes can be seen in Section [1].
7.6.2 Summary of planned activities In light of these plans, Islington CCG is proposing to run a public consultation for 12 weeks starting in early July 2018 to the end of September 2018.
A draft consultation document, questionnaire and Frequently Asked Questions have been developed and can be found in Appendix [9]. These will be finalised and approved by CCG GBs in June 208. The consultation aims to:
Understand the views of the local community on the development of two new mental health community hubs, one in Camden and another in Islington.
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Understand the views of the local community on the relocation and development of new Camden and Islington NHS Foundation Trust mental health inpatient services from the St Pancras Hospital site to a site by HMHC and Whittington Hospital; and
The CCGs will speak to as many people in the local community as possible, ensuring they hear from a wide range of service users of all of the services proposed for relocation, the local community, local voluntary organisations and the two local Healthwatch, as well as other key stakeholders such as local Councillors and MPs.
7.6.3 Consultation communications and engagement channels
The channels used to share the consultation and gather as many views as possible are set out in Figure [7.1].
Figure [7.1]: Communication channels for the consultation
Channels Implementation assumptions Websites/online media A full consultation document containing a
survey about the proposals will be available on Islington CCG, Camden CCG, the Trust and Healthwatch websites. Prompts placed on the Trust social media channels will advise on how to leave feedback and join the public consultation meetings
Paper copies Copies of the full consultation will be available at each service affected by the St Pancras redevelopment, at other Camden and Islington Foundation Trust sites and upon request. Posters and leaflets in all 30 Trust sites will advise on the consultation and opportunities for feedback. Paper copies of the survey will also be available at each site. All paper publications will be in an easy to read format, with copies available in large print, easy read, community languages, braille and audio on request. There will be a dedicated telephone line for local people either requesting the consultation documents or any questions they may have.
Public meetings Held at easily accessible sites for people in Camden and Islington to discuss and provide feedback on the consultation.
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There will be a drop-in session with the Trust’s Clinical Director.
Focus groups Healthwatch Camden and Healthwatch Islington will be commissioned to undertake targeted research with groups that face barriers to accessing services and do not traditionally have their views heard in service redevelopment.
Staff Engagement Trust and CCG staff will be updated on the consultation via staff meetings and staff newsletters. GP member practices will also receive regular updates in GP forums, locality meetings and GP newsletters.
NHS Provider Roadshows Targeted engagement using the consultation document and survey with the services users of the other NHS providers affected by the proposed redevelopment.
Targeted Interventions Using the EIA to identify disadvantaged or vulnerable groups, the Trust will support the CCGs to consult with these groups. Further targeted engagement using the consultation survey with service users across all five of the Trust’s divisions – Acute, Services for Ageing and Mental Health, Recovery and Rehabilitation, Substance Misuse Services and Community Health. This work will be carried out by Healthwatch Camden.
Local networks The consultation document and survey will be shared with local groups for distribution amongst their members, including Islington Patient and Community Groups, Trust Service User Groups, Patient representatives, local voluntary and community sector groups.
As mentioned in Section [7.4], following pre-consultation engagement feedback, the Trust’s Clinical Director will attend all service user groups to introduce the consultation, and service users across the Trust’s five divisions will be targeted with surveys.
7.6.4 Proposed consultation timeline The table below (Figure [7.2]) provides an overview of the primary consultation activities and communications planned.
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Figure [7.2]: Timeline for Consultation Activities
Action
Lead Date
Consultation documents and methodology sign off
Islington CCG Governing Body June 2018
Camden CCG Governing Body June 2018
Consultation documents and methodology reviewed by Camden and Islington Health and Overview Scrutiny Committees
ICCG and CCCG
June 2018
Public consultation goes live ICCG early July 2018 to end September 2018
Evaluation of responses External agency
October 2018
Results of consultation published and shared
Islington CCG, Camden CCG, the Trust and partners
November 2018
Final Business Case prepared
Islington CCG
November 2018
Consideration of Final Business case by Islington CCG Governing Body
Islington CCG
November 2018
Consideration by Camden CCG Governing Body
Camden CCG
November 2018
A decision is made by Camden and Islington CCGs on the final Business Case
Camden and Islington CCG
November 2018
The decision is communicated with the local community, OSCs, HealthWatch and partners
Islington CCG / Camden CCG / The Trust
November 2018
7.6.5 Results, feedback and analysis The CCGs will appoint independent partner (third party agent) to evaluate the consultation responses and to analyse the results of the consultation. The partner will develop a process and infrastructure that reassures stakeholders of the independent nature of the evaluation. This will inform proposals in a Decision-Making Business Case (“DMBC”) that will validate the consultation outcomes.
Following the closure of the consultation on in September 2018, the evaluation team will have a period to analyse the results and present these to both of the CCG GBs.
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Islington and Camden CCGs will then make a recommendation on the redevelopment proposals to NHS England and both OSCs for Islington and Camden.
The results will be available publically, which will include, sharing on CCG and Trust websites and sharing through other stakeholders networks, such as Healthwatch Islington and Camden.
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8 Options development, analysis and evaluation process
This section sets out the range of options identified to address the objectives set out in the Case for Change and documents the appraisal process used to evaluate these.
The local health organisations have developed a four-stage process (Figure [8.1]) for the identification of a preferred option from a long list of options. This includes:
1. An initial feasibility study; 2. The development and application of a set of ‘hurdle’ Critical Success Factors (CSF)
to create a short list of options; 3. The development and application of a more detailed set of qualitative CSFs to
appraise short-listed options; and 4. A value for money assessment of the short-listed options.
The outcome of this process is to enable the local health organisations, through the St Pancras Hospital Redevelopment Oversight Group, to determine preferred options for each area that will be subject to full public consultation.
Figure [8.1]: Overview of option evaluation process
8.1 Option development In advance of developing options for the St Pancras site, a process was run by the local health organisations, incorporating service user input, to decide the appropriate setting for its services; see a summary in Appendix [10]. This work concluded:
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Set 1: Certain services, as set out in Appendix [10], should be provided in community hubs off site (including on existing Trust owned sites at Greenland Road and Lowther Road);
Set 2: Other services, again as set out in Appendix [10], should be provided on the St Pancras site to maintain a presence in the area and to enable the Institute of Mental Health; and
Set 3: Inpatient services should be re-provided on or off site. Therefore, all options to be developed, bar the ‘do minimum’ benchmark option, will include the Set 1 services being provided off the St Pancras site and all options include the Set 2 services being provided on the St Pancras site. The key variable between options is therefore the location of the re-provision of inpatient services (Set 3).
8.2 Appraisal 1: Feasibility Study As lead comissioner, 98% of services provided at the SPH are comissioned by Islington CCG, for the population of the London Boroughs of Camden and Islington, where the majority of patients come from. Therrefore, the focus of the sites search was primarily within the Camden and Islington boroughs to ensure continuity of provision, access for service users and building on the support gained to date from the two councils for this propoal. This is consistent with the pre-consultation engagement feedback receied as set out in Section [7] which detailed concerns around time travel to a new location.
To allow the Trust to support its current cohort of service users effectively, sites were only considered if they were within the boroughs of Camden or Islington, unless there was an exceptional reason for their inclusion. For example, St Ann’s Hospital was included at Strategic Outline Case (SOC) stage as it was identified that the Trust who owns that site (Barnet Enfield and Haringey Mental Health Trust) had land available next to their existing mental health facilities which are located approximately two miles away from the Islington boundary.
The following types of site were considered:
Surplus council owned land in Camden or Islington;
Sites owned by other government bodies which are being decommissioned;
Sites owned by neighbouring NHS providers; and
Privately owned sites. Following identification of the long list of options, these were then screened for viability and site availability. This process was led by the Project Director and Transformation Programme Director in dialogue with local stakeholders and GL Hearn. This assessment was presented to the Boards of the local health organisations for consideration and approval as summarised in Appendix [11].
The boards reviewed the proposed screening of the long list and validated the options to be taken forward to the next stage of evaluation via the CSF process. A detailed description of the options considered can be seen in Appendix [12].
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8.3 Appraisal 2: Hurdle CSF The purpose of Hurdle CSFs is to eliminate options that are not able to satisfy any one of the three hurdles, using a binary pass/fail process. As such the hurdle objectives are CSFs that must be delivered for the project to succeed. These were developed with service users and carers, and were enhanced following pre-consultation engagement feedback around the need to minimise disruption for any inpatients. Figure [8.2] sets these CSFs out in more detail.
Figure [8.2]: Hurdle Critical Success Factors (CSFs)
# CSF Key points 1 CQC
requirements The option provides a safe environment for service users and staff. Facilities must as a minimum meet all CQC requirements, and ideally exceed them.
2 Minimise service user disruption
The option does not require inpatient facilities to be moved more than once and minimises disruption to services users. This is critical due to the nature of the services delivered.
3 Research and development
The option supports and facilitates the creation and successful operation of a research and development institute closely integrated with a top research university.
The four options were then assessed against the three hurdle CSFs as shown below.
Figure [8.3]: Results of Hurdle CSF evaluation
# Option Name
Hurdle CSF 1
CQC requirements
Hurdle CSF 2
Minimise service user disruption
Hurdle CSF 3
Research and
development
Progression to qualitative CSFs
A1 Do minimum with inpatients For
comparison only
A2
Re-provide inpatients at SPH
For Net Present
Cost (NPC) comparison
only
A3 Re-provide inpatients at Whittington Yes
A4 Re-provide inpatients at St Ann’s Hospital Yes
As shown above, the following decisions were made about which options to take forward to the qualitative CSF appraisal:
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Option A1, (Do minimum with inpatients) is not a viable option on the basis that it failed to meet any of the hurdle criteria. However as this provides the baseline comparison it was progressed to the shortlist for evaluation purposes only as a benchmark for the other options in line with NHS capital business case requirements.
Option A2, (Re-provide inpatients at SPH), failed to meet the hurdles as it will cause significant disruption to service users during construction, particularly the large amount of heavy traffic movements and demolition that would be required. There is also concern that privacy and dignity could be compromised on St Pancras for inpatient services, as there are approved development plans around St Pancras are for tall residential blocks (up to 12 storeys) with balconies overlooking the site, and therefore over any inpatient facilities gardens or outdoor areas. In addition the reduction in value of the St Pancras site under this option was found to make it the least affordable and to provide the worst value for money. This option will be considered in the quantitative analysis of net present costs for comparison purposes only in line with an approach agreed with NHS Improvement (NHSI).
Option A3, (Re-provide inpatients at Whittington), was progressed based on meeting all of the hurdle criteria.
Option A4, (Re-provide inpatients at St Ann’s Hospital), was progressed based on meeting all of the hurdle criteria.
8.4 Appraisal 3: Qualitative CSF A total of nine further qualitative CSFs were jointly identified and agreed between the local health organisations, service users and carers. These criteria were judged to be important to the provision of mental health services but would not cause the project to be unachievable in their own right.
Figure [8.4]: Qualitative Critical Success Factors (CSFs)
# CSF Key points 4 Quality of service
user care
The option enables the Trust to deliver the highest possible standards of care quality to service users.
5 Aligned to service user need and supportive of the clinical strategy
The option enables alignment of clinical service location to the needs of the population it serves.
The option supports the Trust and the wider STP objectives for early intervention in a community settings.
6 Destigmatise mental health
The option enables services to be provided in a setting which destigmatises mental health services, creating an attractive welcoming environment for service users.
7 Promotes equality
The option provides facilities which are accessible to all users and helps to promote equality for service users, staff and wider stakeholders.
8 Integrated care The option enables integration of mental health service provision with other healthcare provision.
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9 Located with in-borough or close to Camden and Islington
The option provides new facilities which are based in either the London Borough of Camden or the London Borough of Islington, or if this is not possible, as close as possible to the Boroughs.
10 Support staff wellbeing
The option supports staff health and wellbeing, including the on-site provision of staff wellness services (e.g. fitness classes, changing rooms and staff faith rooms).
11 Consistent with the NCL STP
The option aligns with the plans set out in the STP and facilitates delivery of the STP. It supports and enables wider plans for other Trusts in NCL including proposed relocation of Moorfields
12 Consistent with plans for local community and place development
The option aligns with local authority and community plans for place and area development, including the provision of housing for local people, employment opportunities and environmental benefits
The agreed list of CSFs were evaluated by the local health organisations to establish the appropriate weighting. It concluded that all CSFs should carry equal weighting as there were no ‘mutually exclusive’ or ‘conflicting’ factors. The CSFs which were regarded as constituting an absolute requirement were additionally designated as ‘hurdles’.
8.4.1 Application of the Qualitative CSF The key themes from the quality assessment scoring workshops can be seen in Appendix [13]. The scores across the workshops were averaged to establish a total overall ranking. The detailed option scores arrived at during each workshop is also set out in Appendix [14].
The qualitative options evaluation was carried out by scoring each of the four options against the CSFs, including the hurdles. The option scoring was carried out by the following three groups, for which further information on the members is included in Appendix [15].
The Clinical Reference Group;
The Trust Board; and
The Trust Governors. On each occasion the committees carrying out the scoring were briefed on the options under consideration and provided with a summary of the options. The scoring was carried out in small groups and the options were scored between 0 and 4, with 4 being the highest score. This was done for the three Hurdle CSFs and the nine other CSFs (12 in total). The scores were then averaged across the different groups to give an average score out of 48.
8.4.2 Pre-consultation feedback As laid out in Section [7], the local health organisations completed a range of pre-consultation engagement with key stakeholder groups, such as service user and carer representative groups and Healthwatch teams since March 2017 and will continue to do so throughout the pre-consultation phase. The findings of these preliminary consultations will be used to further shape options, as a good indicator of user and public acceptability of options.
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Of the three key themes identified during the consultation activities was a particular concern over the St Ann’s site in terms of accessibility for service users and staff and also the potential loss of identity by moving alongside another mental health Trust. We understand from this that for service users and staff, the integrity of the service’s identity can be an emotive and important factor. Consequently, when measuring the St Ann’s site against the Whittington site, the Whittington site was preferred as a direct result of pre-consultation engagement activities.
8.4.3 Summary qualitative evaluation of options Overall, option A3 (rebuild at the Whittington) has the highest average score, and therefore highest rank, leading it to being selected as the preferred option from a quality perspective. The key drivers of this are:
Whittington is more accessible and geographically better located for service users, their families and staff;
Whittington will deliver significant benefits to service users through delivering a better clinical environment and a more relaxed suburban community with green space;
Whittington has good transport connections;
The Whittington site is located close to the existing HMHC which provides opportunity for a stronger staff community and joint training;
The Whittington is an inpatient community hospital, with acute services and an A&E. This means that service users will benefits from comprehensive holistic care on one site;
Whittington is in the borough of Islington, with other current in-patient beds located at HMHC in the borough of Camden, and is therefore supported by both the local authorities and the STP; and
The Whittington site enables the construction of the Institute of Mental Health on the SPH site and maintains close links with the Community Hubs.
8.5 Appraisal 4: Value for Money evaluation of options
8.5.1 CCG impact The financial appraisal was undertaken by the Financial Modelling Work stream that is led by the Chief Financial Officer of the North Central London CCGs, (Section [6.1]). The impact was found to not be significant as the commissioning arrangement between the CCGs and the Trust is not one that is directly impacted by any changes in activity (such as Payment by Results arrangements) and instead is based on an agreed settlement for providing mental health services in the region (‘block’ payments). There is no change expected therefore in the financial forecast of either of the CCGs as a result of these proposals.
8.5.2 Trust Impact 8.5.2.1 Economic assessment of options The quantitative evaluation of the options was carried out by KPMG and a specialist long term financial model consultant (‘Assista’). They worked with the finance team from the Trust to verify the current financial status of the Trust, as the starting point for the model.
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The Trust’s finance department worked with Assista to understand what the income and cost of providing services would be going forward, without any changes to the delivery model. This analysis was based on information in the STP and the Trust’s understanding of future funding and likely demand for the Trust’s services as described below.
They worked together to understand the implications of each options, including the do minimum option. This included an evaluation of the risk that a forecast benefit was only partially delivered or not delivered at all.
8.5.2.2 Outcome of quantitative assessment of options For the quantitative assessment, the project costs (capital, revenue and lifecycle), benefits and risks were calculated for the Trust cash flows under the different options in accordance with relevant guidance by independent technical consultants (Turner and Townsend (T&T)).
8.5.2.3 Net present cost (NPC) assumptions The Department of Health and Social Care template Generic Economic Model (“GEM”) was used to generate the Net Present Cost (“NPC”) and Equivalent Annual Value (“EAV”).
8.5.2.4 Capital Costs The Trust and its technical consultants have developed a schedule of accommodation and functional requirements based on the scope agreed with the board to deliver the vision and consistent with the analysis of the bed requirement in Section [5.1.9] of the model of care. This has supported the development of initial designs for the four options being considered in this phase. The capital costs of all options have been developed by T&T and are summarised in the figure below.
Option A1 (Do Minimum) has been based upon the latest estimate of backlog maintenance which is attached at Appendix [16]; therefore, no specific additional capital has been considered.
Figure [8.7]: Capital costs for each option
Reconciliation of costs from LTFM to GEM Option A1 Option A2 Option A3 Option A4
£000s Do minimum Reprovide IP at SPH
Reprovide at Whittington
Reprovide at St Anns
Total incremental capital cost per LTFM - 124,345 135,845 117,693 Less: transitional fees capitalised - (4,852) (4,852) (4,852)Less: land acquisitions - - (14,460) (4,000)Less: decant costs - (589) - - Nominal capital investment (nominal) - 118,904 116,533 108,841
Discount nominal to real (17/18 prices) - (10,036) (8,501) (7,923)Less: Planning contingency (real) - (7,371) (7,555) (7,123)Less: VAT (real) - (18,145) (18,005) (16,820)Real capital investments (less contingency and VAT) - 83,353 82,472 76,975
Discount real to NPC - (9,580) (8,228) (7,664)Capital investment NPC per GEM - 73,773 74,243 69,311
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8.5.2.5 Operating costs and lifecycle An LTFM has been produced for each option that covers the period from 2017/18 to 2025/26. This was used as the basis of the operating cost assumptions for that period. Beyond that period it was assumed that costs were flat in real terms.
8.5.2.6 Quantifiable benefits The Trust has sought to quantify the public benefits that the proposed development will deliver to the local and wider community as well as NHS. To do this, members of the project team reviewed the benefits identified to set out those benefits that were able to be quantified. The Trust worked through the list of potential benefits with input from clinicians delivering the services.
Once benefits were identified as quantifiable, they were considered either as a reduction in cost or an increase in income. Where benefits were reducing costs, full consideration was given to the cost at present and to the impact that the change would have on that cost. Where an additional income stream was identified this was valued based on past experience and current benchmarks. Once the benefit was identified the period when it is most likely to have an impact was agreed an applied to the model, there were then discounted where appropriate in the model.
Appendix [17] summarises the benefits identified, the value of those benefits and the key assumptions associated with those benefits.
8.5.2.7 Net Present Cost summary The figure below sets out the outputs of the assumptions given above for the four options. As described above, Option A1 and Option A2 are only provided for comparative purposes as both have failed the Trust’s Hurdle CSFs.
Figure [8.9]: NPC calculations of the options
Net Present Cost (NPC) Option A1 Option A2 Option A3 Option A4
£000s Do minimum Reprovide IP at SPH
Reprovide at Whittington
Reprovide at St Anns
Property and opportunity cost 71,770 36,781 34,963 25,827 Initial capital investment - 73,773 74,243 69,311 Other capex - - - - Lifecycle and business as usual capex 59,413 59,413 59,413 59,413 Total capex 131,183 169,967 168,619 154,551
Fees - 4,349 4,349 4,349 Total transitional costs - 4,349 4,349 4,349
Operating costs 3,078,767 2,978,245 2,958,380 2,973,361 Working capital adjustments (6,875) (7,616) (7,635) (7,635)Total opex 3,071,893 2,970,630 2,950,746 2,965,727
Externalities - - - - Total NPC (unadjusted) 3,203,076 3,144,946 3,123,715 3,124,627 Total Risk Adjustment 73,370 90,625 92,407 93,219 Trust total (risk adjusted) 3,276,446 3,235,572 3,216,121 3,217,846
Rank 4 3 1 2
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As shown above, Option A3 (rebuild at Whittington) has the lowest net present cost, slightly ahead of Option A4 (rebuild at St Ann’s) and therefore is ranked as the preferred option from a NPC perspective. Whilst the initial capital investment is slightly higher for this option the operational savings delivered through co-location with both mental health and acute facilities at the Whittington has driven this outcome (see benefits above).
8.6 Combined appraisal The quality ranking has been averaged with the quantitative NPC ranking in the figure below. This resulted in option A3 (build a new inpatient facility at Whittington) being identified as the preferred option.
Figure [8.10]: Combined rankings of the Options
The option to build a new inpatient hospital facility on land vacated by the Whittington Hospital is the preferred option from both the quantifiable and qualitative appraisal. Trust clinicians also believe that the Whittington option delivers the closest alignment to the clinical objectives of the STP and the Trust’s Clinical Strategy.
8.7 Impact of the preferred option 8.7.1 Quality Impact Assessment A Quality Impact Assessment (QIA) process was developed and led by the Clinical Workstream Group for the preferred option to evaluate the impact on quality of care. This was developed in partnership with clinicians at the Trust to ensure it provides an accurate reflection of the changes to service delivery.
Specifically, the QIA of the proposed redevelopment will provide assurance that any resultant reconfiguration services will not adversely affect the quality of service user care.
Preferred option analysis Option A1 Option A3 Option A4
Do minimum Reprovide at Whittington
Reprovide at St Anns
Quantifiable appraisalTotal risk adjusted NPC (£m) 3,276.4 3,216.1 3,217.8Total risk adjusted EAC (£m) 121.0 118.8 118.8
Qualitative benefits (weighted scores)Weighted benefits score 18 42 28
Quality points per EAC 0.149 0.354 0.236
Quantifiable appraisal 3 1 2Qualitative appraisal 3 1 2Points per EAC 3 1 2
Preferred option 3 1 2
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This is defined by NHS England as care that is clinically effective, safe and that provides as positive an experience for service users as possible
8.7.2 Independent review The Clinical Senate Liaison Group was established as part of the pre-consultation phase to ensure proposals are independently reviewed and guided by NHSE Clinical Senate. Clinical Senates provide independent strategic advice and guidance to commissioners and stakeholders regarding healthcare provision. A request for advice from the London Clinical Senate (LCS) was requested on 29 February 2018 by Islington CCG, with support from both the Trust and Camden CCG. The LCS request sought guidance on:
Whether the change of environment will improve clinical care for inpatient and community services
Whether the proposals for changes to inpatient and community mental health services:
o will enable improvements in clinical care and quality benefits for patients o are informed by best practice o align with national policy and are supported by STP plans and commissioning
intentions Whether the approach ensuring the inpatient demand of population growth is
absorbed by the development of mental health community services.
The Local Clinical Senate will complete its work in June 2018. The recommendations will be shared with the CCG GBs for to ensure recommendations are addressed. NHSE conducts a series of assurance tests including financial assurance which will be required before CCGs can launch the public consultation.
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9 Finance case
9.1 Introduction The purpose of the financial case is to set out the impact of the preferred option on the CCGs and Trust’s financial performance and position and to show the impact of the key financial risks. This is important as it demonstrates the options being considered for consultation are sustainable financially.
9.1.1 CCG impact The CCG’s current spending plans with the Trust will not significantly change as a result of these proposals directly because of the contract arrangements in place between the CCGs and the Trust. Specifically, the Trusts receive a fixed amount per period from each CCG to provide mental health services to the local population. Unlike tariff arrangements this is not directly correlated to changes in activity by volume or type, therefore any service expansion requiring investment will need to be agreed in advance by CCGs.
Both of the CCGs have reviewed the activity and financial modelling undertaken by the Trust. The CCGs are assured that the underlying assumptions behind the activity and income are consistent with their own projections, and the wider STP expectations. Specifically, the Chief Financial Officer for both Camden CCG and Islington CCG corroborated the financial information presented below with the Director of Finance for the Trust. Most of the commentary in the section below therefore focuses on the impact on the affordability of the proposals to the Trust as a provider – the Trust will see substantive impacts on its cost base, balance sheet and cashflows as a result of the proposals in this document.
9.1.2 Provider impact The impacts of the proposals impact almost exclusively on the Trust in terms of providers and therefore the system affordability of the proposals can be shown by setting out the position for the Trust. This section sets out what those impacts are from a financial perspective and that the preferred option is affordable for the Trust.
For the purposes of this analysis, affordability is defined as:
ensuring that the Trust has the cash required to complete the estates programme;
having sufficient cash to cover the Trust’s working capital requirement throughout the ten year period (assumed to be two months of operating costs, circa £20.0m);
the Trust being forecast to have a sustainable positive net surplus position by the end of the period considered; and
the Financial Sustainability Risk Rating (FSRR) will be at least 3 in all years when appropriate adjustments are made for the impact of bridge financing.
This section of the business case:
Shows the financial forecast of the investment case, with an analysis of the incremental impact against the baseline (do minimum) case;
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Shows that the preferred option is affordable in the base case.
9.2 Basis of preparation The projections in this section have been prepared on the following basis:
The Trust has completed NHSI’s 10 year Long Term Financial Model (LTFM). In line with the approach agreed with NHSI, 2016/17 was the outturn year used based on the forecast outturn at month 11 that had been submitted to NHSI. Separate models were populated for the baseline and the preferred option and a comparison of the outputs was used to assess the incremental impact.
The assumptions for the baseline case (do minimum) were based on a revised version of the Trust’s annual operating plan over the ten-year LTFM period.
The costs of the investment and associated operating and financing costs were obtained from the Trust’s facilities building cost model.
9.3 Financial projections A series of assumptions have been used to forecast the Trust’s Income & Expenditure (I&E), Balance Sheet and Cash Flow statements. These are set out in Appendix [18].
The figures presented in the financial case may differ from those presented in the economic case due to discounting. The financial case figures are all nominal and not discounted, whereas the economic case figures are discounted.
9.3.1 Income and expenditure The Figure below sets out the Trust’s projected income and expenditure under the investment case. This covers the period of construction (from 2018/19 to 2021/22) and the following three years of steady state operations.
The incremental impact of the investment over the baseline is shown further below (the full baseline income and expenditure is set out in Appendix [19]). A bridge is also included, which shows the incremental impact of the investment on the first full year of operation (2022/23).
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Figure [9.1]: Projected income and expenditure for the investment case
The projected investment case income and expenditure shows that:
Income growth is driven principally by the underlying growth in contractual income from clinical services (from the CCGs), with inflation accounting for 33% of the increase. This growth is partially offset by the assumed loss of £0.8m Sustainability and Transformation Fund (STF) funding from 2019/2020.
Pay costs are forecast to remain at £97.0m in 2017/18, due to the underlying growth being matched by the Trust’s CIP programme (3.2% of pay costs in that year). In subsequent years pay CIPs are projected at between 1.2% and 1.5%, thereby only partially offsetting the underlying pay cost growth. The investment is projected to reduce substantive and agency staff costs by £1.6m from 2021/22. Any increases above this amount in line with recent government announcements are assumed to be funded and it is therefore assumed would not have an impact on affordability. This will be modelled at FBC stage.
Non-pay costs are projected to fall from £29.0m in 2016/17 to £27.6m in 2017/18 due to recurrent CIP savings of £2.2m in other expenses (8.4% of other expenses). The CIP target for other expenses is £0.8m per year thereafter. The investment is projected to generate savings in other expenses of £3.5m in 2021/22, increasing to £4.4m in 2025/26).
An impairment of £8.2m is projected upon completion of the building works in 2021/22. This is the result of the requirement to change the valuation method of the new building from a cost basis to depreciated replacement cost upon its completion.
As shown above the Trust remains in surplus throughout the projection period except for two years:
2020/21: the £(0.1)m deficit is projected due to the increased finance costs incurred during construction, with the benefits not being realised until the building is completed in the following year.
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
IncomeClinical income 108.4 108.0 109.4 110.2 111.7 112.8 113.9 115.0 116.1 117.2 Research & training 19.2 19.1 19.3 19.3 19.3 19.3 19.3 19.3 19.3 19.3 Other income 9.0 9.0 8.8 8.0 8.0 8.0 8.0 8.0 8.0 8.0 Total income 136.6 136.1 137.5 137.5 139.0 140.0 141.1 142.2 143.4 144.5
Operating costsPay (97.0) (97.0) (98.1) (99.6) (101.2) (101.8) (103.4) (105.3) (107.3) (109.4)Non-pay (29.0) (27.6) (27.4) (27.1) (26.0) (23.1) (22.4) (21.7) (21.3) (20.8)Total operating expenses (126.1) (124.6) (125.4) (126.7) (127.3) (124.9) (125.8) (127.0) (128.6) (130.2)
EBITDA 10.5 11.5 12.1 10.8 11.7 15.2 15.4 15.2 14.8 14.3 Impairment - - - - - (8.2) - - - -Depreciation & amortisation (4.7) (5.2) (5.4) (5.4) (5.4) (6.4) (7.9) (7.9) (7.9) (7.9)
Financing 0.1 0.0 0.0 0.1 (3.5) (3.5) (3.2) (2.8) (2.4) (2.0)PDC (4.3) (4.3) (4.7) (4.8) (2.9) (4.2) (3.9) (3.5) (3.1) (2.2)Surplus/(deficit) 1.7 2.0 2.0 0.7 (0.1) (7.1) 0.4 1.0 1.4 2.2
£m
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2021/22: the £ (7.1) m deficit is projected due to the one-off impairment chargedescribed above.
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Figure [9.2]: Incremental impact of the investment on income and expenditure
£m 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Income
Protected revenue - - - - - - - - - -
Research & training - - - - - 0.0 0.0 0.0 0.0 0.0
Other - - - - 0.0 0.0 0.0 0.0 0.0 0.0
Total income - - - - 0.0 0.0 0.0 0.0 0.0 0.0
Operating costs
Pay - - - - 0.3 1.5 1.9 1.9 1.9 1.9
Non-pay - - - - 0.8 3.5 3.8 4.2 4.3 4.4
Total operating expenses - - - - 1.1 5.0 5.7 6.1 6.2 6.3
Earnings before Interest, Tax, Depreciation and Amortisation (EBITDA) - - - - 1.1 5.0 5.7 6.1 6.2 6.3
Impairment - - - - - (8.2) - - - -
Depreciation & amortisation - - - - - (1.0) (2.5) (2.5) (2.5) (2.5)
Financing - (0.0) (0.0) (0.1) (3.7) (3.6) (3.3) (2.9) (2.6) (2.1)
Public Dividend Capital (PDC) - (0.3) (0.6) (1.3) 0.5 (0.9) (0.7) (0.4) - 0.9
Surplus/(deficit) - (0.3) (0.6) (1.4) (2.0) (8.7) (0.8) 0.3 1.1 2.5
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The incremental impact of the investment on income and expenditure described above shows:
The investment is projected to generate a marginal increase in income (£30,000 per year) from research and development and other income.
Pay and non-pay cost reductions are described above.
The investment is projected to increase EBITDA by £6.3m (recurrently) by the end of the projection period.
The impairment relates to the revaluation of the new building, as described above.
Depreciation on the new building is projected to start from 2021/22, as the building is brought into use.
The investment is projected to cause an increase in financing costs throughout the construction and operating phases. This relates to the cost of financing the bridging loan described above in Figure [9.2]. This is a short term loan that could be substantially repaid within five years but to be prudent the Trust has modelled as having a ten year term.
The net impact of the investment is a deficit through construction from 2017/18 and into the first year of full operation (2022/23). As loan repayments reduce the financing cost, the investment is projected to yield a surplus from 2023/24.
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Figure [9.3]: Net deficit/surplus bridge between the baseline and investment cases at 2025/26
The £(0.3)m net deficit forecast in 2025/26 for the baseline case is significantly improved in the investment case to a £2.2m net surplus. As noted above, the additional financing cost is expected to fall to nil from 2026/27, further improving the investment case position over the baseline case.
9.3.2 Statement of financial position The investment case statement of financial position is set out below, along with the incremental impact assessed against the baseline case (the statement of financial position for the full baseline case is included in Appendix [20]).
£(0.3)m
£1.9m
£4.4m £(2.5)m
£(2.1)m
£0.9m £2.2m
£(1.0)m
-
£1.0m
£2.0m
£3.0m
£4.0m
£5.0m
£6.0m
£7.0m
£8.0m
Baseline case2025/26 deficit
Pay costs Non-pay costs Depreciation &amortisation
Financing PDC Investment case2025/26 surplus
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Figure [9.4]: Projected statement of financial position for the investment case
The investment case projected statement of financial position shows:
The property, plant and equipment balance is projected to increase significantly in the construction phase from 2017/18 to 2021/22. An impairment of the new building of £8.2m is projected in 2021/21 as set out in the assumptions above. The sale of the St Pancras site is projected to be phased between 2022/23 and 2025/26, reducing the property, plant and equipment balance significantly in each of these years.
The trade receivables balance is projected to remain fairly constant, as no significant changes in trade receivables days are assumed.
Cash is projected to remain above the Trust’s requirement of £20.0m, which is sufficient to meet its working capital requirements. Cash is discussed further in the following section.
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Property, plant and equipment 122.1 137.7 139.6 142.4 213.0 231.1 208.6 185.7 162.8 125.8
Trade receivables 12.7 12.7 12.8 12.6 12.5 12.6 12.7 12.8 12.9 13.0 Other current assets 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 Cash and cash equivalents 44.0 24.9 23.7 21.8 76.1 37.5 47.7 58.9 70.5 97.0
Total assets 180.2 176.7 177.5 178.2 302.9 282.6 270.4 258.8 247.6 237.3
Trade payables (6.8) (6.9) (6.9) (7.0) (6.8) (6.1) (6.0) (5.9) (5.8) (5.7)Loans: current - - - - (12.5) (12.5) (12.5) (12.5) (12.5) (12.5)Other current liabilities (18.1) (12.4) (11.2) (11.2) (11.2) (11.2) (11.2) (11.2) (11.2) (11.2)
Loans: non-current - - - - (112.5) (100.0) (87.5) (75.0) (62.5) (50.0)Other non-current liabilities (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)
Total liabilities (24.9) (19.4) (18.2) (18.2) (143.0) (129.9) (117.2) (104.6) (92.0) (79.4)Net assets 155.3 157.3 159.3 160.0 159.9 152.7 153.1 154.2 155.6 157.8
PDC 60.3 60.3 60.3 60.3 60.3 60.3 60.3 60.3 60.3 60.3 Retained earnings 42.8 44.8 46.8 47.4 47.3 40.2 40.6 41.6 43.0 45.3 Revaluation reserve 52.2 52.2 52.2 52.2 52.2 52.2 52.2 52.2 52.2 52.2 Total equity 155.3 157.3 159.3 160.0 159.9 152.7 153.1 154.2 155.6 157.8
£m
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The fall in the trade payables balance of around £1.1m between 2017/18 and 2025/26 is driven by the reduction in other expenses which form part of CIP savings. There are no significant changes in trade payables days assumed over this period.
A loan of £125.0m is projected to be drawn down in 2020/21 (current element: £12.5m, non-current element: £115.5m). As noted in the assumptions table, this is the amount required for the Trust to maintain a minimum cash balance of £20m, required for working capital. As shown below the Trust’s cash balance presents an opportunity to optimise these loan arrangements to improve the net surplus position and this will be considered further throughout the Trust’s business case process as part of the commercial dialogue with the Independent Trust Financing Facility (ITFF).
The capital receipt from the redevelopment of the SPH site is expected to be greater than this. In the Trust’s OBC, a red book valuation has been undertaken as per NHSI and HMT guidance which presents a prudent value. Therefore, the risk of not achieving a level of capital receipt to cover the costs of the redevelopment is low.
Figure [9.5]: Incremental impact on the projected statement of financial position
The incremental impact of the investment on the statement of financial position shows the following:
The property, plant and equipment balance increases during the construction phase, subsequently falling as the St Pancras site is sold.
The negative impact on the cash balance is managed through the projected loan draw down, so that the Trust maintains sufficient cash for its working capital requirement.
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Property, plant and equipment - 15.4 17.9 34.9 106.8 126.3 105.1 83.5 61.9 26.2
Cash and cash equivalents - (15.6) (18.8) (37.2) 13.7 (27.5) (19.7) (10.4) (0.2) 25.5
Total assets - (0.3) (0.9) (2.2) 120.6 98.7 85.4 73.0 61.7 51.7
Trade payables - - - - 0.2 0.8 0.9 0.9 1.0 1.0 Loans: current - - - - (12.5) (12.5) (12.5) (12.5) (12.5) (12.5)
Loans: non-current - - - - (112.5) (100.0) (87.5) (75.0) (62.5) (50.0)Total liabilities - - - - (124.8) (111.7) (99.1) (86.6) (74.0) (61.5)Net assets - (0.3) (0.9) (2.2) (4.3) (13.0) (13.8) (13.5) (12.4) (9.8)
Retained earnings - (0.3) (0.9) (2.2) (4.3) (13.0) (13.8) (13.5) (12.4) (9.8)Total equity - (0.3) (0.9) (2.2) (4.3) (13.0) (13.8) (13.5) (12.4) (9.8)
£m
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The trade payables balance is projected to decrease by £1.0m as a result of the CIPs enabled by the investment that reduce other expenses.
Loans are drawn down and repaid.
Retained earnings is lower in the investment case, principally due to the additional financing costs (£21.1m), additional depreciation (£11.1m) and impairment of the new building (£8.2m), which is partially offset by the improved underlying cost base (£30.6m).
9.3.3 Cash flows Figure [9.6] below sets out the sources and uses of funding for the proposal on the Trust for the scheme. It can be seen that the funding is provided through a source of land value from SPH, Tottenham Mews and Trust reserves.
[Figure 9.6]: Source and uses of funds excluding external financing
Sources of funds Uses of funds
SPH Land value 95.4 Land receipt for Trust space 5.0
Tottenham Mews 12.0 Land purchase 14.5
Hanley Road 1.0 New inpatient facility 59.0
Trust reserves 32.0 Community hubs 40.6
SPH hub 16.4
Fees 4.9
Total 140.4 Total 140.4
Figure [9.7] below shows the cash flow statements for the investment case. The incremental impact of the investment against the baseline case is shown on the following figure and the full baseline cash flow statement is included in Appendix [21].
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Figure [9.7]: Projected cash flow statement for the investment case
The cash flow statements show the following:
Surplus from operations corresponds to the EBITDA shown in Figure [9.1].
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Surplus from operations 10.5 11.5 12.1 10.8 11.7 15.2 15.4 15.2 14.8 14.3
Movement in working capital(Inc)/dec in NHS trade receivables (1.3) (0.0) (0.0) 0.1 0.2 (0.1) (0.1) (0.1) (0.1) (0.1)
(Inc)/dec in non-NHS trade receivables 1.2 - - 0.0 (0.0) (0.0) - - - -
(Inc)/dec in other receivables 0.3 - - - - - - - - -(Inc)/dec in prepayments (0.2) - - - - - - - - -Inc/(dec) in deferred income 0.2 - - - - - - - - -Inc/(dec) in provisions (0.3) - - - - - - - - -Inc/(dec) in trade payables 0.0 0.1 (0.0) 0.1 (0.2) (0.6) (0.1) (0.1) (0.1) (0.1)Inc/(dec) in other payables (2.1) - - - - - - - - -Inc/(dec) in accruals 2.7 (5.7) (1.2) - - - - - - -Net cash inflow/(outflow) from operating activities
11.1 5.9 10.8 11.0 11.6 14.4 15.1 15.0 14.6 14.1
Capital expenditure (4.2) (20.7) (7.3) (21.2) (76.0) (32.7) (4.5) (4.1) (4.1) (4.1)Proceeds on disposal of PPE - - - 13.0 - - 19.1 19.1 19.1 33.2 Net cash inflow/(outflow) from investing activities
(4.2) (20.7) (7.3) (8.2) (76.0) (32.7) 14.6 15.0 15.0 29.1
Dividends paid (4.1) (4.3) (4.7) (4.8) (2.9) (4.2) (3.9) (3.5) (3.1) (2.2)Net interest (paid)/received 0.1 0.0 0.0 0.1 (3.5) (3.5) (3.2) (2.8) (2.4) (2.0)Drawdown/(repayment) of loans - - - - 125.0 (12.5) (12.5) (12.5) (12.5) (12.5)
Net cash inflow/(outflow) from financing activities
(4.0) (4.3) (4.6) (4.8) 118.6 (20.2) (19.6) (18.8) (18.0) (16.6)
Net cash inflow/(outflow) 2.9 (19.1) (1.2) (1.9) 54.3 (38.6) 10.2 11.2 11.6 26.6 Opening cash balance 41.2 44.0 24.9 23.7 21.8 76.1 37.5 47.7 58.9 70.5 Closing cash balance 44.0 24.9 23.7 21.8 76.1 37.5 47.7 58.9 70.5 97.1
£m
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Working capital movements are as described below. These show minimal projected movements in the working capital requirement, apart from accruals.
Capital expenditure includes the capital investment, as well as ongoing maintenance capped at between £2.3m and £2.7m per year.
Proceeds on the disposal of Property Plant and Equipment (PPE) includes the sale of Tottenham Mews (£12.0m) and Hanley Road (£1.0m) in 2019/20 and receipts relating to the sale of St Pancras of £19.1m each year from 2022/23 to 2024/25 and a final receipt of £33.2m in 2025/26.
The increase in interest costs relate to the financing of the bridge loan, which is due to be fully repaid by the end of 2025/26.
The projections show a minimum cash balance of £21.8m in 2019/20, which is sufficient to cover its working capital position.
Figure [9.8]: Incremental impact of the investment on the cash flow statement
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Surplus from operations - - - - 1.1 5.0 5.7 6.1 6.2 6.3
Movement in working capital(Inc)/dec in non-NHS trade receivables - - - - (0.0) (0.0) - - - -
Inc/(dec) in trade payables - - - - (0.2) (0.6) (0.1) (0.1) (0.0) (0.0)Net cash inflow/(outflow) from operating activities
- - - - 1.0 4.4 5.7 6.0 6.2 6.3
Capital expenditure - (15.4) (2.5) (17.1) (71.9) (28.6) (0.4) - - -Proceeds on disposal of PPE - - - - - - 19.1 19.1 19.1 33.2 Net cash inflow/(outflow) from investing activities
- (15.4) (2.5) (17.1) (71.9) (28.6) 18.7 19.1 19.1 33.2
Dividends paid - (0.3) (0.6) (1.3) 0.5 (0.9) (0.7) (0.4) - 0.9 Net interest (paid)/received - (0.0) (0.0) (0.1) (3.7) (3.6) (3.3) (2.9) (2.6) (2.1)Drawdown/(repayment) of loans - - - - 125.0 (12.5) (12.5) (12.5) (12.5) (12.5)
Net cash inflow/(outflow) from financing activities
- (0.3) (0.6) (1.4) 121.8 (17.1) (16.5) (15.8) (15.1) (13.8)
Net cash inflow/(outflow) - (15.6) (3.1) (18.4) 50.9 (41.3) 7.8 9.3 10.2 25.7 Opening cash balance - - (15.6) (18.8) (37.2) 13.7 (27.5) (19.7) (10.4) (0.2)Closing cash balance - (15.6) (18.8) (37.2) 13.7 (27.5) (19.7) (10.4) (0.2) 25.5
£m
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The incremental impact of the investment on the Trust’s cash flows over the baseline shows:
An improvement in surplus from operations, resulting from the CIPs that are enabled by the investment.
A slight decrease in trade payables, driven by the reduction in other expenses CIPs.
Capital expenditure relating to the investment.
Proceeds from the sale of the St Pancras site. Note that the sale of Tottenham Mews and Hanley Road in 2019/20 are assumed in both baseline and investment cases and therefore does not form part of the incremental impact.
The £125.0 million bridging loan (assumed to be ITFF) is projected to be drawn down in 2020/21 and repaid at £12.5m per year over 10 years by 2031.
The net impact on cash of the investment is projected to be a cash outflow in each year of the projections except 2020/21, due to the loan receipt, and in 2025/26, when the final payment for the St Pancras site is assumed to be received.
There is no assumed income statement impact from the disposals at this stage. The Trust will formally review this treatment at FBC stage once the development partner is identified as in the commercial case. This will not impact on affordability insofar as it does not impact on cash and would be treated as an exceptional item if a gain were recognised.
The principal factors of the investment that impact the cash balance at 2025/26 are illustrated in Figure [9.9] below.
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Figure [9.9]: 2025/26 cash bridge from the baseline to the investment case
The main differences in cash between the baseline and investment cases arise from the following cumulative impacts:
Operating surplus: £30.6m, of which £21.0m relates to other expenses, £9.4m relates to reduced pay costs and £0.2m relates to additional income.
Capital expenditure of £131.0m is set out in the capital bridge above.
The drawdown of a £125.0m loan to bridge the temporary cash shortfall10.
Loans repaid of £62.5m.
10 The Trust have assumed a £125m facility is available at ITFF rates. There is a risk that this funding will not be available at the time it is needed or altogether which could delay the project
timescales.
£71.5m
£30.6m £(1.0)m
£(135.8)m
£90.4m
£(2.8)m
£125.0m
£(62.5)m
£(18.3)m
£97.1m
£(50.0)m
-
£50.0m
£100.0m
£150.0m
£200.0m
Baseline case2025/26 cash
Operatingsurplus
Workingcapital
differences
Capitalexpenditure
Proceeds ondisposal of
PPE
PDC dividendpaid
Loansdrawndown
Loans repaid Net interest Investmentcase 2025/26
cash
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Net interest paid increases by £21.1m, relating to the bridging loan described above.
9.4 Impact on financial sustainability risk rating (FSRR) The financial sustainability risk rating (FSRR) is NHSI’s view of the level of financial risk a Trust is exposed to and is a therefore key metric to consider for this transaction. Ratings go from 1 to 4, where 1 is the highest risk and 4 is the lowest risk.
The FSRR scores for the investment and baseline cases are set out in Appendix [22]. The FSRR calculation performed by the LTFM yield a capital service cover risk rating of 1 for the investment case, as the bridge loan repayments are included in the debt service total
9.5 Sensitivities The Trust has run a number of sensitivities to understand the impact of different risks on the project: 1. Construction programme delay by one year: This has an initial I&E and cash benefit, but worsens the position by 2025/26 as the benefits
are also delayed. 2. Development/capital cost increase by 10%: This has a limited impact on the net surplus (decreasing it by £0.8m by 2025/26) but it reduces
the forecast cash balance by £15.3m by 2025/26. 3. Land value at Whittington 50% higher: This has a limited I&E impact (decreasing it by £0.5m by 2025/26), but reduces forecast cash by
£10.0m by 2025/26. 4. Land value at SPH 10% lower: This has a limited I&E impact (decreasing it by £0.4m by 2025/26), but reduces forecast cash by £11.6m by
2025/26. 5. Benefits delivered at 50% below plan: This reduces the recurrent net surplus by £3.8m £2.3m and cash by £16.6m at 2025/26. 6. Benefits delivered at 30% below plan: This reduces the recurrent net surplus by £2.3m and cash by £10.0m at 2025/26. 7. Recurrent CIP 30% lower than plan: This reduces the recurrent net surplus by £5.7m and cash by £21.3m at 2025/26. 8. Pay costs 5% higher than plan: This reduces the recurrent net surplus by £6.7m and cash by £40.2m at 2025/26. As this sensitivity is also
considered in the baseline case analysis, it has no impact on the incremental impact of the transaction. 9. Pay costs 2.5% higher than plan: This reduces the recurrent net surplus by £3.4m and cash by £20.2m at 2025/26. As this sensitivity is
also considered in the baseline case analysis, it has no impact on the incremental impact of the transaction. The sensitivities set each have minimal or no impact on the forecast FSRR score when considered individually. A combined downside case will be considered in the Trust’s FBC along with the impact on the FSRR, including the impact of delays in land receipts.
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9.6 Conclusions The projections show that the Trust will have sufficient cash to implement the investment, while maintaining sufficient headroom for the working capital requirement. The adjusted FSRR scores also imply an acceptable level of financial risk.
The projections require that a bridge loan of £125.0m is made available by the ITFF from 2020/21. The Trust will need to secure a commitment on this loan or to make alternative funding arrangements in order to proceed with the investment.
There is no financial impact on any other parties, including both of the CCGs due to the block-payment contract provided to the Trust for the delivery of mental health services.
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10 Implementation
This sections sets out what happens after the consultation phase, namely, how the Trust plans to manage the project and sets out in more detail the actions that will be required to ensure the successful delivery of the scheme in accordance with best practice.
10.1 Post consultation process Following the close of the consultation and decision-making process as set out at the end of Section [7], the CCGs will hand back decision making responsibility to the Trust. The Trust will implement the proposal, having already factoring in considerations from the consultation process, as set out in subsequent sections.
10.2 Programme management arrangements The Trust has implemented a robust programme management and governance structure which ensures accountability through clear allocation of responsibilities, and provides assurance through regular reporting, enabling quick identification and addressing any issues as they arise. This section describes the following programme management arrangements:
Programme management approach; Project implementation budget; Risk Management Arrangements; and Benefits management.
10.2.1 Programme management approach The Trust will follow the PRINCE2 principles in their approach to project management to ensure the delivery of the project. This is the de facto standard in use in the public sector in the UK.
Project implementation budget
The implementation costs for the project are expected to be £4.9m in nominal terms over the project implementation period and are inclusive of costs associated with the programme team, town planning and technical support.
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10.2.2 Risk Management The risk management strategy is in line with the HM Treasury Green Book and NHS guidance for capital projects.
There is an existing risk management process in place for the Programme, and this process will continue throughout the implementation and delivery phase of the programme to ensure that risks are identified, monitored and where possible, mitigated. The overarching risk management policy is based on an iterative process of:
Identifying and prioritising the risks to the achievement of the Programme aims and objectives;
Evaluating the likelihood of those risks being realised and the impact should they be realised;
Managing the risks efficiently, effectively and economically. The Programme Office maintains the Risk Register for the Programme. Project risks registers are maintained by the project manager/work stream lead and risks escalated where necessary via reporting.
10.2.3 Programme governance structure The key elements of the programme governance structure include:
A clear governance and delivery structure from operational workstreams to the Trust Board.
The structured relationship between programme management and delivery.
The interface between the Programme Board and its assurance mechanism.
The interface between the Trust Board and its assurance mechanism.
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The programme governance structure surrounding this project is illustrated in the diagram below:
Figure [10.1]: Project Governance Structure
The day to day development of the case is delivered by a series of project workstreams within which the membership will vary in line with the specific needs of the workstream and the phase of the business case.
Finance and Procurement
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Lead: Director of Finance, the Trust or nominee
To monitor the development expenditure and advice on elements such as cash flow, VAT and compliance with finance requirements. Procurement should advise on best practice for contracts and equipping new schemes.
Workforce
Lead: Director of HR & OD, the Trust
Review the project for any impact on the workforce that creates change, and set out the process for achieving this within the business case.
Estates
Lead: Director of Estates and Facilities, the Trust
To review the proposals for Estates issues and advise and provide solutions.
Operational
Lead: Chief Operating Officer, the Trust or nominee
To review the design proposals, advise on operation issues such as compliance and working with Trust objectives and policies.
Clinical
Lead: Medical Director, the Trust or nominee
Review the clinical implications of the design proposals.
IM & T
Lead: Associate Director of ICT, the Trust
Review the design proposals against the Trust IT strategy and advice how this can be best delivered.
Partnership
Lead: Transformation Programme Director, the Trust
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To work closely with the Trust partners to keep them informed and understand and report on any deliverables, groups include: On Site Partner, Stakeholders Holder Reference Group, Council of Governors Site Development Working Group.
Communication
Lead: Head of Communications and Engagement, the Trust
To set out the communication strategy to deliver and monitor the plan.
10.2.4 Trust implementation team The Trust implementation team will comprise approximately 4-6 people on a whole time equivalents (WTE) basis to be engaged at various points during the implementation. The function requirements during the implementation include:
Programme Director;
Project Director;
Project Managers:
Main Inpatient Build;
Community Projects;
St Pancras Hub and Disposal;
Finance Support;
HR and Workforce Support;
Clinical Support; and
Administration.
Figure [10.2]: Trust implementation team
Role 2017/18 2018/19 2019/20 2020/2021 2021/22 2022/23
Programme Management Office WTE WTE WTE WTE WTE WTE
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Role 2017/18 2018/19 2019/20 2020/2021 2021/22 2022/23
Leadership 2 2 1 1 1 ¼
Management 1 ¼ 2 1 ¾ ½
Activity Modelling ½ ½
Financial 1 1 1 1 1 1
HR support ¾ ½ ½
Project Support 1 1 1 1 1 1
Total 4 ½ 5 ¼ 4 ¼ 5 ½ 5 ¼ 2 ¾
This proposed staffing profile for the implementation team has been informed by the recommendations of the Project Director based on experience of similar schemes.
10.3 Project implementation plan The key milestones for implementation are set out in Figure [10.3] below. These milestones will be updated on a regular basis as more information becomes available and the project develops. For further details on the consultation phase and approval timeline, see Section [7.5].
Figure [10.3]: Project milestones
Date Key item
TBC Approval of OBC
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Date Key item
TBC Go to market for Development Partner
TBC Appointment of Development Partner
TBC Planning application for new inpatient facility
TBC Planning application for community facilities
TBC Planning Application for SPH
TBC Completion of FBC
TBC Approval of FBC
TBC Construction of new inpatient facility completed
TBC Decant of inpatients into new inpatient facility
June 2022 Community hubs operational
February 2022 Redevelopment of SPH site begins
August 2023 SPH site operational (for C&I)
TBC Post project evaluation
10.4 Post project evaluation The Trust has developed a high level post project evaluation plan which identifies the mechanisms that would enable monitoring and review of performance at different stages of the project. These are to be shared with and approved by the Trust at each key milestone.
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A thorough and robust post project evaluation will:
Facilitate continual learning from the project to be implemented at subsequent stages as well as future projects. Ensure that the project adheres to the project plan/ milestones and review of project risks Enable measuring of project performance against project aims including the realisation of benefits Provide useful feedback and knowledge that can be shared with key stakeholders as well as the NHS as a whole.
The key components of the Trust’s post project evaluation arrangements are:
A review of performance against Project Programme throughout the life of the project; A review of actual performance toward achieving the benefits detailed in the Benefits Realisation Plan and confirmation that they have
been met; A review of project implementation to learn lessons for future; and A review of the FBC capital and revenue costs to assess their robustness and accuracy.
At the OBC stage, Design Quality Indicator (DQI) workshops have been conducted to review and improve the design and construction approach based on input from a range of stakeholders.
Going forward, service users, staff and the project team will be asked to evaluate the project through the use of questionnaires, stakeholder consultation meetings, staff focus groups and benefits realisation data.
The arrangements for the Post Project Evaluation will be established in accordance with best practice. The Trust will identify responsibilities and resource requirements for management of the Post Project Evaluation during the FBC development period, and Post Project Evaluation will be an integral part of the post implementation operating model.
10.5 Approvals process for investment by the Trust NHS Improvement require Trusts to submit a SOC, OBC and FBC for approval for capital investment proposals of this value (i.e. >£50m). The SOC submitted to NHSI in November 2016 has already been approved, while the OBC was submitted in June 2017 and is currently going through approvals with an open dialogue with NHSI. The FBC may take between 3-6 months to gain approval. The process for approval of each case is shown in figure [10.3].
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Figure [10.3]: Capital Business Case Approval Process
Source: Capital Regime, Investment and Property Business Case Approval Guidance for Trusts and Foundation Trusts, NHS Improvement, 2016.
HM Treasury Consultation with
DHSC
NHS Improvement Resources
Committee Approval
NHS Improvement
Board Approval DHSC Approval HM Treasury
Approval
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11 The SoS’s Four Tests
NHS England, in ‘Planning and delivering service changes for service users’ published in December 2013, outlined good practice for commissioners on the development of proposals for major service changes and reconfigurations.
Building on this, the 2014/15 mandate from the Secretary of State to NHS England, outlines that proposed service changes should be able to demonstrate evidence to meet four tests:
1. Strong public and patient engagement; 2. Consistency with current and prospective need for patient choice; 3. A clear clinical evidence base; and 4. Support for proposals from clinical commissioners.
Reconfiguration proposals must meet the four tests before they can proceed. These tests are designed to demonstrate that there has been a consistent approach to managing change, and therefore build confidence within the service, and with service users and the public.
11.1 Test 1: Strong public and patient engagement This test evaluates how service users and the public have been involved in the development of the proposals for the redevelopment of the St Pancras site. The extensive stakeholder engagement undertaken to date and that which is proposed over the course of the project is laid out in detail in Section [7] of this document. The methods and approaches for consultation have included presentations, discussions, surveys, meetings and emails.
A summary of these activities includes;
15 Service User engagements; 5 Staff engagements; 5 Carer engagements; 5 for senior stakeholders; 2 Governor engagements; 5 Healthwatch engagements;
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5 local community engagements; 1 local resident engagement.
The figure below lists each of the committees who have considered the pre-consultation plan and associated engagement activities.
Figure [11.1]: Staff Engagement
Meeting/approach Date How were participants informed Staff-side meeting 14 March 2017 Peckwater Centre staff 28 March 2017 Highgate Mental Health staff 04 April 2017 Presentation St Pancras staff 05 April 2017 Lowther Road staff 05 April 2017 C&I Senior Leadership Team Meeting 24 April 2017 Presentation St Pancras and Greenland Road staff 11 May 2017 Presentation Highgate Mental Health staff 12 May 2017 Presentation All-staff briefing 24 May 2017 Email update for staff 02 February 2018 Update email C&I staff briefing, Greenland Road 30 April 2018 Presentation C&I staff briefing, St Pancras 01 May 2018 Presentation C&I staff briefing, Lowther Road 03 May 2018 Presentation C&I staff briefing, Highgate 04 May 2018 Presentation
Figure [11.2]: Service User and Carer Engagement
Meeting/approach Date How were participants informed cBug, iBug, Nubian Users’ Forum, Women’s Strategy Group 24 March 2017
Service User Alliance 31 March 2017 Service Users’ Conference at St Pancras 13 April 2017 Presentation followed by Q&A session cBug 25 April 2017 Islington Carers’ Hub 28 April 2017 Discussion Camden Carers’ Hub 19 May 2017
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iBug 27 June 2017 Nubian Users’ Forum 18 July 2017 Presentation Service User Alliance 22 September 2017 Briefing SMS Service Users at Margarete Centre 28 September 2017 Frontline Service Users 02 November 2017 Meeting of CPPEG 06 November 2017 iCope Islington 15 November 2017 Carers’ Partnership Meeting 09 January 2018 Discussion and Q&A session
Healthwatch inpatient survey 24 January 2018 Verbally by Healthwatch and then asked a series of questions
Healthwatch inpatient survey 26 January 2018 Verbally by Healthwatch and then asked a series of questions
Healthwatch inpatient survey 30 January 2018 Verbally by Healthwatch and then asked a series of questions
Extraordinary Service Users’ Forum 02 February 2018 Update presentation followed by Q&A session
Islington Carers’ Meeting 06 February 2018 Verbally by Healthwatch and then asked a series of questions
Camden Carers’ Meeting 16 February 2018 Verbally by Healthwatch and then asked a series of questions
Previous inpatients Through March 2018 Verbally by Healthwatch and then asked a series of questions
St Pancras Redevelopment Consultation Review Group 07 March 2018 Papers and verbally Two borough community hubs engagement event 15 March 2018 Presentation Communications meeting with Paul Ware 19 March 2018 Verbally Meeting with Paul Ware 18 April 2018 Verbally Nubian Service Users' Forum 09 May 2018 Presentation
Figure [11.3]: Senior Stakeholder Engagement
Meeting/approach Date How were participants informed Stakeholder Reference Group meeting 27 July 2016 Discussion
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Stakeholder Reference Group meeting 05 October 2016 Discussion Stakeholder Reference Group meeting 26 January 2017 Discussion Stakeholder Reference Group meeting 27 February 2017 Discussion Stakeholder Reference Group meeting 29 March 2017 Discussion JHOSC 21 April 2017 Presentation North Central London JHOSC 19 September 2017 Presentation Stakeholder Reference Group meeting 24 October 2017 Discussion Knowledge Quarter 01 November 2017 Presentation followed Clinicians community hubs meeting 26 January 2018 Discussion North Central London Joint Health Overview Scrutiny Committee 23 March 2018 Presentation
Stakeholder Reference Group meeting 24 April 2018 Discussion
Figure [11.4]: Governor Engagement
Meeting/approach Date How were participants informed Council of Governors 09 May 2017 Presentation Email update for governors 02 February 2018 Update email C&I Council of Governors 08 May 2018 Presentation
11.2 Test 2: Consistency with current and prospective need for patient choice This test is to illustrate whether the proposed redevelopment will maintain the availability of service user choice.
For most service users that currently access mental health services in the Borough of Camden and Islington, the entry pathway will remain the same following the proposed redevelopment. As the clinical model remains unchanged, with the majority of services continuing to be delivered in the community and via primary care, the range of service user choice is unaffected.
For service users of the inpatient facilities at St Pancras, the proposed changes will have minimal impact on the choices available due to the fact that there is no change in the number of providers serving the local area and the Trust’s own services are moving 2.5 miles further away.
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Currently the closest alternative provider of inpatient mental health is at Gordon Hospital (operated by CNWL and 3.7 miles from St Pancras and 5.8 miles from the Whittington site). In respect of the fact that many users of this service are admitted to the facility under the Mental Health Act, the relocation would be insignificant in terms of impact on patient choice.
In addition, the travel time identified, there should not be any services users that, following the relocation of services to the Whittington site, would find the travel time an issue or that their choice of provider has substantively diminished. This will be discussed further with service users as part of the consultation phase following approval of the PCBC.
Patient choice would also be improved from a quality perspective as with the proposed redevelopment, service users would have a purpose-built, higher quality, and safer facility from which to receive care than is available currently. This increase in the quality is in line with the CCGs and the Trust’s vision to deliver their vision of excellence; “We will continually improve the quality and safety of service delivery, service user experience and improve outcomes.”
11.3 Test 3: A clear clinical evidence base This test is to demonstrate sufficient clinical evidence and clarity on the case for change. This is clearly outlined in Section [4]. The independent verification of this case for change will be gained through submission for consideration by the London Clinical Senate, engagement with a range of clinicians as detailed below, and using reports from the CQC reports.
The model of care and proposals to relocate certain services have the support of the CCG GP mental health leads and were developed by the Trust’s Medical Director and Director of Nursing.
CQC Report
The Trust’s most recent CQC report was published in March 2018, where the Trust received an overall rating of “Good”. The previous report, published in June 2016 identified the deteriorating St Pancras Hospital site compared to the refurbished HMHC. Due to the ageing and inflexible site at St Pancras, there is a clinical need to move service users to a site without multiple ligature points and multiple blind spots from where staff cannot easily observe service users. After publication of the 2016 report, the CQC was briefed on the Trust’s plans to review the entire St Pancras estate.
London Clinical Senate
The Clinical Senate Liaison group contacted the London Clinical Senate for advice on:
Whether the change of environment will improve clinical care for inpatient and community services
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Whether the proposals for changes to inpatient and community mental health services: o will enable improvements in clinical care and quality benefits for patients o are informed by best practice o align with national policy and are supported by STP plans and commissioning intentions
Whether the approach ensuring the inpatient demand of population growth is absorbed by the development of mental health community services.
The LCS will provide feedback after submission of the PCBC to the CCG GBs. However, consultation will not commence unless LCS have approved the consultation plan.
Clinical engagement
A wide range of clinicians have been engaged and consulted throughout the process to ensure proposals have patient outcomes central to plans. There has been broad and varied communication with a range of clinical staff, further details of which can be found in Figures 7.3 and 7.3. Of particular note are the GB Seminars, which the Trust presented the redevelopment plans. CCG GB leads have been involved in the process throughout, alongside the member GPs.
Furthermore, a meeting of clinical leads from the local health organisations was held on 26 January 2018 to discuss the community hubs. The Trust is scheduled to attend the Camden GP locality meetings in April 2018 and Islington GPs were updated in March 2018. A number of engagement events for Trust staff have been held at various Trust locations where clinicians have attended. Trust clinicians also continue to be kept informed through existing internal meeting structures.
Feedback provided demonstrated a strong level of support for the proposal with a consensus that the changes identified would improve services for service users. A letter of support from the Trust’s Director of Nursing, dated June 13th 2017, provides this assurance on behalf of the clinicians at the Trust, stating that “considering the environmental challenges around access, ligature management, the privacy and dignity of our service users and infection control, we believe that the proposal reflects the collective view on how our local services should be configured”. This can be found in Appendix [23].
11.4 Test 4: Support for proposals from clinical commissioners. This test is to provide assurance that the proposals have the approval of local commissioners.
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Both of the CCGs have been involved and provided their support for the proposed redevelopment as joint commissioners of the Trust. The Chief Operating Officer for Haringey and Islington CCG has led the engagement on behalf of Camden and Islington CCGs and been the primary communicator to senior stakeholders. They also lead the St Pancras Hospital Redevelopment Oversight Group, providing guidance over the Consultation work stream and with representation from Camden CCG and Islington CCG.
Figure [11.5]:
Meeting/approach Date How were participants informed
Target audiences
Number of attendees/number of hits or users
Islington GP Forum 22 March 2018 Presentation GPs
South Camden GP Locality meeting
11 April 2018 Presentation GPs 16
North Camden GP Locality meeting
12 April 2018 Presentation GPs 10
West Camden GP Locality meeting
13 April 2018 Presentation GPs 13
11.5 NHSE’s Bed Closures Test From 1 April 2017, NHSE introduced a new test to evaluate the impact of any proposal that includes a significant number of bed closures and to ensure commissioners are able to evidence that one of the following three conditions have been met;
Sufficient alternative provisions have been made, such as increased GP or community services;
New treatments or therapies will reduce specific categories of admissions, or;
Where a hospital has been using beds less effectively than the national average, that there is a credible plan to improve performance without affecting patient care.
This test is only applied where the proposal includes plans to significantly reduce bed numbers. As this proposal maintains the current inpatient bed provision following activity and bed modelling, as outlined in further detail in section 5, this test is not applicable.
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12 Decision making and next steps
Following consultation, the St Pancras Hospital Redevelopment Oversight Group will review consultation responses received from members of the public and organisations. The committee will then consider the views of the participants and the effect these may have on the decision-making process.
At this stage of the development of options, it is not possible to fully detail the timescales in which decisions will be taken and when subsequent implementation could take place. This is due to a number of factors, including:
The quantity and detail of consultation responses received, and timescales required to analyse those responses;
The consideration of consultation responses by the St Pancras Hospital Redevelopment Oversight Group and subsequent update of analysis and evaluation of options as required;
The development of a decision making business case and confirmation by the St Pancras Hospital Redevelopment Oversight Group; and
The development of detail implementation plans between providers and commissioners on the basis of the decision made by the St Pancras Hospital Redevelopment Oversight Group.
However, to give an indicative timeline, the programme expects the following milestones for this process. These may be subject to change, as described above:
Formal public consultation – July 2018 - September 2018 (12 weeks).
External analysis of consultation responses – October 2018.
Final business case preparation – November 2018
Each CCG GB to consider the final business case document – November 2018
Each CCG to make a decision on the final business case – November 2018
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Appendix Contents
Appendix Number
Name
1 Trust services provided at SPH relocation summary 2 Other Provider’s services at SPH 3 Travel time report 4 Privacy Impact Assessment (PIA) screening questions form 5 Pre-consultation engagement meetings 6 NCL STP stakeholder engagement summary 7 JHOSC meeting minutes 8 Consultation plan 9 Consultation document, questionnaire and FAQs 10 Options development summary 11 Feasibility Study 12 Options considered 13 Qualitative assessment workshop summary 14 Qualitative assessment scoring 15 Qualitative scores of each option 16 Backlog maintenance 17 Quantifiable benefits 18 Trust’s Income & Expenditure assumptions 19 Baseline income and expenditure 20 Baseline statement of financial position 21 Baseline cash flow statement 22 Trust FSRR scores for the investment and baseline cases
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23 Letter of support from the Trust’s Director of Nursing 24 Bed modelling benchmarking 25 Occupied Bed Days Trend Analysis
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Appendix 1 Trust services provided at SPH relocation summary
Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
ST PANCRAS
Dunkley Ward (16 bed mixed sex with 4 learning disability beds) ACUTE
Laffan Ward (16 bed mixed acute mental health) ACUTE
Rosewood Ward (12 bed female acute mental health) ACUTE
Ruby Ward (11 bed female PICU) ACUTE
Montague Ward (14 mixed high dependency rehab ward) R&R
Sutherland Ward (14 mixed long-term complex care ward) R&R
Complex Depression, Anxiety and Trauma Service COMMUNITY
Camden & Islington Psychodynamic Psychotherapy Service COMMUNITY
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Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
Sexual Problems Team COMMUNITY
South Camden iCope COMMUNITY
Traumatic Stress Clinic COMMUNITY
NHS Transition, Intervention and Liaison Veterans’ Mental Health Service (formally known as LVS)
COMMUNITY
ADHD Team Attention Deficit Hyperactivity Disorder COMMUNITY
Adult Autism Clinic COMMUNITY
Camden Mental Health Assessment and Advice Team
COMMUNITY
Islington Practice Mental Health Team
COMMUNITY
South Camden Crisis Resolution Home Treatment ACUTE
Acute Day Unit (Jules Thorn) ACUTE
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Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
The Rivers Crisis House (subject to separate review)
Approved Mental Health Professional Service ACUTE
Recovery College COMMUNITY
Pharmacy ACUTE
Clozapine Clinic COMMUNITY
HIGHGATE
Sapphire Ward (16 bed mixed acute mental health) ACUTE
Emerald Ward (15 bed mixed acute mental health) ACUTE
Opal Ward (16 bed mixed acute mental health) ACUTE
Jade Ward (16 bed mixed acute mental health) ACUTE
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Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
Amber Ward (16 bed mixed acute mental health) ACUTE
Topaz Ward (16 bed acute mental health) ACUTE
Pearl Ward (14 bed mixed older people with mental illness) SAMH
Highgate Day Centre R&R
Malachite Ward (16 bed mixed high dependency rehabilitation) R&R
Coral Ward (12 bed male PICU) ACUTE
Garnet Ward (14 bed mixed dementia care) SAMH
Personality Disorder Therapies Team COMMUNITY
Personality Disorder Community Team COMMUNITY
Accommodation Team R&R
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Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
GREENLAND ROAD
Camden Assertive Outreach Team R&R
Islington Assertive Outreach Team R&R COMMUNITY
Camden Early Intervention Team R&R
Islington Early Intervention Team R&R
Focus Homeless Outreach COMMUNITY
LOWTHER ROAD
North Islington Rehabilitation and Recovery Team R&R
Cornwallis Outreach Project R&R
Islington Mental Health Re-ablement Service R&R
PECKWATER CENTRE
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Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
Camden Community Team SAMH
Camden Memory Service SAMH
Care Home Liaison Team SAMH
South Camden Recovery Team R&R
BLENHEIM COURT (NON-CLINICAL SITE)
Dementia Navigators SAMH
Home Treatment Team SAMH
Islington Community Mental Health Team SAMH
Islington Memory Team SAMH
Care Home Liaison Team SAMH
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Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
MARGARETE CENTRE
South Camden Drug Centre SMS
ARLINGTON ROAD
Camden Alcohol Service SMS
THE HOO
North Camden Recovery Team R&R
DALEHAM GARDENS
North Camden Drug Service SMS
North Camden Recovery Centre R&R
SOUTHWOOD SMITH CENTRE
Accommodation Team R&R
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Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
South Islington Recovery Team R&R
DRAYTON PARK
Islington Learning Disabilities Service COMMUNITY
MANOR GARDENS
iCope - North Islington Team COMMUNITY
CAMDEN MEWS
Community Recovery Service for Older People - covering both Camden and Islington
SAMH
Mental Health Liaison Team ACUTE
OTHER SITES
Aberdeen Park R&R
Highview R&R
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Current locations and services No move (staying as is) Move to new site
Move to Greenland Road
Move to Lowther Road
Stacey Street (subject to separate review)
Raglan Day Centre SAMH
Whittington Hospital
Mental Health Liaison Assessment Team (ILAT),
Key:
Acute: Acute and Crisis Care (Urgent care)
R&R: Recovery and Rehabilitation (Psychosis)
SAMH: Services for Ageing and Mental Health (Older people and Dementia)
SMS: Substance Misuse Services (Alcohol and drugs)
Community: Community Mental Health (Complex psychological and common mental health conditions)
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Appendix 2 Other Provider’s services at SPH
NHS Services & description of service Current address Future location
Rehabilitation inpatient wards (Central and North West London Foundation Trust)
Provides treatment and support for patients whose physical abilities have been reduced through illness, such as a stroke, or a fall or a musculoskeletal condition.
South Wing To remain in current building
Evergreen Ward (University College London Hospital)
A ward predominantly for care of the elderly
South Wing To remain in current building
Kidney dialysis clinic (Royal Free Hospital) St Pancras Hospital
To remain but in a new building
Ophthalmology clinic (Royal Free Hospital) St Pancras Hospital
To remain but in a new building
GP out of hours service (London Central & West Unscheduled Care Collaborative)
St Pancras Hospital
To remain but in a new building
Kings Cross GP Practice (AT Medics) St Pancras Hospital
To stay but in a new building
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Appendix 3 Travel time report
Travel Times by TFL net changes are from SPH to alternative locations Travel times (in minutes) from centre of 4 Fig Postcode to:
Postcode
St Pancras Hospital
Proposed site at Whittington Hospital
Net change
Lowther Road
Net change
Greenland Road
Net Change
Location reference (co-ordinates of centre of post code)
EC1Y8 52 44 -8 37 -15 31 -21 EC1V3 54 44 -10 37 -17 31 -23 EC1R0 24 42 18 31 7 33 9 WC1N 1 27 39 12 29 2 28 1 WC1N3 33 40 7 29 -4 32 -1 WC1X9 29 44 15 30 1 32 3 N17 39 43 4 26 -13 38 -1 N18 38 68 30 55 17 65 27 N19 39 27 -12 30 -9 35 -4 N10 56 48 -8 59 3 47 -9 N11 46 53 7 36 -10 44 -2 51.615158, -0.141236 N12 37 30 -7 44 7 28 -9 51.617495, -0.181364 N13 57 70 13 50 -7 47 -10 51.618230, -0.106456 N14 47 62 15 39 -8 49 2 51.633545, -0.132208 N51 35 46 11 28 -7 28 -7 51.553310, -0.102656 N52 43 47 4 30 -13 32 -11 51.554375, -0.093959 N78 32 43 11 2 -30 31 -1 51.549347, -0.111677 N79 29 39 10 26 -3 22 -7 51.551560, -0.124309 N 16 8 49 61 12 39 -10 48 -1 51.562183, -0.075914 N4 2 35 47 12 28 -7 34 -1 51.566395, -0.097199
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N4 3 31 41 10 25 -6 33 2 51.567320, -0.112734 N4 4 38 44 6 27 -11 41 3 51.574398, -0.111390 NW1 0 8 35 27 35 27 9 1 51.538065, -0.136074 NW1 1 10 36 26 28 18 16 6 51.532439, -0.132713 NW1 2 22 34 12 31 9 16 -6 51.527695, -0.134916 NW1 3 20 38 18 34 14 15 -5 51.528559, -0.141003 NW1 4 39 47 8 45 6 29 -10 51.529906, -0.154057 NW 1 7 21 30 9 34 13 6 -15 51.537078, -0.146046 NW1 8 23 35 12 36 13 11 -12 51.542975, -0.149450 NW1 9 16 38 22 31 15 14 -2 51.543912, -0.133099 NW5 2 25 24 -1 34 9 16 -9 51.550058, -0.136704 NW5 3 30 34 4 34 4 22 -8 51.547283, -0.146975 N7 0 33 28 -5 31 -2 24 -9 51.554683, -0.130209 N7 6 33 32 -1 19 -14 25 -8 51.558817, -0.117177 N7 7 33 38 5 16 -17 29 -4 51.557254, -0.110039 N19 4 34 13 -21 27 -7 25 -9 51.564227, -0.125903 N19 5 29 21 -8 33 4 20 -9 51.561825, -0.137633 N6 5 36 29 -7 32 -4 27 -9 51.575128, -0.140638 N6 6 34 26 -8 51 17 28 -6 51.566573, -0.152082 NW5 1 30 17 -13 38 8 24 -6 51.558391, -0.148134 NW3 1 35 38 3 42 7 26 -9 51.558853, -0.174714 NW3 7 40 39 -1 52 12 31 -9 51.564012, -0.180378 NW3 6 33 43 10 37 4 31 -2 51.551169, -0.182897 NW3 5 40 42 2 49 9 31 -9 51.549675, -0.175029 NW6 1 43 45 2 47 4 36 -7 51.551253, -0.195900 NW6 2 41 42 1 43 2 35 -6 51.546005, -0.197473 NW6 3 39 45 6 47 8 36 -3 51.544084, -0.185658
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NW6 4 41 47 6 54 13 32 -9 51.540061, -0.186773 NW6 5 39 53 14 46 7 38 -1 51.533780, -0.194154 NW2 3 47 49 2 58 11 47 0 51.553103, -0.209803 NW3 3 35 39 4 46 11 26 -9 51.544118, -0.166574 NW3 4 33 36 3 39 6 23 -10 51.547196, -0.165873
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Appendix 4 Privacy Impact Assessment (PIA) screening questions form
Documenting here which of the screening questions are applicable to your initiative will help to draw out the particular privacy considerations that will help formulate your risk register later in the template. This will also assist in ensuring that the investment the organisation makes is proportionate to the risks involved: Remember! – imagine this initiative involved the use of your own information or that of a relative Yes No Unsure Comments
i Is the information about individuals likely to raise privacy concerns or expectations e.g. health records, criminal records or other information people would consider particularly private?
☐ ☒ ☐ No change will be made to the way staff access patient information electronically. The Trust stores paper records in a central off-site facility.
ii Will the initiative involve the collection of new information about individuals?
☐ ☒ ☐ No new information will be collected.
iii Are you using information about individuals for a purpose it is not currently used for, or in a way it is not currently used?
☐ ☒ ☐ There are no changes to the way data is used.
iv Will the initiative require you to contact individuals in ways which they may find intrusive11?
☐ ☒ ☐ Stakeholders, including patients have been publically and privately engaged throughout.
v Will information about individuals be disclosed to organisations or people who have not previously had routine access to the information?
☐ ☒ ☐ There are no staff changes and data remains with the Trust.
vi Does the initiative involve you using new technology which might be perceived as being privacy intrusive e.g. biometrics or facial recognition?
☐ ☒ ☐ There are no new technologies used.
vii Will the initiative result in you making decisions or taking action against individuals in ways which can have a significant impact on them?
☐ ☒ ☐ No impact of the initiative on decision making.
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Appendix 5 Pre-consultation engagement meetings
Pre-consultation engagement activities – Service users and carers
Service User Engagement 24-Mar-17 cBug, iBug, Nubian Users’ Forum, Women’s Strategy Group 31-Mar-17 Service User Alliance 13-Apr-17 Service Users’ Conference at St Pancras 25-Apr-17 cBug 27-Jun-17 iBug 18-Jul-17 Nubian Users’ Forum 22-Sep-17 Service User Alliance 28-Sep-17 Briefing SMS Service Users at Margarete Centre 02-Nov-17 Frontline Service Users 06-Nov-17 Meeting of CPPEG to road-test Public Consultation document and
survey 15-Nov-17 iCope Islington 24-Jan-18 Healthwatch inpatient survey 26-Jan-18 Healthwatch inpatient survey 30-Jan-18 Healthwatch inpatient survey 02-Feb-18 Extraordinary Service Users’ 15-Mar-18 Community hubs engagement event
Pre-consultation engagement activities - Staff
Staff Engagement 14-Mar-17 StaffSide 28-Mar-17 Peckwater Centre staff 4-Apr-17 Highgate Mental Health staff 5-Apr-17 St Pancras staff 5-Apr-17 Lowther Road Staff 11-May-17 St Pancras and Greenland Road staff 12-May-17 Highgate Mental Health staff 24-May-17 C&I All-staff briefing 24-Jan-18 26-Jan-18 30-Jan-18 02-Feb-18 Email update for all C&I staff
Pre-consultation engagement activities – Broader Engagement
Broader Engagement 20-Mar-17 Islington and Camden Healthwatch 21-Apr-17 Joint Health Oversight Scrutiny Committee (JHOSC) (elected
representatives from local Health Oversight Scrutiny Committees (HOSC))
28-Apr-17 Islington Carers’ Hub 09-May-17 Council of Governors
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19-May-17 Camden Carers’ Hub 03-Aug-17 St Pancras Community Association 12-Sep-17 Islington Healthwatch 16-Sep-17 Voluntary Action Camden 25-Sep-17 Camden Healthwatch 29-Sep-17 Service User Conference 17-Oct-17 Camden and Islington Healthwatch 01-Nov-17 Knowledge Quarter (DS)
08-Nov-1707-Dec-17 Margie Butler, CEO at Camden Citizen’s Advice Bureau (MM) 14-Dec-17 Julie Parish, Operational Lead, Octopus Communities (MM) 15-Dec-17 Saul Gallick, Operational Lead and Sam Hopely, Chief Executive, Holy
Cross Centre Trust (MM) 09-Jan-18 Carers’ Partnership Meeting 10-Jan-18 Somers Town Neighbourhood Forum 26-Jan-18 Clinicians community hubs meeting (Trust and CCG clinical leads) 02-Feb-18 Email update for governors 06-Feb-18 Islington Carers’ Meeting (Healthwatch) 16-Feb-18 Camden Carers’ Meeting (Healthwatch)
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Appendix 6 NCL STP stakeholder engagement summary
We have developed a governance structure to enable NHS and local government partners to work together in new ways. The objectives of our governance arrangements are to:
Support effective collaboration and trust between commissioners, providers, political leaders and the general public to work together to deliver improved health and care outcomes more effectively and reduce health inequalities across the North London system;
Provide a robust framework for system level decision making, and clarity on where and how decisions are made on the development and implementation of the North London STP;
Provide greater clarity on system level accountabilities and responsibilities for the North London STP;
Enable opportunities to innovate, share best practice and maximise sharing of resources across organisations in North London; and
Enable collaboration between partner organisations to achieve system level financial balance over the remaining 3 years of the Five Year Forward View timeframe and deliver the agreed system control total, while safeguarding the autonomy of organisations.
The North London Programme Delivery Board oversees delivery of the plan. This is an executive steering group made up of a cross section of representatives from across North London. This group is specifically responsible for providing accountability for the implementation of the workstream plans. Membership includes the Senior Responsible Officers (SRO) of each workstream and SRO leads for CCGs, Providers and Local Authorities.
Two subgroups provide advice to the Programme Delivery Board: the Health and Care Cabinet (formerly the Clinical Cabinet) and the Finance and Activity Modelling Group.
The Health and Care Cabinet meets monthly to provide clinical and professional steer, input and challenge to each of the workstreams as they develop. Membership consists of the five CCG Chairs, the eight Medical Directors, clinical leads from across the workstreams, three nursing representatives from across the footprint, Pharmacy and Allied Health Professions representatives, a representative for the Directors of Public Health and representatives for the Directors of Adult Social Services and the Directors of Children’s Services respectively.
The Finance and Activity Modelling Group is attended by the Finance Directors from all organisations (commissioners and providers). This group currently meets fortnightly, to oversee the finance and activity modelling of the workstream plans as they develop.
The workstreams are responsible for developing proposals and delivery plans in the core priority areas and feed into the overarching governance framework. Every workstream has its own governance arrangements and meeting cycles which have been designed to meet their respective specific requirements, depending on the core stakeholders involved.
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The STP Advisory Board enables a collective partnership approach, and acts as the ‘sounding board’ for the implementation of the STP plans. The membership of this group includes Local Authority leaders, NHS Chairs, and Healthwatch.
In addition to the above governance groups, CEOs and other relevant executive directors and stakeholder representatives will meet quarterly for executive leadership events to enable continued engagement and momentum, regular communication, and to assist with resolving any programme delivery issues identified by the programme delivery board.
Follow this link to view a detailed governance handbook including the terms of reference for all of the governance groups.
Link: https://adoddleak.asite.com/adoddlepublic/dpd/n9xeEI75ebM9H6bjyz
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Appendix 7 JHOSC meeting minutes
Meeting on 19th September 2017 Consideration was given to an amended presentation from the Camden and Islington Foundation Trust. Malcolm McFrederick, the Project Director, was the lead presenter. He explained that they were not as far in the process for the St Pancras site as the Barnet, Enfield and Haringey Mental Health Trust were for St Ann’s. They had submitted an outline business case to NHS Improvement and were waiting for it to be approved. They were anticipating it would be approved in October. If approval was granted, there would be a full CCG-led public consultation.
Mr McFrederick highlighted that the existing buildings were not fit for purpose and it was not viable to bring the St Pancras buildings up to date. They wanted to see good and vibrant community facilities and mental health research taking place. A modern therapeutic environment would be good for patients and safer for staff. Inpatient beds would be moved from the St Pancras site and there would be two new ‘community hubs’. Mr McFrederick said there had been consultation with service user groups, CCGs and local councils. Members were informed that the preferred option of moving inpatient beds to the Whittington, establishing community hubs and bringing researchers and academics onto one site had been reached by considering it against 12 Quality Critical Success Factors. There were benefits from co-locating mental and physical health services. They had also researched the travel patterns of their patients, and had wanted to find a site which was easily accessible to those who used public transport and did not have a car. There was discussion about what would be in community hubs. There would be an office area, clinical space (for mental health services and for other health services), and a community space. The community space could include a café or gallery for service users to spend time in and for voluntary sector organisations to operate in. The Chair mentioned that the Adult Education strategy made mention of community hubs. She asked whether the Trust were working with Camden and Islington on this. Mr McFrederick said that they had spoken to Islington about this and would also speak to Camden in future. Trust officers said that they wished to align their plans for the surplus land in the St Pancras site with the borough’s plans for housing. Members asked how the redevelopment would fit in with wider STP matters. The Trust felt that community hubs would help with the linking of mental and physical health services. The Chair asked where the revenue from estates disposals would go. Mr McFrederick said that the sales proceeds would be used to fund the redevelopment plans. The Trust would be selling 80% of the St Pancras site and retaining 20%. Some of the land would be used for housing and some would be used by Moorfields Eye Hospital.
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Members sought clarification that sales proceeds would not be used for revenue spending. They were assured that this would not be the case. The Trust representatives were asked if a developer had been appointed. They said that this would take place after the outline business case was approved and would then go through the OJEU process.
Members asked about the progress Moorfields were making in terms of their business case for locating on part of the St Pancras site. The Trust representatives said that the two bodies were working together in terms of the timing of their work and submissions. However, they were two distinct schemes and not integrated.
Angela McNab, the Trust Chief Executive, confirmed that land which was surplus to Camden & Islington Foundation Trust requirements would be offered to other health bodies. Members said that there was pent-up demand for GP surgery sites in the area, and they hoped that some of the surplus land could be used for this.
Councillor Connor asked if the number of beds would increase following the move of inpatient facilities from St Pancras to the Whittington. She was informed that they would not decrease, however there had been no indication from commissioners that they would purchase enough beds to allow for the creation of a whole new ward. She expressed disappointment at this and felt it was important to ensure there were more inpatient facilities available for mental health patients, as demand for these had not fallen. Members also wished to avoid patients having to be placed out of area. Officers said that, on average, the number of Camden and Islington patients who had to be placed outside of those boroughs was low. Ms McNab said the Trust had noted that people were being kept in beds here long than elsewhere and that they could be moved into intermediate care.
Councillor Khatoon, who was a ward councillor for the area, addressed the meeting. She wanted to see consultation with local residents and attention given to how more social housing could be provided on the site and if employment opportunities could be created for local residents. Trust officers agreed to arrange an opportunity for Councillor Khatoon to have a walkabout around the site.
Members expressed concern about the availability of key worker housing, and they felt that this was important to recruit and retain staff. Members welcomed the proposals to move beds to the Whittington and felt that it was a suitable site. They wished the final business case to come back to the Committee at a future date.
Meeting on 23 March 2018 – Draft Minutes
Malcolm McFrederick, the Project Director (Camden & Islington Foundation Trust), addressed members on the St Pancras hospital plans. He said that they were planning on selling their site and moving the inpatient facilities to the Whittington site. They were looking to develop two new hubs – on Lowther Road and Greenland Road – and they were considering whether a third site would be required.
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Mr McFrederick said that the Trust were going to go out for tender for a development partner. This could be on a long lease basis rather than for sale. The matter was also complicated by the fact the Department of Health had a historic interest in the site. Mr McFrederick explained that the site could possibly be sold to Moorfields Eye Hospital as a replacement for their old site. The Trust wanted to involve local communities in consultation on the future of the site. Mr McFrederick said that further information would come to both the Camden and Islington health scrutiny committees in June. Members asked whether London Estates Devolution would apply to the schemes. They were informed that they were not at the stage where estates devolution would apply. The Chair voiced concerns about the development board for St Pancras not meeting. Mr McFrederick said that the two development boards – one involving stakeholders and one involving providers – were being amalgamated. He assured the Chair that she would be invited to the next meeting.
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Appendix 8 Consultation plan
Consultation methodology: St Pancras Site Redevelopment Islington Clinical Commissioning Group, together with Camden Clinical Commissioning Group is leading a consultation on the proposals for the redevelopment of the St Pancras Hospital site of which Camden and Islington NHS Foundation Trust is the landlord. These changes will affect the inpatient facility and community mental health services currently delivered on the site and on additional Trust sites. The other NHS services which are delivered on the St Pancras Hospital Site by other NHS Providers such as the Royal Free Hospital and a Camden GP practice will remain on the site. In some cases these services will be delivered in newly refurbished buildings, as part of the redevelopment process. In line with our statutory duties, the CCGs will consult on the redevelopment proposals, ensuring local people are given the opportunity to share their views on the services affected by the redevelopment of the St Pancras Hospital site. The statutory duties are:
Section 242 of the NHS Act 2006 states:
Each relevant English body must make arrangements, as respects health services for which it is responsible, which secure that users of those services, whether directly or through representatives, are involved (whether by being consulted or provided with information, or in other ways) in:
The planning of the provision of those services The development and consideration of proposals for change in the way those
services are provided, and Decisions to be made by that body affecting the operation of those services
Section 14Z2 of the Health & Social Care Act 2012 states: The Clinical Commissioning Group (CCG) must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways): a) In the planning of the commissioning arrangements by the group, b) In the development and consideration of proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and c) In decisions of the group affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact In light of these plans, Islington and Camden CCGs are proposing to run a public consultation for 12 weeks starting from 5h July to end of September 2018. A consultation document, questionnaire and Frequently Asked Questions have been developed.
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Aims of the Consultation:
To understand the views of the local community on the relocation and development of new Camden and Islington NHS Foundation Trust mental health inpatient services from the St Pancras Hospital site to a site by Highgate Mental Health Centre and Whittington Hospital.
To understand the views of the local community on the development of two new mental health community hubs, one in Camden and another in Islington.
The CCGs, with support from Camden and Islington NHS Foundation Trust, will speak to as many people in the local community as possible, ensuring they hear from a wide range of service users of all of the services proposed for relocation, the local community, local voluntary organisations and HealthWatchs’, as well as other key stakeholders such as local Councillors and MPs. Communications and engagement channels The channels we will use to share the consultation and gather as many views as possible are: General Population and Service Users:
A full consultation document with a survey about the proposals will be available on Islington Clinical Commissioning Group, Camden Clinical Commissioning Group, Camden and Islington NHS Foundation Trust and Healthwatch websites
There will be hard copies available of the above with a freepost addressed envelope at Camden and Islington Foundation Trust sites, on request
Posters/ flyers across the Trust’s 30 sites advertising the consultation Prompts on social media, encouraging people to join one of the consultation
meetings or provide their feedback online Public meetings on XXXX dates at venues that are easily accessible to people in
Camden and Islington A drop-in session with CIFT Trust Clinical Director - Vincent Kirchner Sharing the consultation document and survey through our local networks, this
includes to the Islington and Camden patient and community groups and Trust service user groups, our patient representatives and our local voluntary and community sector groups
Sharing information on the consultation through the GP newsletters and at the GP Forums
Sharing information on the consultation through our staff newsletters and at our staff briefings (CCGs and Trust)
Promoting the consultation survey to seek input from groups who traditionally face barriers to accessing services or having their voice heard Availability of the consultation document and survey questions in audio, braille, large print, easy read and in languages other than English, upon request.
There will be a dedicated telephone line for local people either requesting the consultation documents or any questions they may have.
Service Users Specific
It was felt strongly by local HealthWatches and Service Users that there needed to be a focus on consulting with current and ex Service Users as part of the consultation. The points below specifically cover how we will work with service users:
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Attendance (with Clinical Director Vincent Kirchner) to speak at all of the Trust’s service users groups introducing the consultation, taking questions and letting people know how to fill it in (along with taking some hard copies)
Further targeted engagement using the consultation survey with service users across all five of the Trust’s divisions – Acute, Services for Ageing and Mental Health, Recovery and Rehabilitation, Substance Misuse Services and Community Mental Health. This will include both current service users of inpatient services and community services. This work will be carried out by HealthWatch Camden and Islington with Trust service users.
Results, analysis and feedback
Camden & Islington Clinical Commissioning Groups will appoint an independent partner to evaluate the consultation process and analyse the results of the consultation. The partner will develop a process and infrastructure that reassures stakeholders of the independent nature of the evaluation. Following the closure of the consultation on 30th September 2018, the evaluation team will have a period to analyse the results and present these to Islington and Camden Clinical Commissioning Group Governing Bodies. Islington Clinical Commissioning Group will then make a recommendation on the redevelopment proposals to NHS England and Council Overview and Scrutiny Committees for Islington and Camden.
The results will be available publically, which will include, sharing on CCG and CIFT websites and sharing through other stakeholders networks, such as Healthwatch Islington and Camden.
Decision making process
7. Proposed consultation timeline Action
Lead Date
Consultation documents and methodology sign off
Islington CCG Governing Body
June 2018
Camden CCG Governing Body
June 2018
Consultation documents and methodology reviewed by Camden and Islington Health and Overview Scrutiny Committees
Islington CCG and Camden CCG
June 2018
Public consultation goes live Islington CCG 5th July 2018 to 30th September 2018
Evaluation of responses External agency October 2018 Results of consultation published and shared
Islington CCG, Camden CCG, the Trust and partners
November 2018
Final Business Case prepared
Islington CCG November 2018
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Consideration of Final Business case by Islington CCG Governing Body
Islington CCG November 2018
Consideration by Camden CCG Governing Body
Camden CCG November 2018
A decision is made by Camden and Islington CCGs on the final Business Case
Camden and Islington CCGs
November 2018
The decision is communicated with the local community, OSCs, HealthWatch and partners
Islington CCG / Camden CCG / The Trust
November 2018
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Appendix 9 Consultation document, questionnaire and FAQs
Draft – Consultation document Transforming mental health services in Camden and Islington: Proposals for change to the Camden and Islington NHS Foundation Trust Estate Date: July 2018
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Contents 1. Foreword 2. Who we are 3. Introduction 4. Section 1: Inpatient beds 5. Section 2: Community services and development of Community Hubs 6. Section 3: Other non-Camden and Islington NHS Foundation Trust services providing services on the St Pancras Site 7. What will happen to the St Pancras site if the redevelopment happens? 8. Table of all NHS services of the St Pancras site and how they are affected by the redevelopment 9. Consultation details
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Foreword by Clinical Directors from all three organisations To be written Camden and Islington Clinical Commissioning Groups (CCGs) are the local organisations with responsibility for planning, buying and monitoring local primary care, hospital services, mental health care, children's services and community services, with a clear vision and shared priorities for commissioning the best health services for our local community. The two CCGs commission mental health services provided by Camden and Islington NHS Foundation Trust, on behalf of local people. The Trust provides mental health care to service users in their homes, in the community, and in hospital. They provide services for adults of working age, adults with learning difficulties, and older people. The CCGs and the Trust want to ensure local people have the opportunity to shape their healthcare services. Introduction: We are proposing a change to some services, currently delivered on Camden and Islington NHS Foundation Trust’s St Pancras Hospital site, to modernise and improve the quality of care provided to local people. The changes will affect all inpatient services at St Pancras and some community services, based at St Pancras and other Trust sites, will also be affected. These proposals do not include a cut to services. Other NHS organisations, such as the Royal Free Hospital and a GP practice, also provide services from the St Pancras Hospital site. They will all remain onsite and in some cases, these services will be delivered in newly refurbished buildings, as part of the redevelopment process. Before any changes are agreed or made we need to speak with you, our local community and our partners and stakeholders, to listen to views, ideas and concerns about the proposals. There are two sections in this document on which we are seeking your views. These are:
1. The move of the Mental health inpatient beds currently on the St Pancras Hospital site and their proposed relocation and development on the new site by the Whittington Hospital
2. The proposed relocation of some of Camden and Islington NHS Foundation Trust’s community mental health services, and the development of two community hubs – with one in Camden and another in Islington
Section 3 of this document gives additional information on the services provided by other NHS organisations that will remain at the St Pancras Hospital site. We have also included some additional information on how the St Pancras Hospital site will be redeveloped if plans go ahead (on page XXX). The present inpatient mental health services at St Pancras Hospital are provided in buildings that are not designed to meet modern health and safety needs, nor do they provide an ideal therapeutic environment; the site was previously a Victorian workhouse. A Care Quality
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Commission report, published in June 2016, highlighted that the Trust’s inpatient wards require significant improvement. This document explains why we think the proposed changes will lead to better quality services which improve the quality of care provided to our local residents and the way in which the different NHS services currently delivered on the St Pancras Hospital site will be affected by the redevelopment plans. There is a survey attached which we ask you to complete, to let us know what you think about the proposals. If you are only interested in one area of the proposals, please feel free to only answer this section of the survey. We have also developed some Frequently Asked Questions which you can refer to.
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Section 1: Inpatient Beds Introduction Camden and Islington NHS Foundation Trust has around 30 sites in total. The majority of services are based in the community with an inpatient facility at Highgate Mental Health Centre and another at St Pancras Hospital.
We are proposing to move 84 mental health inpatient beds from the St Pancras Hospital site to a new purpose built site on land purchased adjacent to Whittington Hospital and next to Camden and Islington Foundation Trust’s Highgate Centre for Mental Health (which also has inpatient facilities).
The St Pancras Hospital site is a Victorian building (previously a workhouse) and the inpatient units are no longer fit for purpose and are outdated and unsafe.
We are acting now to address issues that we know will become increasingly problematic in years to come. These are:
The St Pancras area has changed considerably over the years. The site isalready overlooked by tall and high rise buildings and with building work set tocontinue, inpatient privacy and dignity will be compromised more and more.Alongside this, there is little outdoor space for patients and the space that is thereis not of the quality that we would strive for.
Some of the structural issues from the building include no clear line of sight to allareas of the wards, thus mirrors have to be installed and there are ligature risksthroughout the building which cannot be changed. This clearly has significantimpact on the patients.
Significant investment would be required to maintain and upgrade the currentpremises to meet modern standards. In addition, due to the basic structure of thebuildings, in some cases, we would still be unable to satisfy the standardsprescribed by the Department of Health best practice guidance.
Benefits for the proposal:
A new building will mean we can design a space which is both welcoming and safefor patients
The new building will exactly meets the needs of patients, as the Trust will develop itwith them
The proposed site by the Whittington Hospital will mean that mental health patientshave easy access to physical health services.
The new site will have more outdoor space with a designed garden area
Initial engagement with service users, staff and carer groups showed the vast majority of service users, staff and carers were in support of the move of the inpatient beds.
Whilst some concerns were raised by people about inpatient beds being moved from the familiar environment of the St Pancras Hospital site, most people agreed that continuing to maintain the buildings was not an option long-term. There was recognition that the St
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Pancras Hospital site buildings are not as good as they could be and a new modern environment, with therapeutic inpatient spaces was welcomed. There was also a desire to move to a more peaceful location than St Pancras Hospital site.
There are no plans to cut any inpatient beds from Camden and Islington as part of the proposals; the aim of the proposal is to strengthen current services. We have done an analysis of the number of inpatient beds needed by service users up to 2025, in tandem with the ambition of providing greater services in the community, and we are confident that there will not be an increase in demand for inpatient beds.
The St Pancras Hospital site is located in the London Borough of Camden. The proposed new site would be located in the London Borough of Islington and inpatients, and their families and friends, may therefore have a greater distance to travel.
The newly developed Inpatient Unit:
We are proposing that the new inpatient facility will be located on land bought from Whittington Hospital. It will comprise a three-storey new build surrounded by landscaped gardens.
The new facility would be designed to have 84 bedrooms across five wards, there will be 17 beds in four wards and 16 beds in the other ward, with 11.8sqm room space and 3.1 sqm en-suites. . However the configuration of each of the wards can be managed flexibly to accommodate clinical need e.g. a ward could be split into two wards. No ward will be over 18 beds in line with national guidance.
At the St Pancras Hospital site there are currently six wards including two with 12 beds, two with 14 beds and two with 16 beds. There is a mix of bedrooms at St Pancras Hospital, based in Ash House and the Huntley Centre. Single rooms vary between 10.4m2 to 13.3m2 and not all bedrooms in the Huntley Centre have en-suite facilities, a limited number are shared. 61 rooms currently have en-suite facilities.
The drawing below shows the layout of two of the new proposed wards.
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Each ward will have two consulting rooms, communal lounges and a garden or outdoor terrace area.
The new building would be fully accessible, with disability access. It would present a warm, therapeutic and welcoming environment, in line with what service users have told us they want from a building.
The new buildings would be developed to the highest standards. Criteria will be based upon sustainability, carbon emission reduction, design, durability, adaptation to climate change, ecological value and biodiversity protection. So you can get a visual idea of the difference between the current inpatient units and the proposed new site – we have included some pictures below.
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Pictures of the current inpatient wards at St Pancras Hospital
Pictures of a newly designed inpatient ward. Please note this is not the proposed inpatient ward – but is the quality, style and standard that we will meet. If the proposals are agreed, the Trust will be working with service users to design the new wards and space:
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Travel: The new location of the inpatient unit will mean that Camden residents will have to travel further to reach it, while the current St Pancras Hospital site is located between Camden Town Station and Kings Cross tube and rail Station, the new site is by the Whittington Hospital which is in Archway. Map:
Travel: The Whittington site is served by 8 bus routes, as well as the Northern Line (Archway) and London Over-ground (Upper Holloway).
By tube: Northern line to Archway
British Rail: the nearest station is Upper Holloway (Barking to Gospel Oak line).
By Bus: 143, 210, 263, W5 and 271 stop outside the Archway Campus on Highgate Hill. 134, 43 and 264 stop alongside the Archway Road.
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Section 2: Camden and Islington Foundation Trust Community services and the development of Mental Health Community Hubs Alongside the move of inpatient beds, we are also proposing to make significant investment into community services and move some mental health community services (please see the table on page 14) from the St Pancras Hospital site and other Trust sites, into newly developed community centres.
Our ambition is that the investment in new community hubs will allow the Trust staff to deliver improved mental health and wellbeing care in the local community.
The hubs’ model has been designed to keep community teams at the centre of mental health service delivery; ensuring care is provided as close to patients’ homes as possible.
Currently there are a high number of community services located across multiple sites, which includes some teams based on the St Pancras site. The development of Community Hubs will allow the relocation of some of these services into more accessible local sites for service users, away from hospital and closer to home. It also brings teams from the same service into one location which improves closer working between professionals.
Community Hubs may also be able to bring opportunities for a wider range of physical health services for service users with mental health needs, to help improve accessibility to physical health services.
These community hubs will be located at Lowther Road (Islington) and Greenland Road (Camden). This should ensure community services are more accessible to Camden and Islington residents and will be provided in a local community setting.
Benefits for redeveloping community services and the community hubs:
Future mental health care will need more services in the community to help manage people’s conditions in the least restrictive environment, with a greater focus on prevention and early intervention.
Developing community care will allow us to work in a more joined-up way across Camden and Islington, with physical health and social care partners, removing the barriers to personalised and coordinated services that our community need
Local people have told us they would prefer more services in the community and our mental health community have highlighted that they need more support to look after their physical health.
The Trust has a number of small buildings that are not used very much. Moving
services based in these buildings to one of the new community hubs will allow the Trust to be more effective and efficient with its money.
Although this would mean fewer buildings overall, patients, families, carers and staff
would benefit from more community mental health services in the same place and working closely together.
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In March 2018 the Trust held an engagement event for service users and carers to carry out further engagement on the proposed new community hubs. Most service users were generally positive about the proposed new facilities. The strongest views were based on wanting services that were inclusive, resourced with knowledgeable and compassionate staff and a non-stigmatising and welcoming environment. Although, it was highlighted that some of the proposed new locations could be more difficult for those with mobility issues, if they did have to travel further, the majority view was that location was less of an issue if services were good, improved and inclusive.
Islington:
It is proposed the site for the Islington community hub would be at a Trust’s existing site on Lowther Road. It would be developed into a four storey community centre. There will also be additional community space, which could be used for more wellbeing or health focused activities such as exercises classes or art classes and office space on the upper levels for Trust support staff.
Lowther Road offers excellent access to the Piccadilly Line at Holloway Road.
Map of where Lowther Road is and travel options. Map of Lowther Road
Travel options:
By Tube: Close to Holloway Tube station (Piccadilly Line)
By bus: 43, 153, 263, 271, 393
Camden:
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It is proposed the site for the Camden community hub will be at Greenland Road, which is an existing Trust site.
Greenland Road will also be developed into a four storey community centre by developing the existing building. This would consist of consulting rooms, community space and office space on the upper floors for Trust support staff.
Map of Greenland Road and Travel Options
Map of Greenland Road
Travel Options:
By tube: Adjacent to Camden Town tube station (Northern Line)
By bus: 24, 27,29, 88,134,168,214,253,274,C2
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The services in each community hub: Below we have pulled together a table which shows which community services are proposed to move into the Lowther Road and Greenland community centres and where the community services are currently located.
Table of community services that are proposed to move into the new community hubs:
Current locations and services Move to
Greenland Road
Move to Lowther Road
St Pancras Hospital Site
South Camden iCope
Camden Mental Health Assessment and Advice Team
Islington Practice Mental Health Team (where there is no GP practice capacity but if you are seen in your practice this will remain)
The Rivers Crisis House
There will be a separate consultation on this
Pharmacy
Highgate Centre for Mental Health: The Pharmacy is currently connected
with the St Pancras Hospital site inpatient unit and, therefore, would move with the inpatient facilities to
Highgate if the proposals are agreed.
Approved Mental Health Professional Service
Highgate Centre for Mental Health:
Most service users are seen in the community or in hospital settings.
Greenland Road
Islington Assertive Outreach Team
Peckwater Centre
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South Camden Recovery Team
Manor Gardens
iCope - North Islington Team
Camden Mews Community Recovery Service for Older People - covering both Camden and Islington
Below we have highlighted which community services are already based at St Pancras Hospital site, Greenland Road and Lowther Road and will remain at these locations:
Current locations and services No move (staying as is)
St Pancras
Complex Depression, Anxiety and Trauma Service
Camden & Islington Psychodynamic Psychotherapy Service COMMUNITY
Sexual Problems Team COMMUNITY
Traumatic Stress Clinic COMMUNITY
NHS Transition, Intervention and Liaison Veterans’ Mental Health Service (formally known as LVS)
COMMUNITY
ADHD Team Attention Deficit Hyperactivity Disorder COMMUNITY
Adult Autism Clinic COMMUNITY
South Camden Crisis Resolution Home Treatment COMMUNITY
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Acute Day Unit (Jules Thorn) Community
Recovery College
Clozapine Clinic
Greenland Road
Camden Assertive Outreach Team
Camden Early Intervention Team
Islington Early Intervention Team
Islington Early Intervention Service 35+: These are highly specialist services and so it is important that the Islington Early Intervention and Camden Early Intervention teams are located together in the same building. This enables them to work together more closely and improve care for services users through sharing learning and best practices. By being located together in this way, both teams also have access to a lead psychologist for support and supervision with complex cases. Some service users are seen onsite but the teams also work with service users in their own homes and in community locations across Islington.
Focus Homeless Outreach
Lowther Road
North Islington Rehabilitation and Recovery Team
Cornwallis Outreach Project
Islington Mental Health Reablement Service
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Section 3: Other NHS services which are currently delivered from St Pancras Hospital site There are additional services, located on the St Pancras Hospital site and are delivered by other NHS providers. All of these services will stay on the St Pancras Hospital site and depending on the service, it could be housed in a refurbished building. As these services are not moving, they will not form part of this consultation. However, for you to fully understand the redevelopment plans we have included information in this document on the NHS services which will be staying on the St Pancras Hospital site.
It is intended that the GP out of Hours service and GP practice will be delivered in a newly refurbished building. We do not envisage the services will have to move at any point during the redevelopment process. However, there is a possibility that we will need to temporarily house the GP out of Hours service and GP practice on the St Pancras Hospital site. If this is the case we will ensure disruption to the service is as limited as possible. Table of services which are staying
NHS Services & description of service
Current address Future location
Rehabilitation inpatient wards (Central and North West London Foundation Trust) Provides treatment and support for patients whose physical abilities have been reduced through illness, such as a stroke, or a fall or a musculoskeletal condition.
South Wing
There will be no change to the site or location of this service
Evergreen Ward (University College London Hospital) A ward for predominantly care of the elderly
South Wing
There will be no change to the site or location of this service
Kidney dialysis clinic (Royal Free Hospital) St Pancras Hospital
New building on St Pancras Hospital site
Ophthalmology clinic (Royal Free Hospital) St Pancras Hospital
New building on St Pancras Hospital site
GP out of hours service (London Central & West Unscheduled Care Collaborative)
St Pancras Hospital
New building on St Pancras Hospital site
Kings Cross GP Practice (AT Medics) St Pancras Hospital New building on St
Pancras Hospital site
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What will happen to the St Pancras Hospital site if it is redeveloped? In order to finance the changes to mental health inpatient and mental health community services, a significant portion of the St Pancras Hospital site, which is owned by Camden and Islington NHS Foundation Trust, would need to be redevelopment. Redevelopment of the land will free the necessary funds to build a new inpatient unit in the more therapeutic setting near Highgate Centre for Mental Health and to invest in community mental health hubs.
The St Pancras Hospital site is 5.4 acres in size and the Trust currently leases out about a third of it. Most of the space the Trust occupies is for inpatient beds. Moorfields Eye Hospital want to purchase two acres to replace their existing Victorian buildings. The Trust is hopeful this will happen, however the redevelopment of the land can happen with or without Moorfields buying a section.
Camden and Islington NHS Foundation Trust will retain a presence on the site. The Trust’s new accommodation at St Pancras will occupy the same amount of space as the existing East Wing. The remaining land would be redeveloped and a minimum of 35% of any housing generated would be for social and affordable housing.
The Trust’s accommodation at St Pancras would consist of consulting rooms, meeting rooms, training facilities and the Recovery College. The Recovery College will include space for both clinical delivery and support facilities for the clinical teams. In the same building the Trust intends to host the new Institute of Mental Health with UCL partners, which will take up approximately the same space. The Trust already has one of the strongest records and reputations in UK mental health research. That is why the vision for the St Pancras site includes the establishment of an Institute of Mental Health, bringing together the Trust’s research facilities and staff. This will enable research departments to collaborate more effectively, making it easier to run world-class research into tailored treatment plans for every individual, ensuring the best treatment and care for local people.
The new plans also mean there will be fewer buildings overall and the new buildings will be modern and energy efficient, helping to reduce running costs for the NHS to further protect services.
The buildings delivering other NHS services will remain (please see Section 3, page XXX for more details).
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The consultation details: The consultation will begin on [xxx June 2018] and run until [xx August 2018 *tbc].
Public meetings will be held in Camden and in Islington [DATE, LOCATION HERE] [DATE, LOCATION HERE] All opportunities to get involved in this consultation will be advertised on Islington and Camden CCGs, Camden and Islington NHS Foundation Trust and Camden and Islington Councils’ websites; as well as in local media in both boroughs to encourage participation from those affected by these proposed changes including service users, stakeholders, and the public. We will also be attending service user groups and speaking directly with those patients who currently use the services. We are keen to hear your views on our proposals and to listen to any suggestions about how we can improve our services in future. If you have any queries about this consultation or you require this document in an alternative format such as Easy Read, large print, audio, braille, and in languages other than English please email CCG email address Or call XXXXX You can fill in the consultation survey online or send the completed survey back to: FREE POST Address – will be an evaluation company
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Appendix 1
Travel in more detail
Below we have calculated the travel from three fixed points across Camden and two fixed points across Islington to the new inpatient unit which will be located by Highgate Mental Health Centre, for anyone interested in further information about travel to the site.
Travel times to Highgate Mental Health Centre Camden St Pancras Hospital Site Between St Pancras Hospital and Whittington Health, Magdala Avenue, N19 5NF. Distance: 2.5 miles Drive: 14 minutes
Tube: 25 minutes Mornington Crescent to Archway on Northern Line followed by a 7 minute walk. Bus: 36 minutes 214 from bus stop N (Royal College St Crowndale Road) to William Ellis School, bus stop GF. From here bus C11 towards Archway and get off at bus stop HQ, Magdala avenue Dartmouth park hill and followed by an approximately 2 minute walk to the site. West Hampstead Station: Distance: 3.5 miles Drive 20 minutes Tube: 29 minutes East London and city line (toward Stratford) to Gospel Oak. Gospel oak (toward Barking) to Upper Holloway and followed by an approximately 13 minute walk Bus and train: 25 minutes West Hampstead to Gospel Oak. Go to bus stop GC and get the C11 bus toward Archway, get off at Magdala Avenue Dartmouth Park Hill, followed by a 2 minute walk Bus: 46 minutes get the C11 bus (toward Archway) from bus stop W, West Hampstead underground station and alight at Magdala Avenue Dartmouth Park Hill, followed by an approximately 2 minute walk Highgate Station Distance: 1.1 miles Drive 6 minutes Tube: 10 minutes, Northern line (southbound to Kennington or Morden) to Archway and followed by an approximately 7 minute walk from the Station. Bus: 18 minutes,134, 43 or 364 from bus stop T to Archway station bus stop W followed by an approximately 7 minute walk. Travel times to Highgate Mental Health Centre Islington Highbury and Islington station:
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Distance: 2.6 miles Drive: 16 minutes Tube: 23 minutes, Victoria line (toward Brixton) to Euston, northern line (toward high barnet) to Archway, followed by approximately 7 minute walk. Bus: 30 minutes, 263 or 271 toward Archway station Stop D followed by an approximately 8 minute walk Farringdon station: Distance: 4.8 miles Drive: 29 minutes Tube: 28 minutes, catch the Hammersmith & city, circle or metropolitan line to Kings Cross station, transfer to the northern line (toward high Barnet) to Archway, followed by an approximately 7 minute walk. Bus: 44 minutes, catch the 63 bus (toward Kings Cross) from bus stop C, Clerkenwell Road Farringdon Road, change at bus stop G, Kings Cross Station York Way and catch the 390 bus (toward Archway) to bus stop U, Archway Station, followed by an approximately 7 minute walk. Community Hubs Travel times
Below we have calculated the travel time to Lowther Road from two fixed points across Islington:
Travel times Islington, Lowther Road Farringdon Station Distance: 2.4 miles Drive: 18 minutes Tube: 22 minutes, Metropolitan line to Kings Cross, change to Piccadilly line to Caledonian Road, followed by an approximately 9 minute walk Bus: 32 minutes, 153 directly to Lowther Road, bus stop SR, followed by an approximately 3 minute walk Or the number 19 or 38 from bus stop Tysoe Street to Highbury Corner, Stop F from here pick up the 43 to Liverpool Road Stop SV, from here there is an approximately 4 minute walk. Highbury & Islington station Distance: 0.5 miles Drive 5 minutes Bus: 10 minutes 43, 271, 263 to bus stop Liverpool Road, followed by an approximately 1 minute walk Walk: 11 minutes Below we have calculated the travel to Greenland Road from three fixed points across Camden:
Travel times Camden, Greenland Road St Pancras Hospital
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Distance: 0.7 miles Drive 8 minutes Buses: 11 minutes 214 to Camden T own bus stop Y and walk approx. 3 minutes to hub Walk: 14 minutes West Hampstead station Distance: 2.8 miles Drive: 16 minutes Bus: 31 minutes C11 toward Archway to Elsworthy Rise stop M, from here bus 31 toward Camden Town to Stop Z, followed by an approximately 1 minute walk. Tube: 20 minutes East London and City Line Train from West Hampstead station to Camden Road, followed by an approximately 7 minute walk from Camden Road Highgate Station: Distance: 3.3 miles Drive: 20 minutes Bus: 30 minutes, 134 towards Camden Town, to Stop S followed by an approximately 3 minute walk Tube: 13 minutes Highgate underground to Camden Town station followed by an approximately 3 minute walk
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ADD FREEPOST ADDRESS HERE.– will be evaluation company
Survey questions 1. Do you have any concerns about the proposed move (to opposite Highgate Mental Health Centre):
Travel (my travel to the centre) Travel (for family and friends) Familiarity: I have been going to St Pancras Hospital for a number of years The location Other: Other free text box
Please give any further comments on your concerns
2. Are there any ways you feel your concerns could be eased?
3. People have told us travel was an area of concern. What, if any, is your biggest concern about travelling to a new site (opposite the Highgate mental health centre)?
The cost of travel Additional travel time A more complex travel journey (i.e. I now have to get more than one mode of
transport such as a bus and tube, I have to change tubes twice, I have to get two buses etc.)
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I have to walk further My family have to travel further There won’t be any parking I don’t know the journey and may get lost or confused I am not concerned about travel to the new site Other: free text box
4. What do you think are the good things about the proposed move (to opposite Highgate Mental Health Centre).
A quieter and therapeutic setting Newly designed wards, bedrooms and shared spaces Being near the Whittington Hospital The location Quality of care Green Space Other – free text
Please give any further comments
5. Please tell us if you support the move of inpatient beds from the St Pancras Hospital site to a new and purpose-built facility by Whittington Hospital and opposite Highgate Mental Health Centre Strongly support Support
Neutral Against Strongly against Not sure
Please add any further comments you have.
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Community Hubs:
1. Are you a Camden or Islington resident? Camden Islington Other
2. Which, if any, community services do you use? Please tick every one you use
List of services to tick None
3. Do you have any concerns about the proposed move of the community services to new locations?
Travel (my travel to the new hub) Familiarity: I have been going to my current location for a
number of years I might not see the same member of staff I am concerned about the range of services being delivered from
the same site Other: Other free text box
Please give any further comments on your concerns
Are there any ways you feel your concerns could be eased?
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4. What do you think are the good things about the proposed move of the community services to new locations?
A newly designed space A range of community services being located together The location Quality of care The new location is easier for me to travel to Other – free text
Please give any further comments
6. Please tell us if you support the proposed move of the community services to new locations? Strongly support Support
Neutral Against Strongly against Not sure
Please add any further comments you have.
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About you
Camden and Islington NHS Foundation Trust is committed to promoting equality of opportunity, to ensure everyone has the chance to participate fully in the activities and decisions of the organisation. By completing this information you will help us understand who we are reaching and how to better serve everyone in our community.
1) Which age group are you in?
18 or under
19 – 34
35 – 49
50 – 64
65 – 79
80+
Prefer not to say
2) What is your postcode?
_________________________________________________________________
3) Which of the following options best describes how you think of yourself?
Female (including trans woman)
Male (including trans man)
Non-binary
In another way
Prefer not to say
4) Is your gender identity the same as the gender you were given at birth?
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Yes No
Prefer not to say
5) Do you consider yourself to have a disability?
Definition of disability under the Equality Act 2010: if you have a physical or mental impairment that has a 'substantial' and 'long-term' negative effect on your ability to do normal daily activities. Yes No
Prefer not to say
6) Please select what you consider your ethnic origin to be. Ethnicity is distinct from nationality.
White: Welsh/English/Scottish/Northern Irish/British
White: Irish
White: Gypsy or Irish Traveller
White: Any other White background
Mixed: White and Black Caribbean
Mixed: White and Black African
Mixed: White and Asian
Mixed: Any other mixed background
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: Any other Asian background
Black or Black British: Black - Caribbean
Black or Black British: Black - African
Black or Black British: Any other Black background
Other ethnic background: Chinese
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Other ethnic background: Any other ethnic group
Please indicate your religion or belief.
7) Please indicate which option best describes your religion or belief.
No religion
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Atheist
Any other religion
Prefer not to say
8) Please indicate the option which best describes your sexual orientation.
Heterosexual
Gay
Lesbian
Bisexual
Prefer not to say
9) In what capacity are you responding to the consultation? Current or former service user Carer/family member Member of the public Voluntary organisation/charity Clinician NHS provider organisation
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Private provider organisation NHS commissioner Industry other public body
Do we want to add an option for resident close to St Pancras site?
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Appendix 10 Options development summary
Service Location Review by Camden and Islington Foundation Trust April 2017
Background
As part of the Outline Business Case one of the options under consideration is the redevelopment of St Pancras with services moving to new community facilities funded through the business case.
In order for the Trust to make a decision on the services to remain on St Pancras a process was agreed with the board for criteria for services to be reviewed.
The criteria is noted below
CQC requirements met in full by facilities Patient disruption must be minimised inpatients moved once only Research and innovation supported alongside wider learning/ knowledge focus
Staff wellbeing supported Enabling of the Sustainability and Transformation Plan (STP) ambitions Enabling wider healthcare transformation across North Central London (NCL) Affordability and value for money achieved St Pancras site to be symbolic of our vision for mental health e.g. visibly
demonstrating integration, recovery, research etc.
Workshops
Two workshops were arranged by Operations to be undertaken on the 24th and 31st March 2017, the attendees at these meetings were Clinical Directors, Consultants, Divisional Directors and Service Managers, a full list of attendees can be seen in the Appendix 2.
The Outcome
Stays at SPH Adult autism ADHD team London Veteran’s Service / traumatic stress clinic Medical education Head Quarters & Staff Facilities? Could be SPH / Could be somewhere else (academic) Recovery College (Community feel) Sexual Problems Clinic Moves with inpatient Adult inpatient Inpatient rehabilitation and recovery service Volunteers
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Advocacy Moves to community Approved Mental Health Professionals Assessment and Advice Team Acute Day Unit (one of two facilities) Phlebotomy - building must have good access, as currently an issue Could go to community but want to be in one place Complex Depression Anxiety and Trauma Services (Acute Day Unit, Crisis House, Crisis Team) – exists in Daleham Gardens – would be good to replicate for Rivers Crisis centre Community / mainly primary care – some admin ICOPE Psychological Therapies Service (Consider future need for TMS machines)
A full table is noted below of the preferences, along with comments made during the two meetings.
The next stage
The work needs to be ratified by a number of groups before being presented to Executive for agreement, so far it has been suggested that this is reviewed by the academics group held at UCL, and the consultants group held at St Pancras.
In addition, Operations have been requested to review other services not currently provided at St Pancras.
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The review output
CQC requirements met in full by facilities
Patient disruption must be minimised; inpatients moved once only
Research and innovation supported alongside wider learning/ knowledge focus
Staff wellbeing supported
Enabling of the Sustainability and Transformation Plan (STP) ambitions
Enabling wider healthcare transformation across North Central London (NCL)
Affordability and value for money achieved
St Pancras site to be symbolic of our vision for mental health e.g. visibly demonstrating integration, recovery, research etc.
Service Adult Autism Diagnostic and Consultation Service
x x x x x x x
Adult inpatient services
x x x x x x x
Approved Mental Health Professionals Team (AMHPs)
x x x x x
Assessment and Advice Team
x x x x x
Attention Deficit Hyperactivity Disorder (ADHD) Team
x x x x x x
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Camden and Islington Psychodynamic Psychotherapy Services
x x x x x
Complex Depression Anxiety and Trauma Service (CDAT)
x x x x x
ICOPE Psychological Therapies Service
x x x x x
London Veteran’s Service
x x x x x x x
Rehabilitation and Recovery Service – Inpatients
x x x x x x x
Sexual Problems Clinic
x x x x x
Acute Day Unit – Jules Thorn
x x x x x
South Camden Crisis Team
x x x x x
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The Rivers Crisis House
x x x x x x
Traumatic Stress Clinic
x x x x x
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The attendees
24th March 2017 Ian Griffiths Clinical Director Acute Suzanne Joel Clinical Director SAMH Gina Waters Consultant psychiatrist Acute Liz McGrath Clinical Director SMS Gillian Paterson Service Manager SMS Dominic O’Ryan Clinical Psychologist STIS Aisling Clifford Divisional Director Acute Adele McKay Senior Service Manager Acute Diana Brown Social Worker CDAT Allison Arekion Service Manager CDAT Matt Allin Psychiatrist RR R&R Robert Murray Divisional Director R&R Neill Wells Senior Service Manager R&R Roger Evans Service Dev. Manager Ops Emily van de Pol Divisional Director CMH Ian Prenelle Clinical Director R&R Chris Dunbar KPMG Neil Turvey Project Director Andy Stopher Acting Director of Ops 31st March 2017 Connor McIntyre Service Manager North Islington R&R Druid Fleming Sen. Service Manager Camden R&R Neill Well Sen. Service Manager R&R Adele McKay Sen. Service Manager Acute James Wakefield Asst. Psychologist CDAT Alison Areilion Service Manager CDAT Emily van de Pol Divisional Director Community Matt Allin Clinical Director SMS Dominic O’Ryan Clinical Psychologist STIS Andy Stopher Acting Director of Ops Chris Dunbar KPMG Lauren Oxley KPMG
Additional Comments
Acute Acute all on one site would be preferable Retain Crisis hub on St Pancras? 12 bed Crisis House Acute day units - Doesn’t need to be on St Pancras, but does function better when
collocated with inpatient acute. In patient facility - Library for head office / back office? Acute – could be some value in collocation (acute day units, crisis house, crisis team) Acute day units – need large group rooms and consulting rooms
Community Hubs
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CRTs – predominantly mobile working – need hot desking space and car parking – need cars
Direction of travel is that crisis teams staffing might grow slightly ADUs should not grow but should develop to do prevention / step down – join up with
CRTs (acute service is currently 9-5) Social housing to supported accommodation – (One Housing and Circle Housing) –
currently there is a lack of move on/step down. Residential development could provide an opportunity for the Trust to incorporate MH focussed social housing/step down facilities.
East London has a step down unit with roadside exits (i.e. access directly from the street) – this represents the next level of step down housing.
Rehab wards remain with acute wards R&R
2 EIS teams (need to be collocated) 2 AOT teams (could be incorporated into community R&R teams) Focus team – (should stay in Camden Town) Community Rehab teams – may not need 2 – where do we co-locate? HOO? HOO – currently difficult to maintain and a long way away. Could be an opportunity. What do we do whilst rebuilding takes place? – Need a solution Always need co-location for a particular cohort with long term needs (AOT and
rehab) Clinical strategy sees movement into GP surgeries but will be an ongoing need for
central spaces for communication / to allow practice based teams to come together – all grades of staff, regular team meetings.
Technology will help, but it won’t eliminate the need for a ‘home’ space. Hot Desking Reasons this might not work for specific teams / individuals:
Special physical / OH requirements OH quiet space Professions requiring dedicated space (i.e. Doctors need dedicated space – although
could possibly hot desk within the dedicated area) Confidentiality / noise distraction Managers – confidential/sensitive discussions Culturally inequitable if not required at all levels (i.e. including Executive)
Other considerations
Lowther Road – pleased to see something being done with this When you create community hubs – need to consider what happens to staff in the
interim as interim accommodation costs can be expensive 154 Camden Mews – could we be doing more with that site? – we need the beds and
the day service Aged Mental Health:
“We are very happy with Peckwater in Camden” – very happy with it as a community site integrated with primary care and CNWL
In Islington we are happy with Brewery Road – but we don’t like that we can’t see patients there. D1 declined. Means Brewery Road could be a possible location for cheap back office space. Would mean we need another community site in Islington.
Southwood – not much opportunity to expand and surrounded by residential development.
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See most people in own homes – need some group rooms and clinic space (can be shared with other services)
Expect to slowly expand service over coming years. Substance Misuse
Holloway Road is not fit for purpose Would be happy for substance misuse to be part of a larger community hub Critical to have dispensing pharmacy in each hub Would like to be more integrated with R&R teams Key things to consider:
1. Future of Margaret Centre Site (HS2 / underutilised) 2. Redevelopment / alternative use of Holloway Road site 3. Daleham site – tenant (GP) dominates – could expand 4. Future of Grays in Road site? – should we keep it 5. Need more flexible space for day programmes / web based delivery 6. Do we want medically assisted detox beds (e.g. upstairs at Daleham?) –
commercial opportunity as no other providers of this service 7. Conference facilities would be beneficial (i.e. for 40/50 people to come together)
– could be provided within community hubs 8. Opportunity for community use of Conference facilities – come in and use (nice
quality) 9. Hubs should have a site coordinator / manager to make the building work 10. Section 75 review in Camden – currently don’t know the outcome but will impact
the role of social workers and level of integration – more focused space Support social enterprises – support GP surgeries – link to physical care – currently
no facilities for online therapy (either public / treatment room or social enterprise use) We are not really engaging the younger population.
Community Mental Health We need to integrate with primary care, and also with other teams Our services (CDAT, PD, traumatic stress) work across boroughs ICOPE benefits in combining across boroughs (call centre / admin space) More and more wanting to see patients within primary care space – but this is dependent
on timescales for expanding GP estate / facilities Many consultation rooms (high volume services) Need group space Need IT capacity / workstations Further comments for considerations
- ‘Where community services are located at the St Pancras site, it is positive when they can be easily accessed without passing through the hospital e.g. Camden iCope is easily reached via the new entrance. Clients can be deterred from engaging with community services if they find that attending the service means they are in contact with clients who are more unwell.
- Crisis teams at hospital locations: on occasion clients are anxious to attend a crisis service at a hospital due to fear of being sectioned. As such being in the community can help de-stigmatize.
- Crisis houses that are not so medicalised in appearance have received positive feedback from clients.’
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Appendix 11 Feasibility Study
Option Name Option Description Option Evaluation Option
Outcome
Camden Council Site
Make use of council land which is either vacant or due to become vacant in the near future in the London Borough of Camden.
Camden Council has recently consolidated its estate and built a new head office near St Pancras. It has advised the Trust that is has no suitable land available.
Islington Council Site
Make use of council land which is either vacant or due to become vacant in the near future in the London Borough of Islington
Islington Council has confirmed that it has no suitable land available.
Pentonville Prison Site
Pentonville Prisons is located near to the western edge of the London Borough of Islington and is due to close in the near future.
The agent responsible for the redevelopment has confirmed they intend to make use of the land for residential development and the timetable is uncertain at this stage as the prison has no close date.
Holloway Prison Site
Holloway Prison is located just to the North of Pentonville Prison and was closed in 2016. The site may therefore be available in the near future.
The agent responsible for the redevelopment has confirmed they intend to make use of the land for residential development and the timetable for works is too short for this project as the prison is closed and negotiations on its redevelopment already well advanced.
Royal Free Site
The Royal Free’s main hospital site is located roughly in the centre of the London Borough of Camden. As the Trust would like to co-locate with an acute hospital Trust this would provide an ideal location.
The Royal Free is landlocked and has no surplus available space.
Moorfields Hospital Site (Moorfields)
Moorfields Eye Hospital NHS FT (Moorfields) is located in the south eastern corner of the London Borough of Islington. Moorfields is a specialist eye hospital.
Moorfields Eye Hospital has its own plans to relocate away from its current site at the North Eastern Edge of the City of London. Their project is reliant on a significant capital windfall as a result of the sale and is therefore not a suitable site for the new inpatient facility.
University College London Hospital
UCLH’s main hospital is located in the south of London Borough of Camden. As the Trust would like to co-locate with an acute hospital
UCLH is landlocked and has no surplus available space.
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Option Name Option Description Option Evaluation Option
Outcome
(UCLH) Trust this would provide an ideal location. UCLH also has excellent links with University College London (UCL) for the development of a research centre.
Vacant Private Sector Land
Any vacant private land of a suitable size that is identified in the area has the potential to be used to deliver the new hospital facility.
No private sector vacant land has been identified.
St Ann’s St Ann’s Hospital was identified during the SOC stage as having the potential to host a new inpatient facility for the Trust.
It is located in the London Borough of Haringey, but has been included as it was identified as the best site during the SOC stage and is a mental health Trust and is within two miles of the Islington border. There is land available to deliver the project and early discussions have taken place.
Whittington The Whittington Hospital is located on the border between Camden and Islington to the North of both Borough’s. It is an acute hospital with land available for the Trust to build a new inpatient facility.
The Whittington Hospital has land available as part of their ongoing capital strategy and is an acute hospital so has the potential to provide a full range of care for service users as part of the collaboration. It is also close to the existing Highgate mental health facility.
Do minimum
Under this option the Trust would carry out the minimum works necessary to improve the quality of their existing estate to enable the Trust to deliver a higher quality of care.
This option requires the minimum amount of capital as the land is available and buildings are already built.
Rebuild at SPH
A new mental health inpatient facility would be built on the existing SPH site.
The land at SPH is currently occupied by the Trust’s existing facilities and therefore these will need to be relocated or worked around while the new site is being built. However the land is the Trust’s to use as required.
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Appendix 12 Options considered
Inpatient options
Option name Option description and key observations
A1 Do minimum (Continue to provide inpatient services in existing buildings).
The configuration of the SPH site will remain unchanged. We will continue to maintain the facilities. As care will still be provided in old buildings, there will be a number of challenges with providing modern facilities. Due to space constraints on the current site there will be no Institute of Mental Health and the ability to fundamentally transform care will be limited.
A2 Re-provide inpatients at SPH
A new inpatient facility will be built on the SPH site. This will provide a modern clinical space which is disability friendly and enable the Trust to deliver a safe service for service users and staff. This would however be on a site that would offer limited ability to offer privacy and dignity to the inpatients. The only location available to enable the build (without the decant of one or two inpatient facilities) would be on the site adjacent to Granary Street, where a recent development scheme has achieved planning permission for up to 13 stories on the opposite side of the road, so this significantly reduces the value that can be realised from the site for reinvestment back into developing sustainable high quality facilities. In addition the Trust is aware of development plans for the so called ‘Ugly Brown Building’ at the south of St Pancras of up to 12 stories directly overlooking the site, therefore a new inpatient facility could be overlooked in two directions, and only a double carriageway apart which is not seen as a desirable environment for delivering mental health inpatient services. The inpatient facilities would also restrict the density of development adjacent to them, if inpatient facilities are to be delivered on the SPH site, to ensure the wellbeing of service users. The Trusts capital receipt will also be affected by the lower density. The Trust would receive less capital receipt due to selling less land and less receipt because of the reduced density on the site; this results in a considerable reduction in the overall capital receipt for the site. This will undermine the Trust’s ability to deliver the requirements of this business case.
A3 Re-provide inpatients at Whittington Hospital
A new inpatient facility will be built adjacent to the Whittington Hospital in Archway, Islington. This will provide a modern clinical space that is disability friendly and enable the Trust to deliver a safe service for service users and staff. Disruption to service users will be minimised during the construction phase as significant work will not commence at SPH until inpatients are moved to the new site. The Institute of Mental Health can be delivered at the SPH site, but there will also be potential to sell some of the site for
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Inpatient options
Option name Option description and key observations
residential development, releasing funds for the rest of the project. The new inpatient facility will continue to be located in the London Boroughs of Camden and Islington.
A4 Re-provide inpatients at St Ann’s Hospital
A new inpatient facility will be built adjacent to the St Ann’s Hospital, Haringey. This will provide a modern clinical space, which is disability friendly and enable the Trust to deliver a safe service for service users and staff. Disruption to service users will be minimised during the construction phase as significant work will not commence at SPH until inpatients are moved to the new site. The Institute of Mental Health can be delivered at the SPH site, but there will also be potential to sell some of the site for residential development, releasing funds for the rest of the project. The new inpatient facility will not to be located in the London Boroughs of Camden and Islington.
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Appendix 13 Qualitative assessment workshop summary
Forum Date of Workshop Key themes
Senior Leadership Team
26 April 2017 Key themes from the Senior Leadership Team included: The benefits of remaining in the London Boroughs of
Camden and Islington to ensure they remain close to their communities was considered an issue for the St Ann’s site – particularly as transport links are not as good as for the other options. There should be good transport links for service users and staff.
Support for improved links between the community and inpatient services offered by the C&I.
There will be long term clinical benefits for service users from developing a new research facility
Whittington option allows for the co-location of a new Whittington Facility with the existing Highgate Mental Health Centre
Co-location with Whittington also provides acute and mental health care on the same site
Clinical Reference Group
25 April 2017 Key themes from the Clinical Reference Group included: Refurbishing the existing facilities at SPH will not ensure
they meet CQC guidelines and will continue to impact the care delivered to service users.
Travelling between St Ann’s and SPH would be a significant challenge for C&I personnel.
Staff wellbeing facilities can be incorporated into the new site, improving staff morale.
Council of Governors
9 May 2017 The council of governors identified: The need to do more work to establish the impact on
service users, staff and other stakeholders of increased travel to the preferred option chosen if moving from SPH. It was confirmed that further work on this will be completed as part of the FBC stage.
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Appendix 14 Qualitative assessment scoring
Option A1 Option A3 Option A4 Summary of comments made by each of the groups when scoring against the critical success factors
Do minimum Whittington St Ann's
CSF 1 0.8 3.9 2.4
The two new build inpatient facilities will meet CQC requirements. However the St Ann’s option creates travel challenges for service users and staff due to limited public transport links and will make co-ordination between inpatient and community activity more difficult.
CSF 2 1.3 3.1 2.7
There will be significant disruption at St Pancras during the refurbishment work over an extended period of time. There will also be some disruption for service users during the transition to either St Ann’s or Whittington although for service users and their families when visiting St Ann's this will be more challenging due to the relative inaccessibility of the site.
CSF 3 1.7 3.9 2.8 The do minimum option does not make any land available for the new research facility. The new inpatient facility at St Ann’s would be considerably more remote from the research hub than an inpatient facility at Whittington.
CSF 4 1.1 3.9 2.6 Only new facilities can have a significant impact on the quality of care. Travel time for carers and family when visiting at St Ann's will have a significant impact on those individuals.
CSF 5 1.3 3.8 2.4 Only new facilities are aligned to the service user needs and enable the clinical strategy. Travel time for carers and family when visiting at St Ann's will have a significant impact on those individuals.
CSF 6 1.2 3.7 2.4
The current SPH cannot support the de-stigmatisation of mental health. Putting the new inpatient site next to an existing mental health site will allow the internal changes to be made but will not support the external perception, which would be supported by co-locating with the Whittington (an acute physical health hospital).
CSF 7 1.4 3.7 2.3 The ability to make changes to SPH to meet the requirements of the Equalities Act 2010 is limited. St Ann's is not as good for the service user cohort due to accessibility.
CSF 8 1.5 3.8 2.2 Whittington is the only site that provides the potential for an integrated whole person health solution (i.e. integrated physical and mental health).
CSF 9 4.0 3.4 1.2 St Ann's is out of area whereas SPH and Whittington are within the borough.
CSF 10 2.3 3.6 2.1 The is concern that staff travelling St Ann's will have a lifestyle impact due to the additional travel time. Whittington has the critical mass of staff to provide more support.
CSF 11 0.3 2.5 2.1
Do minimum, prevents delivery of the NCL STP as it continues to occupy SPH, it doesn't encourage community care and continues to provide care in substandard, high cost facilities. Whittington meets the STP most closely, while the St Ann's option is outside the borough.
CSF 12 0.7 2.7 2.6 Both Whittington and St Ann’s enable delivery of the local plans, in particular delivery of new housing. SPH in its current form does not allow housing on the land it occupies.
Overall Score 18 42 28 Option A3 (Rebuild at Whittington) has the highest score in the
qualitative assessment and therefore is the preferred option.
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Overall Rank 3 1 2
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Appendix 15 Qualitative scores of each option
Senior Leadership Team and Board Scores
Critical Success Factor
Option A1
Option A3
Option A4
Notes
1) CQC requirements 1 4 2 Community inpatient link weaker at 3 compared to 2 due to location
2) Minimise service user disruption 1 3 3
3) Research and development 1 4 4 It was noted that a new research facility
could not be constructed under option 1
4) Quality of service user care
1 4 3 Again the community - inpatient link was emphasised, hence 2 scoring greater than 3
5) Aligned to service user need and supportive of the clinical strategy
1 4 3 Yet again the community - inpatient link was emphasised, hence 2 scoring greater than 3
6) De-stigmatise mental health 1 4 3
A view that option 3 creates a large mental health facility compared to a mental health facility collocated with physical health in option 2. Options 2 and 3 will both facilitate new facilities on the St Pancras site
7) Promotes equality 2 4 2 The accessibility of option 3 was a concern, as was the accessibility for the current buildings in Option 1
8) Integrated care 2 4 3 Option 2 provides colocation with physical health that the other options do not.
9) Located with in-borough or close to Camden and Islington
4 3 1
10) Support staff wellbeing 2 4 3
The effective creation of a larger mass of staff in option 2 gives this option the extra point
11) Consistent with the NCL STP 1 3 3
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12) Consistent withplans for localcommunity andplace development
1 3 3
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Council of Governors Scores
Critical Success Factor
Option A1
Option A3
Option A4 Notes
1) CQC requirements 0.4 3.7 2.1 St Pancras doesn't meet the criteria
2) Minimise service user disruption 0.8 3.2 2 St Ann's impact on friends and family
travelling to see admitted patients
3) Research and development 2 3.8 2.4 St Pancras already undertakes this
4) Quality of service user care 1.4 3.8 1.8
5) Aligned to service user need and supportive of the clinical strategy
1.9 3.3 1.2 St Pancras is a good location, St Ann's is too far
6) De-stigmatise mental health 2.7 3.1 1.2 Whittington does put all our beds close
together, and concentration of patients
7) Promotes equality 2.2 3 2
8) Integrated care 1.6 3.4 1.6
9) Located with in-borough or close to Camden and Islington
4 3.2 0.6
St Ann's is out of area
10) Support staff wellbeing 3.8 2.7 1.2
Don't need a building to support staff development, this is cultural, but longer travel could affect staff
11) Consistent with the NCL STP 0 0.6 0.2 Not all members of the group scored this
CSF, which has distorted the average.
12) Consistent with plans for local community and place development
0.2 2 1.8
Some people will want to keep SPH beds
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Clinical Reference Group Scores
Critical Success Factor
Option A1
Option A3
Option A4 Notes
1) CQC requirements 1 4 3
New facilities will meet the criteria, existing unlikely too due to the age of the building and the lack of amenity space and the ability to put adequate accessibility into buildings designed in the C18th. Concern was noted that the location of St Ann’s would meet the accessibility criteria for service users due to the lack of close tube or train service directly to the site and it being only on one bus route
2) Minimise service user disruption 2 3 3
The greatest known disruption would be at St Pancras given the planning approvals around the site but also noting the other options also have building plans
3) Research and development 2 4 2
Under option 1 there will be no available space for an IoMH on the St Pancras site, as services will continue to be delivered in the same way. Locating Institute of mental health at St Pancras with easy link to Archway will be better than having our main facilities at St Ann’s due to the difficulty of access between the St Pancras and St Ann’s as whilst the nearest tube to St Ann’s is Seven Sisters a further walk of c20mins is needed to get to the site.
4) Quality of service user care
1 4 3
Only new facilities can ensure this criteria but travel difficulties to St Ann’s noted in scoring The travel relates to carers of those being in the trust premises, as St Ann’s is not as easy to get to as Archway which is accessible on buses as well as the tube for our Camden and Islington residents, whereas as St Ann’s is not on many bus routes is difficult to get to from Camden and Islington and only with substantial walking
5) Aligned to service user need and supportive of the clinical strategy
1 4 3
As with the CSF above the same reasoning
6) Destigmatise mental health 0 4 3
St Pancras Hospital does not achieve this in current layout, all options with community hubs improve this aside from St Ann’s being similar to St Pancras as being recognised as a specific mental health
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hospital site, not a general hospital site as the Whittington
7) Promotes equality 0 4 3
St Pancras has poor EA10 compliance new builds should be better but transport links to St Ann’s are poor
8) Integrated care 1 4 2
Only the Whittington options provides fully integrated care with inpatient and community hubs located within Camden and Islington, and the inpatient facilities co-located with acute facilities, whilst St Ann’s option will provide the community hubs, the inpatient facility is not located in Camden or Islington or on an acute site but a mental health site.
9) Located with in-borough or close to Camden and Islington
4 4 2 The 3rd option only has community hubs in borough, St Ann’s is close but not within
10) Support staff wellbeing 1 4 2
The new facilities can provide a higher level of staff wellbeing, but the score also reflects staff being isolated at St Ann’s
11) Consistent with the NCL STP 0 4 3 Only options 2 &3 support this and option 2
is more aligned to closer to home
12) Consistent with plans for local community and place development
1 3 3 Options 2 &3 enable this to be delivered at St Pancras
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Building External Internal M&E External Internal M&E External Internal M&E External Internal M&E External Internal M&E Total Comments
Ash House - SPH 48,900 75,000 - - - - - 1,200 - 125,100£
Bloomsbury Building - SPH 211,931 13,600 75,000 - 50,000 - - 350,531£
Boiler House - SPH 35,300 100,000 100,000 - - - 235,300£
East Wing - SPH 100,000 300,000 47,950 - - 447,950£
Camley Centre/Estates Office - SPH - 300,000 50,000 - - - - - 350,000£
Jules Thorn Day Hospital - SPH - 44,348 - - - 150,000 200,000 394,348£
Gate House Building - SPH 58,132 75,000 75,000 16,650 - 27,650 - - 10,650 - 263,082£
Huntley Centre - SPH 350,000 97,951 100,000 - 10,100 - 558,051£
Former Kitchen - SPH - - - - - - 100,000 300,000 - - - - - 400,000£ Cost to bring building back to beneficial use
Former Mortuary Building - SPH - 50,000 50,000 - - - - - - - - 100,000£
North East Building - SPH 199,473 150,000 400,000 24,365 20,000 - - - - - 793,838£
North Wing - SPH - 114,201 - 11,700 200,000 - - 325,901£ This is RF cost under lease but shown to indicate extent of BLM
Post Room Building - SPH - 65,000 47,000 - - - - - - - 112,000£
Former Residence Building - SPH - 400,000 - 250,000 400,000 - 400,000 - - - 1,450,000£ Cost to bring building back to beneficial use
River Crisis House - SPH - - 1,800 20,000 - - - - - - 21,800£
South Wing - SPH 100,000 97,650 400,000 391,018 150,000 56,200 - 3,200 1,198,068£
The Well - SPH 36,305 1,276 1,225 - 4,000 1,739 6,344 - - 50,888£
West Wing - SPH 10,650 181,370 250,000 300,000 250,000 13,350 56,350 - 1,061,720£
SPH Site Infrastructure & Services 1,218,000 543,000 1,761,000£
HMHC M Block 100,000 47,760 3,500 550,000 7,000 - 20,000 - 728,260£
3-5 Daleham Gardens 8,140 7,678 2,850 10,469 20,000 - 6,962 3,500 - 5,441 15,000 - 80,040£
19 Aberdeen Park 4,600 2,940 7,540 2,226 10,000 4,475 15,088 600 - 350 - 47,819£
Camden Mews - 100,000 1,200 100,000 4,920 - - - 206,120£
154 Camden Road - - 100,000 1,200 - 4,780 - - - 105,980£
Drayton Park 7,872 - 1,400 50,463 2,320 5,090 - - - - 67,145£
Greys Inn Road 9,024 - - - - 2,850 - 2,120 - - 6,500 - 20,494£
Greenland Road 350 - 26,700 100,000 350,000 5,920 - - 15,000 - 497,970£
75 Hanley Road 60,000 300,000 100,000 - - 460,000£ BLM liability assuming retention
Hornsey Lane - - - - -£ Leased to third party - no residual BLM liability
The Hoo 20,000 150,000 110,298 14,000 2,800 100,000 9,900 41,807 20,222 5,000 3,850 200,000 677,876£
Holloway Road 5,784 3,698 2,830 614 1,000 - 2,943 780 - 33,582 2,500 - 53,730£
Lowther Road 19,100 100,000 350,000 1,200 6,500 780 477,580£
Margarete Centre - - 7,939 - - - - 50,000 50,000 107,939£
Southwood Smith Building 2,370 800 - - 62,660 10,730 527 - - - - - 77,087£
Stacey Street 13,557 5,868 2,050 2,987 3,500 3,435 209 15,000 - 28,681 - - 75,287£
Highview Residential - 3,000 1,600 - - 2,242 9,418 5,240 650 - - - 22,150£
Blenheim Court Brewery Road - - - - -£ Leased but no BLM liability beyond repairing covenants
Caledonian Road - - - - -£ Not owned by C&I - no BLM liability
Finsbury Health Centre - - - - -£ Not owned by C&I - no BLM liability
Raglan St - - - - -£ Not owned by C&I - no BLM liability
Hanley Gardens - - - - - - - - - - - - -£ Not C&I properties - no backlog liability
Highgate Road - - - - -£ Not owned by C&I - no BLM liability
Hunter Street - - - - -£ Leased building no residual BLM liability - possible vacation
Isledon Road - - - - -£ Not owned by C&I - no BLM liability
Manor Gardens - - - - -£ Leased but no BLM liability beyond repairing covenants
Netherwood St - - - - -£ Not owned by C&I - no BLM liability
Peckwater - - - - -£ Leased building no residual BLM liability - possible vacation
Simmons House - - - - -£ Leased and sublet - no residual BLM liability
Tottenham Mews - - - - -£ Derelict Building surplus to requirements - potential disposal
71,346£ 950,000£ 1,107,835£ 2,034,640£ 2,300,332£ 1,830,552£ 1,977,847£ 1,685,147£ 745,060£ 57,546£ 200,618£ 90,280£ 203,850£ 450,000£ -£ 13,705,054£
2,129,181£ 6,165,525£ 4,408,054£ 348,444£ 653,850£ 13,705,054£
St Pancras Hospital -£ 850,000£ 956,641£ 1,666,370£ 1,373,276£ 1,675,333£ 1,096,225£ 1,200,000£ 678,800£ 15,089£ 112,693£ 25,150£ 150,000£ 200,000£ -£ 9,999,578£
HMHC -£ 100,000£ 47,760£ -£ -£ 3,500£ 550,000£ -£ 7,000£ -£ -£ 20,000£ -£ -£ -£ 728,260£
Community Sites 71,346£ -£ 103,434£ 368,270£ 927,056£ 151,719£ 331,622£ 485,147£ 59,260£ 42,457£ 87,925£ 45,130£ 53,850£ 250,000£ -£ 2,977,216£
Total 71,346£ 950,000£ 1,107,835£ 2,034,640£ 2,300,332£ 1,830,552£ 1,977,847£ 1,685,147£ 745,060£ 57,546£ 200,618£ 90,280£ 203,850£ 450,000£ -£ 13,705,054£
Annual Total Annual Total Annual Total Annual Total Annual Total
Capital 2016/17 Capital 2017/18 Capital 2018/19 Capital 2019/20 Capital 2020/21
Appendix 16 Backlog maintenance
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Appendix 17 Quantifiable benefits
Type of Benefit Benefit
Option A1 Do Minimum
Option A2 Rebuild SPH
Option A3 Whittington
Option A4 St Ann’s
Assumptions
Activity (less acute because more community intervention / early intervention / less duplication)
Quicker service user recovery frees up bed capacity and reduced cost (non-cash releasing, recurrent)
N/a £1.5m per annum (from 2023/24)
£1.5m per annum (from 2023/24)
£1.5m per annum (from 2023/24)
Improving the environment for service will mean they make a quicker recovery.
Identifying service users earlier, means that the severity of their conditions is reduced.
Reduced cost of physical healthcare through co-location of mental and physical healthcare services (non-cash releasing, recurrent)
N/a N/a £70k per annum (from 21/22)
N/a Costs of care for the Trust will reduce as a result of co-locating with an acute Trust.
Costs of service user transport will reduce
Staffing (reduced staff costs through less agency, more productive and happier staff)
Reduced agency staffing, so reducing cost, through improved staff working conditions and therefore retention (cash releasing, recurrent)
N/a £800k per annum
£800k per annum
£800k per annum
The new facility will improve staff morale.
The new facility will therefore encourage staff to stay in post, reducing vacancies and therefore agency staffing costs.
Reduced costs due to new build wards, with large bed capacity and better layout (cash releasing, recurrent)
N/a £800k per annum
£800k per annum
£800k per annum
Reducing the number of wards by one but maintaining the number of beds means that the number of senior staff required on each shift will reduce.
Reduced cost of staff training due to co-location of the site with other similar medical facilities (non-cash releasing, recurrent)
N/a N/a £80k per annum (from 2021/22)
£80k per annum (from 2021/22)
By training staff in larger groups or being able to offer more training on site will reduce costs.
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Staff progression and therefore satisfaction will increase due to increased opportunity
Admin staff flexibly located to increase operational efficiency (non-cash releasing, recurrent)
N/a £100k per annum (from completion of the project)
£100k per annum (from completion of the project)
£100k per annum (from completion of the project)
Admin staff are more accessible to clinical staff, reducing inefficiency.
By making effective use of flexible working arrangements less space is required.
Overheads Operating costs of a new building are lower than those of an old building (cash releasing, recurrent)
N/a £1.8m per annum (from 2021/22)
£1.8m per annum (from 2021/22)
£1.8m per annum (from 2021/22)
Lifecycle cost report provided by T&T shows a significantly reduced costs from a more efficient new building.
Energy and utility costs (cash releasing, recurrent)
N/a £360k per annum (from 2021/22)
£360k per annum (from 2021/22)
£360k per annum (from 2021/22)
The new building will be more efficient due to using better building design / materials.
Renegotiation of existing FM contracts (cash releasing, recurrent)
N/a £575k per annum (from 2018/19)
N/a N/a Based on benchmarking data the existing FM costs can be reduced by renegotiating the contract.
Other Increased research income from working closely with the Institute of Mental Health (IoMH) (cash releasing, recurrent)
N/a £10k per annum (from 2021/22)
£10k per annum (from 2021/22)
£10k per annum (from 2021/22)
IoMH works closely with the Trust and therefore benefits from some research grants.
Sub-let consultancy rooms (cash releasing, recurrent)
N/a £20k per annum
£20k per annum
£20k per annum
2% of consultancy rooms sublet on a regular basis to enable the provision of other services.
Uptake of these rooms will be high.
Realisation of land proceeds from access community and hospital estate. (cash releasing, non-recurrent)
N/a £66.3m (between
£90.4m (between
£90.4m (between
Land which is surplus to requirements in both the
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2017/18 and 2026/27)
2017/18 and 2026/27)
2017/18 and 2026/27)
community estate and inpatient estate can be sold at market value to realise a financial gain
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Appendix 18 Trust’s Income & Expenditure assumptions
Area Assumption
Income Baseline and investment case Contractual income from clinical services with Camden CCG and Islington
CCG is assumed to grow at an average rate of 0.7% and 1.7% per year between 2016/17 and 2025/26 (before inflation).
Income from other contracts for clinical services is assumed to fall from £13.3m in 2016/17 to £11.7m in 2017/18 (an 11.5% decrease) and then grow by 0.8% per year (before inflation).
Non-contract activity income is assumed to remain at the 2016/17 level of £1.3m per year throughout.
Section 75 income is assumed to remain at £12.7m per year throughout. A reduction in income reflecting the risk of funding from parity of esteem has
been applied from 2019/20 at £0.7m, increasing to £1.9m by 2025/26. STF funding has been assumed at £0.8m per year for 2016/17, 2017/18 and
2018/19. No funding has been assumed thereafter. Investment case The investment case is assumed to increase research and development and
other revenue by £10k (from 2021/22) and £21k (from 2020/21) respectively.
Expenditure: Pay costs
Baseline and investment case Activity growth is assumed to increase pay costs across all staff groups by
1.0% in 2017/18 and 0.6% per year thereafter. Pay-related CIPs are assumed at 3.3% of total pay costs in 2017/18 and
between 1.5% and 1.2% per year thereafter. The impact of agenda for change (AfC) pay rates is assumed to be an annual
increase of 1.2% in pay costs across all staff groups. The cost associated with additional parity of esteem funding is assumed at
0.3% for 2019/2020, around 0.7% for 2020/21 and 0.5% per year thereafter. Investment case The investment is assumed to reduce spend on substantive nursing staff by
£0.9m per year from 2021/22. This is a CIP plan to reduce the number of staff by one ward, made possible by the larger modern wards in the new building.
CIP plans to further reduce agency staff costs through: more efficient staff rotas, better staff retention and co-locating admin staff with community hubs is assumed to reduce agency costs by:
o £0.3m in 2020/21 o £0.6m in 2021/22 o £0.9m per year thereafter
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Area Assumption
Expenditure: Non-pay costs
Baseline and investment case Activity growth is assumed to increase drug costs, clinical supplies and directly
managed staff costs by 0.7% in 2017/18 and is assumed to have no further impact thereafter.
Parity of esteem funding is assumed to increase drug costs by 0.4% in 2019/20, 0.9% in 2020/21 and 0.6% thereafter.
Other expenses (general supplies, establishment costs, premises and plant costs and other costs) are assumed to fall slightly from £27.1m in 2016/17 to £27.4m in 2017/18 and in each year thereafter (before CIP and inflation).
Other expenditure CIPs are assumed to be achieved recurrently at £2.2m in 2017/18, with a further £0.8m assumed recurrently each year thereafter.
Investment case The investment is assumed to reduce other expenses by £0.8m in 2020/21 and
around £3.5m per year thereafter. This is the result of three CIP schemes: o £1.8m from the reduced operating costs of the new building; o £1.5m from reducing the length of stay (LOS) resulting from the
improved therapeutic environment; and o £0.4m from reduced energy costs of the new building.
Cost improvement plans
Baseline and investment case The assumptions underlying the pay and non-pay CIPs are set out in the
relevant sections above. All CIPs are assumed to be recurrent. No income CIPs are assumed. CIPs are assumed at, as a percentage of operating expenditure:
o 4.1% for 2017/18 o 1.8% from 2018/19 to 2019/20 o 1.7% from 2020/21 to 2023/24 o 1.6% from 2024/25 to 2025/26
Investment case The investment is assumed to generate pay cost savings of £1.8m by 2022/23,
as set out in the pay costs section above. Other expenses CIPs are assumed at £3.5m from 2021/22, as set out in the
non-pay costs section above.
Interest expense Baseline case No interest costs are included in the baseline case.
Investment case Interest costs under the investment case are assumed to be 2.9%.
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Area Assumption
Inflation Baseline and investment case Inflation has been assumed at the following rates:
2018/19 2019/20 2020/21 2021/22 2022/23+ Income 0.1% 0.3% 0.3% 0.3% 0.3% Pay costs 1.0% 1.0% 1.0% 1.0% 1.0% Drug costs 3.5% 3.5% 3.5% 3.5% 3.5% Other expenses 2.0% 2.0% 2.0% 2.0% 2.0% Capex 3.0% 3.0% 3.0% 3.0% 3.0%
The above inflation rates are consistent with the Trust’s Sustainability &Transformation Plan (STP) assumptions
Note, in addition to the inflation rates above, the Trust has assumed a 1.2%AfC increase that whilst not technically inflation will compound with the inflationrates above to increase wages in cash terms.
Transitional support
The Trust has not assumed that it will receive any transitional support fundingas part of its affordability assessment. Funding for the clinical transformationand estates strategy will be from land sales and internally generated reserves.As described above, due to the timing of the major cashflows (constructioncost and land purchases coming before land sales), the Trust has assumed abridging loan to ensure that it can maintain sufficient working capital over theLTFM period.
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Appendix 19 Baseline income and expenditure
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Appendix 20 Baseline statement of financial position
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Appendix 21 Baseline cash flow statement
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Appendix 22 Trust FSRR scores for the investment and baseline cases
The financial sustainability risk rating (FSRR) is NHSI’s view of the level of financial risk a trust is exposed to and is a therefore key metric to consider for this transaction. The FSRR is a combination of the following four metrics:
Liquidity: days of operating costs held in cash or cash equivalents
Capital servicing capacity: the degree to which the organisation’s generated income covers its interest and debt repayments. Note that this may exclude repayment of bridging debt at NHSI’s discretion (discussed further below).
Income and expenditure (I&E) margin: the degree to which the organisation is operating a surplus/deficit with respect to its total operating and non-operating income. Surplus/(deficit) is calculated before impairments and gains/losses on asset disposal.
Variance from plan in relation to I&E margin: the variance between a trust’s planned and actual I&E margin.
Each of the metrics yields a score between 1 (greatest risk) and 4 (least risk). An overall FSRR score is calculated from the average of the four metrics, although this is capped at 2 if one of the metrics is a 1. Trusts that score a 1 or 2 may be subject to an investigation by NHSI.
The details of the FSRR calculations criteria are shown in Table F1 below.
Table F1: FSRR criteria
Notes:
The metrics are weighted equally (i.e. averaged), then rounded to produce a single FSRR
If the trust scores 1 on any metric, the overall rating will be capped at a 2.
1 2 3 4
Balance sheet sustainability Capital service capacity (times) <1.25 1.25-1.75 1.75-2.5 >2.5
Liquidity Liquidity (days) <(14) (14)-(7) (7)-0 >0
Underlying performance I&E margin (%) <(1) (1)-0 0-1 >1
Variance from plan Variance in I&E margin as % of income
<(2) (2)-(1) (1)-0 >0
Risk categoriesMetricFinancial criteria
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The FSRR scores for the investment and baseline cases are set out in Tables F2 to F4 below. The FSRR calculation performed by the LTFM yield a capital service cover risk rating of 1 for the investment case, as the bridge loan repayments are included in the debt service total. This significantly distorts the position as the Trust has sufficient cash to make these repayments as shown in the tables above. The LTFM itself provides an area where adjustments can be made to reverse out the impact of bridge loan financing from the FSRR analysis and that is deemed appropriate here. These repayments are excluded for bridge loans and the impact of this is shown in Table F3 below.
Table F2: FSRR scores for the investment case (unadjusted)
As noted above, the inclusion of the bridge debt repayments as debt service in the capital service capacity calculation causes this metric to become 1. Table F3 below presents the FSRR scores after these payments have been excluded from the calculation.
Table F3: FSRR scores for the investment case (adjusted for debt repayments)
The adjusted FSRR shows an I&E margin rating of 2 in 2020/21, as the projections show a small net deficit in this year of £(0.1)m. The overall rating remains at 3 for this year and at 4 for all other years.
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Capital service capacity 3 4 4 3 3 1 1 1 1 1Liquidity 4 4 4 4 4 4 4 4 4 4I&E margin 4 4 4 3 2 3 3 3 3 4Variance in I&E margin n/a 4 4 4 4 4 4 4 4 4
Overall FSRR n/a 4 4 4 3 2 2 2 2 2
Risk score
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26
Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Capital service capacity 3 4 4 3 3 3 3 3 4 4Liquidity 4 4 4 4 4 4 4 4 4 4I&E margin 4 4 4 3 2 3 3 3 3 4Variance in I&E margin n/a 4 4 4 4 4 4 4 4 4
Overall FSRR n/a 4 4 4 3 4 4 4 4 4
Risk score
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Table F4: FSRR scores for the baseline case
Under the baseline case, the FSRR remains at 4 throughout, although the declining net surplus position causes the I&E margin score to fall to a 2 by 2025/26.
The sensitivities set out in the previous section each have minimal or no impact on the forecast FSRR score when considered individually. A combined downside case will be considered in the FBC along with the impact on the FSRR.
2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26Outturn Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast
Capital service capacity 3 4 4 4 4 4 4 4 4 4Liquidity 4 4 4 4 4 4 4 4 4 4I&E margin 4 4 4 4 4 4 3 3 3 2Variance in I&E margin n/a 4 4 4 4 4 4 4 4 4
Overall FSRR n/a 4 4 4 4 4 4 4 4 4
Risk score
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Appendix 23 Letter of support from the Trust’s Director of Nursing
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Appendix 24 Bed modelling benchmarking
On the graphs below, the Trust is identified as M11.
Adults
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Acute
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Length of Stay
2015/16 2017/18 Length of stay MPICU 55 89 Length of stay WPICU 36 Length of stay Acute 49 67 Length of stay Older Adult 135 118 Length of stay Rehab 1103 721
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Appendix 25 – Bed occupancy
Bed Occupancy
• Acute: Reduction approx. 3% • R&R: Reduction approx. 2% • SAMH:33% reduction in usage
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Number of Out of Area Placements (OAPs)
• Reduction in ECR • 5
thApril zero ECR bed
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Camden Clinical Commissioning Group Governing Body Meeting 9 May 2018
Report Title Unaudited Finance Report Month 12 – 2017/18
Agenda Item 5.1 Date 09.05.18
Committee Chair (where applicable)
Dr Birgit Curtis, Finance, Performance & QIPP Committee Chair
Lead Director Simon Goodwin, Chief Finance Officer
Tel/Email [email protected]
Report Author Becky Booker, Deputy Director of Finance Officer
Tel/Email [email protected]
GB Sponsor(s) (where applicable)
Dr Birgit Curtis, Finance, Performance & QIPP Committee Chair
Tel/Email [email protected]
Report Summary The report sets out the unaudited Camden CCG Financial & QIPP Position at month 12 being March 2018
Purpose (tick onebox only)
Information Approval To note
Decision
Recommendation The Governing Body is asked to note the contents of this report.
Strategic Objectives Links
Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for money services.
Identified Risks and Risk Management Actions
This report sets out the unaudited financial position for the year 2017/18. Risks and mitigations have been included within the financial position as appropriate.
Conflicts of Interest
None
Resource Implications
Camden CCG has reported a year-end surplus of £2.018m against the month 12 budget of £422.4m.
This surplus is due to the release of the 0.5% non-recurrent reserve of £1.8m and £0.2m for the Category M medicines rebate.
The month 12 positon is in line with the NHSE expected position for Camden CCG for 17/18. All risks and mitigations are included in the financial position.
All over-performance is contained within the CCGs control total by use of contingencies and non-recurrent reserves.
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Engagement Not applicable for the purpose of this report.
Equality Impact Analysis
This report has been written in accordance with the provisions of the Equality Act 2010.
Report History and Key Decisions
The Governing Body receives regular Finance and QIPP updates.
Next Steps Continued oversight by the Finance, Performance and QIPP Committee.
Appendices None
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Unaudited Finance Report: 1 April 17 to 31 March 2018 1. Introduction
This paper presents to the Camden CCG Governing Body Committee the Camden Clinical Commissioning Group unaudited financial performance for the financial year 2017/18.
2. Executive Summary
The month 12 financial performance is summarised below:
Table 1: Financial Performance Summary
Budget Actual Variance M11 FOTVariance vs
Actual£000's £000's £000's £000's £000's
Revenue Resource Limit 422,369 422,369 0 422,369 0
Total Income 422,369 422,369 0 422,369 0
Acute Spend 199,178 206,339 7,161 205,696 643Non Acute Spend 150,539 155,174 4,636 154,063 1,111Primary Care Delegated Commissioning 36,752 38,233 1,481 38,285 (52)Investment Spend 7,997 7,351 (646) 8,149 (798)Running Costs 5,612 5,571 (40) 5,577 (6)Overheads & Contingencies 22,293 7,683 (14,609) 10,599 (2,916)
Total Expenditure 422,369 420,351 (2,018) 422,369 (2,018)
Surplus / (Deficit) 0 2,018 2,018 0 2,018
Full Year M11 Forecast
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Graph 1: 2017/18 Forecast Outturn by Expenditure Area
Camden CCG has reported a year-end surplus of £2.018m against the month 12 budget of £422.4m. As expected this surplus is due to the release of the 0.5% non-recurrent reserve of £1.8m and £0.2m for the Category M medicines rebate.
The month 12 positon is in line with the NHSE expected position for Camden CCG for 17/18. All risks and mitigations are included in the financial position.
The below table 2 summarises the month 12 and the month 11 areas of under/over-performance.
Table 2: Month 12 & 11 under/over-performance
Month 12 (£m)
Month 11 (£m)
Movement (£m)
Acute spend over-performance 6.6 5.1 1.5Non-Acute spend over-performance 4.6 3.6 1.0Primary care delegated commissioning cost pressure 1.5 1.5 0.0
Investment programmes (0.6) 0.1 (0.7)General overheads 0.3 (0.1) 0.4Total 12.4 10.2 2.2
Acute technical adjustment (IVF) 0.6 1.4 (0.8)
Total 13.0 11.6 1.4
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The most significant points to note include: -
• Subject to audit the CCG has met its 2017/18 control total.
• At month 12 there was an increase in over-performance of £2.2m from month 11. This is mainlydue to an increase in acute over-performance of £1.5m and non-acute of £1m, offset by areduction in investment programmes of £0.7m.
• In the acute sector the £1.5m movement is mainly due to a number of small movements acrossthe portfolio with the most notable being an improvement in UCLH of £0.3m, an increase in over-performance at Royal Free £0.4m and the Whittington of £0.2m and other acute £0.1m.
• The Non-Acute sectors £1m movement against last month FOT primarily related to an increasein CHC over-performance, £0.5m, increased prescribing costs, £0.3m, and other communitycosts, £0.2m.
• The below summarises the main areas of non-acute over-performance, for the year:
Continuing Health Care (CHC) £1.8m Community Services £1.3m Primary Care Prescribing £0.6m Learning Disabilities £0.5m Children Services £0.4m
• The acute technical adjustment for IVF treatment has been made, £0.6m
• All risks and mitigations are included within the reported position.
1. Acute ExpenditureAt month 12 the acute over-performance is £7.2m against a budget of £199.2m. The below table 3 summaries the year-end position by the main acute providers.
Table 3: Over performance by provider
Graph 2 below shows the acute spend by main provider by month. Where appropriate the marginal rate on acute contracts has been applied.
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Graph 2: Acute Expenditure
2. Non-Acute ExpenditureThe below table 4 details the Non-acute year-end position. At month 12 Non-Acute was £4.6m overspent showing an increase in £1.1m against the M11 forecast. This movement is mainly contained within Continuing Healthcare and within Learning Disabilities.
Table 4: Non Acute Expenditure
Continuing Healthcare shows £1.8m (12%) overspent against budget, a £0.5m movement against the M11 FOT.
Learning Disabilities expenditure has increased against the M11 FOT by £0.4m to increased costs.
ServiceFull Year Budget
Full Year Spend
Variance Unfav/(Fav)
M11 FOT Variance vs Actual
Unfav/(Fav)
£000 £000 £000 £000 £000Mental Health 52,526 52,636 110 52,657 (21)Children's Services 11,266 11,656 390 11,589 68Continuing Care 14,504 16,266 1,762 15,792 474End of life 2,077 2,185 107 2,147 37Community 34,004 35,345 1,341 35,434 (89)Quality & Clinical Effectiveness 26,225 26,838 614 26,693 145Primary Care (LCS) 4,526 4,382 (144) 4,365 17Other 5,411 5,866 455 5,386 480Total 150,539 155,174 4,636 154,063 1,111
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Prescribing has a year-end over-performance of £0.6m against a budget of £26.2m, this is an increase of £0.3m on the month 11 position. Contained within this position is a cost pressure of £1.2m for no cheaper stock obtainable (NCSO) medicines.
3. General Practice Delegated Commissioning Expenditure
Table 5 below, summarises of the General Practice Delegated Commissioning budget. At month 12 the CCG reported a budget overspend of £1.5m, in line with previous months.
Table 5: General Practice Delegated Commissioning
Service Annual Budget M12 Actual
Expenditure YTD Variance
£000's £000's £000's PMS 20,170 20,327 157 GMS 14,610 14,456 (155) APMS 3,262 3,225 (37) Other Medical Services (1,290) 225 1,516
Total 36,752 38,233 1,481
4. Other BudgetsInvestment programmes, which include Primary Care, Children’s and Mental Health & CIDR programmes, show a year-end underspend of £0.6m against a budget of £8m.
Running costs have delivered a breakeven position for the year. General overheads are £0.6m overspent, due to the recognition of prior year invoices. Staffing has delivered an underspend of £0.3m for the year.
5. QIPPFor 2017/18 QIPP savings were £16.3m achieving 90% of the CCG’s £18.1m plan. The shortfall relates to under performance of schemes within Acute Services.
Table 6, below, summarises cumulative and forecast QIPP, as reported to NHSE, within the month 12 non-ISFE return.
Table 6: QIPP Summary
£m £m £mSummary Area of SpendAcute Services 10.257 6.554 (3.703)Mental Health Services 0.813 0.973 0.160Community Health Services 1.485 2.197 0.712Continuing Care Services - 0.302 0.302Primary Care Services 0.654 0.528 (0.126)Primary Care Co-Commissioning - - -Other Programme Services 4.827 5.743 0.916Commissioning Services Total 18.036 16.297 (1.739)Running Costs 0.107 0.040 (0.067)Unidentified - - -TOTAL CCG EFFICIENCIES 18.142 16.337 (1.806)
CCG EFFICIENCY PLANSFull Year
PlanFull Year
ActualVariance
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6. SummaryThe CCG met its required control total for 2017/18. The CCG achieved this by offsetting over-performance through the release of non-recurrent reserves and contingencies.
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Integrated Performance Report Agenda Item 5.2 Date 09.05.18
Committee Chair (where applicable)
Dr Birgit Curtis, Chair Finance Performance and QIPP Committee
Lead Director Sally Mackinnon, Director of Transformation, Planning & Delivery
Tel/Email [email protected]
Report Author Richard Cartwright Head of Performance
Tel/Email [email protected]
GB Sponsor(s) (where applicable)
Dr Birgit Curtis Tel/Email [email protected]
Report Summary The Integrated Performance Report reports on provider performance against the constitutional targets, financial performance, quality and outcomes.
The main areas of concern for the CCG are currently performance against the A&E, 62 day cancer, and RTT waiting times standards.
Purpose (tick one boxonly)
Information Approval To note
Decision
Recommendation The Governing Body is asked to note the contents of the Integrated Performance Report.
Strategic Objectives Links
Commission the delivery of NHS Constitutional rights and pledges Improve the quality and safety of commissioned services
Identified Risks and Risk Management Actions
These are identified within the report.
Conflicts of Interest
Not applicable for the purpose of this report.
Resource Implications
Not applicable for the purpose of this report.
Engagement Not applicable for the purpose of this report. Equality Impact Analysis
This report has been written in accordance with the provisions of the Equality Act 2010.
Report History and Key Decisions
This report is a standing item on the Governing Body agenda.
Next Steps None Appendices None
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Integrated Performance ReportMay Governing Body 2018
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1. Access1.1 CCG Operating Plan Targets
Key messages:
RTT, Cancer waiting times and A&E 4 hour waits are the key areas of concernand focus for the CCG.
CancerCamden CCG was compliant against all but one of the nationally set cancertargets in February. Stronger performance against cancer standards has beenseen across NCL which reflects the significant work undertaken across thesystem in delivering action plans, and improving the flow of patients referredbetween Trusts.
RTTBoth UCLH and Royal Free are non-compliant with the RTT standard. RoyalFree performance is driving the CCG’s performance, as Camden’s cohort ofpatients waiting at UCLH is currently above the 92% target.
A&EIn March 2018, 18 of 22 London Trusts did not achieve the 95% A&Estandard. Camden CCG continues to have regular joint meetings with UCLH,NHSE and NHSI. High priority actions have been agreed and progress isreviewed at the A&E Delivery Board with the aim of driving performanceabove 90%, and achieving the national ambition of 95% by March 2019.
Target/Threshold
RTT Incomplete Pathways within 18 Weeks 92% Feb-18 90.7% 91.6% RTT 52+ week waiters 0 Feb-18 10 93
Diagnostics Diagnostics - 6+ week waiters 99% Feb-18 99.2% 98.8% A&E 4 Hour Waits 95% Mar-18 85.9% 87.9% Delayed Transfers of Care - Acute - Feb-18 191 3805 Delayed Transfers of Care - Non-Acute - Feb-18 197 2389
Total delayed days per 100,000 18+ population - Feb-18 195 n/a
2 week wait 93% Feb-18 93.8% 94.2%
2 week wait breast symptomatic 93% Feb-18 96.7% 94.1% 31 day 1st definitive treatment 96% Feb-18 100.0% 97.7% 31 day 1st subsequent treatment - surg. 94% Feb-18 100.0% 94.1% 31 day 1st subsequent treatment - chemo. 98% Feb-18 100.0% 100.0% 31 day 1st subsequent treatment - radio. 94% Feb-18 100.0% 98.0% 62 day standard 85% Feb-18 89.3% 80.7% 62 day standard - screening 90% Feb-18 0.0% 84.6% 62 day standard - upgrade No Target Feb-18 50.0% 89.7%
Mixed Sex Mixed Sex Accommodation Breaches 0 Feb-18 5 65 MRSA Reported Cases (CCG Assigned) 0 Feb-18 0 2 C.Difficile Reported Cases Feb-18 5 63 new LAS Metric Category 1 (Life Threatening - 7 minute response t ime target - mean) 7 minute Feb-18 00:07:26 n/anew LAS Metric Category 2 (Emergencies - 18 minute response t ime target - mean) 18 minute Feb-18 00:23:21 n/anew LAS Metric Category 3 (Urgent - 120 minute response t ime target - 90th Percent ile) 120 minute Feb-18 02:59:27 n/anew LAS Metric Category 4 (Less Urgent - 180 minute mean response t ime target - 90th Percent ile) 180 minute Feb-18 02:34:17 n/a
CPA Follow-ups 95% 2017/18 Q3 92.4% 94.9% IAPT Access 1.25% Dec-17 0.9% 1.4% IAPT Recovery Rates (NB national data presented) 50% Dec-17 40.0% 42.8% 6 Weeks IAPT Waiting Times 75% Dec-17 85.0% 85.6% 18 Weeks IAPT Waiting Times 95% Dec-17 97.0% 97.9% Dementia Diagnosis Rate 67% Feb-18 88.5% 88.3% Psychosis (EIP) - 2 Week Wait, NICE approved package 50% Feb-18 81.8% 87.1% Eating Disorders Waiting Times (4Wk Routine) 95% 2017/18 Q3 87.0% 83.3% Eating Disorders Waiting Times (1Wk Urgent) 95% 2017/18 Q3 100.0% 100.0% New children and young people receiving treatment from NHS funded community services 30% tbc Await MHSDS
V2 data, tbcAwait MHSDS V2 data, tbc
Individual children and young people receiving treatment by NHS funded community services 30% tbc Await MHSDS
V2 data, tbcAwait MHSDS V2 data, tbc
Utilisation of e-RS booking50% (April 2017)80% (Oct 2017) Dec-17 43.0% 42.2%
Wheelchair Service RTT Childrens Wheelchairs within 18 Weeks 100% 2017/18 Q3 80.0% 97.8%
PHBs per 100,000 GP registered pop.11.23 (2017/18 Q1) 2017/18 Q2 16.6 n/a
Camden CCG - Current month Trend Camden CCG -
YTD Trend
e-RS
Personal Health Budgets
Cancer - 31 day
Cancer - 62 day
HCAIAnnual
RTT
New LAS Metrics (London wide)
Mental Health
A&E
Indicator Type
Camden DTOCs (days)
Cancer - 2 week
Reporting Period
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1. Access1.2 Provider Access Targets
NCL A&E performance
RTTUCLH backlog clearance is currently in line with the planned trajectory.The latest Royal Free RTT plan suggests that the Trust will not meet the target in2018/19. The focus of the plan, still in discussion with Barnet CCG, is to meet thenational planning requirement of showing no increase in the waiting list betweenMarch 2018 and March 2019.
A&EBoth UCLH and Royal Free performance against the four hour standard continues toreflect regional and national pressures.
CancerDespite process improvements to inter trust pathways, UCLH performance againstthe 62 day standard in February was impacted by late referrals from other providers.The Trust treated 69 external patients, of which 35 breached the 62 day standard. Ofthe 35, 28 were referred after day 38.
London A&E Performance18 of 22 Trusts did not achieve the 95% standard in March. London was ranked 2nd of the four regions for the month.
Royal Free YTD
Target/Threshold
Reporting Period Performance Trend Performance Trend Performance Trend Performance Trend
RTT Incomplete Pathways 92% Feb-18 91.4% 91.5% 83.4% 88.4%
RTT 52+ week waiters 0 Feb-18 6 30 32 280
Diagnostics Diagnostics - 6+ week waiters 99% Feb-18 99.4% 99.3% 99.4% 99.1%
A&E 4 Hour Waits 95% Mar-18 85.9% 88.1% 84.1% 84.5%
A&E 12 Hour Waits 0 Mar-18 0 3 0 0
Delayed Transfers of Care (days) - Trust level - Feb-18 698 8394 384 9257
Delayed days per occupied beds % 2.5% Feb-18 5.6% 6.0% 9.1% 9.5%
2 week wait 93% Feb-18 93.5% 94.3% 93.0% 93.4%
2 week wait breast symptomatic 93% Feb-18 94.7% 92.9% 95.5% 93.8%
31 day 1st definitive treatment 96% Feb-18 96.3% 93.9% 98.5% 97.8%
31 day 1st subsequent treatment - surg. 94% Feb-18 95.2% 94.1% 95.7% 97.4%
31 day 1st subsequent treatment - chemo 98% Feb-18 100.0% 100.0% 100.0% 100.0%
31 day 1st subsequent treatment - radio 94% Feb-18 98.6% 99.1% 97.1% 99.8% 62 day standard 85% Feb-18 68.0% 68.1% 84.9% 83.1%
62 day standard - screening 90% Feb-18 85.7% 76.1% 94.4% 92.7%
62 day standard - upgrade 90% (UCLH) Feb-18 78.6% 81.3% 90.8% 88.7%
Mixed Sex Mixed Sex Accommodation Breaches 0 Feb-18 30 341 39 381
Cancelled Ops for non-clinical reasons rebooked >28 days 100% 2017/18 Q3 91.4% 91.6% 97.4% 88.7%
Urgent operation cancelled for the 2nd time 0 Feb-18 0 0 0 0
MRSA Reported Cases (Trust assigned) 0 Feb-18 0 1 0 3
C.Difficile Reported Cases Feb-18 8 64 9 75
Handover time over 30min of arrival 0 Feb-18 201 2493 147 1834
Handover time over 60min of arrival 0 Feb-18 55 448 46 1032
% of Data recorded electronically 90% Feb-18 91.8% 92.1% 89.8% 88.0%
VTE VTE Risk Assessed Admissions 95% Dec-17 95.5% 95.4% 96.4% 96.0%
SHMI Summary Level Hospital Mortality Indicator <100
Oct 2016 to Sept 2017 76.7 n/a 86.8 n/a
RTT
UCLH UCLH YTD Royal Free
Indicator Type
A&E
DTOCs
Cancer - 2 week
Cancer - 31 day
Cancelled Ops
HCAI-
Ambulance Handover
Jan-18 Feb-18 Mar-18
LONDON #REF! 87.6% 87.3% 86.4% 89.6% 89.3% 17.2% 68
# delays > 12 hrs in current month
13 month performance
Performance (against 95% standard)
Current 12 month rolling perf
% A&E attendances admitted (12
month rolling)
Previous 12 month
rolling perf
NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST 75.5% 82.4% 76.5% 82.0% 80.9% 19.5% 0ROYAL FREE LONDON NHS FOUNDATION TRUST 86.1% 86.5% 84.1% 87.6% 86.6% 21.1% 0THE WHITTINGTON HOSPITAL NHS TRUST 86.5% 86.1% 83.2% 87.4% 89.4% 17.3% 0UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST 86.1% 86.0% 85.9% 88.2% 88.0% 21.4% 1
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1. Access1.3 Demand Management
Extended AccessUtilisation of the service has significantly improved since AT Medics took over the contract.Camden CCG is working with AT Medics to identify issues in low usage and DNAs at the Somers Town hub.The CCG is working with NHS 111 to improve the direct booking process into slots.
The service provider, AT Medics, is implementing an agreed communications and engagement plan with oversight by the CCG. Messaging focuses on the new direct booking route for patients: a dedicated phone number, open 8-8 seven days a week.
Communication activity includes: • practice training, focusing on those with lowest historical referral rates.• digital and print advertising in practices, pharmacies, libraries and leisure centres• targeted leaflet drops to households• outdoor advertising (primarily on bus stop poster sites from January 2017)• social media updates• editorial in the Camden Magazine (council publication delivered to all Camden households in February 2017)• advertising in local media (Camden New Journal and Ham and High)• content in CCG partner websites, social media and publications.
This activity is being reinforced by a four-week London-wide extended access campaign by the Healthy London Partnership in Dec/Jan.
Extended Access utilisation: Haverstock Health
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1. Access1.4 DTOCs and CHC performance against trajectory
DTOC Performance against target for JanuaryTarget = 10.73 monthly average daily delaysPerformance for January = 20.65
Continuing Healthcare Target < 15% of assessments in the acute settingPerformance for February = 11.1%
All NHS Continuing Healthcare assessments completed within 28daysTarget 100%Performance for March = 88.9%
• Daily meetings between the CCG and UCLH have made improvements to discharges and flow.• Delays waiting for residential home placements are in part caused by a capacity shortfall in the
market place for residential and nursing home places.• Patients waiting further non-acute care can be attributed partially to flow issues into rehab
beds. The CCG is using winter funding money to recruit a discharge flow coordinator to improvethis.
• An NCL choice policy is under development to agree the threshold for facilitated dischargewhich should reduce patient or family choice delays.
Month Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Feb-18
Mar-18
Target Total Days 15.8 14.46 13.53 11.93 10.73 10.73 10.73 10.73 10.73
Total number of patients 42 42 40 41 51 59 76 42 70
Total Days - Actual 17.1 15.66 15.71 20.5 22.0 23.29 17.9 11.68 20.65
NHS Attributable (target) 6.85 6.85 7.07 7.02 7.05 7.05 7.05 7.05 7.05
NHS Attributable - Actual 6.61 7.13 6.94 10.77 11.37 10.19 8.74 5.29 10.52
Unify
Average daily cases/days of Delayed Transfers of Care - NHS Attributable
6.61 7.97 6.09 8.9 13.2 10.7 9.45
ASC Attributable (target) 8.95 7.6 6.46 4.91 3.68 3.68 3.68 3.68 3.68
ASC Attributable - Actual 10.48 8.53 8.77 9.73 10.53 12.52 8.16 5.39 7.10
Unify
Average daily cases/days of Delayed Transfers of Care - ASC Attributable
10.48 8.90 9.55 10.00 10.5 13.7 9.83
Attributable to both (ASC & NHS) No target N/A N/A N/A N/A N/A 0.58 1.0 1.0 3.03
Q1 2017/18Actual
Percentage of CHC decision support tool
assessments (taken from total number of Non-Fast
Track assessments) to take place in the acute
hospital setting
68% 47% 42% 29% 19% 11%
Mar-18Q2 2017/18 Q3 2017/18 Jan-18 Feb-18
0
50
100
150
200
250
300
Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18
Camden Local Authority Delayed Discharge reasons (Number of delayed days)
A) COMPLETION OF ASSESSMENT B) PUBLIC FUNDING
C) WAITING FURTHER NHS NON-ACUTE CARE DI) AWAITING RESIDENTIAL HOME PLACEMENT OR AVAILABILITY
DII) AWAITING NURSING HOME PLACEMENT OR AVAILABILITY E) AWAITING CARE PACKAGE IN OWN HOME
F) AWAITING COMMUNITY EQUIPMENT AND ADAPTIONS G) PATIENT OR FAMILY CHOICE
H) DISPUTES I) HOUSING - PATIENTS NOT COVERED BY NHS AND COMMUNITY CARE ACT
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1. Access1.4 Delayed Transfer Of Care (DTOCs)
• A new executive led meeting has been set up at UCLH to manage DTOCs.• Discharge teams now operate on the wards ensuring patients are discharged promptly.• The CUR tool is now operational identifying medically optimised patients.• STAR chamber meets weekly and a new process is in place with social care colleagues which covers
cross border patients.
• Barnet CCG continue to lead on DTOC meetings for Royal Free, which are held twice each day to expediteearly discharges and free up bed capacity in acute setting.
• STAR chamber meets weekly and a new process is in place with social care colleagues which covers crossborder patients.
0
100
200
300
400
500
600
700
800
NHS
Social Care
NHS and Social Care
UCLH Delayed Days by responsible organisation
0
200
400
600
800
1000
1200
NHS
Social Care
NHS and Social Care
Royal Free Delayed Days by responsible organisation
Waiting further NHS Non-Acute care
Patient or family choice
Awaiting care package in own home
Awaiting nursing home placement or availability
Awaiting residential home placement or availability
Awaiting community equipment and adaptions
Housing - Patients not covered by nhs and community care act
Awaiting for completion of assessment
Awaiting public funding
Disputes
Awaiting completion of assessment
Completion of assessment
Royal Free Delayed Days by reason - February 2018
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1. Access1.5 CNWL community services access targets
Key messages:• All performance targets for February were achieved in
adults services. There is underperformance in the YTDposition for some of the measures due to underperformance in earlier parts of the year which have nowbene addressed.
• St. Pancras bed occupancy levels were below 100% for bothCamden and Islington.
• As discussed at the CRG yesterday 1:1 bed days are beingunderutilised by c. 50%. This will result in a financial creditback to commissioners at year end.
• Health visiting reviews within 12 months are now above the85% target in February, which is ahead of the agreedimprovement trajectory.
• Overall activity is forecast at 8% above plan, primarily dueto district nursing contacts. Rapid response activity hasreduced to historic levels, following an initial increase fromOctober – January. This is consistent with the service’sreporting at CRG and will be picked up as part of the widerdiscussion being set up regarding this service and activityand QIPP targets.
Performance across all indicators is discussed and managed atthe regular CNWL CRG meetings, attended by the IntegratedCommissioning team and CSU.
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1. Access1.6 NCL Integrated Urgent Care Service (IUC) Performance against Quality and Performance KPIs
Integrated Urgent Care (IUC) ServiceThere were 28,113 calls to the NCL IUC service in March 2018; a 14% increase on the previous month.
The following pilots have been extended until the end of March 2018:- Enhanced access for Care Homes- LAS crews to an IUC Clinician- Enhanced access to Rapid Response Teams.
The NCL-wide service continues to achieve above the nationally mandated target of 50% of IUC being handled by a clinician. March performance was 58%.The 50% target will remain in place until March 2019.
The NHS111 Online pilot which commenced in February 2017 has been extended to November 2018.
The table shows service performance from April to March 2018. Call waiting time continues to be impacted by rostering issues and shortfall in WTE.Workforce plan progressing to trajectory.
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2. Commissioned Services Register Monitoring
SummaryThe Commissioned Services Register is comprised of a list of contracts that Camden CCG wholly or partly funds. The Register provides monthly oversight of these contracts, broken down into spend and performance, for the purposes of contract monitoring and informed decision-making regarding their future or maintenance.
This month (Apr ’18) the focus is on those contracts with a high and low attention level whose overall RAG status is Red or Amber.
Highlights• UCLH – Acute Hospital Services: There is an over-performance of £2.2m, with the largest pressures continuing to be in non-elective, outpatients, drugs & devices, critical care and maternity. This is
subject to both STP and Marginal rate adjustments which will be added for Hard Close.• Royal Free – Acute Hospital Services: There is a FOT variance of £5.8m, a favourable movement of -£1.2m from previous month. This is driven largely in other and A&E. The Q1 reconciliation disputed
items are now resolved with settlement of patient transport services (£1m), counting & coding challenges (£5.2m), productivity metrics (£3m) and agreement to review the patient transport contractvalue and implement a cost & volume charging arrangement for 18/19. Remaining issues that are to be finalised include marginal rate application, the indicative activity plan and STP achievement.
• UCLH – MSK Services: Delayed mobilisation and completion of transition actions in Year 1 have resulted in Lead Provider not providing sufficient reporting of finance and quality and collection ofbaseline data for setting Year 2 targets and thresholds. Actions include CCG to confirm financial adjustments for 17/18 and 18/19 to ensure no double billing, proposal on reinvestment ofperformance monies allocated to EQ5D and MSK-HQ indicators in MSK QIPP initiative to be submitted to ICC, Medicines Management to finalise prescribing requirements and monthly contractreview meetings to continue.
• Whittington Hospital – Acute Hospital Services: There is a FOT variance of £218k, a favourable movement of £37k from previous month. The in-month movement is driven largely by elective (£35k)and non-elective (£20k). This is offset by maternity (£14k).
• Whittington Health – Adult & Children Community Services: Early discussions have commenced on the recommendations amongst new adult commissioners. A further paper/recommendation willcome to EMT in April ‘18. A meeting took place between Whittington Health and Sarah Mansuralli with agreed next steps to arrange a meeting between CNWL and Whittington Health to discuss thewider adult community service deliver across Camden. Camden are also liaising with Islington and Haringey Wellbeing Partnership on a piece of work around improving community health services.
• North Middlesex University Hospital – Acute Hospital Services: The M12 reported actuals were £320k, ending the year £183k under plan. This is due to underspend in adult critical care (-£137k) andnon-elective (-£50k) offset by overspending in drugs and devices (£21k). Q1 and Q2 reconciliation is agreed at £32k and £47k underspend respectively.
• UCLH – Community Hypertension Service: There are current issues with data reporting and inconsistent referrals from GPs. The service has been extended until 30 June. A business case will besubmitted to EMT and ICC recommending an integrated CKD and hypertension service contracted until March 2020.
• UCLH – Community CKD: There are current issues with data reporting and inconsistent referrals from GPs. The service has been extended until 30 June. A business case will be submitted to EMT andICC recommending an integrated CKD and hypertension service contracted until March 2020.
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3. Quality3.1 Serious Incidents (SIs) & Never Events
UCLHSerious Incidents (SI)Assurances were provided to the Clinical Quality Review Group (CQRG), on 03 April regardinglearning which resulted from a series of incidents which occurred within the Eastman DentalHospital (EDH) last year. Learning and changes to practice include;1. Simulated training developed and delivered by Consultant Oral Surgeons.2. Implementation of the revised EDH Safer Dental Surgery Policy, which aligns with National
Safety Standards for Invasive Procedures (NatSSiPs).3. Implementation of a bespoke audit tool, which focuses on individual and team behaviours, in
conjunction with clinical practice.4. Feedback and learning from incidents is embedded within lectures, audit and governance
days.
Royal Free LondonSerious Incidents (SI) and Never Events
The CQRG were informed on 28 March that Barnet CCG, NHSE and NHSI will be visiting the Trust atthe end of May. The purpose of this visit is seek assurance regarding the implementation of actionsand learning, following investigations into the recent Never Events. A more detailed report will beprovided to the CQRG in June.
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3. Quality3.2 Complaints and Friends & Family Test
UCLHComplaintsThe Trust continue to work with Divisions to ensure thatcomplaints are investigated within the Trusts timeframes.Friends and Family Test (FFT)FFT scores and response rates continue to remain steady,with a small improvement noted within response ratesfor in-patients.
Royal Free LondonComplaintsClinical treatment remains the most commonprimary subject for complaints received, alongwith communication, appointment issues andparking concerns, as reported to CQRG on 28 March 2018.Friends and Family TestThe Trust have reported a decrease within in-patientresponse rates during February. This is likely to beattributed to winter pressures, as reported to CQRGon 28 March 2018.
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4. Activity4.1 QIPP Plan 2017/18 - M12 monthly report
Non-IFSE Return Summary
The CCG submitted its month 12 QIPP position to NHSE with an Full Year position of £16.34mrepresenting a negative variance of £1.81m against plan.
This is an increase of £41k in the adverse impact against the previous month highlighting slippagein transformation projects vs the QIPP profile.
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5. Finance
Overview
The CCG has met has met its required control total for 2017/18 and reports a £2.018m surplus. This is due to the release of the 0.5% non-recurrent reserve of £1.8m and £0.2m for the Category M medicines rebate, as per NHSE requirements. This rebate has been returned to CCGs from NHSE due to cost pressures in relation to the short stocks of generic drugs.
The month 12 positon is in line with the NHSE expected position for Camden CCG for 17/18. All risks and mitigations are included in the financial position.
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6. Improvement & Assessment Framework6.2 2017/18 Dashboard
The IAF dashboard, published by NHSE with data up toJanuary 2018, covers indicators located in four domains:Better Health, Better Care, Sustainability andLeadership.
Indicators that Camden CCG appears in the bottom quartilefor England:
Indicators that the CCG appears in the top quartile forEngland:
NHS Camden CCGBetter Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend
R 102a % 10-11 classified overweight /2013/14 to 2015/16 35.5% 5/11 143/207 R 121a High quality care - acute 17-18 Q2 57 9/11 150/207
R 103a Diabetes patients who achieve2016-17 42.1% 1/11 47/207 R 121b High quality care - primary care17-18 Q2 65 5/11 127/207
R 103b Attendance of structured educ2016-17* 19.2% 1/11 15/207 R 121c High quality care - adult social 17-18 Q2 65 2/11 8/207
R 104a Injuries from falls in people 6517-18 Q1 2,356 6/11 164/207 122a Cancers diagnosed at early sta 2015 54.2% 3/11 61/207
R 105b Personal health budgets 17-18 Q2 17 3/11 75/207 R 122b Cancer 62 days of referral to tr17-18 Q2 82.4% 7/11 108/207
R 106a Inequality Chronic - ACS & UCS17-18 Q1 2,352 6/11 132/207 R 122c One-year survival from all canc2015 74.6% 3/11 19/207
R 107a AMR: appropriate prescribing 2017 09 0.601 1/11 1/207 122d Cancer patient experience 2016 8.6 9/11 148/207
R 107b AMR: Broad spectrum prescrib2017 09 9.5% 5/11 135/207 R 123a IAPT recovery rate 2017 09 52.4% 4/11 86/207
108a Quality of life of carers (not available) R 123b IAPT Access 2017 09 3.9% 4/11 111/207
Sustainability Period CCG Peers England Trend R 123c EIP 2 week referral 2017 11 87.4% 3/11 44/207
R 141b In-year financial performance 17-18 Q2 Amber #N/A #N/A 123d MH - CYP mental health (not available)
R 144a Utilisation of the NHS e-referra2017 10 38.4% 7/11 165/207 123f MH - OAP (not available)
Leadership Period CCG Peers England Trend 123e MH - Crisis care and liaison (not available)
R 162a Probity and corporate governa17-18 Q2 Fully Compliant #N/A #N/A R 124a LD - reliance on specialist IP ca 17-18 Q2 56 6/11 98/207
163a Staff engagement index 2016 3.83 4/11 48/207 R 124b LD - annual health check 2016-17 49.6% 2/11 94/207
163b Progress against WRES 2016 0.20 11/11 206/207 R 124c Completeness of the GP learni 2016-17 0.28% 9/11 200/207
164a Working relationship effective 16-17 59.80 11/11 185/207 R 125d Maternal smoking at delivery 17-18 Q2 3.5% 3/11 7/207
166a CCG compliance with standards of public and patient participation (not available) 125a Neonatal mortality and stillbir2015 5.1 8/11 132/207
R 165a Quality of CCG leadership 17-18 Q2 Green #N/A #N/A 125b Experience of maternity servic 2015 76.4 8/11 169/207
Key 125c Choices in maternity services 2015 67.7 4/11 51/207
Worst quartile in England R 126a Dementia diagnosis rate 2017 11 88.5% 2/11 4/207
Best quartile in England R 126b Dementia post diagnostic supp2016-17 79.4% 7/11 92/207
Interquartile range R 127b Emergency admissions for UCS 17-18 Q1 2,199 5/11 90/207
R 127c A&E admission, transfer, disch2017 12 85.7% 6/11 71/207
R 127e Delayed transfers of care per 12017 11 12.0 4/11 121/207
R 127f Hospital bed use following em 17-18 Q1 444.9 4/11 36/207
* Patients diagnosed in 2015; # Patients diagnosed in 2014 105c % of deaths with 3+ emergency admissions in last three months of life (not available)
128b Patient experience of GP servic2017 83.8% 5/11 130/207
R 128c Primary care access 2017 10 100.0% 1/11 1/207
128d Primary care workforce 2017 03 1.00 3/11 91/207
R 129a 18 week RTT 2017 11 91.6% 4/11 98/207
130a 7 DS - achievement of standards (not available)R 131a % NHS CHC full assessments ta17-18 Q2 46.9% 9/11 180/207
132a Sepsis awareness (not available)
Good
Note: There are no data for NHS Manchester CCG (14L) for the following indictors: 121a, 121b, 121c, 122d, 125b, 125c, 163a, 163b and 164a
2016/17 Year End Rating:
Injuries from falls in people 65yrs +Utilisation of the NHS e-referral serviceProgress against WRESWorking relationship effectivenessCompleteness of the GP learning disability registerExperience of maternity services% NHS CHC full assessments taking place in acute hospital setting
Diabetes patients who achieved NICE targetsAttendance of structured education courseAMR: appropriate prescribingStaff engagement indexHigh quality care - adult social careOne-year survival from all cancersEIP 2 week referralMaternal smoking at deliveryChoices in maternity servicesDementia diagnosis rateHospital bed use following emerg admissionPrimary care access
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Measure TargetQuality
Premium allocation
MaximumAvailable
Type 1 A&E attendances plan
Non elective admissions with zero length of stay plan
NEL 1+ days
Non elective admissions with length of stay of 1 day or more plan
50% 537,570£
Measure TargetQuality
Premium allocation
MaximumAvailable
Early Cancer Diagnosis 4% point improvementORAt least 60% diagnosed at stage 1 & 2
17% £59,184
GP Access and Experience85% of respondents who said they had a good experience of making an appointmentOR3 percentage point increase from July 2018
17% £59,184
Continuing Healthcare
Part a) in more than 80% of cases with a positive NHS CHC Checklist, the NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the ChecklistPart b) less than 15% of all full NHS CHC assessments take place in an acute hospital setting.
17% £59,184
Mental HealthTBC based on CCG choice 17% £59,184
Bloodstream Infections 2017/18
Part a)i - 10% reduction (or greater) in all E coli BSI (30% weighting)ii - core primary care data set for E coli cases (10% Q2 & 5% Q3 weighting)Part b)30% reduction (or greater) in the number of Trimethoprim items prescribed to patients aged 70 years or greater (20% weighting)Part c)i - items per STAR-PU must be equal to or below 1.161 items per STAR-PU (10% weighting)ii - Additional reduction in Items per STAR-PU equal to or below 0.965 items per STAR-PU (25% weighting)
17% £59,184
Local indicator: TBC based on RightCare opportunitytbc
15% £52,221
NHS Constitution requirement Target Weighting Weight Value
The number of patients on an incomplete pathway not to be higher in March 2019 than in March 2018
March 2018 figure tbcFebruary 2018 = 15,740 50% £174,070
Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer
85%50% £174,070
537,570£
Pena
lty in
dica
tors
Emer
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eman
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anag
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icat
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Qua
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Indi
cato
rs
A&E/Short stay 50%
7. Quality Premium7.2 2017/18 Quality Premium
The QP scheme has been updated to align with the requirements in the 18/19 PlanningGuidance on the moderation of emergency care demand. The QP scheme will continue toimprove progress on key quality priorities such as cancer, mental health, RightCare andbloodstream infections.As set out in the 2018/19 Planning Guidance, the structure of the Quality Premium ischanging for the 2018/19 scheme year so as to incentivise moderation of demand foremergency care
As in previous years, the Quality Premium includes three Gateways. The Finance and NHSConstitution Gateways have been revised to align with the Planning Guidance.
Quality Gateway - no cases of serious quality failures at a local provider where CCG is notconsidered to have made appropriate, proportionate response with its partners to resolvefailures. Payments will be discretionary and subject to CCG assurance process criteria inrelation to quality failures where gateway is not achieved.
Financial Gateway - operate in a manner consistent with Managing Public Money; the CCGends the relevant financial year with an adverse variance to their approved plannedfinancial position, or requires unplanned financial support to avoid being in this position;the CCG does not meet the requirements set out in the Commissioner Sustainability Fundguidance.
NHS Constitution GatewayThe operation and focus of the NHS Constitution Gateway has been modified for 18/19. Inparticular, whilst it will continue to apply to the quality indicators, it will not apply to thenew Emergency Demand Management indicators. Given the introduction of an emergencydemand management element, and to remain aligned with the wider programmes, such asthe Urgent and Emergency Care programme, we have suspended the operation of thetests relating to Ambulance response times and 4 Hour A&E.
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9. Glossary
Abbreviation Full Term Description2WW Two Week Wait cancer standard Cancer waiting times standardA&E Accident and Emergency Hospital emergency departmentCCAS Camden Clinical Assessment Service CCG referral management serviceCSU Commissioning Support Unit Provides commissioning support functions to CCGsCWT Cancer Waiting Times Set of indicators measuring cancer performanceDTOC Delayed Transfer of Care When an adult inpatient is ready to be discharged from hospital but this is delayedEIP Early Intervention in Psychosis Access standard - 50% of patients should be treated within 2 weeks of referralIAF Improvement and Assessment Framework Set of indicators on which CCG performance is assessedIAPT Improving Access to Psychological Therapies Programme for treating people with depression and anxiety disorders.MAR Monthly Activity Return Central activity data return QIPP Quality, Innovation, Productivity and Prevention Programme to improve quality of care while making efficiency savingsRAG Red, Amber Green Colour coded rating based on performanceRAP Remedial Action Plan Recovery plan to bring performance back to complianceRTT Referral to Treatment target NHS constitution target to start consultant-led non-emergency treatment within 18 weeks of referralSI Serious Incident A serious event that warrants using additional resources to mount a comprehensive responseSTF Sustainability and Transformation Fund Funding to acute trusts based on delivery of quarterly milestonesSUS Secondary Uses Service Repository for healthcare data
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Camden Clinical Commissioning Group Governing Body Meeting on 09 May 2018
Report Title Approval of the Annual Report and Accounts Agenda Item 6.1 Date 09.08.18
Committee Chair (where applicable)
Richard Strang, Lay Member [email protected]
Lead Director Ian Porter, Director of Corporate Services for NCL
Tel/Email [email protected]
Report Author
Simeon Baker, Head of Communications & Engagement
Tel/Email [email protected]
GB Sponsor(s) (where applicable)
Helen Pettersen, Accountable Officer
Tel/Email [email protected]
Report Summary
Information
EXECUTIVE SUMMARY
All NHS bodies have a statutory requirement to produce an Annual Reports and Accounts (‘ARA’) as a single document. Camden CCG has adopted the template issued by NHS England (‘NHSE’) for the 2017-2018 financial year, which contains the following required sections.
1. The Performance Report: an overview and a performance analysis.2. The Accountability Report: Corporate Governance Report, Remuneration and
Staff Report and a Parliamentary Accountability and Audit Report.3. The Annual Accounts: including financial statements.
Draft submissions of the ARA to NHS England were required by 20th April 2018. The Camden CCG Audit committee reviewed the organisation’s draft ARA at its meeting on 18th April 2018 and the draft was submitted on 20th April.
Under the Constitution the Governing Body has delegated approval of the Annual Report and Accounts to the Audit Committee. The final submission will be presented to the Audit Committee for approval on 21st May 2018.
The table below shows the national and local timelines that the CCG is working to:
Table 1: National and Local Timelines
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Date Actions
April 2018
Friday 20 April
(noon)
CCGs to submit:
• Draft annual report as approved by the Accountable Officer (and passed to appoinauditors for audit).
• A full copy of the draft Head of Internal Audit Opinion statement as issued by the Cinternal auditors. To include a list of all audit reviews undertaken, and the level ofassurance assigned to each review.
• Completed NAO disclosure checklist 2017/18 for draft submission
May 2018
21st May 2018
Final draft of the ARA to be considered by the CCG Audit Committee
Tuesday 29 May
(noon)
Note:
Monday 28 May is a Bank holiday
CCGs to submit:
• Full audited ARA, signed and dated by the Accountable Officer and appointed audas one composite document.
• A full copy of the final Head of Internal Audit Opinion statement as issued by the Cinternal auditors. Submitted a separate document. Summary version included in th
• Completed NAO disclosure checklist 2017/18 for final submission
June 2018
By 15 June
CCGs to publish their ARA in full on their public website.
September 2018
Sept The ARA will be presented in public at a Camden CCG Annual General Meeting
Member Statement As part of our preparation and sign off of the Annual Report and Accounts each individual who is a member of the Governing Body at the time the Members’ Report is approved is required by NHS England to confirm the following statement:
• So far as the member is aware, there is no relevant audit information ofwhich the CCG’s auditor is unaware that would be relevant for the purposesof their audit report; and
• The member has taken all the steps that they ought to have taken in orderto make him or herself aware of any relevant audit information and toestablish that the CCG’s auditor is aware of it.
Governing Body Members are asked to support and confirm this statement.
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Purpose (tickone box only) [See note 6]
Approval To note
Decision
Recommendation
RECOMMENDED ACTION:
The Governing Body is asked to: • NOTE that authority for the approval of the final Annual Report and Accounts
has been delegated to the Audit Committee;• NOTE the Governing Body members’ responses to the disclosure to the
Members’ Report statement.
Strategic Objectives Links
This report supports all of the CCG’s Strategic Objectives by ensuring that Camden CCG continues to report its work transparently and openly through the Annual Report and Accounts.
Identified Risks and Risk Management Actions
This report helps to ensure that the Annual Report and Accounts are completed and approved on time.
Conflicts of Interest
Conflicts of Interest have been managed robustly in accordance with the NCL Conflicts of Interest Policy.
Resource Implications
None.
Engagement The Audit Committee includes lay members, elected GP representatives, internal and external auditors and a patient representative. In addition, the Annual Report and Accounts is a public document.
Equality Impact Analysis
This report was written in accordance with the provisions of the Equality Act 2010.
Report History and Key Decisions
The Annual Report and Accounts are published each year by the CCG. In addition, a draft version of the Annual Report and Accounts was submitted to the Audit Committee on 18th April 2018.
Next Steps To present the final draft Annual Report and Accounts to the Audit Committee on 21st May 2018.
Appendices None.
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Camden Clinical Commissioning Group Governing Body Meeting on 09 May 2018
Report Title Board Assurance Framework Agenda Item 6.2 Date 09.05.18
Lead Director Ian Porter, Director of Corporate Services for NCL CCCs
Tel/Email [email protected]
Report Author Andrew Spicer, NCL Head of Governance and Risk
Tel/Email [email protected]
GB Sponsor(s) (where applicable)
Richard Strang, Lay Member Tel/Email [email protected]
Report Summary The Board Assurance Framework (‘BAF’) captures the most serious risks identified as threatening the achievement of the CCG’s eight strategic objectives. The BAF includes some NCL wide risks escalated from the NCL Joint Commissioning Committee which takes a wider pan-NCL perspective. These are clearly set out as risks from an NCL perspective.
Number of risks
There are 12 risks on the BAF. Five are from a Local perspective with one new risk. Seven risks are from an NCL perspective.
Key Highlights- Local Perspective
Risk 431- Failure to deliver a robust QIPP plan for 2018/19 (Threat): Financial planning across NCL to develop the 18-19 QIPP targets have been completed and initial QIPP schemes identified and PIDS developed. ULCH has agreed the QIPP schemes incorporated into its baseline but negotiations with other providers are continuing. In addition, the current risk score has reduced from 20 to 16.
Risk 362- System Resilience (Threat): Work is continuing to mitigate this risk and the Remedial Action Plans across the CCG and UCLH are being formed into a single joint Remedial Action Plan.
Risk 382 - Failure to deliver the QIPP plan Forecast Out Turn for 17/18 (Threat): This risk is closed as the CCG met its control total in 2017-18.
New Risk
Risk 453- Negotiations of affordable Acute contracts for 2018-19 (Threat): Negotiations are underway with providers to ensure contracts are affordable. Governing Body representatives are reviewing QIPP schemes with provider clinicians and barriers to agreeing QIPP in contracts are being addressed.
NCL Joint Commissioning Committee Risk Register The NCL Joint Commissioning Committee (‘NCL JCC’) risk register has 7 risks with a current risk score of 15 or higher and therefore are reporting them to the Governing Body to ensure visibility and oversight. These risks are from a pan
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NCL perspective and therefore there is some overlap with Barnet CCG only risks.
Key Highlights JCC 1- Delivery of Cancer 62-day waiting time standard (Threat): NCL as a system delivered the standard in December 2017 but additional work is required for this to be sustainable. However, the individual recovery plan from UCLH defers their recovery of the standard from March 2018 to June 2018. Internal pathways are expected to be compliant in April 2018.
JCC 10- Mobilisation of STP and QIPP plans (Threat): The in-housing of functions from NEL CSU into the CCGs is underway. This will provide greater support and capacity to deliver STP interventions. However, additional capacity is needed to progress the work on alternative contract forms.
JCC 11- Managing Acute Contracts within Contract Baselines (Threat): Signed contracts with acute providers in place for 2017/18 and 2018/19 and contracts include marginal rate payments/deductions for variances from plan and 3% growth. This is higher than historic growth trends. System intentions have been issued to providers.
NCL Primary Care Co-Commissioning Risk Register The NCL Primary Care Co-Commissioning Committee in Common (‘NCL PCC’) risk register has 1 risks with a residual risk score of 15 or higher and therefore this risk is being reported to the Governing Body to ensure visibility and oversight. Risks from the NCL PCC can be from either a local perspective or a pan NCL perspective depending on the risk.
Risk 18- Primary Care Support England (Threat): The NHS England primary care support functions provided by NHS England and contracted to Capita have been significantly underperforming. This has led to a disruption in GP business continuity and potential cost pressures to CCGs. This risk is primarily managed by NHS England. NHS England meet with Capita regularly to try to resolve the issues and the NCL CCGs raise issues with NHS England at London primary care meetings.
NCL Risk Register A new NCL Risk Register has been developed which captures the key pan NCL risks that are not captured by our other risk registers.
The NCL Risk Register contains ten risks which include NCL and STP risks.
The NCL Risk Register will be reviewed regularly by the NCL Senior Management Team, the STP PMO and the assurance process will be overseen by the NCL audit committees.
Key Highlights NCL 4- Failure to Effectively Engage with Patients and the Public (Threat): A new Head of Communications for the STP has been recruited and will start in May 2018.
NCL 8- Recruitment and Retention a High Performing Workforce (Threat): The NCL HR team has been fully recruited to with all team members being in place by end of June 2018. Recruitment for the Organisational Development roles is under way.
NCL 9- Delivering Financial Balance Across NCL CCGs (Threat): 2018-19 budget planning is underway and QIPP plans will be implemented throughout the year.
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Purpose Information Approval To note
Decision
Recommendation The Governing Body is asked to review the risks and provide feedback on the updated BAF.
Strategic Objectives Links
The BAF focuses on risks relating to the strategic objectives of the CCG:
• Commission the delivery of NHS constitutional rights and pledges• Improve the quality and safety of commissioned services• Improve health outcomes, address inequalities and achieve parity of esteem• Integrate and enable local services to deliver the right care in the right setting
at the right time• Work jointly with the people and patients of Camden to shape the services
we commission• Involve member practices and commissioning partners in key commissioning
decisions• Maintain financial stability and ensure sustainability through robust planning
and commissioning of value-for- money servicesBuild a high performing organisation that attracts, develops and retains askilled and motivated workforce.
Identified Risks and Risk Management Actions
The BAF is a risk management document which is presented at every Governing Body report. It is available to members of the public on the CCG’s website.
Conflicts of Interest
None identified.
Resource Implications
Updating of the BAF is the responsibility of each risk owner and their respective directorates. The Governance Team helps to support this by providing monitoring, guidance and advice.
Engagement Not applicable for the purpose of this report.
Equality Impact Analysis
This report was written in accordance with the provisions of the Equality Act 2010.
Report History The BAF was last reviewed by the Governing Body on 14th March 2018 and by the Camden Executive Team on 1st May 2018. Risks are kept under review by committees of the Governing Body and risk owners.
Next Steps To continue to manage risk across the organisation in a robust way.
Appendices The following is attached:
1. BAF;2. BAF Heat Map;3. Risk Scoring Key;4. NCL Risk Register.
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1
ID Director Objectives Risk Controls in Place Evidence of ControlsOverall Effectiveness of Controls in Place
Cons
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(cur
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)
Like
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Actions Update on Actions Action Competion Date
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(Tar
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362
Jennifer Murray-Robertson,Director of Commissioning and Contracts
Commission the delivery of NHS Constitutional rights and pledges
TITLE: System Resilience (Threat)
CAUSE: There may be insufficient capacity within the system
EFFECT: Which may lead to the risk that the system may be unable to cope with changes and increases of activity at times of high demand, such as the winter time.
IMPACT: This may lead to performance issues in A&E (UCLH), referral to treatment targets, and elective care which may impact on patient care. The CCG may also suffer reputational damage.
C1. An A&E delivery board has been established which has executive level representation from key providers in the system.C2. A&E Delivery Board has developed a 'Heat Map' dashboard which monitors key parts of the system to highlight any issues in terms of capacity and/or performance.C3. With key providers, and using funding available to the A&E Delivery Board, agreed which parts of the system would benefit from increased capacity or efficiency changes. C4. Continued monitoring of the action plan (RAP) against agreed outcome measures.C5. A North Central London ('NCL') wide review of how winter went across NCL took place on 6th April 2017 to share lessons learned.C6. The A&E Delivery Board submitted plans to NHS England for winter 2017/18 based on experiences and pressures in 2016/17.C7. Community Bed Review completed;C8. Weekend Hub Access in place;C9. Extended Hours Service in place;C10. Senior CCG support in place at UCLH to support increased patient flow and DTOCs
C1. A&E Delivery Board papers (meets monthly)C2. Heat Map discussed at each A&E Delivery Board meetingC3. Bids submitted and considered at the A&E Delivery BoardC4. Monitored through the monthly UCLH performance meetingC5. Notes from the workshop.C6. Winter planC7. Outcome from review;C8. Documents, notes, e-mails;C9. Documents, notes, e-mails;C10. Documents, notes, e-mails.
AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk
4 4 16
Very High
A1. Combine remdial action plans across CCG and UCLH to form a single joint RAPA2. A&E Delivery Board to continue to review Heatmap dashboard and highlight issues;A3. The Remedial Action Plan with UCLH to be refreshed;A4. Implementation plan for Ambulatory Emergency Care to be agreed with UCLH;A5. Agree an increase of admissions avoidance and RAPIDS with CNWL to deliver significant additional volumes.
A1. RAP being reviewed for ongoing recovery trajectory and actions. AAR on winter plan to be carried out in May.A2. A&E Delivery Board continues to meet monthly.A3. Work is progressing on this;A4. Work is progressing on this with delivery planned for October 2018;A5. Work is progressing on this with additional volumes planned for October 2018 from May 2018.
A1. 22.04.18.A2. Meetings are held continuously on a monthly basis;A3. 31.05.2018;A4. 30.06.2108;A5. 30.05.2018
4 3 12
High
434
Jennifer Murray-Robertson, Director of Commissioning and Contracts
Commission the delivery of NHS constitutional rights and pledges
TITLE: Delivery of Cancer 62-day waiting time standard (Threat)
Cause: Performance against the 62 day waiting time standard at UCLH is impacted by whole system performance, particularly late inter-trust transfers.
Effect: There is a risk that the Trust may be unable to cope with the level of demand.
Impact: This may result in patients not receiving treatment within 62 days.
C1. Regular performance meetings with providers and strengthened CCG performance management process in place.C2. Use of contractual leavers where applicable.C3. RAPs being implemented and monitored.C4. North Central London ('NCL') cancer governance arrangements established to cover both performance and transformation.C5. Improvement trajectory agreed with NHS England and NHS Improvement.C6. 38 day transfer protocol in place for inter-provider transfers from district general hospitals to tertiary services with the 38 day standard compatible with treatment commencing within 62 days.
C1. Meeting papers and notes.C2. CPN issued.C3. RAPs monitored at the monthly performance meetingC4. Transfer protocol document.C5. TrajectoryC6. Transfer protocol.
AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk
4 4 16Very H
igh
A1. Continue to work with providers on delivering the trajectories.A2. Continue to work with providers to ensure sustainable delivery and includes work through the cancer vanguard.A3. UCLH recovery of the 62 day standard by end of March 2018.
A1. Meeting with providers on a monthly basis and ensuring their plans are consistent with agreed trajectories.A2. Meeting with providers on a monthly basis.A3. Currently on track for delivery. 62 day standard target was met for Feburary for CCG. UCLH continues on plan against recovery trajectory and delivery of RAP actions.
A1. Meetings are held continuously on a monthly basis.A2. Meetings are held continuously on a monthly basis.A3. 30th June 2018.
4 3 12
High
432
Jennifer Murray-Robertson,Director of Commissioning and Contracts
Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for- money services
TITLE: Increased costs due to acute over-performance (Threat)
Cause: if expenditure on acute contracts exceeds planned contract baselines
Effect: Increased acute expenditure leading to requirement for additional in-year and future QIPP delivery
Impact: recovery plan and additional in-year and future QIPP requirements. may impact on delivering a balanced control total. May increase baseline acute costs in 18-19
C1. Signed contracts in place for 2017/18 and 2018/19C2. Contracts include marginal rate payments/deductions for variances from plan and 3% growth (higher than historic growth trends) C3. Contract management framework in place with providersC4. Issue of contract notices in line with contact provisionsC5.. Mobilisation of STP and QIPP plans (see JCC10)C6. North Central London Finance and Activity Modelling (FAM) Group, with commissioner and provider membership. that oversees system financial positionC7. Work on alternative contract forms to support the Sustainability and Transformation Plan (STP) through the Acute Contract Modelling Group (with commissioner and provider membership)C8. Monthly finance and performance monitoring of acute contracts
C1. Signed contractsC2. Signed contractsC3. Meeting minutes and papersC4. Contract documentation and correspondence including remedial action plansC5. See JCC10C6. Meeting minutes and papersC7. Meeting minutes and papersC8. Finance & Performance reporting
AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk
5 4 20
Very High
A1. Develop, in co-production, with providers, proposals for alternative contract forms for hospital providersA2. Pursue all contractual remedies for inappropriate charging beyond standard challenges. These include PoLCE (incorporating RLHIM), 30-day readmission threshold at local trust, application of access policy, and coding notification issues at a neighbouring trust.A3. Issue all necessary Contract
A1. Consideration of models used elsewhere - Aligned Incentive Contract in Bolton; Accountable Care models. This work is being developed with the STP throughout 2018.A2. The Quarter 2 negotiations with UCLH have concluded. Quarter 3 has been shared . The Quarter 2 negotiations with Royal Free London are continuing. Due to the challenges within the negotiations it is expected that these may not be concluded until summer 2018.A3. Notices have been issued and are followed
A1. 31.12.18.A2. 30.08.18.A3. 30.06.2018.
4 4 16
Very High
NHS Camden Clinical Commissioning Group- BAF Risks From A Local Perspective
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2
ID Director Objectives Risk Controls in Place Evidence of ControlsOverall Effectiveness of Controls in Place
Cons
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nce
(cur
rent
)
Like
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Ratin
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453
Jennifer Murray-Robertson - Director of Contracts & Commissioning
Maintain financial stability and ensure sustainability through robust planning and commissioning of value for money services
Title: Negotiations of affordable Acute Contracts for 18/19 (Threat)
CAUSE: Failure to agree impact of QIPP with acute providers.
EFFECT: Final contract values would be unaffordable and the impact of marginal rate represents significate risk to the CCG.
IMPACT: May impact on delivering balance control total and require significant QIPP intervention.
C1. Joint clinical review of QIPP schemes.C2. Renegotiation of marginal rate mechanisms.
C1. Diary invites, meeting agendas and presentation pack.C2. Options appraisal of existing and potential marginal rates construct.
AVERAGE: The controls have a 61 – 79% chance of successfully controlling the risk
4 4 16
High
A1. GB representatives to review QIPP schemes with RFH cliniciansA2 Review mechanisms behind MR to evaluate potential to lift the barrier to agreeing QIPP in contractsA3. consider not agreeing 18/19 values until 17/18 year end issues are resolved.
A1. Clinical review sessions were held 26th and 27th April. Pending outcome to inform next steps.A2. Work has been commenced to consider amending or removing MR mechanisms in contracts - due for first assessment 4th May. The first draft is expected by 4th May 2018.A3. work continues to reconcile 17/18 year end, however as an action to inform 18/19 this is not yet live. The year end postions are expected to be identified by 31st May 2018.
A1. 30.04.2018;.A2. 04.05.2018A3. 31.05.2018.
3 3 9
Moderate
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North Central London CCG Risk Register as at April 2018
ID Director Objective Risk Controls in place Evidence of Controls
Overall Strength of Controls in
Place
Consequence Likelihood (Current)
Rating (Current)
Risk level (Current)
Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on ActionsConsequence (Target)
Likelihood (Target)
Rating (Target)
Risk level (Target)
A1. 30.09.2017A2. 01.07.2018A3. 23.03.2018
3 12
High
CN1. CCG system leadership for commissioning. Contract requirement to signal major contact/service changesCN2. Proposals for realigning system incentives.
A1. Develop and sign-off system intentions for 2018/19A2. Develop, in co-production, with providers, proposals for alternative contract forms for hospital providersA3. Development of planning assumptions for 2018/19 with providers.
A1. Action completed. System intentions issued to providers. A2. Consideration of models used elsewhere - Aligned Incentive Contract in Bolton; Accountable Care models. Work has commenced on this and is continuing.A3. Planning assumptions are being developed through STP finance meetings following publication of national planning guidance. 4
4 3 12
High
JCC11
Paul Sinden, NCL Director of Performance and Acute Commissioning
Management of acute contracts to ensure contracts are delivered within contact baselines (CCG resource envelopes)
Managing acute contracts within contract baselines (Threat)
Cause: if expenditure on acute contracts exceeds planned contract baselines
Effect: There is a risk that CCGs will not meet their financial duties and/or investment is withheld to support delivery of the Sustainability and Transformation Plan
Impact: This may result in delays to investing in primary care and community capacity and perpetuate the risk over performance on acute hospital contracts
C1. Signed contracts in place for 2017/18 and 2018/19C2. Contracts include marginal rate payments/deductions for variances from plan and 3% growth (higher than historic growth trends) C3. Contract management framework in place with providersC4. Issue of contract notices in line with contact provisionsC5.. Mobilisation of STP and QIPP plans (see JCC10)C6. North Central London Finance and Activity Modelling (FAM) Group, with commissioner and provider membership. that oversees system financial positionC7. Work on alternative contract forms to support the Sustainability and Transformation Plan (STP) through the Acute Contract Modelling Group (with commissioner and provider membership)C8. Quarter one reconciliation agreed with providers as a precursor to establishing the opening contract baseline for 2018/19C9. Agreement of treatment of disputed items with Royal Free London in 2017/18 reached
C1. Signed contractsC2. Signed contractsC3. Meeting minutes and papersC4. Contract documentation and correspondence including remedial action plansC5. See JCC10C6. Meeting minutes and papersC7. Meeting minutes and papersC8. Meeting minutes and papers
Average
4 4 16
Very high
CN1. Development of system intentions for 2018/19CN2. Develop proposals to realign system incentives including new contract forms for hospital contracts
Paul Sinden, NCL Director of Performance and Acute Commissioning
JCC 10
CN1. Realigned CCG and CSU teams for contract frameworks that release resources to support the STPCN2. Proposals for alternative contract form
Very High
3 4 12
High
RISKS FROM THE NCL JOINT COMMISSIONING COMMITTEE
Very High
CN1. Arrangement to be put into place to ensure all providers are abiding by the inter-provider transfer protocol.CN2. Individual providers to resolve internal pathway issues to ensure they meet the 62 day target.CN3. Backlog reduction by providers to level consistent with delivery of the waiting time standard.
CN1. Improvements delivered in-line with agreed trajectories and contained in reports.CN2. Improvements delivered in-line with agreed trajectories and contained in reports.CN3. Analysis agreed with NHS Improvement indicates maximum backlog level to deliver the standard
A1. Continue to work with providers on delivering the trajectories.A2. Continue to work with providers to ensure sustainable delivery and includes work through the cancer vanguard.A3. NCL recovery of the 62 day standard by December 2017.A4. UCLH recovery of the 62 day standard by end of March 2018 and is consistent with system recovery by December 2017. Updated recovery plan required from the Trust.
A1. Provider meetings continue on a fortnightly basis on recovering the trajectories. A2. Cancer vanguard meetings in place with provider and commissioner representation which meet monthly.A3. NCL delivered the standard in December 2017 but further work is required for sustainability. This work is being undertaken and is reflected in action A4.A4. UCLH recovery plan received but defers recovery to June 2018 from expected recovery by March 2018. Internal pathways are expected to be compliant by April 2018.
A1. 30.06.2018A2. 30.06.2018A3. 30.06.2018A4. 30.06.2018
C1. Meeting papers and notes.C2. Plans and trajectories in place with providers to allow NCL to meet the standard overall. Backlog analysis indicates reduction towards sustainable level. Progress most marked at Royal Free London in October and November. C3. Plans. C4. Transfer protocol document.C5. Provider trajectoriesC6. Provider recovery plan
Average
4 4 16JCC 1
Paul Sinden, NCL Director of Performance and Acute Commissioning
62 Days Waiting Time Standard is Met
Delivery of Cancer 62-day waiting time standard (Threat)
Cause: There may be insufficient capacity within the system, and inefficiencies along pathways in particular for inter-provider transfers.
Effect: There is a risk that the system may be unable to cope with the level of demand and has limited resilience to unexpected events.
Impact: This may result in people not receiving treatment within 62 days with potential adverse impact on their health outcome.
C1. North Central London ('NCL') cancer governance arrangements established to cover both performance and transformation.C2. Improvement trajectory agreed with NHS England and NHS Improvement.C3. Remedial Action Plans in place with providers that are not meeting the 62 day standard. Updated plan received from Royal Free London.C4. 38 day transfer protocol in place for inter-provider transfers from district general hospitals to tertiary services with the 38 day standard compatible with treatment commencing within 62 days.C5. Trajectory agreed with providers to meet the 38-day standard for transfers of careC6. Recovery plan received from UCLH, with overall compliance by June 2018 and compliance on internal pathways by April 2018
16
Average
44
Mobilisation of STP and QIPP plans (Threat)
Cause: if we do not ensure that STP and QIPP plans are delivered in accordance with planning assumptions
Effect: There is a risk that contracts will not be delivered within resource envelopes for 2017/18
Impact: This may result in delays to service changes, higher contract baselines for 2018/19 than anticipated in financial plans for CCGs, and a wider system financial gap.
CN1. CCG and CSU redirection of capacity to support mobilisation of STP interventionsCN2. Collaborative work with providers to realign system incentives, and contract form, to support STP delivery
Effective mobilisation of Sustainability and Transformation (STP) plans and CCG QIPP plans to ensure contracts remain within resource envelopes
A1. Finalise proposals to increase support for STP work streams A2. Progress the work of the acute contract modelling group to consider alternative contract forms
A1. In-housing of NELCSU to provide greater support and capacity for delivery of STP interventions is underway.A2. Work is progressing but needs additional capacity to put into place shadow proposals for 2018-19.
C1. Signed contractsC2. Meeting minutes and papersC3. Signed contractsC4. Meeting minutes and papersC5. Meeting papersC6. Meeting papers and project initiation documents
C1. Signed contracts in place for 2017/18 and 2018/19C2. Contract frameworks in place with each provider including Local Delivery Teams to support the STPC3. In-year contract variances subject to marginal rates rather than full tariff adjustments C4. Collaborative arrangements in place through Finance and Activity Modelling (FAM) Group as part of STP governance frameworkC5. Sustainability and Transformation Plan governance and supporting work streams with commissioner and provider membership in placeC6. Development of schemes for 2018/19 underway. Project initiation documents shared with providers for planned care, care closer to home, and urgent and emergency care
A1. 01.07.2018.A2. 01.07.2018
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ID Director Objective Risk Controls in place Evidence of Controls
Overall Strength of Controls in
Place
Consequence Likelihood (Current)
Rating (Current)
Risk level (Current)
Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on ActionsConsequence (Target)
Likelihood (Target)
Rating (Target)
Risk level (Target)
A1. 13.10.2017A2. 30.11.2017A3. 31.12.2017A4. 31.01.2018A5. 31.03.2018A6. 30.04.2018.
A1. 30.11.2017A2. 23.03.2018A3. 23.03.2018A4. 01.07.2018A5. 01.07.2018
A1. 31.01.2018A2. 31.03.2018A3. 23.03.2018A4. 31.01.2018
High
A1. Plans submitted to STP finance group in November 2017.A2. Options being refreshed following issue of national planning guidance.A3. Negotiations are underway with completion targeted in line with national timetable.A4. Work is progressing but needs additional capacity to put into place shadow proposals for 2018-19.A5. Open book approach to provider cost profiles agreed and work is underway to provide the information.
3 3 9
16
Very high
4 4 16
Very JCC 18
Paul Sinden, NCL Director of Performance
Reducing the system financial
NCL is a system in deficit. One of the aims of our Sustainability and Transformation Plan is to deliver financial recovery and maintain and sustainable health and care system. The STP sets out the challenges to financial recovery from demographic and demand trends. (Threat)
Cause: if our plans do not deliver financial balance
Effect: There is a risk that additional savings plans will need to be developed that have a greater impact on service delivery and access than current plans, and the local system comes under greater scrutiny from regulators.
C1. STP finance meeting established that has a common view of system deficit C2. Collaborative approach to contracting round for 2017/18 and 2018/19 C3. Work on alternative contract forms for future years to support cost reductionC4. Monthly reporting cycle and monitoringC5. Working groups established for areas of pressure and with scope for cost reduction - estates, continuing healthcare, demand management etc.C6. Iterative CCG QIPP plans
C1. Meeting papers and minutes from STP finance group C2. Contract documentation; notes from STP finance group.C3. Notes from acute contract modelling groupC4. ReportsC5. Meeting notesC6. Reports.
Average
4 5 20
Very CN1. Identify opportunities for year-end settlements with providers to allow planning certainty and focus on cost reductionCN2. Identification of further savings opportunities for the system CN3. Ensure mobilisation of STP and local interventions (see JCC 10)
CN1. Quarter one reconciliation process. Both CCGs and providers under financial pressure CN2. CCG finance reports - risks outweigh opportunities in 2017/18CN3. See JCC10
A1. Finalise quarter one reconciliation process to identify opportunities for year-end settlementsA2. Continue to identify further savings opportunities A3. 2081/19 planning round to set contract baselines for 2018/19A4. Greater alignment of CCG QIPP and provider cost improvement programmes (CIP) for 2018/19
A1. Action completed. A2. Work is on-going. Opportunities are being developed through STP finance group and locally by CCGs A3. Process for planning round agreed through STP finance group and work is on-going.A4. QIPP/CIP meeting held in January 2018.
JCC 14
Paul Sinden, NCL Director of Performance and Acute Commissioning
Mobilising STP schemes that shifts activity away from acute providers in a way that allows those providers to release capacity and costs, and thereby reduce overall system costs
STP and local plans target the shift of care from hospital into community settings, to reduce the overall system financial deficit this needs to be done in a way that allows hospital providers to reduce capacity and costs. This risk follows on from the initial risk of mobilising STP and local plans in JCC10 (Threat)
Cause: if we are unable to shift care from hospital to community settings that allow providers to make a step-change in capacity
Effect: There is a risk that hospital providers are left with stranded costs and we do not reduce overall system costs
Impact: STP and local interventions do not help reduce the system financial deficit in the anticipated way.
C1. Signed contracts for 2017/18 and 2018/19 that include the impact of STP interventionsC2. System intentions for 2018/19 that seek to align intentions across CCGS so we commission at scaleC3. Agreement of approach to planning round for 2018/19 with providers through STP finance meetings. Contract baselines for 2018/19 to include the impact of STP interventions. C4. Work with providers on alternative contract forms to support STP delivery, with the work informed by provider cost profiles.C5. STP Finance meetings with commissioners and providers that has a common understanding of financial position in NCL systemC6. STP interventions for 2018/19 developed and shared with providers
C1. Contract documentationC2. NCL Systems Intentions letterC3. Meeting paper and notes.C4. Meeting papers and notes. C5. Meeting papers and notesC6. Meeting papers and project initiation documents.
Average
4 4 16
Very high
CN1. Development of STP work streams interventions plans for 2018/19CN2. Agreement of contract baselines for 208/19 CN3. Development of alternative contract models and incentive systems
CN1. Interventions impacts need to be planned and agreed for incorporation into contractsCN2. Signed contracts for 2017-19 require the negotiation of contact baselines for 2018/19CN3. Alternative contract forms need to be shadow run in 2018/19 to be used in contracts from 2019/20 onwards
A1. Work streams development of STP plans for 2018/19.A2. Agree option for setting contract baselines for 2018/19.A3. Negotiation of contract baselines for 2018/19 incorporating 2017/18 plan/outturn, growth and impact of interventions.A4. Agree models for alternative contract forms to be shadow run in 2018/19A5. Create finance and activity schedules that support the shadow running od the alternative contract forms.
A1. Agree escalation process for NCL with NHS England and NHS Improvement A2. Hold winter workshop on 27 SeptemberA3. Identification of further recover plans through winter workshop and A&E Delivery BoardsA4. Provider mutual aid plans developed for January 2018 to free up clinical time from elective care pathways to support emergency patient flows A5. Each A&E deliver board to complete an after action review process for winter 2017-18.A6. Plans for winter 2018-19 to be submitted to NHS England by end of April 2018.
A1. Action completed. NCL approach to escalation agreed in principle with NHS England. All A&E Delivery Boards have agreed escalation protocols to respond to surges in pressure and/or demand A2. Action completed. Actions from winter workshop were actioned through A&E Delivery Boards A3. Additional plans submitted by A&E deliver boards in December 2017.A4. Action completed. A5. Work is progressing on this.A6. Work is progressing on this.
4 420
Very high
CN1. Development of NCL-wide escalation process for winter 2017/18 CN2. NCL winter workshop on 27 September to align plans across A&E Delivery Boards.CN3. Development of further plans for winter 2017/18 to ensure resilience
CN1. NCL wide escalation process;CN2. Notes of workshop;CN3. Plans.
JCC 13
Paul Sinden, NCL Director of Performance and Acute Commissioning
Management of winter pressures to support recovery of A&E waiting time standard and protect capacity for delivery of cancer and referral-to-treatment waiting time standards
Ensuring that management of winter pressures supports recovery of waiting time standards for A&E and cancer and protects capacity for elective pathways (Threat)
Cause: if we are unable to manage non-elective flows within planned hospital and community capacity to meet winter pressures
Effect: There is a risk that patients may receive sub-optimal care and long waiting times leading to the local system missing waiting time standards for A&E and referral-to-treatment. Historically capacity to meet cancer waiting time standards has been successfully ring-fenced.
Impact: Patients may remain in inpatient placements longer than anticipated as community care packages are developed.
C1. Establishment of A&E Delivery Boards with representation across health and care system C2. Establishment of NCL Urgent and Emergency Care (UEC) BoardC3. STP work streams for urgent and emergency care established for long-term sustainability.C4. Winter plans for 2017/18 prepared by each A&E Delivery BoardC5. Recovery plans submitted by each A&E Delivery Board to regain A&E four-hour waiting time standardC6. See JCC2 - recovery of A&E four-hour waiting time standardC7. Supplementary winter plans submitted by each A&E Delivery Board to NHS England and NHS Improvement in December 2017
C1. Meeting papers and minutes from A&E Delivery BoardsC2. Meeting papers and minutes from UEC Board .C3. Work streams plans and QIPP monitoring reportsC4. Plans submitted and reports/dashboards monitoring progress.C5. Plans submitted and reports/dashboards monitoring progress.C6. See JCC2C7. Funding confirmation for priority supplementary schemes from NHS England
Average
4 5
Page 346 of 422
ID Director Objective Risk Controls in place Evidence of Controls
Overall Strength of Controls in
Place
Consequence Likelihood (Current)
Rating (Current)
Risk level (Current)
Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on ActionsConsequence (Target)
Likelihood (Target)
Rating (Target)
Risk level (Target)
3 3 9
High
Very High
CN1. Receipt of Royal Free London remedial action planCN2. Build more effective early warning system for long waits CN3. Development of planned care initiatives in the STP to support delivery of elective pathwaysCN4. Agreement of contract terms including tariff for Clinical Advice and Navigation.CN5. Ensure payment for waiting list backlog consistent with marginal rates set in the contractCN6. Understand impact of winter planning mutual aid on elective waiting time performance
CN1. Plan;CN2. Growth in long waits including waits over 52 weeks (for which clinical harm reviews are undertaken)CN3. STP service developments offset demographic growthCN4. Clinical Advice and Navigation requires a different tariff to outpatient referralCN5 Under performance in 2017/18 due to backlog recouped at marginal rate, pay for backlog clearance at marginal rate if falls into 2018/19CN6. Trust plans to free-up clinical capacity from elective pathways to support winter pressures
A1. Continue to work with UCLH and Royal Free London on delivery of remedial action plansA2. Continue to work with providers to ensure sustainable delivery including work through the STPA3. Develop activity plans for 2018/19 for sustainable deliveryA4. Develop tariff arrangements for Clinical Advice and Navigation
A1. Updated Remedial Action Plan received from Royal Free London in March 2018. Continuing to monitor remedial action plans through contract meetings. A2. Action completed. Development of planned care initiatives for 2018/19 are completed. A3. Development of activity plans for 2018/19 underway taking into account national planning guidance that waiting lists should be maintained at current levels as a minimum.A4. Draft tariff agreed by commissioners which will be shared with providers.
A1. 31.03.2018A2. 30.11.2017A3. 23.03.2018A4. 23.03.2018.
C1. Meeting papers and notes.C2. Agreed remedial action plan C3. STP Project Initiation Documents (PIDs)C4. Draft remedial action plan
Average
4 4 16JCC 20
Paul Sinden, NCL Director of Performance and Acute Commissioning
18-week referral-to-treatment waiting time standard is met
Delivery of referral-to-treatment (RTT) waiting time standard (Threat)
Cause: There may be insufficient capacity within the system, and inefficiencies along pathways.
Effect: There is a risk that the system may be unable to cope with the level of demand and has limited resilience to unexpected events.
Impact: This may result in people not receiving treatment within 18 weeks of referral from their GP with potential adverse impact on their health outcome.
C1. Contract governance arrangements established to cover performance.C2. Remedial action plan agreed with UCLH. C3. Planned Care work stream considering demand management schemes to support RTT delivery including Clinical Advice and Navigation. C4. Remedial action plan received from Royal Free London but with recovery of the waiting time standard targeted by August 2018. CCGs and NHS Improvement are challenging the Trust for a faster recovery.
4 4 16 high
JCC 18 Performance and Acute Commissioning
deficit in line with planning assumptions
Impact: Delivery of our STP developments is slowed down and impact reduced. Greater local resource is taken up with assurance processes
4 5 20 high
Page 347 of 422
BAF Risk Heat Map
2 3 4 5
3
4
5
Consequence
Likelihood
2
1
1
434
434
Current Risk Score: Target Risk Score:x x
362
362
JCC 1
JCC 1
JCC 2
JCC 10
JCC 10
JCC 11
JCC 20
JCC 13JCC 13
JCC 14
JCC 14
JCC 18
JCC 18
432
431
431432
JCC 20JCC 11 453
Page 348 of 422
NCL Risk Register April 2018
ID Director Objective Risk Controls in place Evidence of Controls
Overall Strength of Controls in
Place
Consequence
Likelihood
Rating (Current)
Risk level
Controls Needed Evidence of Controls Needed Actions Action Completion Date Update on Actions
Consequence
Likelihood (Target)
Rating (Target)
Risk level (Target)
NCL 1Will Huxter, NCL Director of Strategy
Successful delivery of the STP transformation agenda
Delivery of the Transformation Agenda (Threat)
Cause: If the STP does not have sufficient clinican and political support and suitable capacity and resources
Effect: There is a risk that the STP will not deliver the expect financial or quality benefits and that services are not appropriately integrated
Impact: This may result in a system wide financial deficit and deterioration in clinical quality which will negatively impact on patient care and reputational damage.
C1. Clinical leaders are in place across workstreams;C2. NCL wide Health and Care Cabinet established to oversee plans;C3. Recruitment to STP programme team is in progress;C4. QIPP Planning processes in NCL aligned with STP;C5. On-going senior enagement with local councillors and with the Joint Health and Overview Scrutiny CommitteeC6. STP programme infrastructure in place including programme board with senior representation from parter organisations and a sector wide finance group;C7. Robust planning process in place including regular reviews with NHS England and NHS Improvement;C8. Commissioning intentions;C9. Service business cases and project plans;C10. CCG commissioning teams and Provider teams in place;C11. Clinically led STP delivery plans in place.
C1. Terms of reference and project documentation;C2. Papers;C3. Job adverts and employment contracts;C4. Finance reports, CCG QIPP plans.C5. Meeting papers.C6. Terms of reference and meeting papers.C7. Programme delivery plans, notes and minutes from meetings;C8. Governing Body papers; C9. Business case and project plan papers;C10. Employment contracts;C11. Documents and papers.
Average
4 3 12
High
CN1. On-going work to link to new CCG operating models is in progress.CN2. Scope and develop provider focussed efficiency workplan;CN3. Complete recruitment to STP programme team.CN4. Strengthen Health and Care Cabinet and link back to partner organisationsCN5. Improve tracking of benefits across programmes.
CN1. Papers, Standing Operating Procedures;CN2. Provider focussed delivery plan;CN3. Employment contracts;CN4. Refreshed Terms of Reference and communications plans;CN5. Benefit tracker.
A1. Continue to work with CCGs on linking CCG operating models to STP plans.A2. Scope and develop provider focussed efficiency workplan;A3. Complete recruitment to STP programme team;A4. Revise terms of reference for Health and Care Cabinet;A5. Develop communications plan;A6. Develop new programme highlight reports containing benefits tracker.
A1. 14.02.2019A2. 01.04.2018;A3. 01.09.2018;A4. 30.05.2018;A5. 30.05.2018;A6. 30.05.2018
A1. Alignment on QIPP is completed. Alignment on risk management is underway;A2. SRO appointed and areas of scoping chosen;A3. 80% posts recruited to substantively;A4. Terms of reference under review;A5. Communication manager recruitment in progress;A6. A review of this is in progress.
4 2 8
High
NCL 2
Paul Sinden, Director of Performance and Acute Commissioning
Maintaining System Stability
Sustainability of Fragile Services (Threat)
Cause: If the STP does not recognise the need for system stability across services and providers
Effect: There is a risk that smaller and fragile services become unsustainable
Impact: This may result in disruption to patient services and system instability.
C1. NCL Joint Commissioning Committee in place which considers issues of system stability;C2. Relevant STP programme boards feed into service plans where appropriate;C3. CCGs have commissioning teams in place;C4. Governing Bodies focus on issues when they arise;C5. CCG commissioning intentions;C6. Commissioners feed into development of workstream plans.
C1. Terms of reference and committee papers;C2. Minutes and notes of programme board meetings;C3. Stuffing structure and employment contracts;C4. Governing Body and committee meeting papers and minutes;C5. Document;C6. Minutes and notes of programme board meetings.
Average
3 3 9
High
CN1. Strengthened oversight of totality of provider contracts: CN2. Centrally held registers of contracts in each CCG;CN3. Overview of fragile services
CN1. Completed register of contracts, named leads;CN2. Completed register of contracts;CN3. Notice from providers on service cessation for unsustainable services.
A1. Development of contract registersA2 Identification of fragile services
A1. 30.06.2018A2. 30.09.2018
A1. CCGs developing contract registers and identifying small contracts rolled forward year-on-yearA2. STP planned care workstream identifying fragile and at-risk services in providers 3 2 6
Moderate
NCL 3 Simon Goodwin, NCL CCGs CFO
Development of an Effective STP Estates Strategy
Failure to Develop an Effective STP Estates Strategy
Cause: If the STP partners do not develop an effective estates strategy for the STP which takes into account the resources within the system and the current limitations of national legislation
Effect: There is a risk that the Estates Strategy does not deliver the most effective use of resources and impacts on services and staff
Impact: This may result in wasted resources, opportunity costs, reputational damage and difficulties in recruiting and retaining high quality staff.
C1. STP Estates Board established;C2. STP SRO appointed;C3. Working with STP partners, regulators and the London Estates Board to understand the key objectives.
C1. Terms of Reference, meeting papers and notes;C2. Papers and notes of meeting;C3. E-mails, papers and notes.
Average
3 3 9
High
CN1. Develop STP estates strategyCN2. Ensure appropriate link between STP Estates Board and NCL CCG Governing Bodies.
CN1. Estates Strategy paper;CN2. Governance chart, Governing Body papers and reports.
A1. Develop draft STP estates strategy for engagement with key partners;A2. Establish appropriate governance arrangements for the STP Estates Board
A1. 30.07.2018;A2. 31.03.2018
A1. Initial draft NCL estates workbook completed – system engagement underway with next draft due 7.2018 A2. Strategy outlines proposed Terms of Reference and governance.
3 2 6
Moderate
NCL 4
Helen Pettersen, NCL CCGs Accountable Officer
Effective Engagement with Patients and the Public
Failure to Effectively Engage with Patients and the Public (Threat)
Cause: If the STP partner organisations do not effectively engage with patients and the public as part of the STP process
Effect: There is a risk that the STP process is not properly understood by patients, the public and their representatives causing them to disengage
Impact: This may result in service design not taking proper account of the needs of local people, reputational damage and a blcokage to integrated services.
C1. STP governance structure which includes significant clinical and public oversight;C2. Health and Well Being Boards;C3. Joint Health Overview and Scritiny Committee;C4. CCG Governing Bodies;C5. Provder Board of Directors and Council of Governors where appropriate;C6. Local Councils and Councillors;C7. NCL Advisory Board including councillors, Healthwarch and the Chairs of STP partner organisations;C8. Health and Care Cabinet with extensive clinical leadership;C9. CCGs and Providers have their own communications and engagement teams and local patient and public engagement mechanisms and meetings;C10. Named Communications Lead in each CCG.
C1. STP plan;C2. Papers and minutes of meetings;C3. Papers and minutes of meetings;C4. Papers and minutes of meetings;C5. Papers and minutes of meetings;C6. Papers and minutes of meetings;C7. Papers and minutes of meetings;C8. Papers and minutes of meetings;C9. Contracts of employment, meeting papers and notes;C10. Employment contracts.
Average
4 3 12
High
CN1. Recruit to Head of STP Communications role;CN2. STP communications and engagement plan;
CN1. Employment contract;CN2. Finalised STP communications and engagement plan.
A1. Recruit Head of STP Communications A2. Draft STP Communcations and Engagement Plan.
A1. 01.09.2018;A2. 30.05.2018
A1. A1. Head of Ccomms due to start in May 2018;A2. This will begin once the Head of STP Communications is in role.
4 2 8
High
NCL 5
Helen Pettersen, NCL CCGs Accountable Officer
Achievement of STP Year 2 Objectives
Purdah Period and the Impact of Local Elections (Threat)
Cause: If there is an inability for decision making at the local Councils due to the Purdah period or if there is signficant change of policial leadership and direction of travel due to local council elections in 2018
Effect: This is a risk that the Council cannot make key decisons as an STP partner organisation and/or that a change in personnel and policy within one of more local councils
Impact: This may result in a delay in the implemntation of the STP workstreams and/or the need to develop and strengthen new relationships to preservice continuity of delivery.
C1. Continued work with the Joint Health Oversight and Scrutiny Committee;C2. Continue to work with local authroity partner organisations;C3. Continue to work with and strengthen relationships with local councillors;C4. Continue to effectively engage.
C1. Papers and minutes of meetings;C2. Papers and minutes of meetings;C3. Papers and minutes of meetings;C4. Papers and minutes of meetings, communications, e-mails.
Average
4 3 12
High
CN1. An STP induction programmeCN2. Ensure clearer narrative between STP programmes and postive impact on local people;CN3. STP Communications and Engagement Plan;CN4. Quickly build relationships with new local councillors;CN5. Involve existing and new local councillors in on-going development of STP.
CN1. Register of attendance, induction pack;CN2. Communications;CN3. STP Communications and Engagement Plan document;CN4. E-mails and correspondence;CN5. E-mails, correspondence and papers.
A1. Create STP indiction pack;A2. Develop KPIs for workstreams which demonstrate positive impact on local people;A3. Draft STP Communcations and Engagement Plan;A4. Identify and make contact with new councillors after local elections in 2018;
A1. 03.05.2018;A2. 03.05.2018;A3. 30.05.2018;A4. 04.05.2018
A1. Action in progress;A2. Action in progress;A3. This in being developed;A4. This will be completed after the results of the local elections are announced.
3 3 9
High
NCL 6Will Huxter, NCL CCG Director of Strategy
Ensuring Effective Decision Making
Lack of Clarity on STP and NCL CCG Governance Arrangements (Threat)
Cause: If there is a lack of clarity on STP and NCL CCGs' governance arrangements;
Effect: There is a risk of confusions as to where decisions are made and that decisions are not made in the correctly or at all
Impact: This may result in decision freeze or in decisions being made ultra vires which may result in signficant delay in delivering integrated services due to an inability to act or legal challenge.
C1. STP Head of Programme Management in place;C2. Interim NCL Head of Governance and Risk in place for the NCL CCGs;C3. STP governance structure in place;C4. CCG and Provider organisations' governance structures in place;C5. STP website containing STP structure and minutes of STP Programme Delivery Board and Health and Care Cabinet meetings;C6. STP governance handbook in place.
C1. Employment contract;C2. Employment contract;C3. STP Plan, structure chart and papers and minutes of meetings;C4. Governance documentation, structure charts, papers and minutes of meetings;C5. Webiste;C6. Document.
Average
3 3 9
High
CN1. STP Communications and Engagement Plan;CN2. Recruit to Head of STP Communications role;CN3. A document clearly outlining STP governance and how it links with STP partners' governance structures;CN4. Recruitment to all governance and Board Secretary posts on NCL CCG Corporate Services structure.
CN1. STP Communications and Engagement Plan document;CN2. Employment contract;CN3. Governance document.CN4. Contracts of employment.
A1. Draft STP Communcations and Engagement Plan;A2. Recruit Head of STP Communications;A3. Create document setting out STP governance and how its links with STP partner organisations' governance structures.A4. Complete recruitment to NCL CCG Corporate Services governance roles.
A1. 30.05.2018;A2. 01.09.2018;A3. 30.04.2018A4. 30.06.2018
A1. This is being developed;A2. Head of Communications due to start in May 2018;A3. This work is due to begin.A4. Board Secretaries recruitment completed. Interim NCL Risk Manager is in role and interviews are being held for interim Governance Lead. 2 2 4
Moderate
NCL Risk Register
Page 349 of 422
NCL 7Will Huxter, NCL CCG Director of Strategy
Delivery of the STP Digital Agenda
Failure to Deliver the Digital Agenda Across the STP (Threat)
Cause: If the STP partners do not deliver the digaital agenda across the STP;
Effect: There is a risk that the STP partners will not be able to deliver the Five Year Forward View and the underlying digital infrastructure such as integrated ditigal care records and will be unable to deliver the required QIPP savings
Impact: This may result in a negative impact on investments across the STP partners, a negaitve impact on the quality of patient care, reputational damage and an inability to meet the required national targets.
C1. Ditigal Programme Board in place;C2. Digital road map between STP partner organisations;C3. NCL IG Group in place;C4. Health Information Exchange ('HIE') delivery plan and Population Health Management ('PHM') delivery plan being developed;C5. Priorities for 2018-19 agreed with SRO being Health Information Exchange ('HIE') and population health management.
C1. Terms of Reference, meeting papers;C2. Terms of Reference, meeting papers;C3. Terms of Reference, meeting papers;C4. Papers;C5. Minutes from February 2018 STP Delivery Board.
Average
4 3 12
High
CN1. STP Digital Strategy;CN2. Clear digital governance structure;CN3. Clear differentiation between commissioner and provider digital roles and responsibilities.
CN1. Digital Strategy paper;CN2. Digital governance structure paper;CN3. Agreement between STP partner orgsnisations showing clear responsibilities.
A1. Develop Digital Strategy;A2. Continue to develop HIE and PHM Delivery Plan;A3. Develop Digital governance structure;A4. Develop agreement between STP partners on responsibilities;A5. HIE and PHM delivery plan to be presented to May 2018 STP Delivery Board.
A1. 30.03.2019;A2. 30.05.2018;A3. 30.05.2018;A4. 01.06.2018;A5. 30.05.2018
A1. This work is due to begin;A2. This work is being developed;A3. This work is being developed;A4. This work is due to begin;A5. PHM delivery plan is being drafted.
3 2 6
Moderate
NCL 9 Simon Goodwin, NCL CCGs CFO
Achiement of Finance Balance Across NCL CCGs
Delivering Financial Balance Across NCL CCGs (Threat)
Cause: If the five CCGs in North Central London fail to deliver their QIPP targets and achieve financial balance by the end of the financial year
Effect: There is a risk that the NCL CCGs will fails to meet the collective NHS England control total.
Impact: This may result in one or more CCGs being placed under legal directions or special measures, destbilisation of one or more CCGs, a negative impact on the local health economy and loss of influence of quality of patient care.
C1. Each CCG has QIPP schemes in place and delivery plans;C2. QIPP planning and delivery is overseen and scrutinised by Governing Bodies and relevant committees;C3. NCL Senior Management Team are QIPP focussed;C4. QIPP managers are in role;C5. Deloitte review of QIPP completed;C6. CCGs working with providers through the STP to deliver QIPP savings;C7. Contractual levers and sanctions;C8. Addtional strategic QIPP capacity in place;C9. Single NCL CFO in place;C10. Financial planning undertaken at NCL level using consistent methology;C11. NCL finance leads meet on a monthly basis;C12. CCG Finance and Performance Committees (and equivalent)
C1. QIPP plans and papers;C2. Governing Body and committee papers and minutes;C3. Meeting papers, minutes and notes;C4. Contracts of employment;C5. Review outcomes document; C6. STP QIPP plans, meeting notes and minutes;C7. Contracts with providers;C8. Contract for services;C9. Employment contract;C10. Plans;C11. Papers;C12. Papers and minutes of meetings.
Average
4 5 20
Veery High
CN1. Develop and implement a 2018-19 budget to offset potential unmitigated financial risks within each CCG;CN2. Implement 2018-19 QIPP plans.
CN1. Agreed budgets and papers;CN2. In year QIPP moniroing reports.
A1. Develop and agree the 2018-19 budgets;A2. Implent 2018-19 QIPP plans.
A1. 30.04.2018;A2. 31.03.2019
A1. 2018-19 budget planning is underway;A2. This will start at the beginning of the 2018-19 financial year.
4 3 12
High
NCL 10
Paul Sinden,NCL Director of Performance and Acute Commissioning
Successful in-housing of the multi-disciplinary contract team from North East London Commissioning Support Unit (NELCSU)
CSU In-Housing of Services (Threat)
Cause: If we do not manage the in-housing of the contract team from NELCSU successfully
Effect: There is a risk that business continuity is disrupted which may have a significant negative impact on services, staffing, organisational stability, finance, performance, and contract delivery.
Impact: This may result in a reduction in contract delivery. an increase in costs, downturn in performance, reputational damage and a potential negative impact on patient services.
C1. Senior Management Team with a high degree of experience and expertise in CSU contracting.C2. Programme Director in place;C3. Working Group in place with Governing Body oversight;C4. Project Plan in place.C5. Contingency for additional support if needed.C6. Signed SLA in place for 2017/18 and 2018/19 as a baseline
C1. Employment contracts.C2. Service Agreement.C3. Minutes and papers of meetings.C4. Project plan document.C5. WAP Process.C6. Signed service level agreement
Strong
4 2 8
High
CN1. Business case for NHS England to be developed.CN2. Business case to be approved by NHS England.CN3. HR engagement process;CN4. Communications and engagement plan.
CN1. Business case a formal part of process to in-house CSU services;CN2. Approval from NHS England required before HR consultation process can begin.
A1. Continue to implement the project plan;A2. Draft the business case for NHS England;A3. Present the business case to NHS England;A4. Develop supporting HR engagement process to start on approval of business case by NHS England;A5. Development of communications and engagement plan to support the HR process;A6. Continue to refine stranded costs included by NELCSU in the business case.
A1. 01.07.2018A2. 28.02. 2018A3. 30.04.2018A4. 30.04.2018A5. 30.04.2018
A1. Weekly project team meetings are held and going to plan;A2. Draft business case circulated;A3. Business case is on track for submission by revised target date;A4. Development of HR process underway;A5. Plan in development;A6. Negotiations overseen by weekly project group meeting.
1 2 2
Low
NCL 8
Ian Porter, NCL CCG Director of Corporatre Servces
Recruit and Retain a High Performing Workforce
Recruitment and Retention a High Performing Workforce (Threat)
Cause: If the NCL CCGs are unable to recruit and retain a high performing workforce;
Effect: The NCL CCGs will be unable to deliver their stategic objectives and operational goals;
Impact: This may result in a negivtive impact on the delivery of CCG workstreams, integrated care and patient services.
C1. STP is developing priorities for key clinical and staff providing care;C2. NCL CCG wide Senior Management Team in post;C3. Chief Operating Officer for each CCG in post;C4. Chief Operating Officers are recruiting to vacant posts on the establishment;C5. NCL SMT are fostering a culture of openness and transparency;C6. Executive leadership development is under way;C7. NHS Staff Survey and acting on the results;C8. NCL HR Team to support the NCL SMT and CCG Chief Operating Officers;C9. Recruiting to NCL HR roles;C10. NCL wide HR policies;C11. Increased focus on Organisational Development;C12. HR and OD groups operating locally in some CCGs and are being developed for all CCGs;C13, Equality, Diversity and Inclusion work is being developed across NCL;
C1. Papers;C2. Employment contracts;C3. Employment contracts;C4. Job adverts, employment contracts;C5. Papers, communications;C6. Papers;C7. Results paper and plans;C8. Employment contracts;C9. Job adverts and Job Descriptions;C10. Policy documents;C11. Papers, communications;C12. Meeting papers and notes;C13. Papers.
Strong
3 2 6
Moderate
CN1. Develop NCL Organisational Development strategy;CN2. Develop specific workforce strategy/plans for each CCG which includes talent management and succession planning;CN3. Develop organisational development strategic plan;CN4. Develop Equality, Diversity and Inclusion Strategy for 2018-19 ;CN5. Complete HR recruitment.
CN1. NCL Organisational Development strategy document; CN2. Strategy/plan documents;CN3. Strategic plan document;CN4. Equality, Diversity and Inclusion Strategy document;CN5. Employment contract.
A1. Develop NCL Organisational Development strategy;A2. Develop specific workforce strategies/plans for each CCG;A3. Develop organisational development strategic plan;A4. Develop Equality, Diversity and Inclusion Strategy for 2018-19 ;A5. Continue to recruit to HR and Organisational Developlment roles.
A1. 30.08.2018;A2. 30.08.2018;A3. 30.08.2018;A4. 30.05.2018;A5. 28.04.2018
A1. This work is due to begin;A2. This work is due to begin;A3. This work is due to begin;A4. This was is being developed;A5. The HR team has been fully recruited to with all team members being in place by end of June 2018. Recruitment for the Organisational Development roles is under way.
2 1 2
Low
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Camden Clinical Commissioning Group Governing Body Meeting on 9 May 2018
Report Title NCL Audit Committee in Common and Individual CCG’s Audit Committees
Agenda Item 6.3 Date 09.05.18
Committee Chair (where applicable)
Richard Strang, Lay Member for Audit and Governance
Lead Director Ian Porter, NCL Director of Corporate Services
Tel/Email [email protected]
Report Author Andrew Spicer, NCL Head of Governance and Risk
Tel/Email [email protected]
GB Sponsor(s) (where applicable)
Tel/Email
Report Summary This paper sets out revisions to the Terms of Reference for each CCG’s audit committee and the NCL Audit Committee in Common. It also sets out the proposed membership and asks the Governing Body to approve these and delegate the power to appoint future members of the CCG’s audit committee to the Chair of the Governing Body.
Purpose (tick one boxonly) [See note 6]
Information Approval
To note Decision
Recommendation The Governing Body is asked to approve: 1. The amended Terms of Reference;2. The membership of the CCG’s audit committee;3. The Chair and Vice Chair of the NCL Audit Committee in Common;4. Delegation of the power to appoint members of the CCG’s audit
committee in line with the membership requirements set out in the Termsof Reference to the Chair of the Governing Body.
Strategic Objectives Links
This report supports all of the CCG’s strategic objectives.
Identified Risks and Risk Management Actions
This report helps to maximise the opportunities for strategic collaboration across the five North Central London Clinical Commissioning Groups and strengthens oversight and assurance of our internal control mechanisms.
Conflicts of Interest
Conflicts of interest have been managed in accordance with the NCL Conflicts of Interest Policy.
Resource Implications
This report if approved will: • Reduce duplication of effort across the five North Central London
Clinical Commissioning Groups;• Reduce the amount of internal and external auditor resource needed to
carry out effective scrutiny of our internal control mechanisms;
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• Better deploy resources and increase expertise, effectiveness andlearning through information, knowledge and skills sharing.
• Provide the flexibility to work together or individually when it best suitsthe needs of an effective audit function.
Engagement This report is being presented to the Governing Bodies of the five CCGs in North Central London which include lay members and elected clinicians. In addition, the lay members for governance and audit in each of the five North Central London Clinical Commissioning Groups were consulted.
Equality Impact Analysis
This report has been written in accordance with the provisions of the Equality Act 2010.
Report History This report builds on the work approved by Governing Bodies in November 2016 to support the development and delivery of their Sustainability and Transformation Plan and integrated working arrangements. A report on the NCL Audit Committee in Common was presented to the Governing Bodies of Camden, Enfield, Haringey and Islington CCG in January 2018 and to the Barnet CCG Governing Body in March 2018.
Next Steps If the recommendations in the report are approved the next step is to mobilise the NCL Audit Committee in Common with the first meeting due to take place in July 2018.
Appendices There is one appendix: 1. NCL Audit Committee in Common and Individual Audit Committees’
Terms of Reference.
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NCL Audit Committee in Common and Individual CCG’s Audit Committees
Introduction This paper sets out revisions to the Terms of Reference for each CCG’s audit committee and the NCL Audit Committee in Common. It also sets out the proposed membership and asks the Governing Body to approve these and delegate the power to appoint future members of the audit committee to the Chair of the Governing Body.
Background In January and March 2018 the Governing Bodies of the five North Central London Clinical Commissioning Groups approved the harmonisation of their audit committee’s Terms of Reference, approved the formation of an audit committee in common known as the ‘NCL Audit Committee in Common’, and approved Terms of Reference for each.
However, membership of these committees had not been agreed and lay members requested some additional amendments to the Terms of Reference to strengthen the quorum requirements and clarify the importance of individual audit committees in terms of accountabilities.
Terms of Reference The revised Terms of Reference contain the following amendments: Paragraph Amendment Reason 1.3, 5.1, 6.1, 7.1, 8.1, 9.1, 10.1, 10.2, 11.1, 11.2, 11.3 12.1, 13.1, 13.3
Minor amendments to wording.
To emphasise the importance of individual audit committees and their accountabilities.
14.4 Inclusion of a paragraph setting out that the lay member for audit and governance from another NCL CCG will be appointed to the audit committee on a non-remunerated basis.
To clarify to basis on which the lay member for audit and governance from another CCG is appointed onto the audit committee.
17.1, 17.2 Amended the quorum requirements so that at least one member of the audit committee must be from the respective CCG for a meeting to be quorate.
This removes any risk of an audit committee being quorate without a member of the respective CCG being present.
18.1, 18.2 Minor amendments to simplify the drafting.
To make the Terms of Reference easier to read.
31.2 Minor amendment so Terms of Reference are reviewed annually.
To increase committee effectiveness and ensure ease of operations.
Membership Under the agreed Terms of Reference the membership of each CCG’s audit committee comprises of three people who are:
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• The CCG’s Governing Body lay member for audit and governance;• A Governing Body lay member for audit and governance from another NCL Clinical
Commissioning Group;• An additional member who is either:
o A Governing Body member who is not the NCL Accountable Officer nor theNCL Chief Finance Officer nor the Chair of the CCG Governing Body; or
o A second Governing Body lay member for audit and governance from anotherNCL Clinical Commissioning Group who is a different person that that referredto above.
In this regard the Governing Body is asked to formally appoint their members of their audit committee. The proposed membership of each audit committee is as follows:
CCG CCG’s Lay Member for Audit and Governance
A Lay Member for Audit and Governance from another NCL CCG
Additional Member
Barnet Dominic Tkaczyk Karen Trew Ian Bretman
Camden Richard Strang Dominic Tkaczyk TBC
Enfield Karen Trew Adam Sharples TBC
Haringey Adam Sharples Lucy De Groot TBC
Islington Lucy De Groot Richard Strang TBC
Governing Bodies are not asked to approve the membership of other CCG’s audit committees.
Chair and Vice Chair of the NCL Audit Committee in Common The Chair and Vice Chair of the NCL Audit Committee in Common are important as they act as convenors of the meeting and help ensure meetings run smoothly. The Chair and Vice Chair only have voting rights on the individual audit committees that they are appointed to.
It is proposed that the Chair and Vice Chair of the NCL Audit Committee in Common are: Name Role CCG Adam Sharples Chair Haringey
Dominic Tkaczyk Vice Chair Barnet
The NCL Audit Committee in Common will review the Chairing arrangements after 12 months.
When CCG audit committees meet individually the Chair shall be the Lay Member for Audit and Governance from that respective CCG.
Delegation to the Governing Body Chair It is a requirement that the members of the audit committee are formally appointed by the Governing Body as set out above.
To maximise operational flexibility, effectiveness and preserve current practices whilst ensuring that our governance processes remain robust Governing Bodies are requested to
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delegate to the Chair of the Governing Body the power to appoint future members of the CCG’s audit committee in line with the membership requirements set out in the Terms of Reference.
Recommendations The Governing Body is asked to approve:
• The amended Terms of Reference;• The membership of the CCG’s audit committee;• The Chair and Vice Chair of the NCL Audit Committee in Common;• Delegation of the power to appoint members of the CCG’s audit committee in line with
the membership requirements set out in the Terms of Reference to the Chair of theGoverning Body.
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NCL Audit Committee in Common and Individual Audit Committees
Terms of Reference
1. Introduction
1.1 The Governing Bodies of the five Clinical Commissioning Groups in North Central London (‘NCL’) have each established their own audit committees to critically review and report to their respective Governing Body on the relevance and robustness of the governance and assurance processes on which each relies.
1.2 The five NCL Clinical Commissioning Groups are: • NHS Barnet Clinical Commissioning Group (‘Barnet CCG’);• NHS Camden Clinical Commissioning Group (‘Camden CCG’);• NHS Enfield Clinical Commissioning Group (‘Enfield CCG’);• NHS Haringey Clinical Commissioning Group (‘Haringey CCG’);• NHS Islington Clinical Commissioning Group (‘Islington CCG’).
1.3 The NCL Clinical Commissioning Groups are working together to form and operate with a common set of controls. To support this and provide strengthened oversight the NCL Clinical Commissioning Groups have agreed to hold their audit committees together at the same time, in the same place, with a common agenda and a common chair as a committee in common. This is known as the ‘NCL Audit Committee in Common.
1.4 The NCL Clinical Commissioning Groups have also agreed to retain the flexibility for their individual audit committees to meet by themselves where doing so best achieves an effective audit committee function.
1.5 These Terms of Reference set out the membership, remit, responsibilities and reporting arrangements of both the individual Clinical Commissioning Group (‘CCG’) audit committees and the NCL Audit Committee in Common.
2. Committees in Common
2.1 The following committees form the NCL Audit Committee in Common: • NHS Barnet CCG Audit Committee;• NHS Camden CCG Audit Committee;• NHS Enfield CCG Audit Committee;• NHS Haringey CCG Audit Committee;• NHS Islington CCG Audit Committee.
3. Statutory Framework3.1 The four key statutory requirements for Clinical Commissioning Group audit committees are:
Provision Requirement Section 14(M) of the NHS Act 2006 (as amended)
A governing body of a clinical commissioning group must have an audit committee
Section 14(1) of the Clinical Commissioning Group Regulations 2012
The audit committee of a CCG Governing Body must have a chair, to be appointed by the CCG for a term to be determined by the CCG
Section 14(2) of the Clinical Commissioning Group Regulations 2012
The chair of the audit committee must be a lay person who has qualifications, exertise or
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experience such as to enable the person to express informed views about financial management and audit.
Section 7(3) of Schedule 1A to the NHS Act 2006 (as amended)
CCG Constitutions may include provision for the audit committee to include individuals who are not members of the governing body.
3.2 The individual audit committees and the NCL Audit Committee in Common are established in line with legislation and with the Constitutions of each of the NCL Clinical Commissioning Groups.
4. Role of the Committee
4.1 The role of the individual audit committees and the NCL Audit Committee in Common is to carry out the duties listed in sections 5 to 13 below. These apply regardless of whether the individual audit committees are meeting by themselves or together as part of the NCL Audit Committee in Common.
5. Integrated Governance, Risk Management and Internal Control
5.1 Each CCG’s audit committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the CCG’s activities that supports the achievement of its objectives.
5.2 In particular the audit committee will review the adequacy and effectiveness of: • All risk and control related disclosure statements (in particular the annual governance
statement), together with any accompanying Head of Internal Audit Opinion, externalaudit opinion or other appropriate independent assurances;
• The underlying assurance processes that indicate the degree of achievement of theorganisation’s objectives, the effectiveness of the management of principal risks andthe appropriateness of the above disclosure statements;
• The policies for ensuring compliance with relevant regulatory, legal and code ofconduct requirements and any related reporting and self-certifications;
• The policies and procedures for all work related to counter fraud and security asrequired by NHS Counter Fraud Authority;
• The policies and procedures for managing conflicts of interest;• The policies and procedures for managing gifts and hospitality.
5.3 In carrying out this work the audit committee will primarily utilise the work of internal audit, external audit and other assurance functions, but it will not be limited to these sources. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management an internal control, together with an indication of their effectiveness.
These will be evidenced through the audit committee’s use of an effective assurance framework to guide its work and the audit and assurance functions that report to it.
5.4 As part of its integrated approach the audit committee will have effective relationships with other key Governing Body committees so that it underpins processes and linkages. However, these other committees must not usurp the audit committee’s role.
6. Internal Audit
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6.1 Each CCG’s audit committee shall ensure that there is an effective internal audit function that meets the Public Sector Internal Audit Standards 2013 and provides appropriate independent assurance to the audit committee, NCL Accountable Officer and Governing Body. This will be achieved by:
• Considering the provision of the internal audit service and the costs involved;• Reviewing and approving the audit strategy, annual internal audit plan and more
detailed programme of work, ensuring that this is consistent with the audit needs of theorganisation as identified in the assurance framework;
• Considering the major findings of internal audit work (and management’s response),and ensuring co-ordination between the internal and external auditors to optimise theuse of audit resources;
• Ensuring that the internal audit function is adequately resourced and has appropriatestanding within the organisation;
• Monitoring the effectiveness of internal audit and carrying out an annual review.
7. External Audit
7.1 Each CCG’s audit committee shall review and monitor the external auditors’ independence and objectivity and the effectiveness of the audit process. In particular, the audit committee will review the work and findings of the external auditors and consider the implications and management’s responses to their work. This will be achieved by:
• Considering the appointment and performance of the external auditors;• Discussing and agreeing with the external auditors before the audit commences the
nature and scope of the audit as set out in the annual plan;• Discussing with the external auditors their evaluation of audit risks and assessment of
the organisation and the impact of the audit fee;• Reviewing all external audit reports, including the report to those charged with
governance (before its submission to the Governing Body as appropriate) and anywork undertaken outside of the annual audit plan, together with the appropriateness ofmanagement responses;
• Ensuring that there is in place a clear policy for the engagement of external auditors tosupply non-audit services.
8. Other Assurance Functions
8.1 Each CCG’s audit committee shall review the findings of other significant assurance functions, both internal and external to the CCG, and consider the implications for the governance of the CCG.
8.2 These will include, but will not be limited to, any reviews by Department of Health arm’s length bodies or regulators/inspectors (for example, the Care Quality Commission, NHS Litigation Authority etc) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges, accreditation bodies etc).
8.3 In addition, the audit committee will review the work of other committees within the CCG, whose work can provide relevant assurance to the audit committee’s own areas of responsibility.
9. Counter fraud
9.1 Each CCG’s audit committee shall satisfy itself that the organisation has adequate arrangements in place for counter fraud and security that meet NHS Counter Fraud Authority’s standards and shall review the outcomes of work in these areas. This will be achieved by:
• Considering the provision of the counter fraud service and the costs involved;
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• Reviewing and approving the counter fraud strategy, annual internal audit plan andmore detailed programme of work, ensuring that this is consistent with the needs ofthe organisation;
• Considering the major findings of internal audit work and management’s response;• Ensuring that the counter fraud function is adequately resourced and has appropriate
standing within the organisation;• Monitoring the effectiveness of counter fraud and carrying out an annual review.
10. Management
10.1 Each CCG’s audit committee shall request and review reports, evidence and assurances from directors and managers on the overall arrangements for governance, risk management and internal control.
10.2 Each audit committee may also request specific reports from individual functions within the organisation.
11. Financial reporting
11.1 Each CCG’s audit committee shall monitor the integrity of the financial statements of its organisation and any formal announcements relating to its financial performance.
11.2 Each audit committee should ensure that the systems for financial reporting to the Governing Body, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided.
11.3 Each audit committee shall review the annual report and financial statements focussing particularly on:
• The wording in the annual governance statement and other disclosures relevant to theterms of reference of the Committee;
• Changes in, and compliance with, accounting policies, practices and estimationtechniques;
• Unadjusted misstatements in the financial statements;• Significant judgments in preparation of the financial statements;• Significant adjustments resulting from the audit;• Letters of representation;• Explanations for significant variances;• Ease of understanding of the contents for patients and the public.
12. Whistleblowing
12.1 Each CCG’s audit committee shall review the effectiveness of the arrangements in place for allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently.
13. Reporting
13.1 Each CCG’s audit committee shall report to the Governing Body on how it discharges its responsibilities.
13.2 The minutes of the audit committee’s meetings shall be formally recorded by the Secretariat and submitted to the Governing Body as required. The Chair of the Committee shall draw to
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the attention of the Governing Body any issues that require disclosure to the full Governing Body, or require executive action.
13.3 Each audit committee will report to the Governing Body at least annually on its work in support of the annual governance statement, specifically commenting on:
• The fitness for purpose of the assurance framework;• The completeness and ‘embeddedness’ of risk management in the organisation;• The integration of governance arrangements;• The appropriateness of evidence that shows the organisation is fulfilling regulatory
requirements relating to its existence as a functioning business;• The robustness of the processes behind the quality accounts.
13.4 The annual report should also describe how the audit committee has fulfilled its terms of reference and give details of any significant issues that the audit committee considered in relation to the financial statements and how they were addressed.
14. Membership
14.1 When the audit committees are meeting as the NCL Audit Committee in Common or as individual audit committees the membership of each audit committee is as follows:
• The CCG’s Governing Body lay member for audit and governance;• A Governing Body lay member for audit and governance from another NCL Clinical
Commissioning Group;• An additional member who is either:
o A Governing Body member who is not the NCL Accountable Officer nor theNCL Chief Finance Officer nor the Chair of the CCG Governing Body; or
o A second Governing Body lay member for audit and governance from anotherNCL Clinical Commissioning Group who is a different person that that referredto in the second bullet point of section 14.1 above.
14.2 The membership requirements are summarised in Schedule 2.
14.3 Audit committee members may nominate deputies to represent them in their absence and make decisions on their behalf.
14.4 The lay member or members for audit and governance from another NCL Clinical Commissioning Group referred to in the second and third bullet points of paragraph 14.1 above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG’s Governing Body.
14.5 The list of voting members is contained in Schedule 1.
15. Attendance
15.1 The individual audit committees and the NCL Audit Committee in Common shall have the following non-voting attendees:
• NCL Chief Finance Officer or a nominated deputy;• Head of Internal Audit and internal audit representatives;• External audit representatives;• Local Counter Fraud Specialists;• A representative from the NCL Corporate Services Directorate;• A representative from North and East London Commissioning Support Unit, as
required;• Other directors and/or managers as appropriate;
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• Representatives from other organisations, as required.
15.2 The NCL Accountable Officer will be invited to attend an audit committee meeting at least once per year to discuss the process for assurance that supports the annual governance statement and the annual report and accounts.
15.3 The individual audit committees and/or the NCL Audit Committee in Common may meet privately with the internal and external auditors at their absolute discretion.
15.4 Non-voting attendees may nominate deputies to represent them in their absence.
15.5 The individual audit committees and/or the NCL Audit Committee in Common may call additional experts to attend meetings on a case by case basis to inform discussion.
15.6 The individual audit committees and/or the NCL Audit Committee in Common may invite or allow additional people to attend meetings as attendees. Attendees may present at meetings and contribute to the relevant discussions but are not allowed to participate in any formal vote.
15.7 The individual audit committees and/or the NCL Audit Committee in Common may invite or allow people to attend meetings as observers. Observers may not present at meetings, contribute to any discussion or participate in any formal vote.
15.8 The list of non-voting attendees is contained in Schedule 1.
16. Chair and Vice Chair
16.1 The NCL Clinical Commissioning Groups’ Governing Bodies have agreed that the Chair and Vice Chair of the audit committee shall vary depending on whether the audit committees are meeting as the NCL Audit Committee in Common or individually by themselves.
16.2 When the audit committees are meeting as the NCL Audit Committee in Common the Chair of the NCL Audit Committee in Common shall be a lay member for audit and governance from either Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG or Islington CCG.
16.3 When the audit committees are meeting as the NCL Audit Committee in Common the Vice Chair of the NCL Audit Committee in Common shall be a lay member for audit and governance from either Barnet CCG, Camden CCG, Enfield CCG, Haringey CCG or Islington CCG.
16.4 The Chair and the Vice Chair of the NCL Audit Committee in Common shall be from different CCGs.
16.5 The Chair and Vice Chair of the NCL Audit Committee in Common shall be appointed upon the agreement of each of the audit committees comprising the NCL Audit Committee in Common.
16.6 When the audit committees are meeting individually by themselves the Chair shall be the lay member for audit and governance. The Vice Chair shall be another lay member.
16.7 The Chair and Vice Chair requirements are summarised in Schedule 2:
17. Quoracy
17.1 When the audit committees are meeting as the NCL Audit Committee in Common each audit committee comprising the NCL Audit Committee in Common must be quorate. Each audit committee is quorate when the following conditions are satisfied:
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• At least two members from the respective audit committee or their nominated deputiesare present; and
• One of the two members present is from the audit committee’s respective CCG.
17.2 When the audit committees are meeting individually by themselves for the meeting to be quorate the following conditions must be satisfied:
• At least two members or their nominated deputies must be present; and• One of the two members present is from the audit committee’ respective CCG.
17.3 If the NCL Audit Committee in Common is not quorate the individual audit committees have the option of meeting as individual audit committees at their absolute discretion and as long as the quorum requirements contained in section 17.2 above are satisfied. The individual audit committees may decide to meet at the same time and in the same room as each other at their absolute discretion.
17.4 The quorum requirements are summarised in Schedule 2:
17.5 If any representative is conflicted on a particular item of business they will not count towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted to satisfy the quorum requirements.
18. Voting
18.1 Each CCG’s audit committee shall vote and make decisions for their CCG only. A vote of one CCG’s audit committee is not binding on another CCG’s audit committee.
18.2 Each audit committee member shall have one vote with resolutions passing by simple majority. The lay member for audit and governance from the respective audit committee’s own CCG or their nominated deputy shall have the casting vote on any resolution.
18.3 When the audit committees are meeting as the NCL Audit Committee in Common the Chair or Vice Chair of the NCL Audit Committee in Common may not participate in the vote of any individual audit committee unless he or she is a member of that audit committee.
18.4 The voting requirements are summarised in Schedule 2:
19. Decisions
19.1 The individual audit committees will make decisions within the bounds of their remit.
20. Authority and Access
20.1 The individual audit committees and the NCL Audit Committee in Common are Governing Body committees. They must act within the remit of these terms of reference and have no executive powers other than those specifically set out in these terms of reference.
20.2 The Head of Internal Audit, representatives of external audit and counter fraud specialists have a right of access to the Chair of the individual audit committees and the Chair of the NCL Audit Committee in Common.
20.3 The individual audit committees and the NCL Audit Committee in Common are authorised by the Governing Bodies to investigate any activity within these terms of reference. They are
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authorised to seek any information they require from any employees or officers and all employees and officers are directed to co-operate with any request made in this regard.
20.4 The individual audit committees and the NCL Audit Committee in Common are authorised by the Governing Bodies to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if they consider this necessary.
21. Secretariat
21.1 The Secretariat to the Committee shall be provided by the NCL Corporate Services Directorate.
22. Frequency of Meetings
22.1 It is expected that the NCL Audit Committee shall meet four times per year. Whilst it is expected that most items of business are suitable for the NCL Audit Committee in Common there may be some items which are better suited to being presented to individual audit committees. Therefore, individual audit committees may meet as required. This is expected to be approximately once per year.
22.2 The NCL Audit Committee in Common and/or the individual audit committees may hold additional meetings as required.
23. Notice of Meetings
23.1 Notice of a meeting shall be sent to all members no less than 7 days in advance of the meeting.
23.2 The meeting shall contain the date, time and location of the meeting.
24. Agendas and Circulation of Papers
24.1 Before each meeting an agenda setting out the business of the meeting will be sent to every member no less than 7 days in advance of the meeting.
24.2 Before each meeting the papers of the meeting will be sent to every member no less than 7 days in advance of the meeting.
24.3 If a member wishes to include an item on the agenda they must notify the Chair via the Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair.
25. Minutes and Reporting
25.1 The minutes of the proceedings of a meeting shall be prepared by the Secretariat and submitted for agreement at the following meeting.
25.2 Each individual CCG will comply with their own Governing Body’s reporting requirements.
26. Conflicts of Interest
26.1 Conflicts of Interest shall be dealt with in accordance with the NCL Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest. The NCL Conflicts of Interest Policy is a master document containing the single conflicts of interest policy agreed
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by each of the NCL CCGs together with a schedule setting out each CCG’s local variations to that policy.
26.2 The individual audit committees and the NCL Audit Committee in Common shall have a Conflicts of Interest Register that will be presented as a standing item on the agenda.
27. Gifts and Hospitality
27.1 Gifts and Hospitality shall be dealt with in accordance with the NCL Conflicts of Interest Policy and NHS England statutory guidance for managing conflicts of interest.
27.2 The individual audit committees and the NCL Audit Committee in Common shall have a Gifts and Hospitality Register that will be presented as a standing item on the agenda.
28. Standards of Business Conduct
28.1 Members, attendees and/or observers must maintain the highest standards of personal conduct and in this regard must comply with:
• The law of England and Wales;• The NHS Constitution;• The Nolan Principles;• The standards of behaviour set out in each NCL CCG Constitution;• Any additional regulations or codes of practice relevant to the Committee.
29. Training and Information
29.1 It is the responsibility of each organisation referred to in section 1.3 above to ensure that their representatives are provided with appropriate training and information to allow them to exercise their responsibilities effectively.
30. Quick Reference Guide
30.1 A quick reference guide to the voting members, chair, vice chair, quoracy, voting methodology and casting votes of the individual audit committees and the NCL Audit Committee in Common can be found in Schedule 2.
31. Review of Terms of Reference
31.1 These Terms of Reference will be reviewed from time to time, reflecting experience of the individual audit committees and the NCL Audit Committee in Common in fulfilling its functions and the wider experience of CCGs in overseeing a common system of controls.
31.2 These Terms of Reference will be formally reviewed annually. These Terms of Reference may be changed or amended by mutual agreement of the individual audit committees and the NCL Audit Committee in Common and on being approved by each of the Governing Bodies of the NCL Clinical Commissioning Groups in accordance with their Constitutions.
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Schedule 1 List of Members
This schedule sets out the membership, attendees, Chair and Vice Chair of each individual audit committee and the NCL Audit Committee in Common.
NCL Audit Committee in Common: The voting members of the NCL Audit Committee in Common are as follows: Committee Voting Members Name and Title Barnet CCG Audit Committee
Lay member for audit and governance from Barnet CCG
Dominic Tkaczyk
Barnet CCG Audit Committee
Lay member for audit and governance from another NCL Clinical Commissioning Group
Karen Trew
Barnet CCG Audit Committee
A person who is either: • A Governing Body
member who is notthe NCLAccountable Officernor the NCL ChiefFinance Officer northe Chair of the CCGGoverning Body; or
• A second laymember for auditand governancefrom another NCLClinicalCommissioningGroup
Ian Bretman
Camden CCG Audit Committee
Lay member for audit and governance from Camden CCG
Richard Strang
Camden CCG Audit Committee
Lay member for audit and governance from another NCL Clinical Commissioning Group
Dominic Tkaczyk
Camden CCG Audit Committee
A person who is either: • A Governing Body
member who is notthe NCL AccountableOfficer nor the NCLChief Finance Officernor the Chair of theCCG GoverningBody; or
• A second laymember for audit andgovernance from
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another NCL Clinical Commissioning Group
Enfield CCG Audit Committee
Lay member for audit and governance from Enfield CCG
Karen Trew
Enfield CCG Audit Committee
Lay member for audit and governance from another NCL Clinical Commissioning Group
Adam Sharples
Enfield CCG Audit Committee
A person who is either: • A Governing Body
member who is notthe NCL AccountableOfficer nor the NCLChief Finance Officernor the Chair of theCCG GoverningBody; or
• A second laymember for audit andgovernance fromanother NCL ClinicalCommissioningGroup
Haringey CCG Audit Committee
Lay member for audit and governance from Haringey CCG
Adam Sharples
Haringey CCG Audit Committee
Lay member for audit and governance from another NCL Clinical Commissioning Group
Lucy De Groot
Haringey CCG Audit Committee
A person who is either: • A Governing Body
member who is notthe NCL AccountableOfficer nor the NCLChief Finance Officernor the Chair of theCCG GoverningBody; or
• A second laymember for audit andgovernance fromanother NCL ClinicalCommissioningGroup.
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Islington CCG Audit Committee
Lay member for audit and governance from Islington CCG
Lucy De Groot
Islington CCG Audit Committee
Lay member for audit and governance from another NCL Clinical Commissioning Group
Richard Strang
Islington CCG Audit Committee
A person who is either: • A Governing Body
member who is notthe NCL AccountableOfficer nor the NCLChief Finance Officernor the Chair of theCCG GoverningBody; or
• A second laymember for audit andgovernance fromanother NCL ClinicalCommissioningGroup.
Chair and Vice Chair of the NCL Audit Committee in Common Position Name and Title CCG Chair Adam Sharples Haringey
Vice Chair Dominic Tkaczyk Barnet
Individual Audit Committees:
Barnet CCG Audit Committee The voting members of the Barnet CCG Audit Committee are as follows: Position Name Title Lay member for audit and Governance from Barnet CCG
Dominic Tkaczyk
Lay member for audit and governance from another NCL Clinical Commissioning Group
Karen Trew
A person who is either: • A Governing Body
member who is notthe NCLAccountable Officernor the NCL ChiefFinance Officer northe Chair of the
Ian Bretman
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CCG Governing Body; or
• A second laymember for auditand governancefrom another NCLClinicalCommissioningGroup
Chair Lay Member for Audit and Governance at Barnet CCG
Camden CCG Audit Committee The voting members of the Camden CCG Audit Committee are as follows: Position Name Title Lay member for audit and governance from Camden CCG
Richard Strang
Lay member for audit and governance from another NCL Clinical Commissioning Group
Dominic Tkaczyk
A person who is either: • Governing Body
member who is notthe NCLAccountable Officernor the NCL ChiefFinance Officer northe Chair of theCCG GoverningBody; or
• A second laymember for auditand governancefrom another NCLClinicalCommissioningGroup
Chair Lay Member for Audit and Governance at Camden CCG
Enfield CCG Audit Committee The voting members of the Enfield CCG Audit Committee are as follows: Position Name Title Lay member for audit and governance from Enfield CCG
Karen Trew
Lay member for audit and governance from another
Adam Sharples
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NCL Clinical Commissioning Group A person who is either:
• A Governing Bodymember who is notthe NCLAccountable Officernor the NCL ChiefFinance Officer northe Chair of theCCG GoverningBody; or
• A second laymember for auditand governancefrom another NCLClinicalCommissioningGroup
Chair Lay Member for Audit and Governance at Enfield CCG
Haringey CCG Audit Committee The voting members of the Haringey CCG Audit Committee are as follows: Position Name Title Lay member for audit and governance from Haringey CCG
Adam Sharples
Lay member for audit and governance from another NCL Clinical Commissioning Group
Lucy De Groot
A person who is either: • A Governing Body
member who is notthe NCLAccountable Officernor the NCL ChiefFinance Officer northe Chair of theCCG GoverningBody; or
• A second laymember for auditand governancefrom another NCLClinicalCommissioningGroup
Chair Lay Member for Audit and Governance at Haringey CCG
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Islington CCG Audit Committee The voting members of the Islington CCG Audit Committee are as follows: Position Name Title Lay member for audit and governance from Islington CCG
Lucy De Groot
Lay member for audit and governance from another NCL Clinical Commissioning Group
Richard Strang
A person who is either: • A Governing Body
member who is notthe NCLAccountable Officernor the NCL ChiefFinance Officer northe Chair of theCCG GoverningBody; or
• A second laymember for auditand governancefrom another NCLClinicalCommissioningGroup
Chair Lay Member for Audit and Governance at Islington CCG
Attendees The non-voting attendees at the individual audit committees and the NCL Audit Committee in Common are:
Position Name Title NCL Accountable Officer Ms Helen Pettersen NCL Accountable Officer NCL Chief Finance Officer Mr Simon Goodwin NCL Chief Finance Officer Head of Internal Audit and Internal Audit Representatives
Mr Clive Makombera
External Audit Representatives Local Counter Fraud Specialists A representative from the NCL Corporate Services Directorate A representative from North and East London
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Commissioning Support Unit
The roles referred to in the list of voting members and non-voting attendees above describe the members’ and non-voting attendees’ substantive roles and/or any successor equivalent roles only and not the individual title or titles of any member. Names and job titles are provided for information purposes only and may be updated as required without the need to formally amend the Terms of Reference.
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Schedule 2 Quick Reference Guide
No Meeting Voting Members Chair Vice Chair Quoracy Voting Methodology
Casting Vote
1. Audit committee when meeting as part of the NCL Audit Committee in Common
The Governing Body lay member for audit and governance.
The lay Member for audit and governance from another NCL Clinical Commissioning Group
A person who is either: • A Governing Body member who is
not the NCL Accountable Officer nor the NCL Chief Finance Officer northe Chair of the CCG GoverningBody; or
• A second lay member for audit andgovernance from another NCLClinical Commissioning Group.
The lay member or members for audit and governance from another NCL Clinical Commissioning Group referred to above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG’s Governing Body.
A lay member for audit and governance from an NCL CCG
A lay member for audit and governance from an NCL CCG but from a different CCG than the Chair
Two members from each of the five individual audit committees or their nominated deputies must be present. One member must be from the respective CCG.
Each of the five individual audit committees must be present for the NCL Audit Committee in Common to be quorate.
If the NCL Audit Committee in Common is not quorate the individual audit committees may decide to meet at the same time and in the same room as each other at their absolute discretion.
Resolutions of each individual CCG’s audit committee pass by simple majority. A vote of one CCG’s audit committee is not binding on any other CCG’s audit committee.
The audit committee lay member for audit and governance or their nominated deputy
2. Audit committee when meeting individually by itself and not as part of the NCL Audit Committee in Common.
The Governing Body lay member for audit and governance.
The lay Member for audit and governance from another NCL Clinical Commissioning Group
A person who is either: • A Governing Body member who is
not the NCL Accountable Officer nor the NCL Chief Finance Officer northe Chair of the CCG GoverningBody; or
The CCG’s lay member for audit and governance
Another lay member
Two members or their nominated deputies. One member must be from the respective CCG.
Resolutions pass by simple majority.
The audit committee Chair or their nominated deputy
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• A second lay member for audit andgovernance from another NCLClinical Commissioning Group.
The lay member or members for audit and governance from another NCL Clinical Commissioning Group referred to above shall be appointed on a non-remunerated basis to the audit committee by the relevant CCG’s Governing Body.
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Integrated Commissioning Committee- Revisions to Terms of Reference
Agenda Item 6.4 Date 09.05.18
Lead Director Ian Porter, Director of Corporate Services for NCL CCGs
Tel/ Email
Report Author Andrew Spicer, NCL Head of Governance and Risk
Tel/ Email
GB Sponsor(s) (where applicable)
Dr Matthew Clark, Secondary Care Doctor Representative
Tel/ Email
Report Summary This report sets out proposed revisions to the Integrated Commissioning Committee’s Terms of Reference.
The proposed revisions are: • Role titles clarified to reflect current arrangements;• Minor amendments to the wording of the Terms of Reference to make
them easier to read;• Purpose and role of the Committee have been amended to better reflect
the joint revised joint commissioning and working arrangements betweenCamden CCG and Camden Council;
• Chair is from Camden CCG and the Vice Chair is from Camden Councilto reflect the changing emphasis of the committee’s business;
• Meetings to be held bi-monthly from June 2018;• Authority delegated to the following people to make decisions outside of
Committee meetings for Camden CCG statutory functions:o Chair of the Committee;o Chief Operating Officer;o CFO/Deputy CFO;o Lay Member;o An elected Governing Body representative.
Purpose (tick onebox only)
Information Approval
To note Decision
Recommendation The Governing Body is asked to approve the revised Terms of Reference.
Strategic Objectives Links
This report supports the achievement of all of the Camden CCG strategic objectives.
Identified Risks and Risk Management Actions
The revisions to the Terms of Reference supports the CCG’s decision making structures and helps empower organisational success for the benefits of our patients.
Conflicts of Interest
Conflicts of interest have been managed robustly and in accordance with the NCL Conflicts of Interest Policy.
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Resource Implications
None.
Engagement There has been engagement with Governing Body members of the Integrated Commissioning Committee including the Executive Director of Supporting People from Camden Council.
Equality Impact Analysis
This report has been written in accordance with the provisions of the Equality Act 2010.
Report History The Terms of Reference for the Integrated Commissioning Committee were last considered at the May 2017 Governing Body meeting.
Next Steps The next step is to conduct a full review of the role and functions of the Committee and revise its Terms of Reference as appropriate.
Appendices This report contains the Integrated Commissioning Committee Terms of Reference.
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Integrated Commissioning Committee Revisions to the Terms of Reference
The Integrated Commissioning Committee was established by Camden CCG and by Camden Council in March 2017 to support integrated decision making for health and social care services between the two organisations.
Following review of the Integrated Commissioning Committee’s Terms of Reference the following amendments have been proposed to support its operation: Paragraph Amendment Reason
Throughout Role titles have been clarified and minor amendments to wording
To reflect amended role titles and make the Terms of Reference easier to read.
2.1, 2.2, 4.1 and 7.1 Wording amended in the purpose and role of the committee to change ‘integrated’ to ‘joint’ commissioning
To clarify and reflect the revised joint commissioning and working arrangements between Camden CCG and Camden Council
6.1 and 6.2 The Chair and Vice Chair arrangements have been amended so that the Chair is from Camden CCG and the Vice Chair from Camden Council
To reflect the changing emphasis of the Committee’s business and the operational arrangements supporting this.
9.1 Meetings are to be held bi-monthly rather than monthly
To streamline the number of Committee meetings held each year from approximately 12 to 6.
18.2, 18.3 and 18.4 Additional paragraphs have been inserted delegating authority to make decisions on Camden CCG statutory functions outside of Committee meetings to a specified group of people and that those decisions are reported to the following Committee meeting.
To ensure that timely decisions can be made outside of Committee meetings where this is appropriate and to ensure a robust process is in place to support this.
Recommendation The Governing Body is asked to approve the revised Terms of Reference.
Further Review The Integrated Commissioning Committee has been operational since March 2017. Since then there have been a number of changes to way in which services are commissioned which requires further review of the Committee’s role, functions and its Terms of Reference. This work will be conducted in May and June 2018 and the proposals from the review will be presented at the July 2018 Governing Body meeting.
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1
NHS Camden Clinical Commissioning Group Camden Integrated Commissioning Committee
Terms of Reference
1. Introduction
1.1 The Camden Integrated Commissioning Committee (‘Committee’) is established as a Governing Body committee of NHS Camden Clinical Commissioning Group (‘Camden CCG’) in accordance with Camden CCG’s Constitution.
1.2 These Terms of Reference set out the membership, remit, responsibilities and reporting arrangements of the Committee.
2. Purpose and Aim of the Committee
2.1 The purpose of the Committee is to:
2.1.1 Provide a forum for joint decision making between Camden CCG and Camden Council; 2.1.2 Provide a forum for Camden CCG only decision making with the facility for Camden
Council representatives to feed into the discussions where appropriate; 2.1.2 Jointly commission, where appropriate, and oversee the performance of high quality
integrated health and social care services for children and adults in the London Borough of Camden in line with the Joint Strategic Needs Assessment and the Camden Local Care Strategy;
2.1.3 Improve health and well-being; 2.1.4 Reduce health inequalities.
2.2 It is the aim of Camden CCG and Camden Council that the Committee promotes and maximises the integration of front line delivery of health and social care services, the oversight and scrutiny of those services and joint working whilst operating within the parameters of each organisation’s governance structure.
3. Joint Working and Decision Making
3.1 The Committee recognises that Camden CCG and Camden Council have different governance arrangements and that any joint decision making has to be conducted accordingly.
3.2 The Camden CCG Governing Body has delegated its authority to the Committee to make decisions on its behalf on its statutory healthcare duties as set out in these Terms of Reference.
3.3 Camden CCG and the Camden Council Cabinet has delegated authority to the Committee to make decisions on and sign off the Better Care Fund.
3.4 The Camden Council Cabinet has delegated authority on certain social care matters to the following Camden Council representatives to make decisions in principle at the Committee on its behalf:
• Executive Director, Supporting People;
• Director of Integrated Commissioning;• Director of Adult Social Care.
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3.5 The Committee is a committee of the Camden CCG Governing Body with representatives from Camden Council present. However, the representatives from Camden Council can make decisions in principle on social care matters from within their delegated authorities from Camden Council.
3.6 For decisions made by Camden Council representatives on social care as per paragraphs 3.4 and 3.5 above Camden Council Cabinet requires some additional steps to be completed before a decision is binding. Once these additional steps have been taken the decision will become binding.
3.7 To ensure that there is certainty of decision making when a decision is made at a Committee meeting which requires social care approval in accordance with paragraphs 3.4, 3.5 and 3.6 above a decision will be taken as binding on the earlier of the two following events:
3.7.1 The relevant Camden Council representative stated in paragraph 3.4 above has completed the additional governance steps required and served notice of this on:
• The Committee Chair and Vice Chair; and• The Committee secretariat; or
3.7.2 At 12pm five working days after the Committee meeting in which the decision was made.
3.8 When either of the events in paragraph 3.7 occur the Committee’s secretariat shall communicate to committee members that the relevant decisions have become binding and reported at the following Committee meeting.
3.9 Decisions shall not be binding on either Camden CCG or Camden Council if by 12pm five working days after the Committee meeting in which a decision was made pursuant to paragraphs 3.4, 3.5 and 3.6 above the relevant Camden Council representative serves notice on the Committee Chair, Vice Chair and Committee’s secretariat that they wish the decision to be rescinded.
3.10 If a notice is received in accordance with paragraph 3.9 above the decision to which the notice relates to shall automatically be rescinded, communicated to committee members and reported at the following Committee meeting.
3.11 If a decision purely relates to a Camden CCG statutory function and does not include a Camden Council statutory function any such decisions become binding as soon as they are passed at a Committee meeting.
4. Role of the Committee
4.1 The role of the Committee is to:
4.1.1 Commission services pursuant to the Local Care Strategy excluding those services that are commissioned by the NCL Primary Care Co-Commissioning Committee in Common and the NCL Joint Committee;
4.1.2 Approve and monitor business cases and authorise commissioning expenditure for joint health and social care services;
4.1.3 Approve and monitor arrangements for the Better Care Fund on behalf of the Camden CCG Governing Body and Camden Council Cabinet;
4.1.4 Approve and monitor pooled funds for joint health and social care services; 4.1.5 Approve and monitor new section 75 and 76 agreements and any amendments or
variations to existing agreements; 4.1.6 Approve and monitor transfer of funding under section 256 and 257 agreements and
any amendments or variations to existing agreements;
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4.1.7 Approve and monitor the decommissioning of joint health and social care services, services commissioned under section 75 and 76 agreements and services paid for under section 256 and 257 agreements;
4.1.8 Provide oversight and scrutiny of services commissioned under section 75 and 76 agreements;
4.1.9 Provide oversight and scrutiny of services paid for under section 256 and 257 agreements;
4.1.10 Provide oversight and scrutiny of funds; 4.1.11 Approve the decommissioning of services and/or service reconfiguration; 4.1.12 Ensure that investments are affordable, value for money, sustainable and are
underpinned by a robust and deliverable Quality Innovation Productivity and Prevention (‘QIPP’) scheme;
4.1.13 Make recommendations to the Governing Body, Camden Council Cabinet, Health and Well Being Board as appropriate;
4.1.14 To endorse or make recommendations to the Governing Body and/or Camden Council Cabinet on:
• Commissioning strategy and intent;• The Annual Commissioning Plan;• Developing input to the Joint Health and Wellbeing Strategy and contributing
to the Joint Strategic Needs Assessment;• Ensuring that the views of the patients and the public are properly reflected in
the development and implementation of commissioning plans;• Commissioning, de-commissioning and re-commissioning of services;• Clinical pathway design and service models;• Oversight of Clinical Cabinet;
4.1.15 Commission services and approve business cases from within its delegated authority limits;
4.1.16 Ensure that decisions on commissioning of services or approval of business cases that are novel, contentious or repercussive are remitted to the Camden CCG Governing Body and/or London Borough of Camden Cabinet as appropriate on a case by case basis;
4.1.17 Commission transformational primary care services and enablers supporting the Local Care Strategy but excluding GP core contracts;
4.1.18 Make commissioning and de-commissioning decisions not covered by the NCL joint committee or the NCL Primary Care Co-Commissioning Committee in common.
5. Membership
5.1 The Committee shall comprise of the following voting members:
Camden CCG Representatives:
5.1.1 Four Camden CCG Governing Body elected representatives; 5.1.2 Camden CCG Secondary Care Doctor; 5.1.3 Camden CCG Lay Member; 5.1.4 Camden CCG Chief Financial Officer or their nominated deputy; 5.1.5 Camden CCG Chief Operating Officer; 5.1.6 Camden CCG Director of Quality and Clinical Effectiveness; 5.1.7 Camden CCG Director of Commissioning and Acute Contracts; 5.1.8 A Camden Patient and Public Participation Group patient representative; 5.1.9 A Camden CCG Nurse Representative.
Camden Council Representatives: 5.1.9 Executive Director of Supporting People, Camden Council; 5.1.10 Director of Integrated Commissioning, Camden Council; 5.1.11 Director of Adult Social Care, Camden Council; 5.1.12 Representative from Public Health.
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5.2 The Committee shall comprise of the following non-voting members: 5.2.1 Director of Transformation, Planning and Delivery.
5.3 The list of voting and non-voting members is set out in Schedule 1. Schedule 1 does not form part of the Terms of Reference and may be amended without the need to formally amend these Terms of Reference.
5.4 The Director of Integrated Commissioning listed in paragraph 5.1.10 above is a joint post between Camden CCG and Camden Council. However, to help to manage conflict of interest and to reflect the authority for social care decision making delegated to the role it is listed in the membership and treated for voting purposes as a Camden Council representative.
5.5 Committee members may nominate deputies to represent them in their absence and make decisions on their behalf.
5.6 The Committee may call additional experts and/or representatives from provider and other healthcare organisations to attend meetings on a case by case basis to inform discussion.
5.7 The Committee may invite or allow additional people to attend meetings as attendees. Attendees may present at Committee meetings and contribute to the relevant Committee discussions but are not allowed to participate in any formal vote.
5.8 The Committee may invite or allow people to attend meetings as observers. Observers may not present at Committee meetings, contribute to any Committee discussion or participate in any formal vote.
6. Chair and Vice Chair of the Committee
6.1 The Committee shall have a Chair and a Vice Chair.
6.2 The Chair of the Committee shall be a clinical voting member of the Camden CCG Governing Body.
6.3 The Vice Chair of the Committee shall be the Executive Director, Supporting People, from Camden Council.
7. Voting
7.1 The Committee’s voting mechanism has been established to promote genuine joint working and equality between Camden CCG and Camden Council whilst respecting and working within each organisation’s governance structure.
7.2 For health care decisions that fall under the statutory authority of Camden CCG only Camden CCG representatives may vote with decisions passing by simple majority. Camden Council representatives may contribute to the discussions but may not participate in any formal vote.
7.3 For those health care decisions referred to in paragraph 7.2 above in the event of a tied decision the Camden CCG elected Governing Body representative holding either the Chair or Vice Chair position shall have the casting vote.
7.4 For social care decisions that fall under the statutory authority of Camden Council only the representatives from Camden Council with the appropriate delegated authority from Camden Council Cabinet may vote with decisions passing by simple majority. Camden CCG and Camden Council representatives without the appropriate delegated authority from Camden Council Cabinet may contribute to the discussions but may not participate in any formal vote.
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7.5 For those social care decisions referred to in paragraph 7.4 above in the event of a tied decision the Camden Council representative holding either the Chair or Vice Chair position shall have the casting vote.
7.6 For those decisions which span the statutory authorities of both Camden CCG and Camden Council the following two conditions must be met for any decision to pass:
7.6.1 A simple majority of Camden CCG representatives must vote in favour. In the event of a tied vote the Camden CCG elected Governing Body representative holding either the Chair or Vice Chair position shall have the casting vote; and
7.6.2 The representative(s) from Camden Council with the appropriate delegated authority from Camden Council Cabinet must vote in favour. In the event of a tied vote the Camden Council representative holding either the Chair or Vice Chair positon shall have the casting vote.
7.7 Due to the provisions of paragraphs 7.1 to 7.6 above no organisation is able to out vote the other on their own statutory functions.
7.8 In the event that the Camden CCG elected Governing Body representative holding either the Chair or Vice Chair position referred to in paragraph 7.6.1 above is conflicted on an item of business the Camden CCG Lay Member shall have the casting vote.
8. Quorum
8.1 A Committee meeting will be considered quorate when at least four voting members are present. These must include:
8.1.1 Three members from Camden CCG one of whom must be an elected Governing Body member; and
8.1.2 One member from Camden Council with the appropriate delegated authority from Camden Council Cabinet to make decisions in principle on its behalf.
8.2 If any representative is conflicted on a particular item of business they will not count towards the quorum for that item of business. If this renders a meeting or part of a meeting inquorate a non-conflicted person may be temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements. If a clinician is conflicted the person temporarily appointed or co-opted onto the Committee to satisfy the quorum requirements must be a clinician.
8.3 If a meeting is not quorate the Chair may adjourn the meeting to permit the appointment or co-option of additional members if necessary.
8.4 If all elected Governing Body members on the Committee are conflicted on an item of business the requirement contained in paragraph 8.1.1 above that one of the three members from Camden CCG must be an elected Governing Body member does not apply.
9. Frequency of Meetings
9.1 Committee meetings will be held bi-monthly or as otherwise agreed by the Chair and Vice Chair.
10. Secretary
10.1 The Camden CCG Board Secretary or a nominated deputy will provide secretariat support to the Committee.
11. Notice of Meetings
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11.1 Notice of a Committee meeting shall be sent to all Committee members no less than 7 days in advance of the meeting.
11.2 The meeting notice shall contain the date, time and location of the meeting.
12. Agendas and Circulation of Papers
12.1 Before each Committee meeting an agenda setting out the business of the meeting will be sent to every Committee member no less than 7 days in advance of the meeting.
12.2 Before each Committee meeting the papers of the meeting will be sent to every Committee member no less than 7 days in advance of the meeting.
12.3 If a Committee member wishes to include an item on the agenda they must notify the Chair via the Committee’s Secretariat no later than 7 days prior to the meeting. The decision as to whether to include the agenda item is at the absolute discretion of the Chair.
13. Minutes and Reporting
13.1 The minutes of the proceedings of a meeting shall be prepared by the Committee’s Secretariat and submitted for agreement at the following Committee meeting.
13.2 Camden CCG and Camden Council will comply with their own reporting requirements.
14. Conflicts of Interest
14.1 Conflicts of Interest shall be dealt with in accordance with the NCL Conflicts of Interest Policy, NHS England statutory guidance for managing conflicts of interest and the relevant Camden Council policy for managing conflicts of interest. The NCL Conflicts of Interest Policy is a master document containing the single conflicts of interest policy agreed by each of the NCL CCGs together with a schedule setting out each CCG’s local variations to that policy.
14.2 The Committee shall have a Conflicts of Interest Register that will be presented as a standing item on the Committee’s agenda.
15. Gifts and Hospitality
15.1 Gifts and Hospitality shall be dealt with in accordance with the NCL Conflicts of Interest Policy, NHS England statutory guidance for managing conflicts of interest, the NCL Gifts and Hospitality Policy and the relevant Camden Council’s policy for gifts and hospitality.
15.2 The Committee shall have a Gifts and Hospitality Register that will be presented as a standing item on the Committee’s agenda.
16. Standards of Business Conduct
16.1 Committee members, attendees and/or observers must maintain the highest standards of personal conduct and in this regard must comply with:
• The law of England and Wales;• The NHS Constitution;• The Nolan Principles;• The standards of behaviour set out in each NCL CCG Constitution;• Any additional regulations or codes of practice relevant to the Committee.
17. Sub-Committees
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7
17.1 The Committee may not delegate any of its powers to a committee or sub-committee but it may appoint sub-committees and/or working groups to advise and assist it in carrying out its functions.
17.2 Any sub-committees or working groups must abide by the NCL Conflicts of Interest Policy, NHS England statutory guidance for managing conflicts of interest, any relevant Camden Council policies for managing conflicts of interest and relevant gifts and hospitality policies.
18. Delegated Authority
18.1 To the extent this is possible the Committee may agree to delegate its authority to a Committee member or members to make decisions on the Committee’s behalf outside of a Committee meeting at its absolute discretion on a case by case basis.
18.2 The Committee has delegated its authority to make decisions on its behalf outside of Committee meetings for Camden CCG statutory functions to the following Committee members or their nominated deputies: 18.2.1 The Chair of the Committee; 18.2.2 The Camden CCG Chief Operating Officer; 18.2.3 The Camden CCG Chief Finance Officer or the Deputy Chief Finance Officer; 18.2.4 The Camden CCG Lay Member; 18.2.5 A Camden CCG elected Governing Body representative.
18.3 If the elected Governing Body representative listed at paragraph 18.2.5 above is conflicted on the item or items of business under consideration they will not have delegated authority to make decisions under paragraph 18.2 and will not form part of the decision making.
18.4 Decisions made outside of Committee meetings must be reported to the Committee at the next Committee meeting.
19. Minor Changes to Locally Commissioned Services
19.1 The Committee may delegate responsibility for agreeing minor changes to Locally Commissioned Services or any equivalent successor services as set out below:
19.1.1 Minor changes to Locally Commissioned Services or any equivalent successor services may be agreed by the Director with responsibility for the Locally Commissioned Service or their nominated deputy;
19.1.2 Where the Locally Commissioned Services or any equivalent successor services sit across two or more programmes each Director or their nominated deputy with responsibility for each of the affected programmes must agree the changes;
19.1.3Any changes made pursuant to paragraph 19.1.1 and 19.1.2 above come into effect at a date and time to be decided by the Director responsible for the Locally Commissioned Services or their nominated deputy;
19.1.4 Before making any changes to Locally Commissioned Services or any equivalent successor services pursuant to paragraphs 19.1 – 19.3 above the relevant Programme Group or equivalent group must be consulted;
19.1.5 The Committee may issue guidance on the meaning of the term ‘minor changes to Locally Commissioned Services or any equivalent successor services’ as set out above. However, at a minimum the term ‘minor’ means changes which do not require any additional funding over and above that already provided;
19.1.6 A financial appraisal of the proposed change must be agreed with the Chief Finance Officer or their nominated deputy prior any proposed change to a Locally Commissioned Service.
19.2 Any and all changes to Locally Commissioned Services or any equivalent successor services changed pursuant to the above paragraphs must be reported to the Committee meeting immediately following the change.
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19.3 The Committee reserves the right to overturn or change any decision made to change a Locally Commissioned Service or equivalent successor service at its absolute discretion.
19.4 The Committee does not have responsibility for agreeing changes under paragraph 19.1 above where these are for primary care services. These must be agreed by the NCL Primary Care Committee in Common.
19.5 The Committee does not have responsibility for agreeing changes under paragraph 19.1 above where these are for acute services, urgent care services or mental health services associated with the Transforming Care Programme. These must be agreed by the NCL Joint Committee.
20. Authority
20.1 The Integrated Commissioning Committee is accountable to the Camden CCG Governing Body and will operate as one of its committees. The Camden Council representatives at the Committee are accountable for social care decision making to the Camden Council Cabinet.
20.2 The Committee may approve business cases and authorise commissioning expenditure according to the financial authority set out by the Governing Body in the Standing Financial Instructions. The Camden Council representatives at the Committee may approve business cases and authorise commissioning expenditure in principle in line with their delegated authority limits from Camden Council Cabinet.
20.3 The Committee may approve decisions on the Better Care Fund as delegated to it by the Camden CCG Governing Body and the Camden Council Cabinet.
21. Reporting Responsibilities
21.1 The Committee will report at each formal meeting of the CCG Governing Body on all matters within its duties and responsibilities.
21.2 The Committee will make recommendations to the Governing Body it considers appropriate on any area within its remit where action or improvement is needed.
21.3 The Camden Council representatives shall report to the Camden Council Cabinet and make recommendations to it as appropriate.
22. Committee Effectiveness Review
22.1 The Committee shall arrange for periodic reviews of its own performance to ensure it is operating at maximum effectiveness and make any recommendations to the Governing Body and/or Camden Council Cabinet it considers necessary.
23. Review of Terms of Reference
23.1 These Terms of Reference will be formally reviewed in March each year following the establishment of the Committee.
Approved: May 2018 Date of Next Review: July2018
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Appendix 1 Committee Members
Camden CCG Voting Members:
Position Name
CCG Governing Body elected representative Dr Martin Abbas
CCG Governing Body elected representative Dr Jonathan Levy
CCG Governing Body elected representative Dr Sarah Morgan
CCG Governing Body elected representative Dr Kevan Ritchie
Camden CCG Lay Member Bss Glenys Thornton
Camden CCG Secondary Care Doctor Dr Matthew Clark
Camden CCG Chief Financial Officer or Nominated Deputy Ms Becky Booker
Camden CCG Chief Operating Officer Ms Sarah Mansuralli
Camden CCG Director of Commissioning and Acute Contracts Ms Jennifer Murray-Robertson
Camden CCG Director of Quality and Clinical Effectiveness Ms Neeshma Shah
A Camden Patient and Public Participation Group patient representative
Mr David Richards
Camden CCG Nurse Representative Ms Jane Davis
Camden Council Voting Members:
Position Name
Executive Director of Supporting People Mr Martin Pratt
Director of Integrated Commissioning Mr Richard Lewin
Director of Adult Social Care Ms Sarah McClinton
Representative from Public Health Ms Julie Billett
Non-Voting Members:
Position Name
Director of Transformation, Planning and Delivery Camden CCG
Ms Sally MacKinnon
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Finance, Performance and QIPP Committee Report
Agenda Item 7.1 Date 09.05.18
Lead Director Simon Goodwin, NCL Chief Finance Officer
Tel/Email [email protected]
Report Author Kofo Abayomi, Board Secretary Tel/Email [email protected]
GB Sponsor(s) Dr Birgit Curtis Tel/Email [email protected]
Report Summary A summary report of the meeting on 31 January 2018
Purpose Information Approval To note
Decision
Recommendation The Governing Body is asked to note the report.
Strategic Objectives Links
This report links with the following strategic objectives:
• Commission the delivery of NHS constitutional rights and pledges;• Improve health outcomes, address inequalities and achieve parity of esteem;• Maintain financial stability and ensure sustainability through robust planning
and commissioning of value-for- money services.
Identified Risks and Risk Management Actions
The Committee oversees performance and finance risks rated 12 or higher in line with the CCG’s standard risk management processes
Conflicts of Interest
There are no conflicts of interests arising from this report. The Committee identifies and manages conflicts of interests in line with CCG processes.
Resource Implications
None
Engagement This summary report is shared with the Camden Public and Patient Engagement Group.
Equality Impact Analysis
There are no equality impacts arising from this work
Report History The Finance and Performance Committee reports to each Governing Body Meeting.
Next Steps The Committee and QIPP Workshops will continue to meet as planned
Appendices None
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Name of committee: Finance and Performance and QIPP Committee Date of meeting: 28 March 2018 Issues discussed Finance Report: Month 11
In Summary:
- Increase in acute over-performance to £5.1m from £3.2m in month 10. This was mainly due to adeterioration to the University College London Hospital (UCLH) position, resulting from anadverse movement in marginal rate relating to the Evergreen ward (St Pancras site) and criticalcare.
- Increased performance in relation to the pace and treat service at the Royal Free Hospital.Invoices over and above the budgeted amount was received by the CCG.
- Over performance in non-acute area relating to section 256 risks previously discussed at theCommittee. This is now included in the financial position and it is expected to be paid in 2017/18.
- Technical adjustment is in place in relation to funding IVF treatment.
QIPP Report: Month 11 Progress and QIPP 2018/19 Update
The Committee noted that the CCG submitted its monthly report to NHS England (NHSE) with a YTD position of £13.5m against a plan of £16.15m. This represents 84% delivery, an overall CCG RAG rating of amber. The CCG is reporting a forecast outturn for QIPPP of £16.37m against a plan of £18.14m, representing 90% delivery.
Integrated Performance Report
The main areas of concern continue to be performance against the 62 day cancer and RTT waiting times standards and A&E performance.
The Committee noted that there was stronger performance against cancer standards across NCL which reflects the significant work undertaken across the system in delivering action plans and improving the flow of patients referred between Trusts. Attention was drawn to the deadline of July 2018 for patient referral booking to be done via ERS. Work is being done with UCLH particularly around urgent referrals to address online automated appointment challenges. It was noted that the UCLH Cancer Collaborative offered support to the CCG to reduce delays in the 2 week pathways.
Data Assurance Action Plan
The Committee’s attention was drawn to changes to the resourcing of the Care Insights Team and additional work to be carried out to embed the key programme work. Assurance was provided to the Committee regarding the robustness of monthly reporting which undergoes challenge in line with the national timetable.
Update on Contracting Arrangements for 2018/19
The Committee noted updates on contracts with Providers, of which one of the four acute contracts have been agreed. Further discussions are planned with remaining providers to agree the final positions by 30th April.
Issues for the Governing Body None. Decisions for the Governing Body None
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Integrated Commissioning Committee Report
Agenda Item 7.2 Date 09.05.18
Lead Director Richard Lewin, Director of Integrated Commissioning
Tel/ Email
Report Author Kofo Abayomi Board Secretary
Tel/ Email
GB Sponsor(s) (where applicable)
Dr Matthew Clark Tel/ Email
Report Summary This paper presents a summary of the Integrated Commissioning Committee meetings held on
Purpose Information Approval To note
Decision
Recommendation The Governing Body is asked to note the Integrated Commissioning Committee Report.
Strategic Objectives Links
• Commission the delivery of NHS constitutional rights and pledges• Improve health outcomes, address inequalities and achieve parity of
esteem
Identified Risks and Risk Management actions
Any major risks are highlighted as part of this report.
Conflicts of Interest
There are no conflicts of interest arising from this report.
Resource Implications
None
Engagement This summary report is shared with the Camden Public and Patient Engagement Group.
Equality Impact Analysis
There are no equality impacts arising from this report.
Report History The Committee reports to each Governing Body meeting.
Next Steps None
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Name of Committee: Integrated Commissioning
Date of meeting: 28 March 2018
Issues discussed
• Marie Curie Business Case• Social Prescribing Services: Procurement Update and Specification• Termination of Pregnancy Services (TOPS) Contract Award• Team Around the Practice (TAP) within Primary Care
Decisions Made:
Marie Curie Business Case
The Committee approved the business case (option 3) for Marie Curie Hampstead Hospice. This option was to award the contract to MCH for 2 years with 2 optional 6 month extensions by publishing a Voluntary Ex Ante Transparency (VEAT) notice.
Social Prescribing Services: Procurement Update and Specification
The Committee at its February meeting requested an update on the procurement and specification. Attention was drawn to details relating to the background and rationale for the remodelling of the service. Developing the specification included engagement with public health and incorporating contractual levers and key performance indicators into the specification. There has also been extensive engagement with the procurement team about procuring the new model given potential challenges to the procurement process. A further update will be provided at the next Committee meeting to cover areas of Committee discussion.
Termination of Pregnancy Services (TOPS) Contract Award
A report was presented to the Committee highlighting outcomes of the NCL TOPs procurement. This procurement process had concluded with the contract awarded to three providers (Marie Stopes, British Pregnancy Advisory Service and the National Unplanned Pregnancy Service).
Team Around the Practice (TAP) within Primary Care
A report was presented at this meeting following the request of the Committee in February to develop options on how TAP is recommissioned within primary care. Two options were set out in the report:
Option one, aimed to establish step down access to primary care and less intensive settings which was the recommended option as there are currently a high number of patients within cluster 11 that could be managed in primary care. It was noted that cluster 11 patients are stable with low symptoms and should be treated in the primary care setting however they are currently treated in secondary care which is less than ideal. If these patients could be released on a phased plan it would gradually release capacity for the Trust and improve the quality of secondary care services.
Option 2 aimed to treat patients in an integrated care setting in primary care and combining physical and mental health care through multidisciplinary team care and case management.
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The Committee approved option 1 and requested that a service specification which included KPIs, monitoring arrangements, a mobilisation plan for the service and addressed key issues with respect to clinical governance responsibility, primary care estate and increased primary care workload. Issues for the Governing Body: None to report.
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Locality Committees Report Agenda Item 7.3 Date 09.05.18
Lead Director Meena Mahil, Interim Director of Primary and Community Commissioning
Tel/ Email
Report Author Amanda Rimington Senior Commissioning Manager, Primary Care
Tel/ Email
Report Summary This paper is a summary report of Locality Committees held in March and April 2018
Purpose (tick one box only)
Information Approval To note
Decision
Recommendation The Governing Body is asked to note the contents of this report.
Strategic Objectives Links
Involve member practices and commissioning partners in key commissioning decisions.
Identified Risks and Risk Management Actions
There are no risks associated with this report.
Conflicts of Interest
None
Resource Implications
None
Engagement Not applicable for the purpose of this report Equality Impact Analysis
Not applicable for the purpose of this report
Report History The Locality Committees Report is presented at every Governing Body meeting
Next Steps None
Appendices None
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Camden CCG Locality Committees Report
1. Introduction
One of the key ways that Camden CCG engages with its members is through Locality Committees. The South Locality Committee is chaired by Dr Jonathan Levy, the North by Dr Martin Abbas and the West by Dr Birgit Curtis. This report summarises the March and April 2018 committees.
2. March and April 2018 Locality Committees
The following commissioning items were brought to all three Committees. The meetings in April had a limited agenda as there was a last minute cancellation from one of the speakers.
March 15 & 21 agenda: 1. Extended Access Service Update2. QIPP Opportunities3. Contracts with GP Federations 18/19 and 19/20
April 11, 12 & 13 agenda: 1. Universal Offer discussion2. St Pancras Site Redevelopment Update
March agenda:
1.) Extended Access Service Update: Amanda Rimington, Senior Commissioning Manager attended the March Committees to give an update on the Extended Access Service. This included an overview of the service’s performance and the contract monitoring mechanism used to oversee the contract.
2.) QIPP Opportunities: Harrison Spencer and Miro Zvoc updated the committee on the current QIPP plan and asked the group what ideas they had to bridge the gap with current QIPP ideas, future services they would like to see and canvassed their views on overall QIPP plans.
3.) Contracts with GP Federations 18/19 and 19/20
April agenda:
1.) St Pancras Site Redevelopment Update: This was given by Vincent Kirchner Medical Director at Camden & Islington, who informed the localities of the latest position on the redevelopment of the St Pancras Hospital site. Key Information included:
• Funding is provided entirely by Camden and Islington NHSE Foundation Trust at St PancrasHospital with no input from NHSE or CCCG
• The programme includes re-building of new mental health wards but without reducing thecurrent capacity of beds
2.) Universal Offer discussion: Primary Care Investment 2018/19 and Federation and neighbourhood investment updates were discussed at both the March and April localities by Vanessa Cooke, Senior Commissioning Manager (March and April) and Meena Mahil, Director of Primary and Community Care (April only). The proposal outlines changes to some Universal Offer service payments to release £150,000 to invest in new services which deliver QIPP savings was discussed. Vanessa and Meena gave an update on the current situation, listened to feedback and explained the on-going input from the LMC
3. Forward look
Upcoming dates:
• May – South Locality: 16 May; North/West joint meeting: 17 May• June – South 13th June, North/ West 14th June
Agenda items:
• Implementation of LTBI Screening in Camden• Maternity & Perinatal service update• PMS contract and reinvestment review update• Supporting at scale working in 2018/19
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Camden Clinical Commissioning Group Governing Body Meeting 09 May 2018
Report Title Report of the Audit Committee Agenda Item 7.4 Date 09.05.18
Lead Director Rebecca Booker Deputy Chief Finance Officer
Ian Porter Director of Corporate Services
Tel/Email [email protected]
Report Author Kofo Abayomi Board Secretary
Tel/Email [email protected]
GB Sponsor(s) (where applicable)
Richard Strang Lay Member
Tel/Email
Report Summary This report provides a summary of the key topics discussed at the 18 April 2018 Audit Committee meeting.
Purpose (tick onebox only)
Information Approval To note
Decision
Recommendation The Governing Body is asked to note the Audit Committee Report.
Strategic Objectives Links
• Commission the delivery of NHS constitutional rights and pledges• Maintain financial stability and ensure sustainability though robust planning
and commissioning of value for money servicesIdentified Risks and Risk Management Actions
Audit Committees have a crucial role to play in the governance of NHS organisations. They report on the relevance and rigour of underlying structures and processes and on the assurances that the Governing Body receives.
Conflicts of Interest
Not applicable for the purpose of this report.
Resource Implications
None identified.
Engagement Not applicable for the purpose of this report.
Equality Impact Analysis
There are no equality impacts arising from this report.
Report History The Audit Committee reports to the Governing Body at regular intervals.
Next Steps None
Appendices Appendix 1, summary of the April 2018 meeting of the Audit Committee.
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Appendix 1
This report provides a summary of the items considered by the Audit Committee on 18 April 2018.
Internal Audit
Internal Audit Progress Report
The Committee considered the Internal Audit Internal Progress Report which contained a summary update on progress against the CCG’s and CSU Quality Assurance 2017/18 work plan. The following reviews have been finalised:
• CSU Contract Monitoring• Primary Care Delegated Commissioning – Part One and Two• Conflicts of Interest• Provider Performance Management• Board Assurance Framework and Risk Management• Financial Reporting and Governance• QIPP and Sustainability
The Committee noted the current status regarding management actions raised.
The Committee also discussed the structuring of Internal Audit reports under the new NCL Audit Committee in Common model (taking effect from July) – with a request for an executive summary to be produced for each meeting of key issues for each CCG arising from the Internal Audit reports being presented.
Head of Internal Audit Opinion (Draft)
The Committee considered the draft Head of Internal Audit Opinion for the 12 months ended 31 March 2018. Overall the draft Head of Internal Audit opinion confirmed that Camden CCG has an adequate and effective framework for risk management, governance and internal control.
Areas for further enhancements were identified to ensure that the framework of risk management, governance and internal control remains adequate and effective.
Draft Annual Report 2017/18
The Committee considered the draft Annual Report 2017/18 and noted that the first draft will be submitted to NHS England within deadline (20 April 2018) for their initial review and feedback. The Committee broadly endorsed the report’s content and suggested some minor additions. Overall, the Audit Committee was content with the written presentation of the Annual Report.
The Chair took an action to draw the attention of the Governing Body to the member statement of disclosure to the CCG’s Auditors:
Statement of Disclosure to Auditors
“Each individual who is a member of the CCG at the time the Member’s report is approved confirms:
• so far as the member is aware, there is no relevant audit information of which the CCG’s auditoris unaware that would be relevant for the purposes of their audit report
• the member has taken all the steps that they ought to have taken in order to make him or herselfaware of any relevant audit information and to establish that the CCG’s auditor is aware of it.
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An updated draft annual report and accounts will be presented to the Governing Body on the 09 May with the recommendation that it delegates its authority to the Audit Committee to approve and submit the final version to NHSE when it meets on the 21 May 2018.
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NORTH CENTRAL LONDON (NCL) JOINT COMMISSIONING COMMITEE Minutes of the meeting held in public on Thursday 1 February 2018, 15:00-17:00
Committee Room, Holbrook House, Cockfosters Road, Barnet, EN4 0DR
Present:
Voting Members Ms Karen Trew (Chair) Governing Body Vice Chair and Lay Member, Enfield CCG Dr Mo Abedi Governing Body Chair, Enfield CCG Ms Angela Dempsey Nurse Representative, Enfield CCG Dr Debbie Frost Governing Body Chair, Barnet CCG Ms Bernadette Conroy Governing Body Lay Member, Barnet CCG Ms Kathy Elliott Governing Body Vice Chair and Lay Member, Camden CCG Dr Peter Christian Governing Body Chair, Haringey CCG Ms Catherine Herman Governing Body Non-Clinical Vice Chair and Lay Member,
Haringey CCG Ms Sharon Seber Practice Nurse Member, Haringey CCG Dr Jo Sauvage Governing Body Chair, Islington CCG Ms Lucy De Groot Governing Body Lay Member, Islington CCG Ms Helen Pettersen NCL Accountable Officer, Barnet, Camden, Enfield,
Haringey and Islington CCGs Mr Simon Goodwin NCL Chief Finance Officer, Barnet, Camden, Enfield,
Haringey and Islington CCGs
Non-Voting Members Ms Parin Bahl Chair, Healthwatch Enfield Ms Sharon Grant Chair, Healthwatch Haringey Cllr Hugh Rayner Councillor, Barnet London Borough Council Cllr Patricia Callaghan Councillor, Camden London Borough Council
In attendance Mr Paul Sinden NCL Director of Performance and Acute Commissioning,
Barnet, Camden, Enfield, Haringey and Islington CCGs David Stout Senior Programme Director, North Central London STP Ms Vicky Aldred Director of Quality, Barnet CCG Professor Fares Haddad Clinical Lead for Adult Elective Orthopaedic Services,
University College London Hospitals NHS Foundation Trust Mr Rob Hurd Chief Executive, Royal National Orthopaedic Hospital NHS
Trust
Apologies: Cllr Janet Burgess Councillor, Islington London Borough Council Cllr Jason Arthur Councillor, Haringey London Borough Council Cllr Richard Olszewski Councillor, Camden London Borough Council Cllr Alev Cazimoglu Councillor, Enfield London Borough Council Dr Neel Gupta Governing Body Chair, Camden CCG Dr Matthew Clark Secondary Care Clinician, Camden CCG Ms Sorrel Brookes Governing Body Lay Member, Islington CCG
Dr Jeanelle De Gruchy Director of Public Health, Haringey London Borough Council
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Minutes: Ms Brenda Thomas Board Secretary (Interim) Enfield CCG
1 Introduction 1.1 The Chair welcomed everyone to the meeting, particularly new attendees to the
Committee - Ms Vicky Aldred, Director of Quality (Interim), Barnet CCG and Ms Lucy De Groot who was deputising for Ms Sorrel Brookes, Governing Body Lay Member, Islington CCG. Apologies for absence were noted, as recorded above.
1.2.1 Members and attendees confirmed their entries in the Register of Declarations of Interest.
1.2.2 The chair invited Members to declare any interests in respect to items on the agenda. The Chair declared an interest in item 2.1 ‘Chairing of the NCL Joint Commissioning Committee and Terms of Reference’, as this relates to her position as Chair of the Committee. She would not be required to leave the meeting for this item, but would not take part in the discussion and decision. Dr Jo Sauvage agreed to chair the meeting for this item.
1.2.3 Action: Add Catherine Herman to the Declarations of Interest Register.
1.3 There were no declarations of gifts or hospitality offered or received.
1.4 Minutes of the Committee meeting on 7 December 2017
1.4.1 The minutes were approved as an accurate record, subject to including the discussion on diagnostic standards, for which an action should be raised and included in the action log.
1.4.2 Action: add waiting times for diagnostic testing and reporting for local providers to the action log.
1.5 Action log
1.5.1 The Committee agreed to close actions 1 and 2.
1.5.2 Actions 3 and 4: Update to be provided when available.
1.5.3 Action 5: Concordia started providing service on North Middlesex University Hospital (NUMH)’s behalf on 15 January 2018 at NMUH site. This is a 12 month’s contract. However, notice has been served to end the contract on 15 July 2018, therefore a commissioning arrangement needs to be in place prior to this date. Royal Free London (RFL) are yet to confirm their readiness to take on this service. No change is envisaged in the short term and this is being worked through commissioning arrangements.
1.5.4 It was suggested that this item stays on the agenda to monitor any increase in delay on treatment and to ensure appropriate arrangements are in place.
Action JCC/001/18: Paul Sinden to include update in the Acute Commissioning Report for the next meeting.
1.6 Questions from the public
There were no questions from the public.
2 Governance
2.1 Chairing of the NCL Joint Commissioning Committee and Terms of Reference
2.1.1 As earlier noted under Introduction, Dr Jo Sauvage chaired the meeting for this item. Ms Karen Trew had declared an interest in this item and did not take part in the discussions or decision.
2.1.2 The Committee received a report on the Chairing of the NCL Joint Commissioning
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Committee and Terms of Reference noting that interviews for the Independent Chair for the Committee took place in August 2017 but an appointment was not made. At the Committee Seminar held on 7 September 2017 it was therefore agreed that a Lay Member representative from the Committee undertake the role of Chair for six months, after which the appointment of an Independent Chair would be further considered. At the seminar in September 2017 it was agreed that Karen Trew, lay representative from Enfield CCG, would Chair the Committee during this time. The appointment was effective for 2017/18 with further consideration therefore required for April 2018 onwards.
2.1.3 The terms of reference at the time stated that the Chair of the Committee would be independent with a Lay Member representative as stand-in, and a Vice Chair was yet to be nominated.
2.1.4 In discussing the recommendations put forward, the Committee: • Suggested having the option of a CCG lay member of the Committee as Chair, as well
as an Independent Chair, to eliminate the need for further revision to the terms ofreference should circumstances change in future;
• Suggested that the Vice Chair was sourced from either Barnet or Camden CCG, giventhat the proposal was to have the Committee Chair from Enfield CCG, and that theChair and Vice Chair for the NCL Primary Care Committee-in-Common were carried outby members of Haringey and Islington CCGs respectively.
2.1.5 The Committee: • APPROVED that the Committee Chair continues to be sourced from CCG Lay Member
for the 2018/19 year;• APPROVED That Karen Trew, lay member representative for Enfield CCG, continued
as Chair of the Committee for 2018/19;• APPROVED that a further review of Chair arrangements for the Committee be
undertaken in the final quarter of 2018/19;• RECOMMENDED that a process be utilised by lay member representatives to
appoint a Vice Chair from Barnet or Camden CCG, for reasons noted during discussion;• APPROVED that the terms of reference be amended to reflect that the
appointment of the Committee Chair could be a CCG lay member representative or anindependent individual;
• NOTED that the updated terms of reference were to be sent to Governing Bodiesin March 2018, with the revised terms of reference effective from April 2018.
2.1.6 Action JCC/002/18: Andrew Spicer to rework the terms of reference and circulate the updated version to Committee members in readiness for the Governing Bodies in March 2018.
2.1.7 Action JCC/003/18: Lay Members to nominate Vice Chair of Committee for 2018/19.
3 Activity and Performance
3.1 Acute Commissioning Report
3.1.1 Paul Sinden provided a summary of the report and highlighted the key areas for noting. • Cancer 62-day standard was showing a slowly improving position in NCL. Initial reports
for December showed performance over 80% with RFL expected to achieve the 85%standard. The main deficit in performance remained the waiting list backlog at UniversityCollege London Hospital (UCLH), with the updated Trust recovery plan indicatingcompliance by June 2018 and within this compliance on internal pathways by April 2018.Weekly calls were hosted with providers to go through inter-provider transfers on apatient by patient basis to determine common themes of delay and actions to be taken.
3.1.2 The experience during this winter had been: • A&E attendances in 2017/18 remained in line with 2016/17; however, emergency
admissions were higher in 2017/18, with spikes in admission in late December 2017 and
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through January 2018 with the increase in admissions for respiratory problems and over 75s;
• Delayed transfers of care (DToCs) in 2017/18 were lower than for the previous yearsupported by the introduction of discharge-to-assess pathways and more continuinghealthcare assessments being carried out in the community;
• An increase in length of stay with more people in hospital beds for more than seven daysthan last winter;
• An increase in the incidence of flu and loss of bed capacity to infection (including norovirus);• An increase in ambulance turnaround delays over 30 minutes compared to last year in
particular at NMUH, RFL and Barnet Hospital. A&E Delivery Boards would be looking atplans with London Ambulance Service (LAS) and hospital providers as to how to reduceambulance turnaround times.
3.1.3 North Middlesex University Hospital (NMUH): Trust performance was the most challenged in London; however, A&E performance had been improving from 80.3% in August 2017 to 87.2% in October 2017, but there has been a subsequent deterioration since then with a performance of 72.6% in December 2017 and continued reduced performance indicated in the provisional data for January 2017. This report has previously reported on concerns raised by the General Medical Council, Health Education England and the Care Quality Commission regarding the learning environment of trainee doctors in the Trust’s Emergency Department. Weekly support calls with these stakeholders continued in order to ensure progress of the agreed action plan.
3.1.4 Referral to Treatment (RTT): RTT performance continued to deteriorate, with both Royal Free London (RFL) and UCLH not meeting the standard (92% of patients waiting less than 18 weeks) in November with UCLH at 91% and RFL at 87%. Both providers had submitted recovery plans with UCLH now indicating recovery of the standard by March 2018 (previously February 2018) due to an increase in demand for Ear Nose Throat (ENT) services, and Royal Free London by August 2018 (the latter trajectory was yet to be accepted by commissioners).
3.1.5 Patient Experience: Friends and Family Test (FFT) responses received a low positive response rate at North Middlesex University Hospital (NMUH) for outpatient appointments, maternity and A&E attendances relative to other providers in North Central London and across London. Healthwatch Enfield were working with patients in the emergency department as part of the plan to improve patient experience at the Trust.
3.1.6 London Ambulance Service (LAS): Formal contract reports were not yet available but LAS had provided a weekly report that included some monthly performance data for the programme. The snapshot in the report from December 2017 indicated that LAS were not meeting most of the waiting time standards in NCL and across London. LAS would be invited to a future meeting to discuss performance issues.
3.1.7 Never Events: Since the beginning of the financial year North Middlesex University Hospital (NMUH) and Royal Free London (RFL) had reported an increased number of Never Events. In response Barnet CCG organised an assurance visit on Never Events for 30 January 2018 and commissioned North East London Commissioning Support Unit (NELCSU) safety team to undertake an in-depth Thematic Review to be completed by March 2018. Haringey CCG were undertaking a thematic analysis of the learning following previous Never Events and were planning an assurance visit to NMUH with a focus on root causes and action plans for February 2018.
3.1.8 Contracts and Finance: NCL CCGs had reported overall year-to-date over performance of £15.7m on acute contracts and forecast outturn over performance of £22.8m. The forecast for the year-end took into account individual CCG adjustments for the impact of Sustainability and Transformation Plan (STP) interventions later in the year and the impact of marginal rates, with the impact of the latter being a £13.5m reduction in forecast outturn across acute contracts. Forecast outturn had increased by £4.9m at month nine compared to month eight, driven by increases in Trust reported activity in the four main NCL acute
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trusts, with over 60% of the increase accruing from non-elective admissions at Royal Free London (an increase in the run-rate of admissions and a backdated but legitimate switch in coding to Best Practice tariff by the Trust for respiratory admissions). Delivery of Sustainability and Transformation Plan (STP) interventions had also reduced to 61% of plan from 63% in the previous month, reducing the impact of interventions by £0.6m. At the request of the Committee a split of the marginal rate by provider by CCG would be included in the next report.
3.1.9 Action JCC/004/18: Split of marginal rate impact by provider to be included in the next commissioning report.
3.1.10 Whilst an agreement has been reached with RFL on the three main disputed items of patient transport, productivity metrics and counting and coding, the final impact of the application of marginal rate had yet to be agreed with the Trust. This was wrapped up in the ongoing discussions about a full and final year-end settlement or a settlement agreed based on year end activity levels.
3.1.11 During discussion on the Acute Commissioning paper, the Committee: • Noted that Enfield Healthwatch were undertaking a piece of work on the reasons patients
attended A&E and what services they accessed prior to their attendance, to improveurgent and emergency care services at North Middlesex University Hospital (NMUH). Itwas further noted that Healthwatch Haringey had carried out a similar exercise, with thereport submitted to NMUH for comments. Evidently, a large percentage of the peopleinterviewed had been seen and directed to A&E by their GP. The Committee conveyedthanks to Enfield and Haringey Healthwatch;
• Referred to the table provided on the yield of claims by CCG and queried the amount andtime spent on these items and whether a better process could be in place. SimonGoodwin noted that the payment by result (PBR) system required the claims process tobe in place;
• Noted continued concern over the quality of counting and coding at Royal Free London(RFL) and the focus this was putting on transactional processes rather than delivery ofthe Sustainability and Transformation Plan. Paul Sinden noted that quarter one and tworeconciliations were resolved with providers with relative ease, with the exception of RFL.There was £9.2m counting and coding changes from the Trust identified at quarter one,with several iterations developed to reach an agreement and a proposal put forward tothe Trust to involve a third party expert to mediate to reach an agreement;
• Queried whether the improvement in delayed transfers of care (DTOCs) was consistentacross NCL providers, and noted that DTOCs in NCL were slightly lower than in London.Substantial work has been undertaken to reduce delays through A&E Delivery Boardsand implementing discharge to assess pathways;
• Requested further clarity on the Never Events figures, with the nine Never Eventsreported regarded as high. The feeling of not having a systematic approach toaddressing this issue was also expressed. The Committee was assured that NeverEvents and Serious Incidents (SIs) are reviewed in detail at the Clinical Quality ReviewGroup (CQRG) and are also reviewed at individual CCG’s Quality Committee. There isno benchmark for Never Events and there are 14 national categories designated asNever Events, with clear safeguards usually in the form of national policies. There wasrelatively little or no harm for the eight (nine reported, one deescalated) Never Events atRFL. However, these are indicators of serious lapses in clinical care which could result insignificant harm, therefore should be taken seriously. NHS Improvement (NHSI) andBarnet CCG are impressed with the work being done by RFL to ensure improvement intheir safety issues on surgical problems and there is ongoing clinical quality oversightarrangement to ensure this traction continues.
• Requested that London Ambulance Service (LAS) be pursued for communications on theintroduction of the new ambulance response programme to alleviate public concern;
• Noted there was an ongoing theme in the narrative of the report about contractperformance being dependent on delivery of Sustainability and Transformation Plan
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(STP) interventions. The Committee also noted that delivery of the interventions would also impact on patient experience. The Committee therefore requested receipt of a description of the top ten STP interventions, with their activity and monetary value and expected impact on patient experience. It was noted that a presentation on the STP given at Barnet CCG would be a template for this;
• Reinforced that an NCL-wide approach should be taken when dealing with Providers. From this Camden CCG requested an overview of the Royal Free London contract position as an Associate Commissioner;
• Noted that there is discussion at the Haringey Adult Safeguarding Board, about current pressures at NMUH, the implications for safeguarding and actions being taken. It was noted that clinicians are sighted on Never Events, SIs and Near Misses via the CQRG and there is a new policy on Human Trafficking. Annual reports on safeguarding could be shared if required.
3.1.11 Action JCC/005/18: Provide the Committee with an overview of Sustainability and
Transformation Plan (STP) interventions at a future meeting.
Action JCC/006/18: Paul Sinden to feedback to Kathy Elliot outside the meeting, actions being taken in the short term in relation to RFL and bring back to the Committee concerns (if any) that comes out of the review, either within the Acute Commissioning report or as a separate report.
3.1.12 The Committee NOTED the report.
3.2 Transforming Care Programme Update
3.2.1 Paul Sinden gave an overview of the report which set out: • NCL performance against the bed reduction trajectory; • The current position on the proposed funding transfer agreement from Specialist
Commissioning to CCGs; • The financial position for each CCG/Local Authority area for CCG funded patients
discharged from 1 April 2016 with an admission of 12 months or more.
3.2.2 In December 2017 across NCL there were 64 people in inpatient beds against a trajectory of 65, although within this there were more people remaining in long-stay placements (31) against the trajectory of 29. In February 2018 there were four discharges into the community offset by three new admissions to inpatient placements, and one scheduled discharge that failed. The NCL-wide Positive Behaviour Support Team, established from central NHS England monies, focused on admission avoidance. Although the bed trajectory reduction was being met across NCL there was differential performance across CCGs and boroughs.
3.2.3 An updated funding transfer agreement had been received from NHS England (NHSE) following challenge from Transforming Care Partnerships across London to the previous proposal. The updated funding transfer agreement featured: • Expected payment from NHSE of £1.3m, with £165k for eligible transfers in 2016/17,
£470k for eligible transfers to date in 2017/18, and £639k for future transfers in the rest of 2017/18 and 2018/19;
• Payment for people who had been in inpatient beds for more than five years transferred into community packages of care in 2016/17 and 2017/18 (previous version only covered 2017/18);
• An incentive payment for a net reduction in inpatients amounting to £180k per net discharge, with this offset by a payment back to NHSE for re-admissions. This arrangement excluded patients with the length of stay in excess of five years (see above) where separate payments were agreed.
3.2.4 The funding transfer agreement from CCGs to Social Care reflected the NHSE agreement
and covered transfers of care from 1 April 2016. From the agreement funds flowing from
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CCGs to Social Care to date would be £1.1m; with £499k relating to transfers made in 2016/17 and £598k to transfers made in 2017/18.
3.2.5 The cost pressure based on the funding transfer proposal from NHSE was £3.6m across NCL. This increased by £1.7m to £5.2m when taking into account new patients entering the Transforming Care cohort, and incentive payments for a net reduction in inpatient placements.
3.2.6 The Committee, in discussing the report:
• Noted that the full £5.2m cost pressure would accrue in 2018/19; • Noted the importance of patients’ voice to be embedded in the report. Healthwatch
offered support in this regard; • Queried when funding would be transferred to Councils in accordance to NHS England
and local funding transfer arrangements in the context of the cost pressures to Councils and in particular, where admissions to hospitals had successfully been prevented;
• Noted that funding transfer agreements would be recurrent for as long as patients were not re-admitted.
• Noted that the Enfield CCG position needed to be clarified in relation to stranded costs following transfers into community packages.
3.2.7 Action JCC/007/18: Paul Sinden to circulate a briefing on when funding would be available
and its recurrent nature. Action JCC/008/18: Paul Sinden to provide an updated position for Enfield CCG.
3.2.8 The Committee:
• APPROVED the funding transfer agreement for CCG funded placements with an inpatient stay of more than 12 months effective for transfers from 1 April 2016.
4 Commissioning
4.1 Planning for 2018-19
4.1.1 The Committee received an overview of progress with planning for 2018/19. Formal planning guidance for 2018/19 from NHS England and NHS Improvement was yet to be received. The Committee would receive an update once the guidance was received. Local progress in agreeing contract baselines for 2018/19 is being made, with further work required and in the absence of clear guidance, the latest intelligence is being used.
4.1.2 The Committee then received an update on local progress to date:
• Resolution of the quarter one position for 2017/18 with providers as a precursor to establishing opening contract baselines for 2018/19;
• Opening baselines for 2018/19 had been issued to providers; • Analysis of activity growth trends on contracts in 2017/18, compared to the planning
assumption of 3%, to inform growth trends to be applied to contracts in 2018/19; • Generation of plans for Sustainability and Transformation Plan (STP) and local CCG
interventions that target a reduction in acute hospital activity in 2018/19. Supporting project initiation documents (PIDs) setting out activity and financial impact of the interventions have been shared with providers in January 2018;
• Contract terms for marginal rates, claims and challenges, CQUIN and key performance indicators will be rolled forwards from 2017/18 into 2018/19.
4.1.3 In response to the update the Committee emphasised that contracts for 2018/19 should be
fully reflective of STP and local QIPP interventions. 4.1.4 The Committee NOTED the report.
4.2 Adult Elective Orthopaedic Services: Achieving the Best Value for Patients
4.2.1 Mr Rob Hurd Chief Executive, Royal National Orthopaedic Hospital NHS Trust and Professor
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Fares Haddad, Clinical Lead for Adult Elective Orthopaedic Services at UCLH presented the paper which set out a project proposal to establish a review of adult elective orthopaedic services across NCL, as part of the planned care workstream in the Sustainability and Transformation Plan (STP). This review would seek to identify opportunities to improve outcomes for patients; improve the quality of services by reducing unwarranted variation; and improve value for money. There was evidence of substantial benefit from other health economies that had carried out similar proposals.
4.2.2 Good practice for consultation and engagement on service changes was being followed and
would include a focus on engagement with both staff and patients. CCGs would have representation on the Review Group, and assurance of the mandate from each of the Providers in NCL would be secured, with a clinical lead from each site involved in the project. The review would be clinically led and undertaken as part of the NCL STP, with final decisions on any proposed changes to be taken by the NCL Joint Commissioning Committee.
4.2.3 The supporting paper provided further detail and set out:
• Project governance with the Adult Orthopaedic Elective Services Review Group reporting into the NCL STP Health and Care Cabinet for clinical oversight and scrutiny. The review would have four workstreams: developing the clinical case for change, demand and capacity modelling, communications and consultation, and workforce;
• The intent to engage with clinicians and patients and the public through the review, with advice taken from Healthwatch and the NCL Joint Health Overview Scrutiny Committee;
• Project timescales and capacity. It was anticipated that the service review would be completed by March 2019, and would come back to the Committee for approval.
4.2.4 The following comments were made by the Committee during discussion:
• A request that the project be ambitious for outcomes and delivery. In response the project leads noted that a realistic scale of ambition would be set and options for the service model would be generated;
• The review would incorporate independent hospitals and assess evidence of outcomes from these providers as part of the case for change;
• This would be a clinically led programme of work with a focus on quality and outcomes; • Assurance was sought on avoiding slippage on the timetable and the consequent
impact on CCG and system finances. The Committee was assured that extra resources would be brought in to oversee the project but delivery was also dependent on the release of local clinical time, and this would be included in the project risk register;
• Discussion was needed at a local and NCL level about central and satellite services, and the open commitment to work with patients was welcomed. The Committee noted that conversation had started on co-producing the service model with service users;
• In response to a question on the aspiration to work towards an Academy and become a centre of excellence for orthopaedics, it was noted that the scale of ambition was to create world leading services for the local population and that the potential for this existed in NCL given the partnership links and local clinical expertise.
• The project should consider primary, tertiary and secondary interventions and how rotation of workforce could be achieved as a system, and the service model should support existing work on musculo-skeletal pathways;
• Whether a change in the adult orthopaedic service would have an impact on the children’s services. The interdependencies on other services was noted, however the impact on children would be less compared to that of trauma services.
4.2.5 The Committee:
• APPROVED the establishment of the Adult Elective Orthopaedic Services Review Group.
• AGREED for key points (e.g. engagement methodology and final recommendations) for decision making to be brought back and report by exception.
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5 Risk
5.1 NCL Joint Commissioning Committee Risk Register
5.1.1 The Committee noted that there were no recommendations for change to the Risk Register since the last meeting and raised the following points in relation to the register: • Include the impact of managing acute contracts from the proposal to in-house the
Commissioning Support Unit contract function on the risk register; • Review actions with obsolete dates, their impact and next steps; • Review some of the risk rating and to give consideration to closing some risks; • Consider how to ensure attendance of Council representatives at the Committee including
substitute membership and agenda planning (for relevance); • The ability to meet the aspiration in the Sustainability and Transformation Plan to invest in
prevention services whilst hospital contracts remained on a payment-by-results basis, and the contribution that Health and Wellbeing Boards could make in raising the profile of prevention in the STP.
5.1.3 Action JCC/009/18: Helen Pettersen to have a conversation with the Local Authorities to
assure attendance at Committee meetings.
5.1.4 The Committee NOTED the risk report. 6 Questions from public
6.1 There were no questions from the public. 7 Any Other Business
7.1 Forward Planner 2017-18
7.1.1 The Committee agreed the following: • Updates on the Adult Elective Orthopaedics Services Review to be added for 2018/19; • Mental Health falls outside the scope of the Committee, however, there were some
mental health related decisions that the Committee should be sighted on. The workplan for 2018/19 should create space for such interdependencies.
• Remove business cases for Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) and Camden and Islington Foundation Trust (CIFT), as these should be discussed by the CCGs and sat outside of the remit of the Committee.
7.1.2 The Committee NOTED the forward planner. 7.1.3 The Committee was notified by Andy Spicer that the logo for papers would change to meet
national communication standards for NHS.
8 Date of next meeting
8.1 Thursday 5 April 2018 3-5pm, Hendon Town Hall.
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Appendix 3
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Voting Members Lay Member Representatives Ms Cathy Herman–Chair Haringey CCG Ms Sorrel Brookes(Vice Chair) Islington CCG Ms Bernadette Conroy Barnet CCG Ms Kathy Elliott Camden CCG Ms Karen Trew Enfield CCG GP Representatives Dr Tal Helbitz Governing Body GP Member, Barnet CCG Dr Kevan Ritchie Governing Body GP Member, Camden CCG Dr Jahan Mahmoodi (Apologies) Medical Director, Enfield CCG Dr Punit Sandhu (representing Enfield CCG)
GP Member, Enfield CCG
Dr Dina Dhorajiwala (unable to stay for the whole meeting)
Governing Body GP Member, Haringey CCG
Dr Dominic Roberts (also representing Haringey CCG when Dr Dina Dhorajiwala leaves the meeting)
Clinical Director, Islington CCG
Officer Representatives Ms Colette Wood Director of Care Closer to Home, Barnet CCG Ms Sarah Mansuralli (Apologies) Local Executive Director, Camden CCG Amanda Rimington (representing Camden CCG)
Senior Commissioning Manager, Camden CCG
Ms Deborah McBeal Deputy Chief Operating Officer, Enfield CCG Mr John Piesse (Apologies) Head of Primary Care Commissioning, Enfield CCG Mr Anthony Browne Deputy Chief Finance Office, Islington CCG Ms Clare Henderson Director of Commissioning, Haringey CCG and Islington CCG Mr Paul Sinden (Apologies) NCL Director of Performance and Acute Commissioning Mr Simon Goodwin (Apologies) Ms Helen Pettersen (Apologies)
NCL Chief Finance Officer NCL Accountable Officer
Practice Nurse Representative Ms Charlotte Cooley (Apologies) Governing Body Practice Nurse, Camden CCG Non-Voting Members Ms Emma Whitby Chief Executive, Healthwatch Islington Mr Greg Cairns (Apologies) Director of Primary Care Strategy, Londonwide LMCs To be confirmed Health and Wellbeing Board Representative In attendance Ms Vanessa Piper Mr Ian Bretman (Observer) Ms Neeshma Shah Mr John Wardell Ms Vivienne Ahmad
Head of Primary Care, NCL Primary Care Team Lay member, Barnet CCG Director of Quality & Clinical Effectiveness, Camden CCG Chief Operating Officer, Enfield CCG Board Secretary, Islington CCG
North Central London Primary Care Committee in Common Minutes (Part 1) Date: Thursday 22nd March 2018 Time: 15.00 – 17.00 Venue: Conference Hall, Resource for London, 356 Holloway Road, London, N7 6PA
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Minutes Ms Muna Ahmed Corporate Affairs, Islington CCG 1 Welcome and Apologies
1.1
Ms Cathy Herman (Chair) welcomed the members and attendees to the North Central London Primary Care Committee in Common and clarified in order to ensure quoracy was upheld, that Mr Dominic Roberts (Clinical Director for Islington CCG) would act for Haringey CCG, when Dr Dina Dhorajiwala leaves the meeting.
1.2
Apologies were received from Mr Paul Sinden, Mr Simon Goodwin, Mr John Piesse, Mr Greg Cairns, Dr Jahan Mahmoodi, Ms Charlotte Cooley, Ms Helen Pettersen and Ms Sarah Mansuralli.
1.3
It was noted that Dr Jahan Mahmoodi will be leaving Enfield CCG at the end of March and that there will be a new Clinical Director. Dr Punit Sandhu will continue to be the reserve GP representative for Enfield CCG. It was noted that Charlotte Colley, Governing Body Nurse representative for Camden CCG, had been appointed as the nurse representative on the Committee.
2 Declarations of interest
2.1
Interest declared Dr Tal Helbitz declared that he is a member of the Care Closer to Home Integrated Network member that covers Oakleigh Road (item 11) Management of this conflict The Committee agreed that Dr Tal Helbitz will not participate in any discussion related to item 11. Interest declared Dr Punit Sandhu declared that she works as a GP across Enfield and Camden and that although there are Enfield practices on the agenda, she was not associated with any of them. Management of this conflict The Committee were satisfied that Dr Sandhu was not conflicted for any items and no further action was required.
2.2 There were no further additions to the list of declarations in the papers.
3 Minutes and actions from the previous meeting 3.1 The minutes were APPROVED as a true and fair reflection of the meeting.
3.2
Action Log The following actions were discussed: 46 – NCL wide ledgers are currently being discussed and will go to Audit Committees. Update required. Open 58 – NHS England has been asked to provide run rate information to augment the finance report. Mr Anthony Browne will chase again and bring an update to the next meeting. 59 – Ms Vanessa Piper was nominated to bring a paper on comparing service charges between practices. This would come to the Committee in June 2018. 61 – Mr Paul Sinden was not present to provide an update on whether Barnet will retain the Primary Care allocation, following a merger with a GMS contract going forward. Open
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62 – Neeshma Shah, Director of Quality has joined the committee. Close. 63 – Simon Goodwin is in the process of recruiting an NCL primary care estates lead, who will be best placed to deal with this. Open 64 – NHSE confirmed no further applications for estates founding could be submitted. All NCL CCGs were asked to submit bids and only Haringey and Islington replied. The applications made were successful. Close.
3.3 The Committee agreed the action log.
4 Questions from the public 4.1 There were no questions submitted from the public.
Items for Discussion 5 Finance Report
5.1
Mr Anthony Browne presented the Finance Report for month 11, highlighting: • For NCL delegated primary care budgets there is a £1.5m underspend, with a £2.2m
underspend forecast for year end. • Overall balance in 2017/18 is achieved by the non-recurrent solution to balance the financial
risks across NCL CCGs. In future years the expectation is that financial pressures will be met within respective CCG delegated primary care allocations.
5.2
Primary Care Financial plans Mr Anthony Browne confirmed that Operating Plans for 2018/19 are currently going through internal CCG governance processes. NHSE was supported by CCGs to set the budget and more finance will be received from NHSE. All CCGs were asked to allocate £3 per head for primary care, for 2018/19 (appendix D). The final Operating Plan sign off deadline is 30th April.
5.3
There was a discussion about the extent to which QIPP will be applicable to Primary Care budgets. Mr Browne confirmed that it is down to the individual CCGs to decide how much they utilise QIPP in primary care budgets.
5.4 Action: Mr Anthony Browne will bring finance planning for 2018/19 to the next meeting.
5.5 The Committee NOTED the month 11 financial position and NOTED the recommendations for the 2018/19 primary care priorities.
6. Operating Plan 2018/19
6.1
Mr John Wardell presented the Operating Plan 2018/19 and highlighted: • The report provides an overview of the operating plan priorities for primary care; • Indicative budgets were set out in the paper and would be finalised through local CCG
governance processes; • NCL CCGs will receive an additional £2.2m to support the delivery of primary care at scale.
Further discussions are taking place with NHSE regarding the process and criteria to receive the funding;
• The “Plan on a page” provides an overview on developing primary care at scale in NCL; • In April 2018, the committee will receive primary care medical services budgets for
2018/19, as well as plans for developing primary care at scale, for approval.
6.2
Ms Karen Trew found the report helpful and said it will be useful to understand the at scale funding process of readiness by Federations, and how we learn from that, as it will be a model used, going forward in future years.
6.3
Ms Karen Trew highlighted the need to build the key deliverables for primary care into the forward planner for the Committee.
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6.4
Ms Kathy Elliot noted that this was the first time we had seen a paper at the Committee that considered both core and enhanced primary services. Ms Elliot queried where the £2.2m for use across NCL will be held, as Camden were developing their plans for primary care at scale, with proposals considered at Camden Procurement Committee and Commissioning Committee. Ms Elliott also queried the local and London criteria that would be used to consider and evaluate the at scale work. Ms Elliott also informed all that concerns have been raised by stakeholders and patients on whether investment in Federations and at scale, will take away investment from frontline GP delivery, services, and the sustainability of practices.
6.5
Ms Neeshma Shah agreed with the concerns raised by Ms Elliott, relating in particular to maintaining a sustainable workforce.
6.6
Mr John Wardell informed the Committee that there is a London wide framework underpinning how funds for delivering primary care at scale can be delivered. This included an assessment of the maturity of Federations. More information will be brought back to this Committee by Mr Paul Sinden.
6.7
Ms Bernadette Conroy sought clarification that the £2.2m is to fund primary care at scale working, and in addition to this, there will be a money for estates and IT. Ms Conroy reiterated that it is important to understand our processes in advance and be proactive on this, so that all CCGs had the opportunity to access these funds to maximise investment across NCL. With regards to “Plan on a page” - risks and issues section, Ms Conroy advised that money and scale of investment should be highlighted as a risk.
6.8
Ms Kathy Elliot informed all that “Plan on a page” went to Part 2 of the Camden Governing Body and that implementing the Health Information Exchange was a material factor in the successful development of primary care operating at scale. Clarity on funding and future development of the Health Information Exchange was therefore required.
6.9 Mr Wardell will feedback the comments made, to Mr Paul Sinden for onward response to the Committee.
6.10
Ms Cathy Herman indicated that the Committee would receive a briefing on the refresh of the primary care strategy and update on plans for developing primary care at scale at the April 2018 meeting.
6.11
Action: Mr Paul Sinden to feed back to the Care Closer to Home workstream the requirement to add money and scale of investment as a risk on the “Plan on a page” document.
6.12
Action: Paul Sinden to bring an update on the refresh of the Primary Care Strategy and plans for developing primary care at scale to the April 2018 meeting.
6.13 Action: Ms Muna Ahmed to add Primary Care Operating Plan to the Committee's workplan.
6.14 The Committee NOTED the report.
7. PMS Review
7.1
Ms Deborah McBeal informed the Committee that the contract packs have been issued to PMS practices for review following agreement of commissioning intentions. The practices are required to return consent forms within two weeks of receiving the pack. The majority of the consent forms have been received, and CCGs are working with practices to receive the forms still outstanding.
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Next steps – PMS contracts will be issued and GMS practices will receive the NHS Standard contract, with commissioning intentions.
7.2
Ms McBeal reported that NELCSU support in preparing the packs will cease at the end of March. Therefore, it is important to complete the processes, as soon as possible. The CCGs will then quality assure the consent forms returned, for accuracy.
7.3 Contracts will be effective from 1st April 2018. The next PMS Oversight Group meeting is scheduled for 24th April and will assess progress and take actions to mitigate any risks.
7.4
Ms Karen Trew confirmed that all commissioning intentions have been approved. Initial contract offer letters have been sent out. Contracts have gone out to Camden PMS and GMS practices. The other CCGs will use the Camden model for contract sign off. The PMS Oversight Group would like the Committee to endorse sending out contracts to all remaining practices by Easter, on the condition that CCGs follow the Camden model. If CCGs do not do this, there will not be sufficient time for practices to review, sign off the contracts and for finance to make any adjustments by the end of May. If the deadline is missed, the process will have to be restarted and re-run financial modelling to start from the 1st of July.
7.5 Ms Trew informed all that LMC has not signed off on this and that the risk remains low, given the impact on practices, if the deadline is missed.
7.6 Dr Tal Helbitz informed all that his practice is a PMS practice in Barnet.
7.7
Ms Sorrel Brookes asked what the potential risks are. Ms Trew stated that the LMC could have an issue with the commissioning intentions not fully incorporated within the contracts. It was highlighted that it is a risk not to take this action.
7.8 The LMC has been contacted already and the London lead is aware and will go back to LMC with the decision from the Committee today.
7.9 The Committee ENDORSED the recommendation by the PMS Oversight Group to issue contract to all practices.
Items for Decision 8. PMS Contract Variations 8.1 Ms Vanessa Piper presented the contract variation papers. 8.2 Southbury Surgery – resignation of a GP (Enfield)
The practice would be supported as part of the super partnership. 8.3 The Enfield CCG members APPROVED the contract variation. 8.4 Forest Road Surgery– addition of 2 GPs (Enfield)
No issues or concerns were raised. 8.5 The Enfield CCG members APPROVED the contract variation.
8.6
Cricklewood APMS Contract extension (Barnet) Barnet members are asked to approve the extension of contract from October 2018 to 31st March 2019. The extension went beyond the term set out in the contract, but was necessary to align to the expiry date for the walk-in-centre contract that was co-located with the practice. The practice has been notified that the contract will not be extended after 31st March 2019.
8.7 The Barnet CCG members APPROVED the contract extension. 9. Angel Surgery and Dover House Surgery – merger (Enfield CCG)
9.1 Ms Vanessa Piper informed all that this merger involves one PMS practice and one GMS practice. The GMS contract will be terminated and the PMS contract will be taken forward. The merger will be effective from 1st April 2018.
9.2 Ms Piper confirmed the PMS premium and transition money are retained within the CCG budget.
9.3 The Enfield CCG members APPROVED the merger. Items to Note – Urgent Decisions Taken Since the January Meeting 10 Dover House Surgery and Angel Surgery Relocation to Silver Point Health Centre (Enfield)
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10.1 Ms Vanessa Piper confirmed Enfield CCG Committee members approved the decision for the two surgeries to relocate to Silver Point Health Centre.
11. Oakleigh Road Health Centre – list closure request (Barnet)
11.1
Ms Vanessa Piper presented the item and explained that the Barnet Committee members were unable to make a decision because they did not have enough information. The practice was asked to provide the additional information requested but did not respond. Therefore, no decision was made. Ms Piper will write to the practice to inform them that a decision could not be made. The application will then be closed, unless the practice re-applies or provides the additional information requested.
11.2
Ms Emma Whitby queried why under the “Public Sector Equality Duty Implications/Impact”, it says “Stakeholder consultation will be undertaken to gain feedback”. Ms Piper confirmed that this was an error, as the practice did carry out stakeholder consultation. Ms Piper will feed this back to the author of the report.
11.3
Ms Whitby added that to ensure robust consultation, do we know whether people from all of the nine protected characteristics are included in the consultations. Ms Piper stated that practices are encouraged to consult with all patients on their practice list and not just the patient group.
11.4
Ms Deborah McBeal informed all about a recent discussion with their Healthwatch members regarding consultation and protected characteristics, and that there is a standard operating procedure on changes, which includes engagement and consultation.
11.5 Action: Ms Deborah McBeal to share the standard operating procedure document on consultation and engagement with the Committee.
Items to Note and for Information 12. Risk Register 12.1 Mr John Wardell presented the risk register and provided an update on the following risks: 12.2 Risk 9 – Loss of service provider without notice due to regulatory action – opportunity to build
in resilience programmes through at scale funding for 2018/19.
12.3 Risk 14 – Alternative Primary Medical Services – there is an interim service for Camden, Haringey and Islington in place and procurement of a NCL wide service is in progress, based on a London wide service specification.
12.4 Risk 15 – PMS review - the Committee is asked to approve the reduction in the risk rating from 12 to 9, due to the progress made and as discussed earlier in the meeting.
12.5 Dr Tal Helbitz mentioned that there is a risk in terms of the resilience of some PMS practices, which could lead to closures. It was noted that this would be post implementation.
12.6
Risk 16 – Embedding of NHSE primary care team into local commissioning structures – the actions set out opportunities to better align the commissioning of core and enhanced primary care services.
12.7
With regards to risk 14 and the Special Allocations Service, Dr Dominic Roberts requested that when the service comes up for long term procurement, it should be extended to include non-violent patients who are challenging for practices, as they would benefit from this service and this would lighten the burden on practices.
12.8 Ms Clare Henderson was unclear about the procurement timescales for the Special Allocations Service and would like the risk to be updated to include this.
12.9 Ms Kathy Elliott would like more information on risk 16, regarding the standard operating procedure between NHSE and London STP and the governance process around this.
12.10
Dr Punit Sandhu would like to see more clarity on risk 14 – Alternative Primary Medical Services, in particular, where it will be based and how it will go forward. There is currently a lot of confusion around how patients and GPs will access the Special Allocations Service.
12.11 Action: Ms Vanessa Piper to bring a review paper on Special Allocations Service in April 2018.
13. Standard Operating Procedure for Delegated Commissioning 13.1 Ms Vanessa Piper informed all that this paper was added for “noting” and acknowledged that
it may need to be brought back to the next meeting.
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13.2 Ms Sorrel Brookes would like more time between committees to read the paper and make some comments.
13.3
Ms Bernadette Conroy would like to see more clarity on the governance process for the paper, as this paper states this Committee is asked to approve the paper, on behalf of Governing Bodies. Ms Conroy would also like more time to review the paper.
13.4
Ms Karen Trew asked what the difference was since the last version of the paper and whether anything had come out of the paper that needs to be added to the workplan and look at potential duplication.
13.5
Ms Neeshma Shah referred to page 144 - Controlled Drugs and queried that under the tasks “complete the periodic self-assessments…” if this is reference that CCGs seek these declarations from General Practice, the CD statutory guidance states that it is the CDAO (NHSE) who does this. The CDAO can ask for co-operation from CCGs, but this co-operation does not include this function.
13.6
With regards to safeguarding children and adults, Ms Shah highlighted that Working together and Children’s Act / Care Act defines the statutory functions of CCGs, which does not include “providing assurance to NHSE that practices are compliant with safeguarding standards”. In order to understand what is meant by this, it would be helpful to know / have the evidence of what NHSE undertook prior to delegated co-commissioning that fulfilled this. To note, there is no further narrative under the Tasks column.
Ms Shah will send further comments to Ms Piper after the meeting. 13.7 Ms Emma Whitby commented that she was glad to see interpreting in the paper. 13.8 Ms Elliott observed that on page 95, under “financial processes”, the columns on whether a
national/London SOP/policy/report exist, are blank, although they are in the annexes.
13.9 The Committee NOTED the paper. However, the Committee requested more clarity on the governance process and the acknowledgement that this Committee has the responsibility to sign the paper off, rather than just to note it.
13.10 Action: Ms Vanessa Piper to bring the Standard Operating Procedure for Delegated Commissioning to the next meeting and provide more clarity on governance.
14. Committee work plan 14.1 Ms Cathy Herman noted that there will be further additions to the workplan, following the
discussions from the meeting. 14.2 Ms Karen Trew requested that the paper on the London wide service charge financial
assistance policy is added to the workplan for August, as mentioned in the action log.
14.3 Ms Trew queried whether the Conflicts of Interest (COI) policy should come to this Committee. Ms Conroy felt the COI and other policies should come to Committee, in order to note the primary care aspect and how it is translated to the Committee’s governance structure.
15. Any Other Business 15.1 None raised.
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Appendix 3
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NCL Primary Care Joint Committee
Action Log – Part 1
Meeting Date
Action No.
Action Action lead Deadline Status update Date closed
19/7/17 46 PSi to ensure that any NCL wide consideration of access to ledgers be conducted in a unified way with one paper considered by all CCGs.
Paul Sinden 20/9/17 22/09/17 - One paper for all CCGs to be produced and sent to each Audit Committee. 17/01/18 - NCL wide ledgers are currently being discussed and will go to Audit Committees. 22/03/18 – PSi not present to provide an update. 19/04/18 – Access to ledgers for NHSE Finance Team being picked up through NCL-wide work on Scheme of Delegation.
17/01/18 58 Anthony Browne to include the run rate and adjustments on future finance reports.
Anthony Browne
22/03/18 22/03/18 – AB is still waiting for a response from NHSE and will chase.
17/01/18 59 A paper to be brought to a future meeting, which compares service charges between practices.
Vanessa Piper 21/06/18 Scheduled for June 2018
17/01/18 60 Vanessa Piper to bring a review paper on the London Wide Service Charge Financial Assistance Policy, to the August meeting and to be added to the workplan.
Vanessa Piper 16/08/18 Scheduled for August 2018
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17/01/18 61 Mr Paul Sinden to confirm whether Barnet’s Primary Care Allocation money will stay in Barnet, following a merger and change to a GMS contract.
Paul Sinden 22/03/18 The funds will be retained by Barnet CCG in the overall delegated budget for primary medical services budgets.
17/01/18 63 A paper on how the bids for the estates capital funding will be managed going forward.
Simon Goodwin
21/06/18 22/03/18 – The action has been allocated to Simon Goodwin. MA to email SG.
22/03/18 65 Mr Anthony Browne will bring finance planning for 2018/19 to the next meeting.
Anthony Browne / Paul Sinden
19/04/18
This report will come to the Committee in June 2018 to ensure plans incorporate practice list size as at April 2018, which in turn will determine any headroom capacity for investment. Primary Care budgets will also need to go through CCG Committees before coming to the Committee-in-Common.
22/03/18 66 Mr Paul Sinden to add money and scale of investment as a risk on the “Plan on a page” document.
Paul Sinden 19/04/18
Care Closer to Home informed on Committee request. Also added to risk register for 19 April 2018
22/03/18 67 Mr Paul Sinden to add Primary Care Strategy process and refresh update to the agenda for the meeting in April.
Paul Sinden 19/04/18
Primary Care Strategy refresh on the agenda for 19 April 2018
22/03/18 68 Vanessa Piper to share the NHSE SOP for relocation of GP practices and the responsibilities in relation to consultation and engagement with patients, stakeholders and other practices.
Vanessa Piper 29/05/18
For the next meeting on 21 June
22/03/18 69 Ms Vanessa Piper to bring a review paper on Special Allocations Service in April.
Vanessa Piper 19/04/18
On the agenda for 19 April 2018
22/03/18 70 Ms Vanessa Piper to bring the Standard Operating Procedure for Delegated Commissioning to the next meeting and provide more clarity on governance.
Vanessa Piper 19/04/18
On the agenda for 19 April 2018
22/03/18 71 Ms Muna Ahmed to add Primary Care Operating Plan to the Committee's workplan
Muna Ahmed 19/04/18
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Appendix 3
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