Haringey CCG Governing Body 9 November 2017

STP – 6 month progress report

Helen Pettersen – Accountable Officer & STP ConvenorWill Huxter – Director of Strategy North Central London CCGs

• Ambition of the STP

• Achievements and challenges

• System-wide working including style

• Clinical and managerial leadership

• Urgent and Emergency Care

• Adult Social Care

• Finances

• Priorities to 31 March 2018

AMBITION OF THE STP

Ambition of the STP

• Ambition for the STP is built on existing CCG values and strategy: to improve the health of the local population, maximise care outside hospital, and reduce health inequalities

• 4 key elements to the plan: prevention, service transformation, productivity, enablers

• A partnership of the NHS and local authorities, working together where it’s the most efficient and effective way to deliver on the shared ambition; and working together with the public, patients and

Healthwatch.

ACHIEVEMENTS AND CHALLENGES

Examples of recent achievements (1)

• Strengthened relationships, visibility and understanding

• Sharper view of priorities

• Development of 2018/19 system intentions

• CC2H: each CCG producing local road map aligned to NCL strategic approach

• Planned care: MSK, urology and neurology pathway work underway

Examples of recent achievements (2)

• Digital: agreement to progress to Health Information Exchange as route to ICDR and population health management

• Mental health: specialist community perinatal service now live

• UEC: general surgery ambulatory care pathway pilot up and running

• POLCE: Enfield GB agreed changes post-consultation; consultation to be rolled out across remaining CCGs

• Maternity: agreed likely hubs for pilot

Challenges this year

• CCG, provider and local authority financial positions/pressures

• Capped Expenditure Process

• Timetable and capacity for delivery of transformation alongside business as usual

• Communication and engagement

• Strengthening connections within the STP – between CCGs and workstreams, providers, local authorities, and patient representatives

SYSTEM-WIDE WORKING

System-wide working

• Big cultural change to focus on the system not on individual organisations/institutions

• Providers agreeing joint programme of work they can do together on productivity, over and above individual CIP plans (eg patient transport, facilities)

• Commissioner lead from one CCG co-ordinating input from all CCGs on individual workstream initiatives –gains in consistency, efficiency, and professional development

NCL CCGs’ SMT

Role Name

Accountable officer, NCL CCGs and STP convenor

Helen Pettersen

CFO, NCL CCGs Simon Goodwin

Director, Acute and Performance, NCL Paul Sinden

Director of Strategy, NCL CCGs Will Huxter

COO, Barnet CCG Kay Matthews

COO, Camden CCG Sarah Mansuralli

COO, Enfield CCG John Wardell (starting December)

COO, Haringey and Islington CCGs Tony Hoolaghan

POD Director, NELCSU Eileen Fiori

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CLINICAL AND MANAGERIAL LEADERSHIP

Clinical leadership and engagement

• Fundamental to development and implementation of every aspect of the STP

• Input into each workstream essential –leadership across CCGs

• Challenge and assurance of STP initiatives via Health and Care Cabinet

• STP Advisory Board includes Chairs of all CCGs

• Looking at systematic approach to quality improvement across all of the STP, with initial focus on CC2H

Workstream SROs and Clinical Leads

STP Workstream SRO(s) Clinical Lead(s)

Prevention Dr Julie Billett, Director of Public Health, Camden and Islington Dr Karen Sennett, GP, IslingtonDr Tom Aslan, GP, Camden

Health and Care Closer to Home Tony Hoolaghan, COO Islington and Haringey CCGs Dr Katie Coleman, GP, Islington

Urgent and Emergency Care Sarah Mansuralli, COO/Local Executive Director, Camden CCG Dr Samit Shah

Mental Health Paul Jenkins, CEO Tavistiock and Portman Foundation Trust Dr Vincent Kirchner, Medical Director, C&IDr Jonathan Bindman, Medical Director, BEHDr Alex Warner, GP, Camden

Cancer Professor Kathy Pritchard-Jones, Chief Medical OfficerDr Clare Stephens, GP Barnet CCG

Professor Geoff Bellingan, Medical Director, UCLH

Planned Care Marcel Levi, CEO UCLH NHS Foundation Trust Dr Richard Jennings, Medical Director, Whittington HealthDr Ahmer Farooqi, GP Barnet

Maternity Rachel Lissauer, Director of Commissioning, Haringey CCG Professor Donald Peebles, Clinical DirectorMai Buckley, Director of Midwifery

Children and Young People Charlotte Pomery, AD Children’s Services, Haringey Council Dr Oliver Anglin, GP, Camden

Estates Simon Goodwin, NCL CCGs Chief Finance Officer TBC

Digital David Sloman, CEO Royal Free London NHS FT Dr Katie Coleman, GP/Primary Care LeadProfessor Stephen Powis, Group Medical Director, RFHDr Cathy Kelly, Chief Clinical Information Officer, UCLH

Workforce Maria Kane, CEO BEH Mental Health NHS Trust Dr Jo Sauvage, GP, Islington

Communications and Engagement Paul Jenkins, CEO Tavistock and Portman NHS Foundation Trust TBC

Provider productivity and service sustainability

David Stout, Senior Programme Director, STP TBC

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Managerial leadership

• Refresh of SROs and governance for major workstreams (UEC, Planned Care, CC2H, Digital)

• Dedicated programme management support appointed for all the workstreams with major savings target

• Workstream leads brought together to understand interdependencies, and priorities for joint working

URGENT AND EMERGENCY CARE

Summary of progress on programme commitments and deliverables

Considerable progress on urgent integrated care developments with current focus on streaming and redirection being implemented.

Simplified discharge (Discharge to Assess) is ahead of schedule and live from October 2017

Engagement with stakeholders for last phase of life is having a positive impact and a business case is in development to ensure investment to support the model of care is available.

Majority of work streams are on track and work is in progress to strengthen relationships between STP work stream leads and UEC CCG/provider leads

Dashboard to measure impact through activity and finance by CCG is in development, taking into consideration planned impact from DTOC and CHC trajectories submitted to NHSE

Delivery plan for 2018/19 being reviewed and refreshed with aim of ensuring specific deliverables are prioritised including the establishment of a communications work stream

Programme governance to be revised to be less intensive, accelerate delivery and focus on monitoring impact across NCL

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Work stream resourcing and programme governance structure being reviewed to improve capacity

Strengthening engagement and involvement of CCG UEC leads and A&E Delivery Boards to maximise capacity and reduce duplication

Patient engagement and co-production events taking place throughout the autumn to ensure patient input to design of new services

Accelerating progress of national must do’s to enable improved performance over winter, e.g. simplified discharge and a consistent approach to admission avoidance

Ensuring monitoring of impact against finance and activity metrics for all work streams within UEC, as well as qualitative performance indicators

Increasing multi-agency involvement in programme team and working through Transforming Care and Systems Leadership programme (NHSI) to address barriers to change

Developing implementation plans for new initiatives for 18/19

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Current status of programme

The position reported reflects a CCG assessment of YTD (month 5 based on M4 SLAM) andFOT, with material adjustments made to the FOT for Critical Care, Marginal rate and QIPP delivery

The activity data needs further validation before conclusions can be drawn, but is subject to this, at an NCL wide level.

Based on month 4 actuals, there appears to be over-performance in A&E, non-electives and out-patients, and under- performance in elective care.

As per caveats above, contract performance in all Trusts for NCL CCGs indicates that:

• A&E attendances -activity YTD 4% above plan, finance YTD 6.1% above plan• NEL spells- activity YTD 0.1% above plan, finance YTD 2.2% above plan

UEC work stream interventions:

• YTD - £0.9m achieved v. £1.5m plan, adverse variance £0.6m (40%)

• FOT- £7m forecast v. £8.9m plan, adverse variance of £1.9m (21%)

• 87% of delivery forecast to be in months 6-12

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Current status of programme - finance

Delivery Goals

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Work stream Delivery Goals

Integrated Urgent Care

Fornt door Streaming and Redirection live across NCL A&E departments Business case to secure funding for 24/7 GP in the Hub (currently piloted) enabling

continuation of the * 567 lines Business case to develop a business intelligence platform to monitor effectiveness

of 111 services and IUC Hub Extend direct booking functionality to weekdays NHS 111 online application live across NCL Standardise the facilities and functions available across all of the NCL UCCs

Ambulatory Care and Admission Avoidance

Consistent offer and tariff for ambulatory care across NCL Increased ambulatory care volumes across NCL, and hence reducing non-elective

admissions Consistency of in- & out- reach admission avoidance services across NCL Single referral process for all admission avoidance services across NCL

Simplified Discharge and Early Supported Stroke Discharge

Discharge to assess pathways 0-3 implemented consistently across NCL, including a single referral form for rehabilitation services

Business case for Early Supported Stroke Discharge approved and implemented Trusted assessor model is developed, implemented and embedded

Last Phase of Life Agreed model of care for last phase of life across NCL Business case and investment to implement model of care approved and delivering

Communications Stakeholder analysis of key stakeholders and actions required to change behaviours

and perceptions Improved engagement with key stakeholders to enable system changes required

ADULT SOCIAL CARE

North London Councils Adult Social Care Programme – Progress

Date Key Milestones

Jan 2017 Programme Lead seconded to develop the approach to involvement of Camden, Islington, Haringey, Barnet and Enfield

London Borough Councils in ongoing shaping of STP. Initial workshop held with Directors of Adult Social Services

(DASS) to formulate approach.

Feb – Mar

2017

EY commissioned to do high level analysis of financial challenges facing local authorities and areas for further

engagement and involvement. Results highlighted particular challenge in adult social care and need to scope

opportunities for 5 Councils to develop joint solutions to shared problems.

Apr 2017 STP updated to reflect growing engagement with adult social care. Areas of focus for Councils confirmed as:

1. Hospital admission avoidance and discharge

2. Market management

3. Workforce

4. Learning disabilities

May 2017 DASS workshop held to feed back EY work and decide on next steps. Agreement reached to jointly fund project team for

rest of 2016/17 to fully scope the four areas.

Jul 2017 Agreement on approach to developing business cases on the four areas

Aug 2017 New team starts work on scoping four areas

Oct 2017 DASS workshop held – project leads feed back on progress so far and prioritise areas for deeper analysis. Shortlist of 16

specific areas for collaboration produced and prioritised to 5:

1. Improving consistency in the social care element of the hospital discharge process across NCL

2. A joint approach to recruitment and retention of staff in health and social care, focusing on nursing and the

independent sector

3. Building more capacity in the nursing home sector looking at options for joint-capital investment to build more homes

4. Joint brokerage of health and social care packages of care, looking at options to combine the existing operations run

by Councils and CCGs

5. Looking to develop a stronger provider market to support people with complex LD needs, focusing on prevention of

needs escalating into the ‘transforming care’ cohort and those transitioning from children to adulthood

Nov 2017

– Jan 2018

Business case development on five areas takes place, including design workshops to engage wider partners.

FINANCE

Executive Summary month 5 financial position

• The year to date deficit reported across NCL is £61.6m, an adverse variance to plan of £16.7m, with 10 organisations (4 CCGs plus 6 Trusts) reporting year to date variances to plan, and 8 of these forecasting recovery in months 6-12. A straight line extrapolation of the YTD position would be a deficit of £148m, compared with the £70m reported, demonstrating the degree of recovery required.

• The month 5 forecast outturn is a deficit of £70.5m (increased from £62.2m at month 4), a £18.5m variance to plan (£10.2m at month 4), and £105.1m adverse variance to control total (£96.8m at month 4). The £8.3m movement reflects the outturn deficit reported at month 5 by Barnet CCG.

• Trust CIP delivery has an adverse YTD variance of £8.3m (c17%), with a forecast outturn projection of £9.8m (c6%) under-achievement. c72%% of achievement is profiled into months 6-12.

• The net CCG risk position has reduced from £26.4m at month 4 to £18.1m at month 5, largely reflecting that Barnet risk has now crystallised in a forecast outturn deficit.

• On QIPP, there are both YTD and FOT adverse variances reported of £7.6m (c33%) and £23.2m (c27%) respectively. c75% of total QIPP achievement is profiled into months 6-12.

• An updated overall NCL risk assessment has been undertaken and suggests total risks of c£75m over and above the current forecast outturn.

• Subsequent to month 5 reporting, a revised control total has been agreed by NHSI for the Royal Free, which is based on the Trusts plan (excluding STF) of £27.5m deficit, plus a potential STF due in Q2-4 of £16.3m, resulting in a £11.2m deficit revised control total, (compared to £23.9m surplus previously). A revised 17/18 control total has also been agreed for RNOH, which will eliminate the £5.4m gap to control total (£3.4m via a change in control total, £2m via a change in plan, including £1m of STF).

• All other things being equal, these changes will have the impact of reducing the NCL plan to £33.8m deficit, changing the control total to £3.9m deficit, and reducing the FOT gap to control total to £48.4m when incorporated into reporting at month 6. However the 18/19 control total for the Royal Free has been increased as part of this change to £58m surplus, increasing the challenge in 18/19.

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PRIORITIES TO 31 MARCH 2018

• Delivery of existing 2017/18 workstream plans

• Development of 2018/19 workstream plans

• 2018/19 contracting round – alignment of CCG, provider and workstream plans

• Enhancing communications and engagement –public, patients, and within STP partners

• Explore scope for more NCL-wide working where appropriate

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October – December 2017

Week of2 – 6 Oct

Week of9-13 Oct

Week of16-20 Oct

Week of23-27 Oct

Week of 30 Oct –

3 Nov

Week of6–10 Nov

Week of13-17 Nov

Week of 20-24 Nov

Week of 27 Nov –

1 Dec

Week of 4-8 Dec

Week of 11-15 Dec

Week of 18-22 Dec

Week of 25-29 Dec

QIPP Oversight Meeting 1(3 Oct)- Review and signoff process

QIPP Oversight Meeting 2(24 Oct)

CCGS to each develop local, non-acute QIPP plans

QIPP Oversight Meeting 4(21 Nov)

QIPP Oversight Meeting 6(5 Dec)

CCGS to each develop bottom-up acute QIPP plans

UEC, PC, HCCH to update their delivery plans to include draft plans for 18/19

Approval of individual CCG QIPP plans

Alignment meetings between 3 workstreams and 5 CCGs

Approval of workstream delivery plans: Workstream Boards, HCC, FAM and PDB

Pull together aggregated CCG plan

Outputs: 5 initial draft CCG QIPP plans + 3 draft workstream plans

18/19 STP workstream/CCG QIPP plan development

Stage 1 Stage 2

Other workstreams to update and finalise detailed plans

UEC, PC, HCCH finalise w.streamplans

Stage 3 Stage 4

QIPP Oversight Meeting 3(7 Nov)

Outputs: 5 final draft CCG QIPP plans; final workstream plans

Final plans complete(28 Nov)

Final plans complete(15 Dec)

CONCLUSION

• Good progress on existing workstream plans, although further to go

• Strong team in place working together across the CCGs, providers and local authorities

• Good relationships between all STP partners

• More to do on patient and public involvement, working with Healthwatch

• Finance positions very challenging across NCL

• Need to focus relentlessly on delivery.