hertfordshire partnership university nhs … kaushik mukhopadhaya executive director quality &...

Hertfordshire Partnership University NHS Foundation TrustPUBLIC MEETING OF THE BOARD OF DIRECTORS

Board of DirectorsThe Colonnades - Beaconsfield Road, Hatfield, AL10 8YE

29 September 2016 10:45 - 29 September 2016 13:30

Overall of 190

INDEX

Agenda Item 1.0 - Public Board Meeting Agenda - 29 September 2016.doc.................................5

Agenda Item 3.0 - DRAFT Minutes of Meeting dated 28 July 2016 v0 4.docx...............................7

Agenda Item 4.0 - Matters Arising Schedule.doc...........................................................................19

Agenda Item 5.0 - CEO Brief.doc...................................................................................................21

Agenda Item 5.0a - HCT - HPFT Alliance.docx..............................................................................27

Agenda Item 6.0 - Trust Strategy - 'Good to Great'.docx.............................................................33

Agenda Item 7.0 - Arrangements for Junior Doctor's Strike.docx.................................................41

Agenda Item 9.0 - Quality Improvement Performance Framework QIPF - NEW.do........................55

Agenda Item 10.0 - Annual Medical Appraisal and Revalidation.docx...........................................61

Agenda Item 11.0 - Hertfordshire and West Essex Sustainability and Transforma.........................77

Agenda Item 11.0a STP Slide Deck.pptx.......................................................................................79

Agenda Item 12.0 - NHS Operational Planning and Contracting Guidance.docx..........................89

Agenda Item 12.0 a - NHS Oerational Planning Guidance - 2017 to 2019.pdf..............................91

Agenda Item 12.0b - NHSP Briefing - 2017 to 2019 Planning Guidance.pdf.................................161

Agenda Item 13.0 - Financial Summary to end August 2016 - Public Board.pdf...........................173

Agenda Item 14.0 - Report from the Audit Committee.docx...........................................................179

Agenda Item 15. 0 - Single Oversight Framework Update.docx.....................................................181

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www.hertspartsft.nhs.uk

PUBLIC BOARD OF DIRECTORS

A Public meeting of the Board of Directors Thursday 29 September 2016 – 10.45 – 13.30

VENUE: The Colonnades, Beaconsfield Road, Hatfield AL10 8YE, Da Vinci B+C

A G E N D A

Presentation: Nick Lloyd (Service User) 10.45 – 11.15

1 Welcome and Apologies for Absence: Dr Oliver Shanley| Michelle Maynard

2 Declarations of Interest CL

3 Minutes of Meeting dated 28 July 2016 CL Attached

4 Matters Arising Schedule CL Attached

5 CEO Brief HCT / HPFT Alliance

TC Attached

Time

11.15

QUALITY AND SAFETY 6 Trust Strategy – ‘Good to Great’ IE Attached

7 Arrangements for Junior Doctor’s Strike KM Attached

8 Safe Staffing Levels Report JL Verbal

9 Quality Improvement Performance Framework

JK Attached

10 Annual Medical Appraisal & Revalidation KM Attached

QUESTIONS FROM THE PUBLIC

11.40

OPERATIONAL AND PERFORMANCE11 Hertfordshire and West Essex

Sustainability & Transformation PlanIE / TC Attached

12 NHS Operational Planning and Contracting Guidance 2017 - 2019

IE Attached

13 Financial Summary to end August 2016 KL Attached

12.35

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www.hertspartsft.nhs.uk

REGULATORY AND RISK14 Report from the Audit Committee CD Attached

15 Single Oversight Framework Update HP Attached

16 Any Other Business

QUESTIONS FROM THE PUBLIC

17 Date and Time of Next Public Meeting

27 October 2016 10.30 – 13.30Da Vinci B+C

13.05

Chris Lawrence – Chair

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Public Board of Directors 28 July 2016 - Page 1 of 11

PUBLIC MEETING OF THE BOARD OF DIRECTORS

Thursday 28 July 201610.30 am to 13.30 pm

Da Vinci B + CTrust Head Office, The Colonnades, Hatfield, Hertfordshire

A T T E N D A N C E

NON-EXECUTIVE DIRECTORSMr Christopher Lawrence Chair CLMs Manjeet Gill MGMs Sarah Betteley SBeMs Loyola Weeks LWMr Peter Baynham PBMr Robbie Burns RBMr Simon Barter SBaEXECUTIVE DIRECTORSMr Tom Cahill Chief Executive TCDr Oliver Shanley Deputy CEO / Executive Director Quality and Safety OSMr Iain Eaves Executive Director Strategy & Improvement IEMr Keith Loveman Executive Director Finance KLMr Jess Lievesley Executive Director Service Delivery & Customer Experience JLMs Karen Taylor Executive Director Integration & Partnerships KTIN ATTENDANCEDr Asif Zia Deputy Medical Director AZMs Sue Darker Assistant Director, Herts County Council, Health Care Services

(Mental Health & Learning Disabilities)SD

Mariejke Maciejewski Deputy Director of Workforce MMaMEMBERS OF THE PUBLICMr Simon Harwin Trust wide Enablement Lead / Programme Lead for Barnet, Enfield and Haringey Mental Health NHS TrustMr John Walmsley Elected Public GovernorMr Barry Canterford Elected Public GovernorMr Bob Taylor Elected Public GovernorOBSERVINGJane Padmore Deputy Director of Nursing & QualityJulie Hollings Deputy Director of Communications & MarketingAPOLOGIESMrs Helen Potton Company Secretary HPMrs Jinjer Kandola Executive Director Workforce & Organisational Development JKDr Kaushik Mukhopadhaya Executive Director Quality & Medical Leadership KMMs Michelle Maynard NED MM

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IN PROFESSIONAL CONFIDENCE

PUBLIC MEETING OF THE BOARD OF DIRECTORS

Thursday 28 July 201610.30 am to 13.30 pm

Da Vinci B + CTrust Head Office, The Colonnades, Hatfield, Hertfordshire

M I N U T E S

94/16 Apologies for AbsenceHelen Potton | Dr Kaushik Mukhopadhaya | Jinjer Kandola | Michelle Maynard

95/16 Declarations of InterestThere were no declarations of interest.

96/16 Minutes of Public Meeting held 28 April 2016

The Board approved the Minutes as an accurate record subject to the following amendments :

o Page 8 Safety & Effectiveness of Services; Remove “All targets & KPIs have been met”.

o Page 10 Annual Plan 2016 / 17; Replace “The priorities are” with “The foundations that need to be in place”.

97/16 Matters Arising Schedule / Matters Arising

o Questions from Members of the Public - Item 43/16The Director of Service Delivery & Customer Experience confirmed appropriate action had been taken and the issue closed off.

98/16 CEO Brief

National Update

TC commented that the new Prime Minister’s opening stance had indicated good news for continued investment into mental health services. The implementation of The Five Year Forward View for Mental Health had been published and headlines suggested that mental health services would receive an extra £3.97bn investment over the next five years which represented a better deal for people with mental health issues, particularly those who had a First Episode Psychosis (FEP). The Executive would review the details and report back to Board.

Action : KM update the Board on the relevant details of The Five Year Forward View for Mental Health by end December 2016

The first cut of the Sustainability and Transformation Plan (STP) had been submitted although at the present time there was no collective overview of the National position. The plans demonstrated the real pressure on the NHS to deliver sustainable patient services and would require significant further detail.



NHS Improvement (NHSI) had sought to reset the financial position working on a new two year planning cycle from December. The approach looked to encompass both STP funding together with the Control Total criteria, with due regard to the Lord Carter Report targets with a key focus being placed on consolidation and the Pay Bill.

Workforce

Although the Junior Doctor Contract not being accepted by Junior Doctors, the Government has announced its intention to impose the new contract in August 2016 with doctors transitioning onto the new terms on a phased basis from October 2016.

Some national commentators considered the new contract to be reasonable and early indications are that there will be no further strike action against its imposition.

Governance

NHSI has published its Single Oversight Framework (SOF) Consultation which sets out how Providers will be managed and regulated under five key themes. It will bring together the regulation of both Foundation Trusts and NHS Trusts. NHS Providers are looking will be submitting a system wide response to the Consultation which closes on 4 August2016.

Internal & Reputation

Operationally the Trust remained busy both internally and externally. Although internal pressures persisted, quality and staffing levels remained a priority and the Executive continued to monitor hotspots.

Financially the overall position remained positive but the underlying pressures remain which will continue to be monitored and reported to the Board.

In terms of Performance, NHSI targets for Quarter 1, including delivery of the FEP target, had been met but it remained challenging.

Sickness Absence had reduced with the Trust recording its best return to date - 3.98%.

The Board noted the changes in Government and the potential impact of the new Prime Minister and Secretary of State. The Executive would assess in more detail as further detail emerged.

Action: The Executive to review the finer detail of the Government changes and advise if there are any specific issues for HPFT by October 2016.

Following the BREXIT result, TC confirmed that there were no further developments to report upon. However approximately 6 percent of the Trust workforce were from the EU. The Trust was seeking to provide assurance to its workforce, and TC would be giving an interview later that day for BBC Look East.

The Board noted the Report

99/16 Report from Integrated Governance Committee (IGC)

SBe provided a verbal report drawing attention to the following headlines :

Statutory & Mandatory Training TargetsIGC noted 92% achievement and considered how further compliance could be driven through working with the delivery of the current provision and strengthened joint working with external organisations and partners.



Discussion centred on better links with the Norfolk and Essex localities. TC reported that video conferencing could be used. The IGC had noted the regional reduction in L&D funding and expressed concern regarding the potential impact on staff development.

Bullying & Harassment UpdateThe IGC had been pleased with the level of general communication and initiatives to raise awareness and support staff. The Committee would continue to monitor.

Patient Safety ReportThe IGC reviewed the CQC Action Plan. Whilst much progress has been made, many challenges remained. As a result of the difficulties relating to workforce numbers (recruitment and retention) some target dates had been extended. We continue to work closely with the CQC in maintaining progress against plan.

Trust Risk Register and Board Assurance Framework (BAF)Four new risks had been added to the Trust Risk Register and item 110/16 below refers. There were no issues to escalate.


100/16 Patient Safety Report

OS advised the Board that the IGC had reviewed the full Report in detail. He drew attention to the following areas :

Serious Untoward IncidentsThere had been a slight increase in the number of episodes of self-harm, suicides and unexpected deaths this quarter. As outlined the Trust’s response included participation in a County wide approach to suicide reduction.

CAMHS – Forest HouseIncidences of Self harm have increased this quarter and the Team continue to work closely with Service Users to minimise episodes. The increase is largely due to acuity levels which have been much more prevalent across young people.

Ligature Reduction ProgrammeA breakdown of the past year’s figures revealed a large number of ligatures were made from items of clothing. There has been a decrease in the total amount of recorded ligature incidents this quarter, 30 compared to 54 last quarter and 19 in the same period last year. Ligature incidents using anchor points are far less frequent.

The Board noted the actions taken. No additional actions were required.

101/16 Safe Staffing Levels Report

PerformanceOS reported that the general overall position was positive despite high acuity levels across most areas. Norfolk remained a hotspot. The University of Hertfordshire was undertaking training of Student Nurses whilst the Trust’s number one priority would be to develop new types of roles to encourage nurses to remain with the Trust and to look at all of their options.

OS formally thanked Jane Padmore for her commitment and hard work.



National Nursing StrategyThis had now been published and complemented the 5 Year Forward View for Mental Health which focused on how the Trust could work differently as an organisation.

National Quality Board (NQB)New guidance had been published on safe staffing levels. It addressed staffing levels from a two year roll-back perspective but did not cover any specific staff group and dealt with overall staff complement. OS reported that the Trust was well positioned with both NHSI and NHSE who had commissioned work streams nationally. He and Jane Padmore were working closely with them to consider the legitimacies for HPFT. KL advised that the Total Pay Bill and Agency caps should be discussed separately.

OS undertook to report back to a future Board meeting.

Action : Agenda Item for Future Board Meeting – National Quality Board and the National Nursing Strategy

The Board noted the contents of the Report.

102/16 Annual Assurance Reports

JL confirmed that the Report had been discussed in detail at the IGC.

ComplaintsJL reported that every complaint had been investigated with action points or learning notes produced accordingly. These recognised the aspirations of the Trust as a learning organisation which would change and adapt to issues raised by people who have contact with the Complaints service.

Taken into account is the ‘Friends & Family Test’ and ‘Having your Say’ feedback. Compliments were also recorded in this report and were recognised in equal measure. Hotspots were South West and South East localities where recruitment and retention difficulties persisted. The Board suggested consideration is given to how hotspots might be measured in a more standardised way to reflect the number of Service Users in relation to Service User contact. CL advised that it was important that the Board reflected on this information.

Infection ControlOS reported a very positive position overall. There had been no reported cases of MRSA, MSSA or E-coli bacteraemia. There had been no new reports of MRSA colonisation / infection and no reported cases of Clostridium difficile although some challenges remained. There has been a robust approach from the CQC and The Infection Control Committee, Chaired by Jane Padmore, continued to oversee this.

The Board noted the Report outcomes.

CL formally acknowledged the hard work of all staff involved.

103/16 Questions from the Public

There were no questions put to the Board.



104/16 Report from Finance & Investment Committee

SBa provided a verbal report, highlighting the key areas of discussion.

Financial Summary to end June 2016 FIC noted ongoing cost pressure areas of agency caps, the continued challenge with social care placements and the demand for acute and PICU beds for female Service Users with a Personality Disorder diagnosis.

CRES ProgrammeFIC noted an improving position and IGC links with QIAs.

Sustainability & Transformation Fund (STF)FIC had considered the overarching objectives and would evaluate any potential risk areas for the Trust. The Committee would continue to monitor the STF.

Proposed Mental Health Payment SystemsLocal CCGs had proposed two new broad systems (episodic and capitation payment methods) which are within our current contract. The Committee would continue to influence and shape this for the Trust.

2015 / 16 Reference Cost SubmissionThe Committee members approved the return as being in accordance with the relevant guidance.

Innovation and Improvement HubIE had delivered a presentation on the overarching focus and drive of the hub in advance of the September launch. FIC recognised that this was a huge opportunity for the Trust and would continue to support and encourage the Team to deliver on its objectives.

Business Development & Estates UpdateFIC would ensure that there was no loss of momentum with regards to progress at the Hemel Hub. The Buckinghamshire transfer was on track to go live with Service User transition to Dove Ward due this month.

The proposed A-DASH tendering process had changed. The County Council wanted to undertake this in-house and integrate it with the other children’s services by April 2017. This had a proposed impact on six members of staff and a Psychiatrist. FIC would monitor the situation to ensure an optimal outcome for the Trust. TC reported that the Executive would maintain a watching brief on this and would work with colleagues in the local authority.


105/16 Financial Summary to end June 2016

KL reported that the Trust was ahead of plan, which was better than last year. Within that position was provision for non-recurrent resources (IM&T / Safety) and to pump prime the Innovation Fund. He suggested that the Board should remain cognisant of the underlying position.

IGC had discussed in detail the current level of vacancies and ongoing turnover which remained a significant area of focus. There was also a considerable amount of work being devoted to recruitment and retention.

Although agency expenditure had seen a significant reduction over the past 15 months and the Trust remains below trajectory it may not achieve the full cap imposed by NHSI by the end of the year.



KL reported that despite progress in health care placements, difficulties persisted with the demand and management of social care placements and thus remained a risk for the Trust. JL confirmed that there have been separate discussions with the County Council and at the District Health and Wellbeing Board which needed to translate into some positive action.

There was continued focus on the delivery of CRES with work streams evaluating the right approach to deliver best value and efficiencies. This would also align to the Innovation and Improvement Team who would establish key areas to progress.

The Board noted the financial summary

106/16 Q1 Annual Plan Report

IE highlighted the following key areas.

Green / Green Amber Targets

Four of the nine targets were either green or green amber. The five amber pertained to :

o Improving and embedding Smoking Cessationo Challenges in the external environmento Workforce recruitment and retentiono Housingo Continuing to embed new ways of working across services

The Report also supported the Good to Great journey with exciting new areas of emphasis :

o Create a Collective Leadership culture supported by the Lead Ambassadors.o Launch of the Innovation and Improvement Hub in September which would see a

different use of the Colonnades atrium space to encourage and promote sharing and learning from best practice, sharing information in the right way.

o To develop and deliver clear Joined up pathways of care working between HPFT and our partners; Stort Valley, Primary Care and Community Teams.

The Rehabilitation Strategy was currently behind plan and leadership would be brought in to lead the work.

Business Intelligence and information was also moving forward. A Board Workshop was planned for September.

The Board noted the Q1 position.

107/16 Q1 Operational Performance Report

JL reported an overall improvement and asked the Board to:

o Approve the submission of the Performance Declaration based on the Q1 NHSI indicators.

o Approve the submission of the Access to Healthcare Declaration for people with a learning disability.

o Approve the proposed changes to the targets for three KPIs in line with the Quality Account.



The Board noted the ongoing challenges within CAMHS and Essex IAPT. JS reported there had been triangulation of communication with our Essex Commissioners who had agreed a recovery position.

TC formally acknowledged the challenges being faced which needed to be considered when noting the overall position.

There was discussion relating to how performance data regarding “feeling safe” could be collected consistently across all units so that figures were not skewed by the most acute wards. MG questioned how performance was assessed where no targets had been identified. IE confirmed that such areas had not been RAG rated and that overall performance indicators were linked to an overall improvement but not aligned to a specific percentage.

OS confirmed that the Board was aware of the most challenging areas also discussed in detail at IGC.

SBe referred to the Birmingham Model of 24 hour care and questioned what HPFT was learning from other Trusts and how this could be incorporated. The Board agreed to discuss this further at a future Board Meeting.

Action: Agenda Item Future Board Meeting from JL on Birmingham Model of 24 Hour Care by December 2016.

The Board noted the Report, approved the submissions and the changes to the targets for three KPIs in line with the Quality Account.

108/16 Workforce Reports

Workforce Organisational

MMa reported an overall static or improving position.

• Mandatory training compliance had remained consistent throughout Q1 at 87%. • Highest non-compliance was for Relating to People modules 3b & 4, Basic life support

and Resuscitation.

Sickness absence had reduced to below 4% in all areas across the Trust bar one. This included people returning from long term sick leave.

Recruitment and retention remained a key activity. Whilst the vacancy rate had increased to 15.4%, on a like for like basis this would have fallen to 11.5% in Q1 had there not been an increase in the establishment. The Recruitment and Retention group continued to meet on a monthly basis and had a comprehensive programme of work for the next financial year which focused on new and innovative ways of addressing the issues including introducing new ways of working, reviewing internal career pathways, succession planning and improving the employee experience so that staff stayed with the Trust. She noted that there had been more starters than leavers in Q1 although work continued to reduce the overall turnover.

The Pulse feedback revealed an improving trend from staff experiencing bullying and harassment. Much work continued with the launch of the Bullying and Harassment Helpline and the re-launch of the Bullying and Harassment ‘Pledge’ in September.

Work also continued around improved Health and Wellbeing for staff with close attention to the work of the Collective Leadership Ambassadors which would link to the delivery of the OD Strategy.



Development KPIs Q1

CL drew attention to the mandatory training percentage, especially Basic Life Support training. It was confirmed that this had been discussed at IGC and was being addressed. Team Leaders had been tasked with ensuring that there were sufficient numbers of trained members amongst their complement of staff. TC noted that last summer the number of mandatory training undertaken had been reduced to ensure safe staffing levels on Wards.

The Board sought clarification on the 65% completion of Corporate PDPs as compared to the clinical front end (85%). OS confirmed an improvement would be seen as the current position was not satisfactory.

The Board noted the Report findings. No additional recommendations were required.

109/16 Sustainability and Transformation Plan (STP)

IE informed the Board that since the draft submission on 30 June 2016, which had been followed by a meeting with NHSI and NHSE at national level for feedback, the STP was now gathering pace and momentum. It was expected that the STP blueprint for Hertfordshire and West Essex would be finalised by 14 October and that in that submission would be a real commitment to parity of esteem and embedding the priorities set out in the 5 Year Forward View for Mental Health.

Headlines extracted from the Report were :o It would come together as a single system with a single plan.o The challenge would be to close the financial gap.o Additional focus would be place on community and primary care systems.o Additional focus would be needed on sustainability measures.o Acute service configuration.

Next steps :o Submission of financial position by middle of September 2016.o Submission of Final STP towards the end of October 2016.

TC reported that there would also be a resource from HPFT into the STP in financial terms and resource time which the Executive were addressing.

IE undertook to report back to the Board as and when required.

Action : Agenda Item Future Board Meeting by TC on Proposed Final STP Submission as soon as possible

The Board noted the Update

110/16 Governance & Risk

Board Assurance Framework (BAF)OS confirmed that the IGC had discussed the BAF in detail. Headlines from the Report were :

The 2015 Community Mental Health Survey Discrepancies in sampling had resulted in it not being possible to prepare comparisons between 2015 and 2016 owing to Service Users using “outpatient services” having been wrongly excluded.



Supervision Extra assurance was required for supervision in all disciplines in a systematic way. The Board noted that an Electronic Staff Roster System would be launched soon which would encompass an audit tool to monitor supervision but short term actions would be put in place.

Corporate Risk RegisterOS reported that the IGC had accepted all the escalated risks proposed and had discussed other key areas including BREXIT, reduction of L&D funding and the STP.

The Board noted the added Risks to the Corporate Risk Register :

o Risk 661 – Acute Services pressures.o Risk 659 – South West Herts Quadranto Risk 658 – Management of S136 Demando Risk 666 – SPA Business Continuity

The Board noted the Report and agreed the risks identified by the IGC

111/16 Foresight Report and Action Plan

OS reported that this Report was a requirement from Monitor, now NHSI. It was a positive Report and contained a number of recommendations to strengthen the governance system and provide oversight. An Action Plan had been produced to achieve all the requirements contained in the report.

MG questioned how the Trust data could be turned into more user friendly intelligence and requested further discussion at a future Board meeting. It was confirmed that a Board Workshop regarding the Business Intelligence System would be held in September at which a very clear framework would be identified.

Action : Agenda Item September Board Meeting by IE on Business Intelligence System Workshop

TC drew attention to the fact that this was the first time that this Report has been reported at a Public Board Meeting. He said that it indicated how well the Trust was performing and provided an opportunity to move forward. Importantly the independent view of the report concluded that the Trust was a well governed and well-led organisation.

The Board noted the Report.

112/16 CQC Action Plan

OS confirmed that the full Action Plan had been to the IGC. Progress against actions had been satisfactory. IGC have agreed some actions were complete, although further attention to hotspots was required, the majority of which were workforce issues related to vacancies. IGC had requested sight prior to submission and would look to obtain further scrutiny.

The Board noted that only 30% of Trusts have received a ‘good’ rating of which only three Mental Health Trusts had been rated as ‘good’ for safety.

OS continued to meet regularly with the CQC who had been positive about HPFT’s approach to the plan. TC said the Board would want the CQC to re-assess before the end of April, subject to CQC assessment arrangements.

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113/16 Emergency Planning Core Standards

OS presented the report which provided the position statement for NHS England on the core standards for Major Incidents and Business Contingency Planning and had been scrutinised by the Executive.

NHSE and the CCGs had scrutinised the standards earlier in the year following which the Standards had been strengthened. A self-assessment had been undertaken which showed full compliance with the Core Standards.

It is a requirement for the Board to formally adopt their position in relation to the Standards as set out in the paper.

The Board agreed that there was sufficient evidence to agree the Trust Emergency Planning Response and Recovery (EPRR) position statement and action plan in readiness for submission to the CCG by 31st August 2016.

LW requested sight of the full narrative of the Trust’s position in future.

114/16 Any Other Business

TC and CL acknowledged that this would be PB’s last Board meeting and formally thanked him for his commitment and hard work on behalf of the Trust over the years.

CL took the opportunity to welcome KT back from maternity leave.

CL thanked MG for all her work as Senior Independent Director (SID). He advised that SBe had agreed to be the SID going forward.

CL reported that Mr Chris Brearley had stepped down as Lead Governor and that Mr Richard Pleydell-Bouverie had been appointed as the new Lead Governor. CL advised that the new post of Engagement Champion had been proposed to the Council of Governors for Mr Barry Canterford.

Mr Bob Taylor (Public Governor and Carer) raised concern about the numbers of long-term vacancies, particularly for key posts, using the vacant Psychologist post as an example. TC noted that the Trust was working very hard to adopt new ways of recruitment across the board. JL undertook to provide a more detailed response outside of the meeting and confirmed that there were no posts actively frozen. JL to discuss with Mr Taylor.

115/16 Questions from the Public

No questions were put to the Board although invited.

116/16 Date & Time of Next Meeting

September 29 - 9:00 – 1:30pm - Da Vinci B+C


Hertfordshire Partnership University NHS Foundation Trust

FINAL - AGENDA ITEM 4

Matters arising from Board of Directors Public Meeting Held on 28 January 2016

Item No Agenda Item By Whom Action By when / Update

26/16 Cultural Index Q3 JK Following discussion about the returns for Q3, Jinjer Kandola reported that she would be reviewing the OD strategy once the Staff Survey results and the Collective Leadership Report was available. This would then be brought to the Board. The OD Strategy is an Agenda item and the Cultural Index forms part of that.

Verbal Update

Matters arising from Board of Directors Public Meeting Held on 28 April 2016


47/16 Workforce Reports Jinjer Kandola &Helen Potton

Arrange for members of WRES Group to attend a Board Meeting to share experiences & views. A suitable date will be organised for the Autumn.

Future Board 2016

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Matters arising from Board of Directors Public Meeting Held on 28 July 2016


CEO Brief – National Update Kaushik Mukhopadhaya

Provide an update to the Board on the relevant details of the Five Year Forward View for Mental Health.

December 2016

98/16

CEO Brief – Internal & Reputation Executive Team Review the finer detail of the Government changes and advise if there are any specific issues for HPFT.

October 2016

101/16 Safe Staffing Levels Report Oliver Shanley Provide a report on the National Quality Board and the National Nursing Strategy.

Future Board 2016

107/16 Q1 Operational Performance Report Jess Lievesley Provide a report on the Birmingham Model of 24 Hour Care.

December 2016

109/16 Sustainability and Transformation Plan Tom Cahill Provide details of proposed final STP. Agenda Item

111/16 Foresight Report and Action Plan Iain Eaves Deliver a workshop on Business Intelligence System.

Will take place in October 2016.

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Public Board of Directors

Agenda Item 5

Subject: Chief Executive Brief 29 September 2016

External & Strategic

National UpdateThere continues to be significant pressure on demand and capacity within the NHS coupled with ever growing financial difficulties and an aging population with increased lifetime expectancy. These factors are providing the most challenging of environments, more challenging than the NHS has ever faced. Working collaboratively with our partners in a sustainable way is essential to enable us to provide good quality services for our service users.

Finance There is growing concern that the demands being placed on the NHS are becoming increasingly impossible to deliver within the funding available. More than half of Acute Trusts received some form of cash bailout in 2015/16 as total revenue support from the Department of Health reached almost £2bn. To add to this the King’s Fund Quarterly Monitoring Report shows that 47 % of Trusts are currently forecasting a deficit by the end of the financial year. The forward picture requires ongoing significant efficiency gains which will need careful planning to achieve.

Sustainability and Transformation PlansAs the pressure on the system continues the role of the Sustainability and Transformation Plans (STPs) becomes more essential to deliver transformation. There is a clear need to develop effective, efficient and sustainable good quality services, developing new models of care which improve health and wellbeing for our service users.

Final STPS are due to be submitted to NHS England by 21st October. There is recognition nationally that there are clear variations across the 44 STP footprints in relation to an areas’ readiness to implement. The local position of our STP is set out below.

PerformanceMonthly performance figures continue to show the strain that the NHS is under and a worsening picture from this time last year. The long-term trend is one of greater volumes of both urgent and emergency care. Figures also show that a record number of fit for discharge patients are remaining in hospital beds.

For mental health NHSE are developing a set of performance standards to promote the delivery of the Five Year Forward View for Mental Health and it is expected that there will be a number of new key targets including services being expected to treat patients in crisis within four hours to mirror the current A&E target.

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The standard is also likely to include the need for an agreed treatment plan to be in place for service users who have attended A&E.

Mental Health Trusts achieve OutstandingNorthumberland, Tyne and Wear NHS Foundation Trust and East London NHS Foundation Trust have achieved an Outstanding in their CQC Inspections. These are the only two Mental House Trusts out of 55 that have achieved this status, with 17 Trusts, including HPFT, achieving a good.

Some of the key findings of the CQC report show that vacancy levels were low, 3% and 7.2%, respectively with a corresponding minimal agency spend, staff annual appraisal rates were high with regular supervision taking place and, all service users having communication passports with staff receiving additional training in communication techniques including Makaton.

Single Oversight FrameworkNHS Improvement (NHSI) has published its new Single Oversight Framework (SOF) which sets out how the regulator will oversee NHS Foundation Trusts and NHS Trusts to help determine the level of support that they require. The framework, which is due to come into force on 1st October 2016, is designed to help providers attain, and maintain, CQC ratings of good or outstanding although it doesn’t give a performance assessment in its own right. The local position is set out below.

NHS Operational Planning and Contracting Guidance 2017- 2019NHSE and NHSI have published their planning guidance which outlines the expectations of the national bodies for system level planning over the next two years, focusing on contracting and STPs. Further information is contained within the Public Agenda Item on this.

Junior Doctors’ Industrial Action Following the BMA decision to call monthly strikes until the end of the Year, NHSE has sought operational assurance that Provider Boards have signed off plans being implemented to reduce the likelihood of harm to patients during the industrial action and how they will recover afterwards. The local position is set out below.

Local Update

Sustainability and Transformation PlansThe key challenges for the STP are to develop a financial bridge that puts the NHS into balance over the next five years. To do this we will develop and deliver plans:

For acute hospital care that is both futuristic and affordable, For joined up community and primary care that better keeps people as close to their

homes as possible, To better support people look after themselves.

It is largely agreed that for the Herts and West Essex STP we are off the pace. We have two acute hospitals, Princess Alexandra Hospital and West Herts, who are in financial and performance difficulties and need significant capital investment.


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The Trust is playing an active and leading role in supporting the STP process working closely with our partners including the community trust and primary care.

Internal & Reputation

Finance The overall Trust position reported in August for the year to date is a surplus of £639k, which is ahead of the Plan of £400k by £239k. The reported position for the month is a surplus of £150k, ahead of the Plan of £50k by £100k. The overall NHSI Risk Rating, the Financial Sustainability Risk Rating (FSRR), reports as a 4.

This position remains broadly in line with previous months of the year and early indications are that this has continued through September. There are a number of planned non-recurrent investments, particularly in relation to environments and IM&T developments during the second half of the year which will be funded through existing resources.

Whilst on the surface this appears relatively positive, the risk for the Trust is that whilst we are currently achieving the plan, this is generally through non-recurrent one-off opportunities, such as vacancies, and we must tackle the longer term pressures to provide financial sustainability for services.

Looking forwards we have received notification from HCS (Health & Community Services – HCC) that they will reduce social care resources to the Trust by £1m (c.£4.4%) from 1 April 2017. This will be significantly challenging and work is ongoing to fully understand the potential impact on services and statutory responsibilities for social care delegated to the Trust through its contractual agreements.

Performance All of the NHSI targets have been met for August with a good level of headroom against most indicators. Following the introduction of the second street triage car, early indications are that it has had a positive impact on capacity in the S136 Suite with a correlation between the fall in the expected demand and the interventions from the triage car.

As expected , the previous disruptions to SPA over the summer have had a knock on impact on 28 day waits for adult community services, with rates falling to 93% in August, the lowest it has been for the last 12 months. The SPA backlog has now been cleared and SPA performance is predicted to be maintained in September allowing waiting times to recover back to target levels. Action is underway to substantively fill vacancies, but recruitment and retention remains both a local and national challenge.

Teams are being encouraged to explore and test new approaches to address key ‘wicked’ issues that continue to remain below expected levels e.g. IAPT access in Essex and PDP rates.


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QualityFollowing the World Suicide Prevention day on 10th September, the Trust has held a number of workshops to help to raise awareness and talk openly about suicide. The workshops were open to the general public as part of the Trust’s Spot the Signs campaign. We are currently working with our colleagues in public health to run a multi-agency suicide prevention workshop in November. The outcome of this will help to inform and develop a county wide suicide reduction plan in line with the national mental health strategy.

Our Quarter One performance with regard to CQUIN expectations was very positive with commissioners agreeing to make payment for all bar the CAMHS Care and Treatment Reviews which remains at 75% achievement. The Clinical Directors are working with the teams to identify a champion for each area to address this. The Quarter One data for the 11 quality account priorities indicate that the Trust has met or exceeded all the targets.

The Trust continues to work to implement the CQC action plan with progress being made in a number of areas including training, staffing in CAMHS and ligature removal works. The Trust meet regularly with the CQC to feedback on the actions being taken and their feedback has been positive.

Work is underway on the development of our Recovery Strategy which will look at whole life recovery. The strategy will aim to bring together various elements including national strategy, innovation and benchmarking, ensuring that our service users are at the centre. Initial sessions have already taken place with service users and carers, and workshops have been set up with clinicians to start to map out what the overarching strategy will look like.

Junior Doctors’ Industrial Action The Trust has put together a detailed plan to manage the impact of the Junior Doctors industrial action in line with the Trust’s Major Incident and Business Continuity Plans. Further information is contained within the Public Agenda Item on this.

Single Oversight FrameworkAs a Trust we have reviewed the SOF alongside the current regulatory and reporting framework to ensure that we will be able to meet the new framework requirements. Further information is contained within the Public Agenda Item on this.

Quality Improvement Performance FrameworkThe Quality Improvement Performance Framework (QIPF) is the process by which Health Education East of England (HEEoE) assures itself that the education it commissions and delivers on behalf of Employers providing NHS care in the East of England is of the highest quality.

A regional team of around 19 people from HEEoE will be conducting a Formal Quality Improvement and Performance Framework Standards Visit at the Trust on the 4th November 2016 as part of the normal framework cycle. Formal feedback from the visit is scheduled to take place in mid-December. Further information is contained within the Public Agenda Item on this.


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Nursing & Midwifery CouncilOne of our registered nurses has been charged by the Nursing & Midwifery Council (NMC) with failing to maintain professional boundaries which called into question her fitness to practice. The case has been reported in the National Press and the outcome is likely to be given in the next two to three months.

When the incident was reported to the Trust it was taken very seriously and fully investigated. The Police investigation and subsequent prosecution found the nurse not guilty.

The Trust has cooperated fully with the NMC in relation to the hearing.

Executive Team UpdateFollowing the appointment of Oliver Shanley, Executive Director, Quality and Safety/Deputy Chief Executive as Regional Chief Nurse for London, with NHSE and NHSI plans are now underway for his replacement. Whilst that recruitment takes place interim arrangements will be put in place to ensure a smooth transition to the new appointment.

The position of Deputy Chief Executive will be appointed from the current Executive Directors and a recruitment process is currently underway for that.

Medical appraisal and revalidationThe Trust has a responsibility to recommend or defer the re-licencing of doctors every five years based on the completion of comprehensive appraisals which includes feedback, details of any complaints, clinical governance information and other relevant information including professional development. This process is now underway. Further information is contained within the Public Agenda Item on this.

Tom Cahill Chief Executive


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Meeting Date: 29 September 2016 Agenda Item: 5a

Subject: HCT – HPFT Alliance For Publication: Yes

Author: HCT and HPFT Approved by: Iain EavesExecutive Director – Strategy and Improvement

Presented by: Tom CahillCEO

Purpose of the report:

Present a proposal for HPFT and Hertfordshire Community NHS Trust to enter into a strategic alliance.

Action required:

Discuss and endorse the principle of entering into a strategic alliance as set out in the proposal.

Summary and recommendations to the Board:

This proposal sets out the intention for Hertfordshire Community NHS Trust (HCT) and Hertfordshire Partnership University NHS Foundation Trust (HPFT) to enter into a strategic alliance for the benefit of patients/service users, the local communities we serve together as well as commissioners and the wider system.

The HCT and HPFT Boards are asked to endorse the principle of entering into a strategic alliance.

A communication plan should be urgently developed to support the successful development of the alliance.

It is recommended that a Memorandum of Understanding is developed including clarifying scope and governance for sign of in December Board meetings.

In parallel it is recommended that a delivery plan is developed setting out key objectives and milestones for each of the priority areas over the next 12 -18 months.

Relationship with the Business Plan & Assurance Framework (Risks, Controls & Assurance):-

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Equality & Diversity (has an Equality Impact Assessment been completed?) and Public & Patient Involvement Implications:-

Evidence for Essential Standards of Quality and Safety; NHSLA Standards; Information Governance Standards, Social Care PAF:-

Seen by the following committee(s) on date: Finance & Investment/Integrated Governance/Executive/Remuneration/Board/Audit -


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Hertfordshire Community NHS Trust and


Proposal for a strategic alliance

Introduction

This proposal sets out the intention for Hertfordshire Community NHS Trust (HCT) and Hertfordshire Partnership University NHS Foundation Trust (HPFT) to enter into a strategic alliance. This paper sets out initial thinking on:

The scope and principles of the proposed alliance Priorities and the ambitions for the proposed alliance over the next 18 months. Governance considerations

The paper was developed following a number of meetings by executive representatives of both organisations. These meetings immediately identified synergies and opportunities that are set out in this paper. It was also clear from these initial discussions that the climate has changed and that there is a clear expectation (and urgency) from the wider system that individual providers in general, and HCT and HPFT specifically, start working much more closely together.

The paper concludes with recommendations and proposed next steps.

The case for a Strategic Alliance between HCT and HPFT

Successful alliances are built on shared understood aims, common values and trust. As a first step we therefore sought to clarify why we believed that an alliance between HCT and HPFT was important, and how it aligns with each organisation’s ambitions as well as wider stakeholder expectations.

Shared Organisational Ambitions and Direction

On review of each Trust’s visions and strategic objectives there is a strong sense of shared ambition and direction which provides a good platform for an alliance that could be mutually beneficial:

There is strong alignment between HCT’s and HPFT’s stated ambitions (Vision statement, Strategic Objectives) focused around high quality personalised care close to home.

There is also a shared view on the key enablers and approach that will allow these ambitions to be realised e.g. engaged workforce, use of information, ways of working, integration and partnership working


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The thinking and expected behaviours that sit behind each organisation’s values are very similaro HCT: Care, Respect, Quality, Confidence, Improveo HPFT: Welcoming, Kind, Positive, Respectful, Professional

There is significant overlap between the perceived risks facing each organisation e.g. workforce (recruitment and retention), financial pressures, changing external environment (STP, ambitions of other providers) but together both organisations are key to ensuring that the STP ambitions of reducing acute demand and reducing the financial risks in the footprint are progressed.

Benefits of an Alliance

There is a shared view about why we are proposing an alliance between HCT and HPFT and the benefits we would hope to achieve through this for patients/service users, the local communities we serve together, our individual organisations as well as commissioners and the wider system.

Service improvement: The opportunity to provide more joined up, holistic, local care that better meets both people’s physical and mental health needs. Our joint approach to service improvement will be a key deliverable for the STP workstream on primary and community care

Cost Effectiveness: Reducing duplication both at a front line and back office/ corporate support services level. Our joint approach to back office consolidation will be a key deliverable to the STP

Capability and Capacity: Leverage complementary skills, shared building of capabilities required by both organisations (Learning Alliance) and increased bandwidth for managing external relationships

External Positioning & Voice: Stronger unified voice for community physical and mental health services in responding to and driving new models of care

As already noted there is also a strong sense that if we don’t begin to work more closely and effectively together of our own volition and on our own terms then the system will find ways of forcing this to happen in order to deliver on the ambitions of the STP and other pressing national priorities such as back office consolidation. A clear early signal of intent from both organisations quickly followed up by visible action would go a long way towards mitigating this risk.

Scope and Principles

It is important for us to be clear about what the alliance should include and what it should not include, aligned to the agreed aims. Both organisations would retain their separate identities but agree a set of principles about how we would work together in general, as well as setting out key outcomes for the four proposed aims set out above.

There are a large number of potential opportunities for joint working that should be explored in determining the final agreed scope of the proposed alliance which we would expect to evolve over time. These areas include:


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Service Improvement and Service Delivery Synergies

Single Point of Access Children & Young People including CAMHS Older Adults including dementia Improved physical health for people with a serious mental illness Mental wellbeing for people with a long term physical condition Acute liaison and discharge functions

Cost Effectiveness and Capacity/Capability Building through Back Office/ Support Service Synergies

HR and OD Finance Estates IM&T Learning & Development Procurement

External Positioning and Voice

Relationships and collaborative working with GP Federations Positioning and voice within STP Engagement with local communities Building exec and management team capacity though co-representation

Taken together these areas offer huge potential to make significant positive difference to patients, and local communities across Hertfordshire as well as the sustainability of HCT, HPFT and the wider system.

Ultimately the expectation is that the scope of the alliance could increase over time to include each of the areas above as appropriate to deliver on the agreed aims. It is envisaged that this would be based on how (as an Alliance) we make use of existing resources across the two organisations, rather than any net investment into the alliance by either party.

Governance Considerations

Clear governance arrangements will be critical for the success of the Alliance and in setting a clear framework within which staff at a local level can be empowered to work together to develop and implement new ways of joint working.


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Whilst further detailed work is required to work up the governance model it is envisage that the Alliance will be overseen by a non-executive led Board with Director level representatives from both organisations.

Recommendations and Next Steps

The HCT and HPFT Boards are asked to endorse the principle of entering into a strategic alliance as set out above.

A communication plan should be urgently developed to support the successful development of the alliance.

It is recommended that a Memorandum of Understanding is developed including clarifying scope and governance for sign of in December Board meetings. This may require some third party support and advice.

In parallel it is recommended that a delivery plan is developed setting out key objectives and milestones for each of the priority areas over the next 12 -18 months.


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Meeting Date: 29 September 2016 Agenda Item: 6

Subject: Trust Strategy – ‘Good to Great’ For Publication: Yes

Author: Iain EavesExecutive Director – Strategy and Improvement

Approved by:Iain EavesExecutive Director – Strategy and Improvement

Presented by: Iain EavesExecutive Director – Strategy and Improvement


To present the Trust’s ‘Good to Great’ Strategy which sets out HPFT’s future direction and ambitions to improve the quality of the care we deliver and outcomes we achieve together with service users and carers.

Action required:

The Board is asked to ratify the mission, vision and strategic direction set out this document.


This is an exciting and challenging time to be setting out on the next phase of HPFT’s journey. It comes on the back of significant changes to our services through a five year transformation programme leading to a ‘Good’ rating from the CQC in 2015. Following the publication of the final CQC report we have held many conversations with service users, carers, staff, commissioners and the wider communities we serve. These conversations have confirmed our view that we have the opportunity to do even better, to be consistently ‘Great’, and they have shaped this strategy and a simple but ambitious vision: “Delivering Great care, Achieving Great Outcomes – Together”

The Board is asked to ratify the mission, vision and strategic direction set out this document. The next steps are to:

Formally launch ‘Good to Great’ as our strategy with staff, service, users and carers and our wider stakeholders, and engage with them on our plans for delivery

Finalise the detailed supporting strategies that are being developed Develop our specific delivery plans for years 2 and 3 of our journey from ‘Good to Great’.

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Relationship with the Business Plan & Assurance Framework (Risks, Controls & Assurance):Sets out the Trust Strategy for 2016 -2021 that will shape the future Business Plans and the Trust’s Board Assurance Framework.

Equality & Diversity (has an Equality Impact Assessment been completed?) and Public & Patient Involvement Implications:As EIA has been completed and will be followed through for the more detailed delivery plans. The strategy has been developed through significant engagement with service users, carers and stakeholders. Putting each individual, their needs and experience, is at the very heart of the strategy.




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“Good to Great”Our Five Year Strategy 2016 -2021

1. Introduction

This is an exciting and challenging time to be setting out on the next phase of HPFT’s journey. It comes on the back of significant changes to our services through a five year transformation programme leading to a ‘Good’ rating from the CQC in 2015. It also comes at a time when:

Mental health and learning disabilities have never enjoyed a higher profile with the national drive for parity of esteem.

The Five Year Forward View and New Models of Care are driving a huge push to deliver more joined up care around individuals, and are beginning to break down the artificial divide between mental and physical wellbeing

Technology is changing how care can be delivered, and better information solutions are helping to drive improvement and reduce variation in practice

The financial challenges facing the NHS have never been greater

Despite the challenges facing the NHS we are in a strong position to take advantage of the opportunities that arise from this and take the next step from “Good to Great”

2. About Us

We currently provide integrated health and social care for people with mental ill health, and those with learning disabilities, supporting them to keep physically as well as mentally well. We do this mainly in the community, but also in inpatient settings, across Hertfordshire, Buckinghamshire, Norfolk and North Essex.

Our partnership arrangements with the local authority provide an excellent opportunity to develop a recovery orientated approach based on a holistic assessment of both health and social care needs.

We are also a University Trust, with close links to the University of Hertfordshire providing excellent learning and development opportunities for staff, as well as strengthening clinical research.


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3. Our Purpose and Mission

Everything we do is aimed at providing consistently high quality, joined up care, support and treatment that:

Empowers individuals to manage their mental and physical wellbeing Keeps people safe from avoidable harm Is effective and ensures the very best clinical and individual recovery outcomes Provides the best possible experience

We do this in partnership with individuals using our services, their families and/or carers, local communities and other providers and agencies.

This is summarised in in our mission statement:

4. Our Values

Our values define us and are at the heart of how we go about delivering our mission. They were co-produced by service users, carers and staff, and we are proud that the CQC inspection team specifically commented on how they had seen evidence of them being brought to life in teams across the organisation.

Our Values

We help people of all ages live their lives to their full potential by supporting them to keep mentally and physically well.


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5. How we developed this strategy

In 2015 we were amongst the first Mental Health and Learning Disability Trusts to receive a ‘Good’ rating from the CQC. We remain immensely proud of this achievement.

Following the publication of the final CQC report we have held many conversations with service users, carers, staff, commissioners and the wider communities we serve. This has involved focus groups with service users and carers, input from our service user and carer councils, as well as road shows across three counties to meet with and listen to our staff.

These conversations have confirmed our view that we have the opportunity to do even better, to be consistently ‘Great’, and they have shaped this strategy.

6. Our Vision

Our conversations with service users, carers, staff, commissioners and the wider communities we serve have informed a simple but ambitious vision:

Achieving our vision means:

Putting the people who need our care, support and treatment at the heart of everything we do - always

Consistently achieving the outcomes that matter to the individuals who use our services, and their families and carers, by working in partnership with them and others who support them

Providing the very best experience of joined-up care in line with what service users and carers have told us makes ‘Great Care’

7. Delivering on our Vision

In moving progressively towards achieving our vision for Great Care and Great Outcomes over the next five years we will focus on the four linked areas shown in the triangle below. This is because we know that ‘Great Care and Great Outcomes’ are delivered by ‘Great People’ supported by a ‘Great Organisation’. An organisation that creates the conditions for everyone to deliver, or support the delivery of, the very best care – embracing the principles of collective leadership, constantly learning and improving for the benefit of those we serve.

We also know that no matter how good we are as HPFT, what is important to the individuals we serve goes beyond our four walls. To achieve together what really matters to service

“Delivering Great Care, Achieving Great Outcomes - Together”


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users and their families we must have ‘Great Networks and Partnerships’ with others involved in their care, support or treatment.

Service users and carers have told us that the foundation for becoming ‘Great’ is getting the basics right – every time. This includes treating everyone with dignity and respect, communicating effectively and doing what we say will do - in short living up to Our Values. In delivering our Vision we will be relentless in getting the basics right for our service users and carers, but also for our staff.

To become ‘Great’ we have to go further, focusing on those things that will help us to make the difference of the next 5 years. These areas are summarised below:

To help us make this step change we have identified five things that we are asking everyone to keep in in their minds in all that they do, whether they are support workers, board members, nurses, managers, doctors or admin staff. Together we will always be thinking about:

Making sure service user & carer experience is the best it can be

How we improve the staff experience

Looking for opportunities for improvement and innovation

Challenging ourselves to make sure everything we do is adding value; that we are focused on the outcomes that matter to those we serve, and using the money we have and people’s time productively to make the biggest difference possible

How we can develop relationships and partnerships that help us better meet the needs of the local populations we serve


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8. What success looks like

In working towards realising our overall vision we will develop detailed delivery plans and monitor our progress against each of the four themes of our strategy. The first year of our delivery plan is set out in our Business Plan for 2016/17. A summary of what we expect to achieve over the five year period of the strategy is set out below:

Great Care, Great Outcomes

Outcomes will be amongst the best nationally, consistent with an ‘Outstanding’ CQC rating. This means that:

We will consistently achieve the outcomes that matter to the individuals who use our services and their families / carers

People will be supported to keep physically as well as mentally well, reducing the health inequalities gap for people with a learning disability or mental illness

Individuals will progress positively through our services, feel safe and be protected from avoidable harm

People will able to access the right service in a timely way

Staff will report that they are able to deliver safe and effective services

People’s experience of joined up care will be amongst the best nationally consistent with an ‘Outstanding’ CQC rating. This means that:

We will consistently live up to what service users and carers have told us is ‘Great Care’

People will recommend our services to friends and family if they needed them

Carers will report feeling supported and valued in their role

Great People

We will attract, retain and develop people with the right skills and values to deliver consistently great care, support and treatment. This means that:

We will be seen as an employer of choice where people grow, thrive and succeed

Our staff will report feeling engaged and motivated, and recommend the Trust as a place to work

Leaders across all levels will empower staff, encourage openness and transparency, and promote high quality care

All staff will understand how the Trust’s values relate to their specific role and put them into practice


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Great Organisation

The conditions will be in place for everyone to deliver, or support the delivery of, high quality care, effectively and efficiently. This means:

We will make effective use of people’s time and the money we have to deliver on the outcomes that matter to those we serve

We will constantly learn, innovate and improve for the benefit of those we serve, including making the very best use of technology and information

We will always get the basics right

Great Networks and Partnerships

Networks and partnerships are in place locally and beyond to best meet the whole person’s needs: This means that:

Individuals will experience joined up care regardless of organisational boundaries

Mental health and learning disability will be given the same emphasis as physical health in local care planning and delivery

HPFT will be recognised as a leader in planning, co-ordinating and delivering joined up care

9. Recommendations and Next steps

The Board is asked to ratify the mission, vision and strategic direction set out this document. The next steps are to:

Formally launch ‘Good to Great’ as our strategy with staff, service, users and carers and our wider stakeholders, and engage with them on our plans for delivery

Finalise the detailed supporting strategies that are being developed

Develop our specific delivery plans for years 2 and 3 of our journey from ‘Good to Great’.


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Meeting Date: 29 September 2016 Agenda Item: 7Subject: Arrangements for Junior Doctor’s

StrikeFor Publication: Yes/No

Author: Catherine Pelley Deputy Director Safer Care and Standards

Approved by: Dr Kaushik MukhopadhayaExecutive Director Quality & Medical Leadership

Presented by: Dr Kaushik MukhopadhayaExecutive Director Quality & Medical Leadership


This paper will outline the current plans in place to manage the impact of the Junior Doctors Industrial Action in October, November and December.

The paper includes the details of the requirements for reporting prior to action and during industrial action. This includes details of how the Trust will support the wider system including A&E.

Action required:

The Board is asked to note that Chair’s Action was taken and ratify the submission to UNIFY in respect of the industrial action.

The Board is asked to note the content of the action plan developed in preparation for industrial action.

Summary and recommendations to the Board

Following periods of industrial action earlier in 2016 the BMA have confirmed dates for action during quarter 3. The next episode of action which will result in a full withdrawal of labour runs from 0800hrs to 1700hrs each day is split over two periods:

Wednesday 5 to Friday 7 October 2016 and; Monday 10 to Tuesday 11 October 2016

Expectations of organisations has been sent out to Chief Executives in a letter on 8th September 2016.

Comprehensive plans have been put in place across the organisation to prepare for the impact of the action in line with the Trust Major Incident and Business Continuity plan (MI&BCP).

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Work is ongoing to prepare for the action including assessing the impact on planned appointments and ensuring support is targeted to priority services set out in the MI&BCP. A draft version of the current plan is attached. This will continue to be refined up to the commencement of industrial action with further detail provided to the Executive Committee ahead of action.

During the days leading up to action the Trust will need to make decisions on what training and meetings should continue to reduce the longer term impact on the organisation. A targeted approach to cancellations of training will take place.

Prior to commencement of industrial action the Trust is required to submit an UNIFY return providing assurance that plans are in place to manage the industrial action safely. Data on cancellations will be provided.

The Trust was obliged to submit the return by 3pm on Monday 26 September so to comply with this deadline Chair’s Action was taken.

The Board is asked to ratify the submission which set out that we responded positively to all aspects of the assurance framework. The Deputy Director Safer Care and Standards has also discussed our plans with both Hertfordshire CCGs and they have raised no concerns. Discussions with the CCGs also include providing assurance that we will support the provision of service in both A&Es through the RAID, CATT and C-CATT teams.

Relationship with the Business Plan & Assurance Framework (Risks, Controls & Assurance):

None

Summary of Financial, IT, Staffing & Legal Implications:

Equality & Diversity (has an Equality Impact Assessment been completed?) and Public & Patient Involvement Implications:

N/A

Evidence for S4BH; NHSLA Standards; Information Governance Standards, Social Care PAF:

N/A

Seen by the following committee(s) on date: Finance & Investment/Integrated Governance/Executive/Remuneration/Board/Audit


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PUBLIC BOARD OF DIRECTORS

Junior Doctor Industrial Action

Introduction

This paper sets out the plans that have been developed and continue to be developed in advance of the Junior Doctor Industrial action in October, November and December 2016.

The next episode of action which will result in a full withdrawal of labour runs from 0800hrs to 1700hrs each day is split over two periods:


To manage the impact of the industrial action the Trust will operate command and control arrangements as set out in the Trust Major Incident and Business Continuity Plan. A control centre will operate to have oversight of all services and manage issues as they arise. The submission of returns to NHS England will be managed via the control centre.

Assurance

In preparation for the industrial action all providers have been written to and asked to provide assurance submissions in advance of the action and situation reports twice daily during industrial action. The assurance submission includes details on the number of outpatient cancellations during the period 29th September to 14th October.

Operational services are working on managing the outpatient activity to reduce the impact to a minimum.

The Trust response to the assurance submission is as follows

Questions Response and supporting information

Please confirm that you are assured you can maintain business critical services for the duration of the industrial action

YesMajor Incident plan sets out business critical services and these will be maintained during industrial action. Gold command will manage the process of determining which services are reduced based on the availability of junior doctors and wider clinical staff each day.

Are you assured you can provide appropriate mental health crisis intervention teams for the duration of the industrial action?

YesSpecific plans are in place to cover the crisis services. These services are considered a level 1 service and are priority within the business continuity plan.


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Are you assured that you will be able to establish a major incident response, in line with your Incident Response Plan, during the period of industrial action

YesGold command will be established during industrial action this will be maintained in the event of a major incident. Wider command and control arrangements will be established in line with Major Incident Plan.

What is the (percentage) bed occupancy you expect to achieve immediately prior to the commencement of the period of industrial action?

90%

Do you expect to achieve a bed occupance percentage lower than your normal occupancy prior to the commencement of industrial action?

Yes

Please confirm you have checked for any events that may have an impact on your organisation during the period of industrial action (such as primary care training) where appropriate mitigation has not been undertaken

YesAll non-essential meetings and training will be cancelled during the period of industrial action.

Please confirm that you have agreed local arrangements for the immediate return to work of all appropriate staff in the event a major incident is declared

YesContact details of all Junior Doctors will be available to gold command who will determine if a return to work is required

Please confirm that you have engaged with the consultant body and they will cover shifts that are likely to be affected by the industrial action

YesThis has been discussed with the wider consultant body. Plans for specific services are being developed with oversight from the Clinical Directors.

Please confirm that actions have been taken in partnership with and agreed with CCGs, the appropriate A&E delivery Board(s) and other partner organisations to maximise community support to acute trusts, including the purchase of additional bed capacity to help the trust enter the period of industrial action with a positive bed balance and additional primary care capacity

YesWe have provided information to the leads developing the A&E assurance plans ahead of their submission of the A&E assurance return. WE have received conformation from both leads they are happy with the information provided and our contribution to the overall plan. During industrial action we will be participating in system calls to support the wider health economy manage the impact of the action.

Please confirm that arrangements will be in place for executive oversight, command and control and escalation during the period of industrial action

Yes Gold command will be established during the period of industrial action.

Please confirm you have a plan for the recovery to business as usual following the period of industrial action (including

YesThis will be overseen by the control centre


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elective activity)Please confirm that you have a plan to manage the weekend period, including surges in activity, ability to safely discharge and releasing capacity

Yes

Please confirm that you have in place appropriate arrangements for informing patients, carers, relatives and staff regarding the impacts of industrial action and for handling media enquiries, including spokespeople

YesCommunications lead identified to cover period of action and respond to media enquiries. Management of responses will be via Gold command

Please confirm that your assurance for industrial action to manage and mitigate clinical risks has been agreed with your Board or Chairs action taken

YesA review of the risks for HPFT has identified that ECT and on the day urgent services are at risk if there is a substantial walk out. ECT will be provided to critical patients only. Senior clinicians are available to support the delivery of urgent services including deployment of senior clinical staff who work in support services The action plan and this submission was shared with the Chair ahead of the Board meeting on 29th September.

In addition to this we have to confirm that the submission has been agreed by the Accountable Emergency Officer, Chief Executive, Medical Director and CCG Chief Officer.

Data collection

In advance of industrial action and during industrial action the Trust has to submit data to NHS England as per the following timetable.

Collection of assurance data Dates of industrial action

Unify2 opens Unify2 closes

Weds 5 to Fri 7 and Mon 10 to 11 October

1000hrs Mon 19 September 1500hrs Mon 26 September

Mon 14 to Fri 18 November 1000hrs Mon 31 October 1500hrs Fri 4 November Mon 5 to Fri 9 December 100hrs Mon 21 November 1500hrs Fri 25 November

Collection of situation reporting on days of action Dates of industrial action

AM Unify2 collection PM Unify2 collection

Weds 5 to Fri 7 October 0800hrs to 1030hrs daily to report the staffing position as at 0900hrs

1630hrs to 1830hrs return to normal report


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Sat 8 and Sun 9 October (Acute, Ambulance & NHS 111 only)

0800hrs to 1030hrs daily to report continued impact of industrial action

No evening collection

Mon 10 to 11 October 0800hrs to 1030hrs daily to report the staffing position as at 0900hrs


Mon 14 to Fri 18 November 0800hrs to 1030hrs daily to report the staffing position as at 0900hrs


Mon 5 to Fri 9 December 0800hrs to 1030hrs daily to report the staffing position as at 0900hrs


Service prioritisation

To ensure the effective and safe management of services during industrial action the Trust has a service prioritisation framework as part of it Business Continuity Plan. The details of who we will manage the reduction in service if a significant number of junior Doctors take action is set out below.

In advance of the industrial action the Trust has written to all Junior Doctors to ask them if they plan to strike to enable a view on the impact to be taken ahead of action.

The management of this framework will be via the incident control centre running throughout the industrial action.

For this purpose services have been defined into three Levels as follows:

Level 1 – High priority/essential services which must continue to be provided

Level 2 – Essential services which could be provided differently or temporarily reduced to release resources

Level 3 – Services which could be temporarily closed to release resources

The staff currently employed within Level 2 and 3 areas could be released if services are reduced or closed to then be redeployed (assuming they have transferable skills and competencies) to Level 1 and some Level 2 service areas.


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JUNIOR DOCTORS STRIKE CONTINGENCY PLAN – OCTOBER 2016

Plan to set out the business continuity arrangements for the Junior Doctors strike

Dates of action The next episode of action which will result in a full withdrawal of labour runs from 0800hrs to 1700hrs each day is split over two periods:


Issue Issue Action Lead(s) Timescale Update 21ST September

Organisational Oversight Establishment of control centreRegular MD/CD calls during day to be establishedBed status data to be available Loggist access confirmedAW to ensure contact details for acute trust control centre available for HPFT control centreCover for JL/CP to enable effective management of the control centreMDs and CDS to agree service prioritisation list and mutual support across services.

KM/CP/JL From commencement of action

Control centre booked Spider phone to be available for conference calls during periods of action.

NHS England coordinating contact details for system to be available from 1/10/16

CP to coordinate rota for control centre cover. All Ads/Heads of Service asked to contribute to cover for all periods of action.

Service prioritisation list agreed as per MI&BCP.

Handover to on-call director to be in place at end of each day of action. Tel con booked for 30th September to finalise plans ahead of action. Report to Exec on 4th October


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Issue Issue Action Lead(s) Timescale Update 21ST September Consultant list to be created to identify those with transferable skills.

The contact numbers of the Control Centre will be shared with Regional Control Rooms.

Control Room - The Colonnades - 7am to 7pm

Corporate ADs to cover control centre each day during the period of indefinite actionAdmin support rota to be established Exec director rota to be established to cover control centre


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Clarification of Junior DoctorTaking Strike Action

Ensure adequate & safe On-Call Rota provision

Rotas to be agreed with consultants to cover during periods of action.

Daily calls will review the availability of junior Drs to enable deployment to business critical services/tasks

Additional support to be identified to support medical staffing during period of indefinite action

KM/ AZ / CA

From notice of next period of action

Those Junior Doctors not on strike will base themselves where scheduled to but we have their contact numbers should we need to re-deploy. Junior Doctors are expected to re-affirm their intention to strike by 09.00 am on the days of action with their Consultant. Consultants will inform the Medical Staffing by 09.30 am of their intention to strike on the day of the strike.

For those Junior Doctors on strike, we have their contact numbers & will follow the Critical Incident Guidance should we need to call them back. This will be coordinated by Medical Staffing as follows.

Rota in place to complete twice daily sitrep with cover arrangements.

Senior Medical Cover Complete safety checklist for all clinical areas

Consultant & Senior Nurse cover to be available on both days of strike action.

Pharmacy & Team Leads to be informed & will support the clinical areas along with Modern Matrons.

AZ From notice of next period of action

Detailed plans being developed by CDs/MDS to set out the impact in each clinical area of industrial action.

Senior Nurse rota to be finalised to support services focussed on level 1 services


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Issue Issue Action Lead(s) Timescale Update 21ST September Provide additional clinical skills training to maintain level of expertise in physical health

Nursing and AMHP Workforce Cover

Confirmation of staffing levels for all services in place

All Rotas to be reviewed & have sufficient staffing.

Services to be prioritised for additional support: 136 | CATT | C-CATT | RAID

Heads of Nursing are basing themselves in clinical areas to provide support.

All unessential meetings & training for Nurses have been cancelled.

The Resuscitation Officer has been relocated to Kingfisher Court.

AMHP rota to have required number of AMHPs for each day of action.

JP/SDFrom notice of next period of action

Senior Nurse rota to be finalised to support services focussed on level 1 services

AMHP rota to be finalised by 23rd

Corporate staff to support AMHP rota

All non-essential training and meetings will be cancelled


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Support Service Cover Deployment of corporate nursing support via HoNS targeted by demandPharmacist cover in place for in-patient units

JP

CS

5th October All corporate nurses identified and confirmed availability.

Pharmacist cover confirmed.

Review of Services by Pathway Review of all outpatient clinics to assess impact

MDs/CDs to agree priority service list

Additional nursing support to be provided forRAID/CATT/CCATT to support system management of the impact of strike

Confirm with acute Trust availability of anaesthetist for ECT sessions.

MDs/CDs From notice of action

Priority services agreed

Detailed plans for 136/RAID/CATT and CCATT to be finalised by 30th September

Unify Reporting Unify reporting to be maintained through strike

AW/CA OngoingRota for reporting in place.


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Issue Issue Action Lead(s) Timescale Update 21ST September Scheduled Unify reporting will be responded to via the Control Room & phone ins from MDs & CDs.

Updates will be based around Unify return times.

Staff to be identified to complete Unify returns during indefinite action

Management of system pressure Control centre to deploy resource to respond to additional pressureAdditional resource for CCATT/CAMHSNHS England to be asked to set out contingency for access to CAMHS beds

KM/CP/JL HPFT to join daily calls to each CCG to update on impact on organisation/system.

Trust have provided information to both A&E assurance Boards regarding support to A&E by mental health services

Communications All Junior Doctors to be written to by Medical Staffing outlining expectations of communication.

A letter to go to all staff re strike preparation.

JH From notice of next period of action

Comms to liaise with medical staffing on drafting a letter to all staff. We will also draw attention to the letter through HPFT News and follow up in Tom’s blog, as appropriate.

A draft press statement will be prepared for reactive use – setting out the impact for services. We can update information on impact on services as any changes emerge over the 5 days. We will monitor social media and respond as appropriate. We may wish to


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Issue Issue Action Lead(s) Timescale Update 21ST September Communications for both patients & public, to be agreed for each scenario setting out impact on services

Participation in system wide communication to ensure we are able to contribute to maintenance of safe services across health and social care

Communications team to manage media inquiries throughout periods of industrial action

promote any positive messages about preparedness through Twitter.Reminder to staff to refer any media enquiries to Comms.

We have strong links with the NHSE East of England comms network and NHS comms leads from all NHS trusts within Hertfordshire so will ensure that we co-ordinate to joint messages, as appropriate.

Bed State Bed state is being monitored throughout the day.

Confirm with NHS England contingency plans for CAMHS beds in event of sustained action

Control centre lead (CP)

From commencement of action

This will be part of twice daily calls


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Meeting Date: 29 September 2016 Agenda Item: 9Subject: Quality Improvement Performance Framework (QIPF)Author: Lindsey Holman

Interim AD OD and Learning Approved by: Jinjer KandolaExecutive Director Workforce & Organisational Development

Presented by: Jinjer Kandola Executive Director Workforce & Organisational Development


To present an update to the Trust Board on the Trust position with regards to the QIPF standards and requirements and how we will ensure readiness for the planned formal visit for 2016.

Action required:

To note the report and agree on a reporting schedule.

Summary and recommendations to the Committee:

The Quality Improvement and Performance Framework (QIPF) is the process by which Health Education East of England (HEEoE) assures the education it commissions. HPFT receives in excess of £2 million per year to provide education and sign a contract (learning and development agreement) to deliver against the requirements listed in the LDA, associated schedules, GMC Domains, Trainee Doctor and Non Medical Education Key Performance Indicators. HPFT have their formal visit on 4th November 2016.

The report outlines a series of Quality Assurance visits and processes undertaken over the last quarter. There are no immediate concerns raised by HEEoE. Each visit and Quality Assurance process informs an improvement action plan that is overseen by the Strategic Workforce Development Group (SWDG).

Also outlined in the report is the process for preparation for the formal visit.

Relationship with the Assurance Framework GMC trainee doctor, QIPF and LDA

Summary of Financial, IT, Staffing & Legal Implications:

Commissioned by HEEoE to deliver education (£2million contract)

Evidence for S4BH; NHSLA Standards; Information Governance Standards, Social Care PAF:

LDA, QIPFSeen by the following committee(s) on date:

Page 1 of 5Agenda Item 9.0 - Quality Improvement Performance Framework QIPF - NEW.docxOverall Page 55 of 190

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Quality Improvement and Performance Framework

1. Introduction

1.1 The Quality Improvement and Performance Framework (QIPF) is the process by which Health Education East of England (HEEoE) assures the education it commissions. The QIPF was launched in April 2014 and is different to previous assurance visits in that is combines a number of existing processes to review organisations providing a range of learning environments for students and trainees. It is integrated, multi-professional and reflective of the workforce in the current health system.

It is through the framework that HEEoE meets the statutory requirements of national regulators (e.g. General Medical Council, Nursing and Midwifery Council, Health Professions Council) and quality is monitored.

HPFT receives in excess of £2 million per year to provide education and sign a contract (learning and development agreement (LDA)) to deliver against the requirements listed in the LDA, associated schedules, GMC Domains, Trainee Doctor and Non Medical Education Key Performance Indicators. As such HEEoE are key regulatory stakeholders / commissioners for HPFT.

HEE have a quality assurance process that includes ongoing reviews during the year (different schedules for medical and non-medical education) and a formal regulatory visit every three years. HPFT have a formal visit on November 4th 2016.

1.2 Our Multi-professional Learning and Education Strategy recognises our role as a provider of education and outlines 5 overarching objectives to continuously improve our learning climate. These are:

1. Ensure that staff have the right skills and knowledge aligned with the Trusts Values to be safe and competent in their roles

2. Embed the learning organisation philosophy throughout the Trust and so that staff are supported to learn and develop in their chosen career pathways

3. Develop a ‘reputation of quality’, providing education, learning and development programmes that are recognised as examples of best practice and valued by employees and commissioners alike

4. Advance our methods of teaching, increasing use of technology and creating more flexibility for when and where learning takes place

Our focus as an organisation will be to deliver our strategy and meet the requirements of the LDA as a Provider of Education. The quality improvement plans are ongoing and drive continuous improvements (we have clear engagement processes with trainees and students to collate placement feedback that informs our plans).


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The formal visit is an opportunity to demonstrate good practice and provide assurance to our commissioners of education provision (HEEoE).

1.3 The Education Governance Structure is defined for the organisation and ensures that any risks to the provision of education are escalated as appropriate to the Trust Board.

The Strategic Workforce Development Group (consisting of Professional Leads and Head of Learning and Development) oversee the improvement actions plans to deliver a quality infrastructure for education. They highlight risks relating to education, which are entered onto the Workforce, and OD Risk Register. This Group and the Workforce Board report into WODG through to IGC (a sub-committee of the Trust Board)

In addition for medical education we hold a Tutors Committee (local faculty committee) who report through to the medical managers

1.4 This paper outlines the current position in terms of our quality improvement plans and an outline of the preparation for the formal visit.

2. Annual Reviews and Quality Monitoring

The table below outlines the feedback from the process of annual reviews as part of the ongoing

assurance process by HEEoE. A summary of these is outlined below:

Date QA Process Outcome NotesMedical Education QAJune 2015 GP Trainee Formal

VisitPositive Feedback One split placement

changed as a result of feedback

Sept 2016 Quality Monitoring Report submitted

Provides HEE with a self assessment of quality against standards

This outlines the Trust’s response to outliers and previous visit feedback

Aug 2016 GMC National Trainee Survey Report Received

The Trusts outliers have raised a concern with the quality of out of hour supervision for GP trainees

Further investigation is underway and the process of escalation is being re-emphasised atInduction

Non-Medical Education QA

Aug 2016 Annual Quality Visit No Immediate concerns and positive feedback on the recognition of the muti-professional approach to education provision. All of the areas in the previous action plan (2015-16) were either closed or rated as green with the exception of student support as we have ongoing plans for excellence

The Practice Education Team are collating data on our mentors and their qualifications and calculating capacity.

September Self Assessment In progress (to be completed This data will inform our


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2016 against Key Performance Indicators

for a non-medical pre-visit on 21st September)

2016/17 action plan

August 2016 Student Placement Feedback Report Received

There are no outliers in the feedback. The team are reviewing any scores below the regional average and this will inform the 2016/17 action plans

This data will inform our 2016/17 action plan. Qualitative statements will be shared with heads of nursing.

July 2016 Peer Review process undertaken with NELFT

This is a process HEEoE facilitate to support organisations as part of QA process

HPFT provided support to NELFT and guidance on evidence

September 2015

Library Quality Assurance Framework formal monitoring

Achieved 94% against the framework

A library survey has been undertaken to inform the next focus. We will be monitored again in 2017.

Other QA related to LDA

Aug 2016 Talent for Care Gap Analysis (band 1 -4 attraction and development project)

No immediate concerns. RAG rating improved on 2015 scores across the three domains. HPFT have a strong position regionally with the highest appraisal completion rates for band 1-4 staff.

The activity in the talent for care is implicit in our workforce and OD strategy

3. Schedule of QIPF Formal Visit

3.1 HPFT has their formal QIPF visit on 4th November 2016. It will be the Trust’s first

experience of the visit in its current format. The schedule is in three parts:

Pre-visit meeting (September 2016 with senior representatives from HEE)

The day of the visit (which includes: presentations from the trust and key lines of enquiry

with staff involved in the provision of education and representative trainees and students)

Formal feedback report (December 2016 with senior representatives from HEE)

There is an active project plan delivered by the Practice Education Facilitators and monitored by

our SWDG. The project plan is on track and a catalogue of evidence is being collated against the

quality domains and key performance indicators (which once catalogued electronically, can be

maintained for future visits and interim QIPF meetings).


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Involvement

The visit will cover medical and non-medical education standards and the library quality

assurance framework. As a Trust we will submit our evidence electronically in advance of the

visit. The visiting team will the triangulate their data and evidence through interviews with the

executive team and professional leads for education, supervisors, mentors, students and

trainees to hear about their first hand experiences.

4. Ongoing Activity

4.1 The Strategic Workforce and Development Group will monitor the ongoing progress of the

quality improvement action plans resulting from each of the QA processes listed above (and from

student / trainee feedback). They will also review the progress of the multi-professional learning

and education strategy and readiness for the visit. The Interim Associate Director of

Organisational Development and Learning will project manage the process and prepare the Trust

Team.

In delivery of the Learning and Education Strategy and QIPF action plans, we will collectively

continuously improve our learning environment through:

Shared ownership and alignment of the high level objectives in the Multi-professional

Learning and Education Strategy

Active live action plans for development and continuous improvement based on feedback

from external visits, peer review and student and trainee feedback

Develop and maintain an educational risk register

L Holman

Interim Associate Director Organisational Development and Learning

September 2016


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Subject: Annual Medical Appraisal and Revalidation

For Publication: No

Author: Dr Asif ZiaDeputy Medical Director

Approved by: Dr Kaushik MukhopadhayaExecutive Director Quality & Medical Leadership

Presented by: Dr Kaushik MukhopadhayaExecutive Director Quality & Medical Leadership


To update and inform the Board on Medical Appraisal and Revalidation.

Action required:

For discussion and information.

Summary and recommendations to the Committee:

Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality and safety of care provided to patients, and lead to increasing public trust and confidence in the medical system. It went live in Trusts from April 2013, with all employed licensed doctors being given revalidation dates between April 2013 and March 2017.

The Medical Director/Responsible Officer oversees the process for HPFT. As part of medical appraisal and revalidation within HPFT, a robust appraisal system for doctors has been put in place with trained appraisers and a bespoke IT system. This has been procured to support appraisal and revalidation but HPFT now needs to ensure that the IT system is ‘future proof’. Relevant policies have been developed.

This report informs the Board of its statutory responsibilities to ensure that all our doctors keep up to date and that they remain fit to practise, with the aim of improving patient safety by making sure all doctors are part of a managed system of clinical governance, including robust and regular appraisal of their practice.

This report provides assurance that these responsibilities are being met by the monitoring of the frequency and quality of medical appraisals.


Provides assurance around medical revalidation / patient safety.

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Summary of Implications for:

Equality & Diversity (has an Equality Impact Assessment been completed?) and Public & Patient Involvement Implications:

N/A.

Evidence for Essential Standards of Quality and Safety; NHSLA Standards; Information Governance Standards, Social Care PAF:

Medical revalidation is linked to Quality and Safety.

Seen by the following committee(s) on date: Finance & Investment/Integrated Governance/Executive/Remuneration/Board/Audit

Executive Committee on September 6 2016.


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HPFT Annual Board Report August 2016

1. Executive summary

HPFT had 143 doctors with a prescribed connection at March 31 2016. This number excludes doctors in training who have a separate process through Health Education East of England for appraisal and revalidation. HPFT therefore has the responsibility for recommending or deferring the re-licensing of doctors every five years based on completion on comprehensive appraisals covering multi-source feedback, complaints, clinical governance information and other relevant information including professional development.

2. Purpose of the Paper

To update the Board on the progress of medical appraisal and revalidation within HPFT and to ensure that they are aware of any issues that have arisen during the past year.

3. Background

Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical system.

Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations1 and it is expected that provider executive teams will oversee compliance by:

monitoring the frequency and quality of medical appraisals in their organisations;

checking there are effective systems in place for monitoring the conduct and performance of their doctors;

confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and

Ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.

1 The Medical Profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The General Medical Council (Licence to Practise and Revalidation) Regulations Order of Council 2012’


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4. Governance Arrangements

Dr Kaushik Mukhopadhaya was confirmed by the Board of Directors as the Responsible Officer (RO) for HPFT.

Dr Mukhopadhaya, as RO, has attended the relevant training modules and network meetings for the regional ROs.

Dr Asif Zia has been appointed as Deputy Medical Director (DMD) and he, supported by the Revalidation Co-ordinator, has delegated responsibility for the appraisal system for all non-training grade medical staff (including NHS locums but excluding agency locums).

The Revalidation Co-ordinator produces an exception report each month for the DMD and checks the GMC Connect ‘prescribed connection’ list against the staffing lists produced monthly by the Medical Staffing department.

Pre-employment checks are also undertaken by the Medical Staffing department.

a. Policy and Guidance

HPFT’s Appraisal and Revalidation policy is in place and is due for review in October 2016.

5. Medical Appraisal

a. Appraisal and Revalidation Performance Data

142 appraisals have been completed in line with our policy except for those delayed due to sickness (2), maternity leave (2) and investigation (1). Only one locum consultant has not had an appraisal and has not therefore been revalidated. This case is currently with the GMC following a decision by the Assistant Registrar to withdraw their licence to practise.

b. Appraisers

HPFT has increased the number of appraisers from 20 to 27 with training provided by the DMD and the Revalidation Co-ordinator.

Appraiser network meetings are held during the year providing discussion and support for our appraisers.


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An appraiser training workshop was held in October 2015 for both new appraisers and for those wanting a refresher. This workshop was facilitated by Dr Steve Wilkinson and was attended by 14 consultants.

c. Quality Assurance

Currently HPFT uses the Premier IT on-line appraisal portfolio system. Following discussions with other Trusts and with other system providers, the decision has been made to change provider to Allocate. This will enable both medical job planning and appraisal to have the robust systems in place for future years and ensure that all the necessary elements of appraisal and job planning are completed before an appraisal and job plan are signed off.

Before a revalidation recommendation is made, the Revalidation Co-ordinator and the RO check the outputs of the appraisee to ensure that all relevant information is available.

Appendix B – audit of a sample of completed appraisals.

Each appraiser receives feedback from their appraisees and this is shared with the appraiser.

(See Annual Report Template, Appendix B; Quality assurance audit of appraisal inputs and outputs)

d. Access, security and confidentiality

There have been no issues relating to access, security or confidentiality this year.

Instances of patient identifiable information on portfolios have been rectified before the appraisal has been locked. When the Revalidation Co-ordinator sends SUI and complaint data out, the recipient is reminded each time of the need for the information to be redacted to remove any patient identifiable information.

e. Clinical Governance

Complaint and SUI data is sent to the individual doctor for inclusion in their next appraisal. The Performance Team provide data on clustering and risk assessments that is circulated to the doctors for inclusion in their appraisals.


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6. Revalidation Recommendations

Dr Mukhopadhaya scrutinises each appraisal portfolio before a revalidation recommendation is made. The doctor is only recommended if the portfolio is complete and there are no known concerns.

See Annual Report Template Appendix C; Audit of revalidation recommendations

7. Recruitment and engagement background checks

See Annual Report Template Appendix E

8. Monitoring Performance

Performance of all our doctors is monitored on an ongoing basis through the key performance indicators, complaints and SUIs within the three SBUs. There is a mechanism for ensuring that relevant complaints and SUI data is included in the appraisal documentation for discussion. 360 feedback from both colleagues and patients on an individual doctor’s performance is conducted once in a five year revalidation cycle (in line with the GMC requirements) and may be repeated after a shorter interval if it is felt to be necessary.

9. Responding to Concerns and Remediation

HPFT has a ‘Remediation, Rehabilitation & Re-skilling for Medical Staff’ policy. The key focus of this policy is on doctors about whom practise concerns have been raised. In some cases a doctor may have been excluded from work or subject to disciplinary action and/or a performance assessment. Further training is just one option in a range of measures to address concerns about practise.

This policy applies to all HPFT’s doctors.

10. Risk and Issues

Despite the presence of good appraisal systems, it is possible to recommend a doctor for revalidation who subsequently has difficulties with conduct or capability.

There is currently a risk that appraisal and revalidation issues (including the linking of newly appointed medical staff to or the removal of leavers from HPFT’s list on the GMC’s Connect site) may be delayed when the Revalidation Co-ordinator is not at work.


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When locum medical staff are appointed to substantive roles within trusts, information from their locum agency RO doesn’t always get transferred to the trust in a timely manner. Similarly, information relating to NHS locums may not be transferred appropriately.

There is also a risk that the information received from Medical Staffing (monthly staff lists and starter/leaver information) is not accurate and could lead to an incorrect link between the GMC and HPFT.

11. Board Reflections

The Executive Team have approved a change in appraisal system provider from Premier IT (with whom the Trust have worked since 2012) to Allocate in order to future proof the appraisals going forward. Discussions are now in progress with Premier IT regarding the safe and effective transfer of information from one system to the other. It is hoped that the change in provider will be actioned later in 2016.

12. Corrective Actions, Improvement Plan and Next Steps

It is believed that the move to Allocate will provide HPFT with more robust appraisal, revalidation and reporting systems in the future.

13. Recommendations

The Board is asked to note the report, comment and accept (if appropriate).


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Annual Report Template Appendix A

Audit of all missed or incomplete appraisals audit

Doctor factors (total) Number

Maternity leave during the majority of the ‘appraisal due window’ 2

Sickness absence during the majority of the ‘appraisal due window’ 2

Prolonged leave during the majority of the ‘appraisal due window’

Suspension during the majority of the ‘appraisal due window’

New starter within 3 month of appraisal due date 4

New starter more than 3 months from appraisal due date

Postponed due to incomplete portfolio/insufficient supporting information

Appraisal outputs not signed off by doctor within 28 days

Lack of time of doctor

Lack of engagement of doctor 1

Other doctor factors 1

(describe) - investigation

Appraiser factors

Unplanned absence of appraiser

Appraisal outputs not signed off by appraiser within 28 days

Lack of time of appraiser

Other appraiser factors (describe)

(describe)

Organisational factors

Administration or management factors

Failure of electronic information systems

Insufficient numbers of trained appraisers

Other organisational factors (describe)


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Annual Report Template Appendix B

Quality assurance audit of appraisal inputs and outputs

Total number of appraisals completed NumberNumber of appraisal portfolios sampled (to demonstrate adequate sample size)

Number of the sampled appraisal portfolios deemed to be acceptable against standards

Appraisal inputs 15 15Scope of work: Has a full scope of practice been described?

15 15

Continuing Professional Development (CPD): Is CPD compliant with GMC requirements?

15 15

Quality improvement activity: Is quality improvement activity compliant with GMC requirements?

15 15

Patient feedback exercise: Has a patient feedback exercise been completed?

Yes No3 12

Colleague feedback exercise: Has a colleague feedback exercise been completed?

Yes3

No 12

Review of complaints: Have all complaints been included? 15 15Review of significant events/clinical incidents/SUIs: Have all significant events/clinical incidents/SUIs been included?

15 15

Is there sufficient supporting information from all the doctor’s roles and places of work?

14 1

Is the portfolio sufficiently complete for the stage of the revalidation cycle (year 1 to year 4)? Explanatory note: For example

Has a patient and colleague feedback exercise been completed by year 3?

Is the portfolio complete after the appraisal which precedes the revalidation recommendation (year 5)?

Have all types of supporting information been included?

14 1

Appraisal OutputsAppraisal Summary 15 15Appraiser Statements 15 15PDP 15 15


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Annual Report Template Appendix C

Audit of revalidation recommendations

Revalidation recommendations between 1 April 2015 to 31 March 2016

Recommendations completed on time (within the GMC recommendation window)

52

Late recommendations (completed, but after the GMC recommendation window closed)

Missed recommendations (not completed)

TOTAL 52

Primary reason for all late/missed recommendations

For any late or missed recommendations only one primary reason must be identified

No responsible officer in post

New starter/new prescribed connection established within 2 weeks of revalidation due date

New starter/new prescribed connection established more than 2 weeks from revalidation due date

Unaware the doctor had a prescribed connection

Unaware of the doctor’s revalidation due date

Administrative error

Responsible officer error

Inadequate resources or support for the responsible officer role

Other

Describe other

TOTAL [sum of (late) + (missed)]


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Annual Report Template Appendix D

Audit of concerns about a doctor’s practice

Concerns about a doctor’s practice High level

Medium level

Low level Total

Number of doctors with concerns about their practice in the last 12 monthsExplanatory note: Enter the total number of doctors with concerns in the last 12 months. It is recognised that there may be several types of concern but please record the primary concern

2 2

Capability concerns (as the primary category) in the last 12 months

1 1

Conduct concerns (as the primary category) in the last 12 months

1 1

Health concerns (as the primary category) in the last 12 monthsRemediation/Reskilling/Retraining/RehabilitationNumbers of doctors with whom the designated body has a prescribed connection as at 31 March 2016 who have undergone formal remediation between 1 April 2015 and 31 March 2016 Formal remediation is a planned and managed programme of interventions or a single intervention e.g. coaching, retraining which is implemented as a consequence of a concern about a doctor’s practiceA doctor should be included here if they were undergoing remediation at any point during the year

0

Consultants (permanent employed staff including honorary contract holders, NHS and other government /public body staff)Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS and other government /public body staff) General practitioner (for NHS England area teams only; doctors on a medical performers list, Armed Forces) Trainee: doctor on national postgraduate training scheme (for local education and training boards only; doctors on national training programmes) Doctors with practising privileges (this is usually for independent healthcare providers, however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade) Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts, etc) All DBs


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Other (including all responsible officers, and doctors registered with a locum agency, members of faculties/professional bodies, some management/leadership roles, research, civil service, other employed or contracted doctors, doctors in wholly independent practice, etc) All DBs TOTALS Other Actions/InterventionsLocal Actions:Number of doctors who were suspended/excluded from practice between 1 April and 31 March: Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be includedDuration of suspension:Explanatory note: All suspensions which have been commenced or completed between 1 April and 31 March should be included

Less than 1 week1 week to 1 month1 – 3 months3 - 6 months6 - 12 months

Number of doctors who have had local restrictions placed on their practice in the last 12 months?

1

GMC Actions: Number of doctors who:

Were referred to the GMC between 1 April and 31 March 1Underwent or are currently undergoing GMC Fitness to Practice procedures between 1 April and 31 MarchHad conditions placed on their practice by the GMC or undertakings agreed with the GMC between 1 April and 31 MarchHad their registration/licence suspended by the GMC between 1 April and 31 MarchWere erased from the GMC register between 1 April and 31 March

National Clinical Assessment Service actions:Number of doctors about whom NCAS has been contacted between 1 April and 31 March:

For advice 1For investigationFor assessment

Number of NCAS investigations performedNumber of NCAS assessments performed


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Annual Report Template Appendix E

Audit of recruitment and engagement background checks

Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate locum doctors)

Permanent employed doctors 7

Temporary employed doctors 36

Locums brought in to the designated body through a locum agency 92

Locums brought in to the designated body through ‘Staff Bank’ arrangements 2

Doctors on Performers Lists

Other Explanatory note: This includes independent contractors, doctors with practising privileges, etc. For membership organisations this includes new members, for locum agencies this includes doctors who have registered with the agency, etc

Number

TOTAL 137

For how many of these doctors was the following information available within 1 month of the doctor’s starting date (numbers)

Tota

l

Iden

tity

chec

k

Past

GM

C

issu

es

GM

C c

ondi

tions

or

und

erta

king

s

On-

goin

g G

MC

/NC

AS

inve

stig

atio

ns

BDS

2 re

cent

re

fere

nces

Nam

e of

last

re

spon

sibl

e of

ficer

Ref

eren

ce fr

om

last

resp

onsi

ble

offic

erLa

ngua

ge

com

pete

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Loca

l con

ditio

ns

or u

nder

taki

ngs

Qua

lific

atio

n ch

eck

Rev

alid

atio

n du

e da

te

Appr

aisa

l due

da

te

Appr

aisa

l ou

tput

s

Unr

esol

ved

perfo

rman

ce

conc

erns

Permanent employed doctors

7 7 0 0 0 7 7 7 7 7 0 7 7 7 7 1

Temporary employed doctors

36 36 1 0 0 36 36 36 35 36 0 36 36 35 35 1

Locums brought in to the designated body through a locum agency

92 92 N/A N/A N/A 92 92 N/A N/A 92 0 92 N/A N/A N/A 0


14

Locums brought in to the designated body through ‘Staff Bank’ arrangements

2 2 0 0 0 2 2 N/A N/A 2 0 2 N/A N/A N/A 0

Doctors on Performers Lists

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Other (independent contractors, practising privileges, members, registrants, etc)

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total (these cells will sum automatically)

2 2 0 0 0 2 2 0 0 2 0 2 0 0 0 0

For Providers – use of locum doctors: Explanatory note: Number of locum sessions used (days) as a proportion of total medical establishment (days)NB: this section may change as a result of the SCL ProjectThe total WTE headcount is included to show the proportion of the posts in each specialty that are covered by locum doctors

Locum use by specialty:Total establishment in

specialty (current approved WTE

headcount)

Consultant:Overall number of locum days

used

SAS doctors: Overall

number of locum days

used

Trainees (all grades): Overall number of locum

days used

Total Overall number of locum

days used

Surgery

Medicine

Psychiatry 4134 1841 1459 834 4134

Obstetrics/Gynaecology

Accident and Emergency


15

Anaesthetics

Radiology

Pathology

Other

Total in designated body (This includes all doctors not just those with a prescribed connection)

Number of individual locum attachments by duration of attachment (each contract is a

separate ‘attachment’ even if the same doctor fills more than one contract)

Total

Pre-employment

checks completed (number)

Induction or orientation completed (number)

Exit reports completed (number)

Concerns reported to agency or

responsible officer (number)

2 days or less 17 17 17 N/A 1

3 days to one week 14 14 14 N/A 1

1 week to 1 month 10 10 10 N/A 0

1-3 months 25 25 25 N/A 2

3-6 months 14 14 14 N/A 0

6-12 months 12 12 12 N/A 0

More than 12 months 0 0 0 N/A 0

Total 92 92 92 N/A 4


1



Subject: Hertfordshire and West Essex Sustainability & Transformation Plan

For Publication: Yes

Author: Iain EavesExecutive Director – Strategy and Improvement

Approved by:Iain EavesExecutive Director – Strategy and Improvement

Presented by: Iain Eaves / Tom Cahill - CEO


To update the Board on the development of the Hertfordshire and West Essex STP and the emerging key areas of focus

Action required:

The Board is asked to note the update.


Hertfordshire and West Essex are working together to produce a Sustainability and Transformation Plan to tackle the fundamental issues facing the local health and care system, resulting in an affordable, high quality service that is effective in meeting the needs of the local population into the future.

A draft plan on how we will achieve this together is being developed for submission to the national

Page 1 of 2Agenda Item 11.0 - Hertfordshire and West Essex Sustainability and Transformation Plan Update.docxOverall Page 77 of 190

2

arms length bodies by October 21st 2016. This will be shared with the Board as soon as it is available.

The attached update sets out the key areas of focus for the STP for each of the four major initiatives that have been agreed to transform the way health and care services are delivered to the population of Hertfordshire and West Essex. These are:

Prevention and self-care

Community and primary care

Acute services

Bridging the financial challenge

HPFT is playing an active and leading role in helping to shape these plans together with our partners.

Relationship with the Business Plan & Assurance Framework (Risks, Controls & Assurance):The final STP will set out the context within which we will develop our future business and operational plans.




Page 2 of 2Agenda Item 11.0 - Hertfordshire and West Essex Sustainability and Transformation Plan Update.docxOverall Page 78 of 190

Hertfordshire and West Essex Towards a healthier future

Page 1 of 10Agenda Item 11.0a STP Slide Deck.pptxOverall Page 79 of 190

Getting to know the neighbours …


The challenge …Our population is changing:• Birth rates are increasing, and people are living for longer• Public demand for specialist treatments is increasing and

expectations of services are high• Patients with complex conditions are supported to live

on into old age

We currently spend £4.5m per day on health care alone. By 2021 we would have to spend £5.8m per day to keep up with demand, if we continue to provide services in the same way

If we don’t make changes:There will not be enough skilled health and social care staffOur acute hospitals will not be able to meet demandDeaths from preventable illness will increase


We’ve been listening …

“Unnecessary journeys to hospital can be reduced by providing care closer to home”

“Quality and efficiency comes from caring for people as people”

“Local services need to change”

“Professionals and care should be joined up”

“More focus on preventing ill-health and addressing unhealthy lifestyles”

“Build on existing community services so more people benefit from the care and support of voluntary organisations”

“People should take more responsibility for their own health” Page 4 of 10Agenda Item 11.0a STP Slide Deck.pptx


“By 2021, with the support of integrated primary, community and social care services, residents will live as healthily and independently as possible.

“Funding will be used to deliver the right care at the right time and in the right place – with a focus on the promotion of good health and wellbeing.

“Sustainable acute hospital services will deliver specialist healthcare which cannot be accessed closer to home. Patients will be supported to recover and rehabilitate in familiar surroundings wherever possible. ”

Our vision:


What would this mean for you?Our plan puts the patient at the heart of a high quality, sustainable health and social

care system, which emphasises the importance of personal responsibility, preventative care and partnership working.

“I have the expert advice

and tools I need to manage my

long term condition”

“I know that the care I receive

follows best practice

advice and guidance”

“I will be cared for at home, or close to home,

whenever possible”

“I am empowered and motivated to

look after my health and the health of my

family”

“When I need expert help, I can go to a

specialist centre with skilled staff”

“I know where to go for health and care advice

and support”

“Simple treatments, procedures and

consultations are available in my local

area”


How will we get there?Prevention and self-care

Working with people & communities to keep as healthy and as well as possible

More patients are supported to live well with their conditions:• personal health budgets• use of voluntary sector• supporting carers

Starting Well

Developing Well

Living and Working

Well

Ageing Well

Improving the health of NHS staff nationally could reduce sickness rates by a third, the equivalent of adding almost 15,000 staff to the national workforce, saving 3.3 million working days a year.


How will we get there?Community and primary care• Continue to bringing care closer to home – physical and

mental health and social care support provided in the community, by multi-speciality teams.

• Work with our localities and GP Practices to support primary care services

• Making better use of community pharmacists• Continue to work with the voluntary sector to deliver joined

up community based services


How will we get there?Acute servicesWe have already made significant changes in our area but we can do more:

• Standardised pathways of care • Going to hospital for specialist

opinions only when required • Looking after people in the

community will reduce the demand for hospital care

• Closer working between hospitals • Improve our cancer care


How will we get there?Bridging the financial challenge…

• Right staff, right skills, right places• Improving prevention and supporting self

care• Standardised pathways of care • Co-ordinating care and supporting people

to avoid crisis• Going to hospital for specialist services

only• Reducing demand on hospitals with

effective local services• Efficiencies in how we do things,

including administrationPage 10 of 10Agenda Item 11.0a STP Slide Deck.pptx


1



Subject: NHS Operational Planning and Contracting Guidance 2017 - 2019

For Publication: Yes

Author: NHS Arm’s Length Bodies Approved by:Iain EavesExecutive Director – Strategy and Improvement

Presented by: Iain EavesExecutive Director – Strategy and Improvement


To update the Board on the 2017-19 NHS Operational Planning and Contracting guidance

Action required:

The Board is asked to note the guidance and associated NHS Providers briefing, and discuss the implications for HPFT.


On September 22nd the national bodies NHS England (NHSE) and NHS Improvement (NHSI) published their “planning guidance” 2017-2019 NHS Operational planning and contracting.

A briefing paper from NHS Providers that summarises the proposals and the full guidance is attached. We will continue to digest the full implications for HPFT over the coming days for discussion with the Board when it meets on the September 29th.

The planning guidance outlines the expectations of the national bodies for system level planning over the next two years, focussing on contracting and sustainability and transformation plans (STPs) as well as introducing a range of new national business rules.

The key proposals from the planning guidance focus on several areas – changes to contracting processes, STP financing measures and performance metrics, and some further details on sustainability and transformation funding.

The ‘must does’ are the same as outlined in 2016/17 planning guidance, and they remain for the priorities for 2017/18 and 2018/19. They include:

Deliver in full the implementation plan for the mental health five year forward view for all ages. Ensure delivery of the mental health access and quality standards including 24. Increase baseline spend on mental health and eliminate out of area placements for non-specialist acute care by 2020/21.

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2

Deliver Transforming Care Partnership plans with local government partners, reduce inpatient bed capacity. Reduce premature mortality by improving access to health services, education and training of staff, and by making necessary reasonable adjustments for people with a learning disability or autism

Following the introduction of STPs in last year’s planning guidance, this year’s planning guidance potentially cements STPs as a new unit of financial and performance monitoring and management, in addition to their initial primary purpose as a planning vehicle.

The position of each provider’s plan (on finance, activity and workforce) has to be consistent with the STP footprint financial plan for 2017/18 and 2018/19 that will be submitted on 21 October 2016 and with the system control for that STP area

The document notes STP leaders “will have strong governance processes to ensure clarity as to how different organisations are contributing to agreed system working, how progress will be tracked, and how organisations will work together to manage cross-cutting transformational activity.”

From 2017/18 onwards, the guidance states streams of transformation funding will increasingly be targeted towards “the STPs making most progress”. This funding will be focused on delivery of specific national programme objectives “rather than spread thinly everywhere”

The 2017-19 planning and contracting round “will be built out from STPs”. Two-year contracts will reflect two-year activity, workforce and performance assumptions that are agreed and affordable within each local STP. They must include “how they support delivery of the local STP, including clear and credible milestones and deliverables.”

The document reaffirms that the contracting round will be completed by the end of this calendar year, and the contracts signed within this contracting round will last two financial years, starting from April 2017.

Relationship with the Business Plan & Assurance Framework (Risks, Controls & Assurance):Provides the guidance and rules for developing the Trust’s Business Plan for 2017-19




Page 2 of 2Agenda Item 12.0 - NHS Operational Planning and Contracting Guidance.docxOverall Page 90 of 190

2017-2019

NHS Operational Planning and Contracting Guidance

Published by

NHS England and NHS Improvement

Page 1 of 69Agenda Item 12.0 a - NHS Oerational Planning Guidance - 2017 to 2019.pdfOverall Page 91 of 190

Published: Thursday 22 September 2016

Prepared by: NHS England and NHS Improvement

This document is for: commissioners, NHS trusts and NHS foundation trusts

Publication Gateway Reference: 05829


NHS OPERATIONAL PLANNING AND CONTRACTING GUIDANCE FOR 2017-19 3

Contents

Introduction and context: implementing Sustainability and Transformation Plans .........................4

Priorities and performance assessment .......................................................................................6

Developing operational plans and agreeing contracts for 2017-19 ............................................12

Finance and business rules ........................................................................................................17

Specialised Services and other direct commissioning ..................................................................27

Commissioning in the evolving system ......................................................................................29

Annexes

1. The Government’s Mandate to NHS England, 2020 goals .....................................................30

2. The CCG Improvement and Assessment Framework ............................................................34

3. NHS Improvement Single Oversight Framework ...................................................................35

4. October Guidance on Sustainability and Transformation Plans (STPs) .....................................36

5. NHS England and NHS Improvement approach to establishing shared fnancial control totals 39

6. General Practice Forward View planning requirements ..........................................................48

7. Cancer services transformation planning requirements .........................................................58

8. Mental health transformation planning requirements ..........................................................60



Introduction and context: implementing Sustainability and Transformation Plans

1. This document explains how the NHS operational planning and contracting processes will now change to support Sustainability and Transformation Plans (STPs) and the ‘fnancial reset’. It reaffrms national priorities and sets out the fnancial and business rules for both 2017/18 and 2018/19.

2. Our shared tasks are clear: implement the Five Year Forward View to drive improvements in health and care; restore and maintain fnancial balance; and deliver core access and quality standards.

3. In local STPs, these jobs come together as one. Each STP becomes the route map for how the local NHS and its partners make a reality of the Five Year Forward View, within the Spending Review envelope. It provides the basis for operational planning and contracting.

4. STPs are more than just plans. They represent a different way of working, with partnership behaviours becoming the new norm. What makes most sense for patients, communities and the taxpayer should always trump the narrower interests of individual organisations. That is why, although STPs are relatively new, we see them as having a signifcant ongoing role in the NHS.

5. Good organisations cannot implement the Five Year Forward View and deliver the required productivity savings and care redesign in silos. Only through a system-wide set of changes will the NHS be sure of being able to deliver the right care, in the right place, with optimal value. This means improving and investing in preventative, primary and community based care. It means creating new relationships with patients and communities, seeing the totality of health and care in identifying solutions, using social care and wider services to support improved productivity and quality as well as people’s wellbeing. We need new care models that break down the boundaries between different types of provider, and foster stronger collaboration across services – drawing on, and strengthening, joint work with partners, including local government. The solutions will not come solely from within the NHS, but from patients and communities, and wider partnerships including local government, and the third sector; and effective public engagement will be essential to their success.



6. Right across the country, NHS organisations want to spend less of their time locked in adversarial and transactional relationships. Allocating fnite and stretched NHS resources between competing demands will never be easy, and the task gets harder over the next three years. But we do now have the opportunity to settle the numbers earlier and for a longer duration. This will enable us all to devote more of our energies towards getting on with the job of redesigning and delivering better, more effcient care.

7. To support the STP process and embed the ‘fnancial reset’, the annual NHS planning and contracting round will now be streamlined signifcantly. Our aims are to provide greater certainty and stability; simplify processes and ensure they are more joined up; cut transaction costs; and support partnership and transformation.

8. The default will be for two-year contracts in place of those currently negotiated annually. Commissioners will still have the ability to let new longer-term contracts, based on new care models and whole population budgets, revising existing contracts accordingly.

9. The 2017-19 operational planning and contracting round will be built out from STPs. Two-year contracts will refect two-year activity, workforce and performance assumptions that are agreed and affordable within each local STP. We are issuing a two-year tariff for consultation and two-year CQUIN and CCG quality premium schemes. NHS England is engaging with the sector on the indicators and measurements for these CQUINs. For the frst time, a single NHS England and NHS Improvement oversight process will provide a unifed interface with local organisations to ensure effective alignment of CCG and provider plans. And, as requested by NHS leaders, the timetable is now being brought forward to provide certainty earlier – with a target deadline of all 2017-19 contracts signed by 23 December 2016.

10. To ensure that organisational boundaries and perverse fnancial incentives do not get in the way of transformation, from April 2017 each STP (or agreed population/geographical area) will have a fnancial control total that is also the summation of the individual organisational control totals. All organisations will be held accountable for delivering both their individual control total and the overall system control. It will be possible to fex individual organisational control totals within that system control total, by application and with the agreement of NHS England and NHS Improvement. Further details are contained in paragraphs 25-29 of this document.



Priorities and performance assessment

Nine ‘must dos’ for 2017-19

11. In 2016/17 we described nine ‘must do’ priorities. These remain the priorities for 2017/18 and 2018/19. These national priorities and other local priorities will need to be delivered within the fnancial resources available in each year.

2017/18 and 2018/19 ‘must dos’

1. STPs

• Implement agreed STP milestones, so that you are on track for full achievement by 2020/21.

• Achieve agreed trajectories against the STP core metrics set for 2017-19.

2. Finance

• Deliver individual CCG and NHS provider organisational control totals, and achieve local system fnancial control totals. At national level, the provider sector needs to be in fnancial balance in each of 2017/18 and 2018/19. At national level the CCG sector needs to be in fnancial balance in each of 2017/18 and 2018/19.

• Implement local STP plans and achieve local targets to moderate demand growth and increase provider effciencies.

• Demand reduction measures include: implementing RightCare; elective care redesign; urgent and emergency care reform; supporting self care and prevention; progressing population-health new care models such as multispecialty community providers (MCPs) and primary and acute care systems (PACS); medicines optimisation; and improving the management of continuing healthcare processes.

• Provider effciency measures include: implementing pathology service and back offce rationalisation; implementing procurement, hospital pharmacy and estates transformation plans; improving rostering systems and job planning to reduce use of agency staff and increase clinical productivity; implementing the Getting It Right First Time programme; and implementing new models of acute service collaboration and more integrated primary and community services.



3. Primary care

• Ensure the sustainability of general practice in your area by implementing the General Practice Forward View, including the plans for Practice Transformational Support, and the ten high impact changes.

• Ensure local investment meets or exceeds minimum required levels.

• Tackle workforce and workload issues, including interim milestones that contribute towards increasing the number of doctors working in general practice by 5,000 in 2020, co-funding an extra 1,500 pharmacists to work in general practice by 2020, the expansion of Improving Access to Psychological Therapies (IAPT) in general practice with 3,000 more therapists in primary care, and investment in training practice staff and stimulating the use of online consultation systems.

• By no later than March 2019, extend and improve access in line with requirements for new national funding.

• Support general practice at scale, the expansion of Multispecialty Community Providers or Primary and Acute Care Systems, and enable and fund primary care to play its part in fully implementing the forthcoming framework for improving health in care homes.

4. Urgent and emergency care

• Deliver the four hour A&E standard, and standards for ambulance response times including through implementing the fve elements of the A&E Improvement Plan.

• By November 2017, meet the four priority standards for seven-day hospital services for all urgent network specialist services.

• Implement the Urgent and Emergency Care Review, ensuring a 24/7 integrated care service for physical and mental health is implemented by March 2020 in each STP footprint, including a clinical hub that supports NHS 111, 999 and out-of-hours calls.

• Deliver a reduction in the proportion of ambulance 999 calls that result in avoidable transportation to an A&E department.

• Initiate cross-system approach to prepare for forthcoming waiting time standard for urgent care for those in a mental health crisis.



5. Referral to treatment times and elective care

• Deliver the NHS Constitution standard that more than 92% of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment (RTT).

• Deliver patient choice of frst outpatient appointment, and achieve 100% of use of e-referrals by no later than April 2018 in line with the 2017/18 CQUIN and payment changes from October 2018.

• Streamline elective care pathways, including through outpatient redesign and avoiding unnecessary follow-ups.

• Implement the national maternity services review, Better Births, through local maternity systems.

6. Cancer

• Working through Cancer Alliances and the National Cancer Vanguard, implement the cancer taskforce report.

• Deliver the NHS Constitution 62 day cancer standard, including by securing adequate diagnostic capacity and the other NHS Constitution cancer standards.

• Make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission.

• Ensure stratifed follow up pathways for breast cancer patients are rolled out and prepare to roll out for other cancer types.

• Ensure all elements of the Recovery Package are commissioned, including ensuring that:

o all patients have a holistic needs assessment and care plan at the point of diagnosis;

o a treatment summary is sent to the patient’s GP at the end of treatment; and

o a cancer care review is completed by the GP within six months of a cancer diagnosis.



7. Mental health

• Deliver in full the implementation plan for the Mental Health Five Year Forward View for all ages, including:

o Additional psychological therapies so that at least 19% of people with anxiety and depression access treatment, with the majority of the increase from the baseline of 15% to be integrated with physical healthcare;

o More high-quality mental health services for children and young people, so that at least 32% of children with a diagnosable condition are able to access evidence-based services by April 2019, including all areas being part of Children and Young People Improving Access to Psychological Therapies (CYP IAPT) by 2018;

o Expand capacity so that more than 53% of people experiencing a frst episode of psychosis begin treatment with a NICE-recommended package of care within two weeks of referral.

o Increase access to individual placement support for people with severe mental illness in secondary care services by 25% by April 2019 against 2017/18 baseline;

o Commission community eating disorder teams so that 95% of children and young people receive treatment within four weeks of referral for routine cases; and one week for urgent cases; and

o Reduce suicide rates by 10% against the 2016/17 baseline.

• Ensure delivery of the mental health access and quality standards including 24/7 access to community crisis resolution teams and home treatment teams and mental health liaison services in acute hospitals.

• Increase baseline spend on mental health to deliver the Mental Health Investment Standard.

• Maintain a dementia diagnosis rate of at least two thirds of estimated local prevalence, and have due regard to the forthcoming NHS implementation guidance on dementia focusing on post-diagnostic care and support.

• Eliminate out of area placements for non-specialist acute care by 2020/21.



8. People with learning disabilities

• Deliver Transforming Care Partnership plans with local government partners, enhancing community provision for people with learning disabilities and/or autism.

• Reduce inpatient bed capacity by March 2019 to 10-15 in CCG-commissioned beds per million population, and 20-25 in NHS England-commissioned beds per million population.

• Improve access to healthcare for people with learning disability so that by 2020, 75% of people on a GP register are receiving an annual health check.

• Reduce premature mortality by improving access to health services, education and training of staff, and by making necessary reasonable adjustments for people with a learning disability or autism.

9. Improving quality in organisations

• All organisations should implement plans to improve quality of care, particularly for organisations in special measures.

• Drawing on the National Quality Board’s resources, measure and improve effcient use of staffng resources to ensure safe, sustainable and productive services.

• Participate in the annual publication of fndings from reviews of deaths, to include the annual publication of avoidable death rates, and actions they have taken to reduce deaths related to problems in healthcare.

Measuring and assessing performance

12. These priorities do not encompass the full breadth of NHS organisations’ responsibilities. A summary of the current Government Mandate to NHS England is attached at Annex 1 and sets out the areas in which the Government expects the NHS to improve by 2020. Should these mandated objectives change for 2017/18 or 2018/19, we will issue supplementary advice as necessary. There is clear read-across from the Mandate to both the new CCG Improvement and Assessment Framework (CCG IAF) indicators and the new NHS Improvement oversight framework for NHS providers. Annexes E and F of the technical guidance list metrics for which commissioners and providers are required to submit planning trajectories. NHS England is publishing its intentions for specialised services commissioning alongside this document – these are outlined in paragraphs 63-67.

13. NHS England, NHS Improvement, Health Education England, the Care Quality Commission, Public Health England, NHS Digital and NICE are committed to working in a joined up way, together with local government, to support STP areas. NHS Improvement will use its new single oversight framework to look at providers’ contribution to their STP and any associated support needs, and NHS England will do likewise through the CCG IAF. Wherever appropriate, however, we will ensure that our main point of contact to discuss progress with implementation of STPs and any support needed from national bodies is with the shared STP leadership for each area.



14. Drawing on existing data collections from the assurance frameworks, we will publish core baseline STP metrics in November 2016, encompassing as a minimum these metrics:

Finance• Performance against organisation-specifc and system control totals

Quality Operational Performance• A&E performance• RTT performance

Health outcomes and care redesign• Progress against cancer taskforce implementation plan• Progress against Mental Health Five Year Forward View implementation plan• Progress against the General Practice Forward View• Hospital total bed days per 1,000 population• Emergency hospital admissions per 1,000 population

15. STP areas will need to agree trajectories against these areas for 2017-19. The letter sent to STP leaders setting out the expectations for the content of STPs for the October 2016 submission is in Annex 4. These include:

• addressing feedback from the July 2016 conversations, including a crisp articulation of the tangible benefts to patients and communities;

• providing more depth and specifcity on implementation;• ensuring plans are underpinned by the Finance Templates;• setting out the measurable impacts of the STP;• describing how they envisage better integration between health and social care;• describing the degree of local consensus amongst organisations and plans for further

engagement; and• continuing development of the STP’s estates strategy.



Developing operational plans and agreeing contracts for 2017-19

16. The detailed requirements for commissioner and provider plans are set out in accompanying technical guidance. Plans will need to demonstrate:

• how they will be delivering the nine ‘must-dos’;

• how they support delivery of the local STP, including clear and credible milestones and deliverables;

• how they intend to reconcile fnance with activity and workforce to deliver their agreed contribution to the relevant system control total;

• robust, stretching and deliverable activity plans which are directly derived from their STP, refective of the impact that the STP’s well-implemented transformation and effciency schemes will have on trend growth rates, agreed by commissioners and providers and consistent with achieving the relevant performance trajectories within available local budgets;

• how local independent sector capacity should be factored into demand and capacity planning from the outset, and local independent sector providers engaged throughout;

• the planned contribution to savings;

• how risks have been jointly identifed and mitigated through an agreed contingency plan; and

• the impact of new care models, including where appropriate how contracts with secondary care providers will be adjusted to take account of the introduction of new commissioning arrangements for MCPs or PACS during 2017-19.

17. CCG and provider plans will need to be agreed by NHS England and NHS Improvement, with a clear expectation that they must be fully aligned in local contracts. This is more than a technical process. It requires a genuine commitment for local leaders to run a shared, open-book process to deliver performance and improvement within the growing, but fxed, funding envelope available to that local area. We have seen this approach in the development of STPs and expect to see it carried forward into operational plans. Further details on support, review and assurance are set out in the Technical Guidance document.



Dispute avoidance and resolution 18. We expect all contracts to be signed by 23 December 2016. The earlier timetable for operational

planning should give commissioners (CCGs and direct commissioners) and providers greater scope for constructive engagement over contracts. Access to formal arbitration must be a last resort. Our expectation is that commissioners and providers sort out any differences without the need for arbitration, and failure to do so will be seen as a clear failure of collaboration and good governance.

19. To enable a more collaborative approach to contracting, we are making a number of changes to the dispute resolution process as follows:

• increased access to technical advice on contract and tariff issues to reduce the number of technical disputes;

• escalation to NHS England and NHS Improvement chief executives (or delegated national directors) for commissioners and providers that do not agree their contracts to the national timetable.

20. It is our expectation that any parties, including foundation trusts, that are unable to agree contracts in line with the national timetable will submit their disputes for timely resolution through the NHS arbitration process. NHS England will also ensure that any disputes regarding its specialised commissioning activities which have not been resolved according to the national timeline will be referred to the NHS arbitration arrangements. NHS Improvement and NHS England will intervene where necessary, using their oversight and regulatory powers to resolve any cases where organisations refuse to do so. In addition, where a provider refuses to follow the NHS arbitration process, they may forfeit a proportion of their Sustainability and Transformation Fund (STF) monies, and where a CCG fails to comply with the process, quality premium and transformation monies may be forfeited.



NHS Standard Contract

21. We are proposing minimal changes to the NHS Standard Contract for the next two years. To support two-year local plans and contracts, the NHS Standard Contract will be set for two years. NHS England is publishing the revised NHS Standard Contract for consultation, alongside this document.

22. To enable more seamless care for patients, and as set out in the General Practice Forward View, we have strengthened the requirement for transmitting letters to GPs following clinic attendance. The current timescale for production (within 14 days of attendance) will reduce progressively to ten days (from 1 April 2017) and seven days (from 1 April 2018). A new requirement for electronic transmission of clinic letters, as structured messages using standardised clinical headings, will take effect from 1 October 2018. NHS England is also proposing:

• from April 2017, stronger requirements on commissioners to facilitate hospital discharge and on providers to comply with recent NICE guidance;

• from April 2017 mandated use of the e-Referral system (ERS); and from October 2018, non-payment for activity resulting from non-ERS referrals and the right for providers to return such referrals to GPs. We will work with the GP community to resolve practical issues which currently hinder use and uptake of the e-referral system in general practice;

• from April 2017, mandatory data-sharing agreements for urgent and emergency care providers, enabling commissioners to access cross-provider data about utilisation and effectiveness of services;

• from November 2017, the four priority standards for seven-day hospital services for all urgent network specialist services; and

• compliance with new data security standards (April 2017), new conficts of interest guidance (June 2017) and new interoperability requirements for clinical IT systems (January 2019).

23. In addition, NHS Digital intends to amend its guidance to support daily submission of electronic Secondary User Service (SUS) data from April 2018. There will be further engagement with providers before introducing these changes. NHS Digital will also shorten the turnaround of data to improve its utility for providers, commissioners and national bodies, which will in turn reduce burden on the system in providing aggregate data and the same data to multiple organisations. This will also improve the quality of data at source and on source systems.

24. Where providers accept their fnancial control totals and any associated conditions and are therefore eligible for payments from the Sustainability and Transformation Fund, contract sanctions for key performance standards are currently suspended. We propose to extend this suspension until April 2019.



Timetable

Timetable Item (applicable to all bodies unless specifcally referenced)

Date

Planning Guidance published 22 September 2016

Technical Guidance issued 22 September 2016

Commissioner Finance templates issued (commissioners only) 22 September 2016

Draft NHS Standard Contract and national CQUIN scheme guidance published

22 September 2016

National Tariff draft prices issued 22 September 2016

Provider control totals and STF allocations published 30 September 2016

Commissioner allocations published 21 October 2016

NHS Standard Contract consultation closes 21 October 2016

Submission of STPs 21 October 2016

National Tariff section 118 consultation issued 31 October 2016

Final CCG and specialised services CQUIN scheme guidance issued 31 October 2016

Provider fnance, workforce and activity templates issued with related Technical Guidance (providers only)

1 November 2016

Submission of summary level 2017/18 to 2018/19 operational fnancial plans

1 November 2016 (noon)

Commissioners (CCGs and direct commissioners) to issue initial contract offers that form a reasonable basis for negotiations to providers

4 November 2016

Providers to respond to initial offers from commissioners (CCGs and direct commissioners)

4 November 2016

Final NHS Standard Contract published 4 November 2016

Submission of full draft 2017/18 to 2018/19 operational plans 24 November 2016 (noon)

Weekly contract tracker to be submitted by CCGs, direct commissioners and providers

Weekly from: 21/22 November 2016 to 30/31 January 2017

National Tariff section 118 consultation closes 28 November 2016



Timetable Item (applicable to all bodies unless specifcally referenced)

Date

Where CCG or direct commissioning contracts are not signed and contract signature deadline of 23 December 2016 is at risk, local decisions to enter mediation

5 December 2016

Contract mediation 5-23 December 2016

National Tariff section 118 consultation results announced w/c 12 December 2016

Publish National Tariff 20 December 2016

National deadline for signing of contracts 23 December 2016

Final contract signature date for CCG and direct commissioners for avoiding arbitration

23 December 2016

Submission of fnal 2017/18 to 2018/19 operational plans, aligned with contracts

23 December 2016

Final plans approved by Boards or governing bodies of providers and commissioners

By 23 December 2016

Submission of joint arbitration paperwork by CCGs, direct commissioners and providers where contracts not signed

By 9 January 2017

Arbitration outcomes notifed to CCGs, direct commissioners and providers

Within two working days after panel date

Contract and schedule revisions refecting arbitration fndings completed and signed by both parties

By 31 January 2017



Finance and business rules

STP system control totals

25. STP areas are required to submit local fnancial plans showing how their systems will achieve fnancial balance within the available resources. We expect both the commissioner sector and the provider sector to be in fnancial balance in both 2017/18 and 2018/19. Operational plans for 2017/18 and 2018/19 are the detailed plans for the frst two years of the STP.

26. We expect that:

• the transformation and effciency plans, including activity growth moderation plans, set out in STPs will be refected in individual organisational plans;

• there will be aggregate fnancial activity and workforce plans at STP level, underpinned by fnancial control totals, and organisational level operational plans will need to refect those aggregate plans;

• accountability for delivery will sit with individual organisations but they will need to demonstrate how their organisational plans align with STP objectives and planning assumptions; and

• STP leaders will have strong governance processes to ensure clarity as to how different organisations are contributing to agreed system working, how progress will be tracked, and how organisations will work together to manage cross-cutting transformational activity.

27. To support system-wide planning and transformation, we will be setting fnancial system control totals for all STP or equivalent agreed areas for planning purposes, ongoing monitoring and management. In the frst instance, they will be derived from individual control totals for CCGs and provider organisations in that geography. On a by-application basis, there will be fexibility, by agreement with NHS England and NHS Improvement, for STP partners to adjust organisational control totals (both for providers and for CCGs) within an STP footprint, provided the overall system control total is not breached. This process will be managed so that two rules are met: the provider sector achieves aggregate fnancial balance in 2017/18 and 2018/19, and the commissioning system continues to live within its statutory resource limits. Individual organisations will continue to be accountable for managing within their organisational-level control totals.



28. This approach has a number of potential benefts, including the ability to shift money within systems to support agreed transformation plans or planned changes to patient fows; to manage fnancial risk across a health economy; and to pool administrative and other functions across organisations. Annex 5 provides further information.

29. Larger STP areas may wish to propose to NHS England and NHS Improvement a subdivision of their geography for these purposes, with separate system control totals (and governance arrangements) for each subdivision, where this is better suited to operational collaboration and risk management.

Approach to effciency

30. In July 2016, the ‘reset’ publication ‘Strengthening Financial Performance and Accountability in 2016/17 in the NHS’ underscored the responsibilities of individual NHS bodies to live within the funding available. Specifcally, it confrmed actions to support NHS providers in cutting the annual NHS provider defcit in 2016/17 to no more than £580m with a goal of £250m for 2016/17 and a balanced starting position for 2017/18 based on the full year effect of the measures taken. It also set out measures to sharpen the direct accountability of providers and commissioners to live within the public resources made available by Parliament.

31. As noted above, the provider sector will be expected to achieve aggregate fnancial balance in each of the two years of the operational plan after taking into account deployment of the £1.8bn STF. Any deterioration in the opening position for 2017/18 set out in the previous paragraph or in delivery during the plan period will require the relevant individual providers to deliver effciency levels greater than the 2% national requirement to meet the control totals set by NHS Improvement, recognising that by defnition they will have unrealised and undelivered effciency opportunity from previous years.

32. Although there are increased resources available for the NHS in 2017/18 and 2018/19, the level of growth is signifcantly less than has previously been available to the NHS.

33. Therefore, the expectation is that providers and commissioners have a relentless focus on effciency in 2017/18 and 2018/19; and that the opportunities set out in the national effciency programmes and embedded in STPs are further developed in operational plans and delivered by providers and commissioners working together. The national transformation and effciency programmes – RightCare, Continuing Healthcare, New Models of Care, Urgent and Emergency Care, Self Care and Prevention, Getting It Right First Time (GIRFT), and the Carter productivity programme led by NHS Improvement – will support this process, and learning from early adopters is now available.



34. Improvements in operational productivity need to be accelerated within providers and across STPs to reduce unwarranted variation in quality and costs. Particular focus should be given to:

• consolidation of pathology services and back offce functions across STP footprints (and possibly wider);

• compliance with the procurement of items on the mandated list and continuing to submit purchase order information for the Purchasing Price Benchmarking Index and taking action to move to best value items;

• implementing Procurement, Hospital Pharmacy and Estates and Facilities Transformation Plans;

• improved rostering systems and job planning to reduce the use of agency and increase clinical productivity, with reference to benchmarks and guidance around Care Hour Per Patient Day and Cost Per Care Hour metrics;

• participating in the specialised commissioning savings programme for high cost drugs and devices; and

• fully participating in the clinically led Getting it Right First programme by submitting any necessary data and enacting jointly agreed changes to clinical practice to reduce unwarranted variation.

35. Work to roll out Lord Carter’s work in to the mental health and community provider sectors begins in autumn 2016, and providers and commissioners of these services are encouraged to participate.

National Tariff

36. The Tariff Engagement Document published in August 2016 proposed two major changes: • frst, to set a national tariff for two years; and • second, to move from using HRG4 currency design to using phase 3 of HRG4+

complemented by an updated system of top-up payments in order to better refect different levels of complexity and current clinical practice.

37. Subject to consultation, cost uplifts in the national tariff will be set at 2.1% for 2017/18 and

2.1% for 2018/19. The cost uplifts include revised projections for pay drift, the costs of the apprenticeship levy and pass through drugs and exclude HRG-specifc uplifts included in tariff prices for Clinical Negligence Scheme for Trusts (CNST). As previously announced, the effciency defator will be set at 2% in both years.



38. We proposed in the Tariff Engagement Document that we move all follow up outpatient activity to a single block payment. The rationale was to reduce inappropriate outpatient follow-ups. This proposal was not widely supported by either commissioners or providers. We therefore intend as an alternative to increase the percentage of follow-up costs bundled into frst attendances as follows:

• 30% - adult surgical specialties and some medical specialties eg diabetes, cardiology and general paediatric medicine;

• 20% - other medical specialties; and

• 10% (ie no change) – oncology, haematology, paediatric specialties and areas where Best Practice Tariffs apply eg transient ischaemic attack.

39. We encourage local systems to consider more far reaching local payment reform to complement the redesign of frst outpatient appointments and introduction of advice and guidance services under the proposed new CCG CQUIN, as well as to reduce inappropriate outpatient follow-ups, through local variations. Where local schemes are not in place, the default will be the approach set out above.

40. As announced in June, we will also publish the frst new Innovation and Technology tariffs, drawing on the NHS Innovation Accelerator (NIA) programme, to incentivise take-up of the latest innovations across the NHS.

Education and Training Tariffs

41. To provide stability to providers, Health Education England (HEE) will not be introducing changes to the education and training tariff currency design before 1 April 2019. There are three possible exceptions to this:

• The non-medical placement tariff. The Department of Health (DH) consultation on education funding reforms could lead to structural changes from September 2018. HEE will continue to fund the non-medical placement tariff on the same basis as 2016/17, provided there are no material changes to placement numbers;

• Dental undergraduate tariff, where the Department of Health is proposing changes to the structure of the tariff from April 2018; and

• The potential expansion of the standardised education and training tariff for primary care placements.

42. The Spending Review settlement means that there will be no increase to the education and

training tariffs in both 2017/18 and 2018/19, both for clinical placement settings and the salary contributions that HEE currently pays for each post graduate placement (eg F1 doctors in training). Study leave course fees may be removed from the education and training tariff for postgraduate medical placements subject to the outcome of DH proposals currently under consideration.



43. Transition to national education and training tariff price, which has limited provider gains and

losses on a year by year basis, will continue in line with original transition plan. The cap on annual losses will remain at £2m or 0.25% of income. In addition, the non-recurrent supplementary tariff relief provided by DH this year will not be repeated for 2017/18. That relief effectively negated for 12 months the 2% reduction across all education and training tariffs in 2016/17. The Department of Health intends to provide further guidance on the education and training tariffs for 2017/18 and 2018/19 in due course1.

Sustainability and transformation funding

44. The provider sector is required to return to aggregate fnancial balance in 2017/18, including through use of the £1.8bn STF. This is again being made available to providers in 2017/18 and 2018/19. Our expectation is that sustainability funding must deliver at least a pound-for-pound improvement in the aggregate fnancial position.

45. It is intended that the overall disposition of the £1.8bn will be as follows: a £1.5bn general fund allocated on the basis of emergency care; a £0.1bn general fund allocated to non-acute providers; and a £0.2bn targeted fund. The operating rules of the existing £1.8bn STF are subject to agreement with the Department of Health and HM Treasury, and we will set out further details in due course.

46. The baseline for 2017/18 trajectories will be the agreed trajectories for 2016/17. Any provider whose plan for 2016/17 did not deliver one or more of the national standards for operational performance will not be able to reduce this baseline, and will have a trajectory to reach the national standards during 2017/18. All other providers will be expected to deliver the national standard and will submit assurance statements to this effect to NHS Improvement. If a provider does not deliver its performance trajectory during 2016/17 as a result of exceptional circumstances outside of its control, it can use the appeals process to NHS England and NHS Improvement and, if successful, NHS England and NHS Improvement may jointly agree to adjust its trajectory, but this will only very rarely be the case.

1 The Department of Health and Health Education England are currently in discussion with NHS Improvement about the impact of the proposed changes to Education Tariffs



47. The 2016/17 Spending Review provided additional dedicated funding streams for core priorities, including mental health, cancer care, general practice, and technology, building up over the next fve years:

• Primary Care: For 2017/18, NHS England has allocated around £8bn in primary medical care allocations (central and local), an increase of £301m over the previous year, and around £8.3bn in 2018/19 a further £304m increase. CCGs should also plan to spend approximately £3 per head (totalling £171m non-recurrently) in 2017/18 and 2018/19, from their existing allocations, for practice transformational support, as set out in the General Practice Forward View. Additional information is available in the General Practice Forward View Planning Requirements in Annex 6.

• Mental Health: To support the transformation of mental health services, dedicated funding will be available. This includes centrally-held transformation funding of £215m in 2017/18 and £180m in 2018/19.

• Cancer: Most of the extra funding needed to improve and expand cancer services is contained within CCG and specialised commissioning growing core budget allocations. However, there are several specifc elements of the Cancer Taskforce which will be “kick started” with national funds, and these will be announced shortly.

• Technology: £4.2bn of additional transformation funding for technology programmes will be subject to a consolidated approvals process which brings together NHS England, DH and NHS Digital funding as part of the National Information Board and associated new Digital Delivery Board (DDB). Programme plans for the period from 2017/18 to 2020/21 have been developed at a national level, and are subject to confrmation and challenge by DDB. During 2016/17, health economies organised themselves into digital footprints and developed Local Digital Roadmaps which are their plans of how they will digitise the providers in their area and achieve integration of information across care boundaries over the coming years. During the next period, NHS England and NHS Digital will work with STPs to agree allocation of transformation funding to support delivery of their Local Digital Roadmaps.

• Diabetes: The NHS Diabetes Prevention Programme will be scaled up in 2017/18 and 2018/19 in two further phases of expansion, with appropriate national funding to support this. Additionally, we intend to launch a wider programme of investment in supporting the treatment and care of people who already have diabetes, for which CCGs will have the opportunity to bid for additional national funding of approximately £40m per year to promote access to evidence based interventions - improving uptake of structured education; improving access to specialist inpatient support and to a multi-disciplinary foot team for people with diabetic foot disease; and improving the achievement of the NICE recommended treatment targets whilst driving down variation between CCGs.



48. From 2017/18 onwards, the different streams of transformation funding will increasingly be targeted towards the STPs making most progress. However, this funding will need to be focused on full delivery of specifc national programme objectives, rather than spread thinly everywhere. To minimise the administrative burden, we will ensure that the different application processes for different programmes are more co-ordinated, following the submission of STPs in October 2016. This will enable NHS England’s Investment Committee to make investment decisions in time for the beginning of the 2017/18 fnancial year. Transformation funding will only be available to systems whose operational plans meet their required control total and performance trajectories.

49. Improving value in the NHS is at the heart of the Five Year Forward View. Over the course of this year NHS England has used the Best Possible Value (BPV) framework to make investment decisions for year two of vanguard funding and for transformation funding for mental health, cancer and maternity. The BPV framework is a structured approach to assessing the value of a particular project. It uses logic models and success hypotheses to estimate both quality benefts as well as fnancial return on investment and provide a robust mechanism for tracking the delivery of these benefts. For 2017/18 and 2018/19, the BPV framework will be used to assess all applications for transformation investments that are available for the NHS. We expect all STPs to have adopted value-based decision making processes based on the BPV framework, embedded from April 2017.

50. The capital environment remains very challenged with capital resources severely constrained. STPs will enable a clearer view of how capital funding can help deliver transformation. Provider capital plans will need to be consistent with clinical strategy and clearly provide for the delivery of safe, productive services with business cases that demonstrate affordability and value for money. Providers will need to continue to procure capital assets more effciently, maximise and accelerate disposals and extend asset lives. We will shortly issue guidance on commissioner and provider capital processes for 2017/18 and 2018/19.

Risk reserve

51. In 2016/17 we asked CCG and primary care commissioners to ensure the 1% non-recurrent investment was uncommitted at the beginning of the year in order to create a risk reserve for the NHS, which could then be spent later in the year if commissioners and providers are on track to deliver their fnancial plans. In total this was worth circa £800m. To make sure we can manage the risks that both commissioners and providers face in 2017/18 and 2018/19, we will require a similar level of risk reserve, whilst nevertheless maximising purchasing power available to frontline services early in the year.



52. For 2017/18 and 2018/19 we will be looking to both commissioners and providers to help create the risk reserve, as part of a more collaborative and system-wide approach, and to complement the introduction of system control totals at STP level. As in 2016/17, release of the risk reserve to each local system will be dependent on delivery of its control total, subject to a satisfactory national risk profle. The risk reserve will be created from three components, totalling circa £830m:

• CCGs will again be asked to ensure that 1% of their allocation is planned to be spent non-recurrently, but only half of this – equivalent to £360m – has to be uncommitted at the start of the year, with the other half being available for immediate investment.

• NHS England will add circa £200m to this, funded from drawdown.

• 0.5% of the local CCG CQUIN scheme will also be held within the risk reserve, contributing £270m. If a provider delivers its control total in 2016/17, the CQUIN will be paid at the beginning of 2017/18 to the provider, who will be required to hold it as a reserve until release is authorised (with CQUIN for 2018/19 linked to delivery in 2017/18). For providers that do not accept or deliver their control totals in the prior year the 0.5% CQUIN will be held by the CCG prior to potential release. In both instances this element of the risk reserve will be released for investment by the relevant providers when it is demonstrated that the system in question is delivering its control total.

CCG Business rules and allocations

53. The business rules for commissioners for 2017/18 and 2018/19 are set out in full in Annex E of the technical guidance. The key requirements are:

• all CCGs are required to aim for in-year breakeven, with expectations set for the minimum level of improvement in defcit CCGs;

• as in previous years, CCGs should plan for 1% non-recurrent spend: o 0.5% to be uncommitted and held as risk reserve (see above) o 0.5% immediately available for CCGs to spend non recurrently, to support transformation

and change implied by STPs;

• as was the case for 2016/17 and previous years, CCGs should also plan for 0.5% contingency to manage in-year pressures and risks; and

• £0.4bn drawdown will be available supplemented by an increasing level of repayment of cumulative defcits, which will be used to fund:

o a contribution to the risk reserve; o in-year CCG defcits (subject to the fnancial improvement rules set out in Annex E); and o drawdown for CCGs and primary care budgets, which have built up cumulative underspends

above 1% in previous years.



54. Commissioner allocations may be refreshed to refect the impacts of new tariff pricing and updated Identifcation Rules for specialised services. Any adjustments will be published on 21 October 2016.

55. The commissioner sector needs to continue to achieve a balanced position, and within this those CCGs that are currently in cumulative defcit need to recover their position as rapidly as possible. Defcit CCGs are expected to achieve at least breakeven position in-year and plan for return to cumulative underspend over the Spending Review period. Where this is not possible, they will be required as a minimum to improve their in-year position by 1% of allocation per year plus any above average allocation growth until the cumulative defcit has been eliminated and the 1% cumulative underspend business rule is achieved. Any variation from this to refect exceptional circumstances will need to be agreed with the relevant NHS England regional team. Annex E of the technical guidance sets out further details of the expectations for CCGs in defcit.

56. In addition centrally held transformation funding to support delivery of the General Practice Forward View and Mental Health Forward View will be allocated to CCGs for 2017/18 and 2018/19. More details of the approach to this are set out in Annexes 6 and 8 of this document.

CQUIN and Quality Premium

57. The current CQUIN scheme enables providers to earn up to 2.5% of annual contract value if they deliver objectives set out in the scheme. For 2017/18 and 2018/19, the full 2.5% will continue to be available to providers. NHS England is intending to make two changes to the scheme.

58. First, continuing the arrangement of the current year, 1.5% of the 2.5% will be linked to delivery

of nationally identifed indicators. The indicator set has been streamlined, and with different indicator sets for different provider types. For acute and community services, the proposed national indicators cover six areas; there are fve in mental health, and two each in ambulance services, NHS 111 and care homes. The indicators and their rationale are set out in Annex A of the technical guidance. NHS England will seek views over the next month on the measures and thresholds proposed for each indicator, through a new engagement exercise.

59. The national indicators include: • NHS staff health and wellbeing (all providers) • proactive and safe discharge (acute and community providers); • reducing 999 conveyance (ambulance providers) • NHS 111 referrals to A&E and 999 (NHS 111 providers); • reducing the impact of serious infections (acute providers) • wound care (community providers); • improving services for people with MH needs who present to A&E

(acute and mental health providers); • physical health for people with severe mental illness (community and mental health providers); • transition for children and young people with mental health needs (mental health providers);



• advice and guidance services (acute providers); • e-referrals (acute providers, 2017/18 only;) and • preventing ill health from risky behaviours (acute providers 2018/19 only; community and

mental health providers, both years)

60. Secondly, the remaining 1% will be assigned to support providers locally. 0.5% will be available subject to full provider engagement and commitment to the STP process. In effect, this will be a cost free indicator for providers with clear scope for earning the full amount. The remaining 0.5% is discussed in paragraph 52 above.

61. The Quality Premium scheme will continue to be offered to CCGs. This will also become a two-year scheme. The 2017/18 to 2018/19 scheme has evolved from the 2016/17 scheme, in that NHS England has streamlined the indicator set and:

• retained indicators on Cancer Stage of Diagnosis and Patient Experience of Accessing their GP;

• evolved the existing Anti-Microbial Resistance measure into a measure on Bloodstream Infections;

• retained a locally selected indicator towards delivering the aims of the RightCare programme; and

• introduced two new indicators, one to be selected from a Mental Health menu, and one focused on delivery of Continuing Healthcare.

62. The previous Gateway tests will continue to operate for the scheme, covering Finance, Quality and measures within the NHS Constitution. More detail is set out at Annex A of the technical guidance.



Specialised services and other direct commissioning

63. NHS England’s commissioning intentions for specialised services are being published alongside

this document. These set out national priorities for the six programmes of care, and region-specifc priorities. Reviews that will impact in 2017/18 include Hyperbaric Oxygen Therapy, Prosthetics, Spinal Cord Injury, Paediatric Burns, Children’s Epilepsy Surgery, Metabolic Medicine, Intestinal Failure and Paediatric critical care, transport, surgery and extra corporeal membrane oxygenation. The document also sets priorities for clinical and service reform, quality improvement and peer review including the payment system for secure mental health and critical care.

64. The new specialised services framework will enable STPs to include the contribution of specialised care to population based health services and outcomes. Through the continuation of the existing gain-share arrangements, CCGs will also be encouraged to unlock effciencies across whole patient pathways. The national adoption of information rules by all providers will enable clearer identifcation and action on unwarranted variation in utilisation, effciency and outcomes.

65. The contracting approach for specialised services is aligned to implementation of the Carter review. It includes: locally priced services reform, to reduce cost per weighted activity unit; a comprehensive multi-year medicines optimisation approach underpinned by CQUIN; and further reforms to the medical device supply chain, high cost drugs reimbursement and data fows.

66. The specialised services CQUIN scheme has been simplifed and updated following engagement with providers over the summer. The multi-year approach introduced after dialogue in 2016/17 was supported and is continued. The overall funding structure for the scheme will remain as now with 2% of contract value for all acute providers, 2.5% for mental health providers, and 2.8% for hepatitis C lead providers. Furthermore, the incentive payment will be increased from “typical provider cost + 25%” to “typical provider cost + 50%”. The scheme provides a suffcient range of CQUINs to be relevant to the service diversity of specialised providers whilst setting a limited number of CQUINs per contract, proportionate to the fnancial value of CQUIN investment. The largest acute and mental health provider will have ten and fve CQUINs respectively, with an average three CQUINs per contract. NHS England will seek further views on the proposed specialised CQUIN indicators as part of the wider CQUIN engagement exercise in October 2016, and will publish any changes to the fnal scheme at the end of October 2016.



67. The approach outlined in this planning guidance will also apply to NHS England’s other areas of direct commissioning as appropriate, including public health services, services for the armed forces, and healthcare for people in secure and detained settings.



Commissioning in the evolving system

68. Over half of CCGs now have delegated responsibility for commissioning primary medical care. CCGs indicate that this number will increase very signifcantly by April 2017, with almost all having delegated responsibility by the end of 2018/19. CCGs are also playing a bigger role in specialised services commissioning through the regional collaboration hubs. As part of devolution policy, joint working with local government is being strengthened across the country.

69. CCGs and Upper Tier Councils will need to agree a joint plan to deliver the requirements of the Better Care Fund (BCF) from 2017/18 via the Health and Wellbeing Board. The plan should build on the 2016/17 BCF plan, taking account of what has worked well in meeting the objectives of the fund, and what has not. CCGs will be advised of the minimum amount that they are required to pool as part of the notifcation of their wider allocation. BCF funding should explicitly support reductions in unplanned admissions and hospital delayed transfers of care. Further guidance on the BCF will be provided later in the autumn.

70. CCGs’ role will continue to evolve. As new care models are established, the boundary between what is done by CCGs and by new integrated care providers will shift. However, there will continue to be a need for an effective commissioning function in the NHS. This includes acting as funder, setting local priorities and incentives, oversight of contracts, ensuring best value for the taxpayer, and ensuring the provision of a comprehensive local NHS within the available resources.

71. As part of this operational planning process, and within the context of STPs, CCGs will need to consider the opportunities for establishing new care models, the likely timetable for this and the implications for contracting. CCGs have a key role here in defning the scope of services for MCPs and PACS, engaging with local communities and providers over proposals, and running procurement processes. In particular, where the scope of MCP services includes services previously provided in hospitals, CCGs will need to agree revised contracts with the providers of these services. As part of the process for setting up new care models, NHS England will work with CCGs to ensure they have the capability and capacity to operate effectively in the changing provider landscape. This will include building on locally-led initiatives up and down the country for CCGs to work together across larger geographical footprints, for example, through joint appointments, integrated management and governance arrangements.



Annex 1

The Government’s Mandate to NHS England, 2020 goals

1. Through better commissioning, improve local and national health outcomes, particularly by addressing poor outcomes and inequalities.

1.1: CCG performance

Overall 2020 goal:

• Consistent improvement in performance of CCGs against new CCG assessment framework.

2. To help create the safest, highest quality health and care service.

2.1: Avoidable deaths and seven day services

Overall 2020 goals:

• Roll out of seven day services in hospital to 100% of the population (four priority clinical standards in all relevant specialities, with progress also made on the other six standards), so that patients receive the same standards of care, seven days a week.

• Achieve a signifcant reduction in avoidable deaths, with all trusts to have seen measurable reduction from their baseline on the basis of annual measurements.

• Support NHS Improvement to signifcantly increase the number of trusts rated outstanding or good, including signifcantly reducing the length of time trusts remain in special measures.

• Measurable progress towards reducing the rate of stillbirths, neonatal and maternal deaths and brain injuries that are caused during or soon after birth by 50% by 2030 with a measurable reduction by 2020.

• Support the NHS to be the world’s largest learning organisation with a new culture of learning from clinical mistakes, including improving the number of staff who feel their organisation acts on concerns raised by clinical staff or patients.

• Measurable improvement in antimicrobial prescribing and resistance rates.



2.2: Patient experience

Overall 2020 goals:

• Maintain and increase the number of people recommending services in the Friends and Family Test (FFT) (currently 88-96%), and ensure its effectiveness, alongside other sources of feedback to improve services.

• 50-100,000 people to have a personal health budget or integrated personal budget (up from current estimate of 4,000).

• Signifcantly improve patient choice, including in maternity, end-of-life care and for people with long-term conditions, including ensuring an increase in the number of people able to die in the place of their choice, including at home.

2.3: Cancer Overall 2020 goals:

• Deliver recommendations of the Independent Cancer Taskforce, including:

o signifcantly improving one-year survival to achieve 75% by 2020 for all cancers combined (up from 69% currently); and

o patients given defnitive cancer diagnosis, or all clear, within 28 days of being referred by a GP.

3. To balance the NHS budget and improve effciency and productivity.

3.1: Balancing the NHS budget

Overall 2020 goals:

• With NHS Improvement, ensure the NHS balances its budget in each fnancial year.

• With the Department of Health and NHS Improvement, achieve year on year improvements in NHS effciency and productivity (2-3% each year), including from reducing growth in activity and maximising cost recovery.

4. To lead a step change in the NHS in preventing ill health and supporting people to live healthier lives.

4.1: Obesity and diabetes

Overall 2020 goals: • Measurable reduction in child obesity as part of the Government’s childhood

obesity strategy.• 100,000 people supported to reduce their risk of diabetes through the

Diabetes Prevention Programme.• Measurable reduction in variation in management and care for people with

diabetes.



4.2: Dementia Overall 2020 goals: • Measurable improvement on all areas of Prime Minister’s challenge on

dementia 2020, including:o maintain a diagnosis rate of at least two thirds; o increase the numbers of people receiving a dementia diagnosis within six

weeks of a GP referral; ando improve quality of post-diagnosis treatment and support for people with

dementia and their carers.

5. To maintain and improve performance against core standards

5.1: A&E, Ambulances and RTT

Overall 2020 goals:• 95% of people attending A&E seen within four hours; Urgent and Emergency

Care Networks rolled out to 100% of the population.• 75% of Category A ambulance calls responded to within eight minutes.• At least 92% of patients on incomplete non-emergency pathways to have

been waiting no more than 18 weeks from referral; no-one waits more than 52 weeks.

6. To improve out-of-hospital care.

6.1. New models of care and general practice

Overall 2020 goals:• 100% of population has access to weekend/evening routine GP

appointments. • Measurable reduction in age standardised emergency admission rates and

emergency inpatient bed-day rates; more signifcant reductions through the New Care Model programme covering at least 50% of population.

• Signifcant measurable progress in health and social care integration, urgent and emergency care (including ensuring a single point of contact), and electronic health record sharing, in areas covered by the New Care Model programme.

• 5,000 extra doctors in general practice.

6.2: Health and social care integration

Overall 2020 goals:• Achieve better integration of health and social care in every area of the

country, with signifcant improvements in performance against integration metrics within the new CCG Improvement and assessment framework. Areas will graduate from the Better Care Fund programme management once they can demonstrate they have moved beyond its requirements, meeting the Government’s key criteria for devolution.

• Ensure the NHS plays its part in signifcantly reducing delayed transfers of care, including through developing and applying new incentives.



6.3: Mental health, learning disabilities and autism

Overall 2020 goals:• To close the health gap between people with mental health problems,

learning disabilities and autism and the population as a whole (defned ambitions to be agreed based on report by Mental Health Taskforce).

• Access and waiting time standards for mental health services embedded, including:o 50% of people experiencing frst episode of psychosis to access treatment

within two weeks; and o 75% of people with relevant conditions to access talking therapies in six

weeks; 95% in 18 weeks.

7. To support research, innovation and growth.

7.1: Research and growth

Overall 2020 goals:• Support the Department of Health and the Health Research Authority in their

ambition to improve the UK’s international ranking for health research.• Implement research proposals and initiatives in the NHS England research

plan.• Measurable improvement in NHS uptake of affordable and cost-effective new

innovations.• To assure and monitor NHS Genomic Medicine Centre performance to deliver

the 100,000 genomes commitment.

7.2: Technology

Overall 2020 goals: • Support delivery of the National Information Board Framework ‘Personalised

Health and Care 2020’ including local digital roadmaps, leading to measurable improvement on the new digital maturity index and achievement of an NHS which is paper-free at the point of care.

• 95% of GP patients to be offered e-consultation and other digital services; and 95% of tests to be digitally transferred between organisations.

7.3 Health and work

Overall 2020 goals:• Contribute to reducing the disability employment gap.• Contribute to the Government’s goal of increasing the use of Fit for Work.



Annex 2

The CCG Improvement and Assessment Framework

NHS England introduced a new Improvement and Assessment Framework for CCGs (CCG IAF) from 2016/17 onwards, to replace both the previous CCG Assurance Framework and separate CCG performance dashboard. In the Government’s Mandate to NHS England, this new framework takes an enhanced and more central place in the overall arrangements for public accountability of the NHS.

The Five Year Forward View (5YFV), NHS Planning Guidance and the Sustainability and Transformation Plans (STPs) for each area, are all driven by the pursuit of the “triple aim”: (i) improving the health and wellbeing of the whole population; (ii) better quality for all patients, through care redesign; and (iii) better value for taxpayers in a fnancially sustainable system. The new framework aligns key objectives and priorities, including the way we assess and manage our day-to-day relationships with CCGs.

The CCG IAF has been designed to supply indicators for adoption in STPs as markers of success. In turn those plans will provide vision and local actions that will populate and enrich the local use of the CCG IAF.

The NHS can only deliver the 5YFV through place-based partnerships spanning across NHS commissioners, local government, providers, patients, communities, the voluntary and independent sectors. To ask CCGs to focus solely on what resides exclusively within their own organisational locus would miss out what many are doing, and artifcially limit their infuence and relevance as local system leaders. In both the CCG IAF, and STPs, we give primacy to tasks-in-common over formal organisational boundaries.

The CCG IAF is available on the NHS England website.



Annex 3

NHS Improvement Single Oversight Framework

In September 2016 NHS Improvement published the Single Oversight Framework which has fve themes:

• Quality of care (safe, effective, caring, responsive): we will use CQC’s most recent assessments of whether a provider’s care is safe, effective, caring and responsive, in combination with in-year information where available. We will also include delivery of the four priority standards for seven day hospital services.

• Finance and use of resources: we will oversee a provider’s fnancial effciency and progress in meeting its fnancial control total, refecting the approach taken in strengthening fnancial performance and accountability. We are co-developing this approach with CQC.

• Operational performance: we will support providers in improving and sustaining performance against NHS Constitution standards and other, including A&E waiting times, referral to treatment times, cancer treatment times, ambulance response times, and access to mental health services. These NHS Constitution standards may relate to one or more facets of quality (i.e. safe, effective, caring and/or responsive).

• Strategic change: working with system partners we will consider how well providers are delivering the strategic changes set out in the 5YFV, with a particular focus on their contribution to sustainability and transformation plans (STPs), new care models, and, where relevant, implementation of devolution.

• Leadership and improvement capability (well-led): building on the joint CQC and NHS Improvement well-led framework, we will develop a shared system view with CQC of what good governance and leadership look like, including organisations’ ability to learn and improve.

By focusing on these fve themes NHS Improvement will support providers to improve to attain and/or maintain a CQC ‘good’ or ‘outstanding’ rating. Quality of care, fnance and use of resources, and operational performance relate directly to sector outcomes. Strategic change recognises that organisational accountability and system-wide collaboration are mutually supportive. Leadership and improvement capability are crucial in ensuring that providers can deliver sustainable improvement.

The Single Oversight Framework is available on the NHS Improvement website



Annex 4

October Guidance on STPs

The Five Year Forward View set out our shared ambition to improve health, quality of care and effciency within the resources given to us by Parliament. This ‘triple aim’ will only be achieved through local health and social care organisations working together in partnership with the active involvement of patients, stakeholders, clinicians and staff. Sustainability and Transformation Plans are the means of delivering these objectives in each local health and care system.

In June, each STP area shared its emerging thoughts on the three to fve critical issues in its locality. As discussed in our conversations during July, we now expect to see plans with more depth and specifcity. We recognise that each area is at a different starting point and that you will be able to provide more detail in 17/18 than later years but the October submission should build on the previous STP guidance issued in April and:

• Set out your plan to address the feedback from our July conversation. We don’t need another lengthy narrative. It would be helpful if you could provide a summary sheet or ‘plan on a page’ to set out your overall aims, highlighting key changes between the June and October submissions. This should also include a crisp articulation of the tangible benefts to patients and communities.

• Provide more depth and specifcity on how you plan to implement the proposed schemes as annexes. Illustrative PIDs and templates that other footprints have developed will follow to support you in this process. Any proposed shifts in activity from the acute sector should be accompanied by a clear plan to build strong primary care and community based services to provide the appropriate alternative care. Whatever format you choose, your plan will need to set out a clear set of milestones, outcomes, resources and owners for each scheme, as well as overarching risks, governance and interdependencies. This should include which organisation is involved in each initiative to allow you and us to triangulate your STP with local operational plans. We recognise that your plans will be more detailed for 17/18 and 18/19 and more high-level thereafter and subject to the normal rules around consultation and engagement.

• Ensure your plan is underpinned by the fnance template and shows the impact on activity, benefts (costs and returns), capacity, workforce and investment requirements over time. We expect calculations to build from a whole-system view developed in collaboration with local government colleagues. Further guidance will be provided separately.



• Set out the measurable impacts of your STP. These will refect local priorities and show how your local metrics link to the three to fve key issues identifed in your June submission as well as national metrics agreed with the Department of Health. These are likely to include measurements already captured in the CCG Improvement and Assessment Framework and NHS Improvement’s Single Oversight Framework such as emergency admissions, bed days per 1000, A&E and RTT performance as well as delivery against elements of the cancer, mental health and primary care plans. Further information will follow.

• Include a brief statement setting out how you envisage better integration between health and social care commissioning and services could support the overall objectives of your STP and proposals for working between the leadership of the STP and the health and social care integration plan if these are different. The LGA have also produced a tool to support integration (to follow).

• Set out the degree of local consensus amongst organisations and plans for further engagement. It would be useful to know the degree of support your proposals command, the extent that you have engaged stakeholders and the public so far, and your plans for further engagement with patients, stakeholders, clinicians, communities, staff and other partners and how you have held meaningful strategic conversations with both NHS boards, CCG governing bodies and local government leaders (Local Authority arrangements will vary across the country so you should seek the advice of your LA CEO on who best to involve and when). We have produced guidance on engagement and consultation to support you in this (published 15 September 2016).

• Continue to develop your estates strategy to deliver your service strategy; identifying and valuing the opportunities for estates rationalisation and land disposal (as well as funding sources) and any key interdependencies. The strategic estates advisers that supported CCGs in the preparation of their initial Local Estates Strategies will continue to be available to support you.

In order to plan effectively you will need to know the business rules and planning assumptions going forward, including how transformation funds and control totals will be agreed. We will therefore publish the Planning Guidance for your operational plans today – three months earlier than previous years – and we will be in touch to arrange a briefng in advance of publication.

STPs will be system-wide and set out how to deliver locally agreed objectives, how activity will fow between care settings and what each organisation needs to do to deliver the system-wide plan. Operational plans will be at the level of individual CCGs and NHS providers and capture each organisation’s plans for quality improvement, activity and operational performance, including the reconciliation of fnance, activity and workforce plans. This year, operational plans will cover 2017/18 and 2018/19, i.e. years two and three of the STP. The aggregate of all operational plans in a footprint need to be consistent with the STP. Operational plans will be expected to reconcile to STPs.

As you will need to move swiftly from STP to contract agreement, it is important that the key metrics in terms of activity trajectory and outline fnance allocated are addressed within the STP.



Producing system wide STPs and earlier operational plans and contracts will be challenging for us all. Nevertheless, this offers a real opportunity to ensure that operational plans refect our strategic intent rather than simply rolling forward last year’s business model and to free up headroom in 2017 so that we can focus on delivering our plans rather than negotiating them.

Our Regional directors will continue to support you in this process and will provide feedback on your STP in November so you can feed this into the planning round. The role of the STP and the Footprint leader is a vital and evolving one and we will work with you to understand how we can best support each other as we move towards implementation.

Further information on available support will follow separately including a timeline of key milestones.

Submission Plans need to be submitted by Friday, 21 October by 5pm to [email protected], copying in your Regional directors.


mailto:england.fiveyearview%40nhs.net?subject=


Annex 5

NHS England and NHS Improvement approach to establishing shared fnancial control totals

Contents

1 Introduction 40

2 Setting control totals 41

3 Scope and geography for system control totals 42

4 Flexibility 43

5 Local management arrangements 44

6 Reporting 45

7 Benefts realisation 46

8 Application processes 47



1. Introduction

This annex covers the development and implementation of system control totals for 2017/18 and 2018/19. The intent of system control totals is threefold:• To sustain the commitment to collaboration developed across health economies through the STP

process and reduce the incentives for individual organisations to optimise their own fnancial position at the expense of the wider system as the focus moves to operational planning and delivery;

• To create the fexibility for local systems to implement transformational change without being constrained by any resulting shifts in fnancial performance as between individual organisations;

• To maximise the likelihood of success in managing overall fnancial delivery risk in the system by fostering shared risk management approaches across health economies.

System-wide control totals are intended to complement rather than replace individual organisational control totals, and all organisations will therefore be held accountable for delivering both their individual control total and the relevant overall system control total.

The degree of fexibility offered to individual systems will depend on their appetite for collaborative fnancial management and the maturity of the processes and governance they put in place to support it. For 2017/18 this will be on a ‘by application’ basis. Flexible system controls will become the default from 2018/19, though each area will still be required to demonstrate that it has the appropriate mechanisms in place to ensure successful functioning of a shared control total.



2. Setting control totals

System control totals for each STP area are being developed and will be communicated to STP leaders to ensure that STP submissions in October deliver fnancial balance on a national basis in 2017/18 and 2018/19 and in each system by 2020/21. For 2017/18 and 2018/19 these system control totals will be derived from NHS England and NHS Improvement draft requirements of individual organisations (including direct commissioning on a basis consistent with the STPs) but will also take into account insights from the modelling undertaken to date by individual areas. These control totals should then be refected in fnal STPs.

We expect individual operational plans to be a direct disaggregation of the agreed STPs to the component organisations, and the resulting individual control totals for operational planning and delivery should add up to the agreed STP control totals.



3. Scope and geography for system control totals

Control totals will be applied across providers and CCGs together.

For operational purposes, the system control total will exclude direct commissioning (other than delegated primary medical care) at least for the next two years. Ambulance trusts and highly specialised organisations with predominantly national remits will also be similarly excluded, as will local authorities. However, systems will need to consider the fnancial impact of their decisions on these other organisations.

The default is for operational control totals to apply to the same geography as the STP. However, larger STP areas may wish to propose to NHS England and NHS Improvement a subdivision of their geography for these purposes, with separate system control totals (and governance arrangements) for each subdivision, where this is better suited to operational collaboration and risk management. The subdivisions must cover the entire STP area between them, and each must be of a demonstrably suffcient size to provide appropriate risk pooling. System control totals are not expected to operate over a wider footprint than an STP.



4. Flexibility

Systems will also be able to apply for in-year fexibility to vary individual control totals whilst maintaining the overall system control total. System control total fexibilities can be applied within a given fnancial year only, not across fnancial years.

Shifts can only be made prospectively, for example to allow for the fnancial impacts of an agreed transformation plan or planned changes to patient fows. Systems may apply for changes to control totals at the planning stage and then quarterly thereafter.

Any changes will be subject to joint approval by the NHS England and NHS Improvement regional teams. As well as the inherent merits of individual proposals this will need to take into account the need for the provider sector to achieve aggregate fnancial balance in 2017/18 and 2018/19 and for the NHS England Group – comprising NHS England and CCGs – to live within its statutory resource limits.

The system control total approach will routinely apply to the planned underspend or defcit of the control group, but areas may also wish to explore combined arrangements for contingency, 1% non-recurrent spend, or other specifc business rules. Where this option is taken, areas must ensure that such agreements are clearly documented and transparent.

Local system leaders should also give consideration to joint approaches to the accessing and deployment of national transformation resources, collaboration arrangements and pooled budgets with local authorities and gain share arrangements with specialised commissioning.



5. Local management arrangements

Areas will need to articulate the monitoring and management arrangements that will be put in place to ensure that a system control total can operate effectively. This is particularly important where they are seeking to apply the fexibilities outlined above. The arrangements will need to include the following:

• An oversight group comprising the leaders across the health economy with a named chair and including senior fnancial representation;

• Terms of reference which clearly articulate the limit of the group’s decision making and how any escalation and dispute resolution will be managed;

• Arrangements for the operation of the group which have been approved by the boards or governing bodies of the constituent organisations;

• Reporting arrangements to receive timely fnancial and performance information to allow monitoring of performance against the control total and other related factors such as delivery of effciency savings and CIPs plans; and

• Scenario planning which has been discussed and agreed by the group showing how delivery of the system control total will operate in various scenarios, where individual organisations fall short of their control total.

These arrangements will form a key part of any application for additional fexibilities and will also be subject to NHS England and NHS Improvement assurance processes.



6. Reporting

Reporting requirements for system control totals will be multi-level.

Each individual organisation will continue to report fnancial performance through its own governance route and in addition as part of the system control group.

NHS England and NHS Improvement will continue to monitor and report the fnancial performance of individual organisations against their agreed plans.

The system control total will provide a mechanism for monitoring the fnancial performance of an STP compared with its agreed strategy, and thus whether the STP’s progress towards fnancial sustainability is being delivered. NHS England and NHS Improvement will put additional reporting mechanisms in place to allow us collectively to monitor performance against system control totals.



7. Benefts realisation

Establishing fexible system control total processes is not an end in itself but should be seen as a means for seeking improvement across the system that could not otherwise be achieved.

In designing their arrangements and applying for fexibilities, areas should consider how tangible benefts will fow from establishing the control total. Benefts may arise in the following ways:

Direct fnancial improvement – establishing a system control total may allow for greater certainty over income and expenditure within the health economy which may in turn allow for a more positive system control total than the sum of the individual control totals.

Improved risk management – working collaboratively across a control group may lead to an enhanced ability to manage fnancial risk across the health economy and hence improved risk management. This may then allow for earlier and greater release of risk reserves for investment.

Improved use of/reduction in admin resources – collaborative working across the health economy may yield benefts from a resource perspective, for example by combining programme offces, reducing the amount of resource dedicated to generating and challenging provider income claims, or negotiating contracts and disputes. Health economies may also wish to look at collaboration on common resources such as drugs purchases and call centre arrangements.

Behavioural change – in combination with the STP process, the establishment of a system control total approach may provide a better platform for medium term change by breaking through organisational barriers and helping to align the leaders of the health economy behind a common purpose. Behavioural change may provide short term measurable beneft if conficting incentives are removed from the system and organisations are therefore acting in a goal congruent manner.



8. Application processes

Any systems wishing to manage system control totals over smaller operational footprints than the STP area should set out their proposals, including the rationale and supporting information in relation to the criteria set out above. This should be sent to [email protected] by 31st October 2016 for review and discussion with regional teams, leading to confrmation by 30th November 2016.

Those systems wishing to apply for fexibility in operating their operational control totals for 2017/18 should submit a proposal covering the following:• A description of how the control total will operate, including the planned footprint, any initial

fexibility proposals and the likely further fexibility required during the fnancial year;• The accountability proposals;• The oversight and monitoring arrangements for the operation of the control total;• The additional reporting arrangements that will be required;• An explanation of the expected benefts, including how these will be measured; and • Any considerations for specialised services commissioning or provision, and any other cross border

issues relevant to the application.


mailto:[email protected]


Annex 6 General Practice Forward View planning requirements

1.1 Introduction ...........................................................................................................................49

1.2 Investment .............................................................................................................................50

1.2.1 Elements of Sustainability and Transformation package .........................................................50

1.2.2 Funding to improve access to general practice services ..........................................................51

1.2.3 Estates and Technology Transformation Fund (primary care) ...................................................52

1.2.4 Other funding for general practice ........................................................................................52

1.3 Care redesign.........................................................................................................................52

1.3.1 Improved access ....................................................................................................................53

1.3.2 Effective access to wider whole system services .....................................................................54

1.3.3 Time for Care Programme .....................................................................................................54

1.3.4 Deployment of funding for reception and clerical staff training,

and online consultation systems ............................................................................................55

1.4 Workforce ..............................................................................................................................55

1.5 Workload ...............................................................................................................................56

1.6 Practice infrastructure ..........................................................................................................57



1.1 Introduction

This technical annex outlines the planning requirements of CCGs to support implementation of the General Practice Forward View (GPFV)

The GPFV, published on 21 April 2016, sets out our investment and commitments to strengthen general practice in the short term and support sustainable transformation of primary care for the future. It includes specifc, practical and funded investment in fve areas – investment, workforce, workload, practice infrastructure and care redesign.

Many of the actions in the GPFV are for NHS England, Health Education England and the Care Quality Commission to take forward. This guidance focuses on the actions needed to implement the more local aspects.

Strengthening and transforming general practice will play a crucial role in the delivery of STP plans, and already many STP footprints are integrating the aims and more local elements of the GPFV into the system wide plans. To complement this, CCGs should similarly translate the aims and key local elements of the GPFV into their more detailed local operational plans. This technical annex distils the priorities that CCGs should consider as they develop these local plans. Some of these are for CCGs to consider alone; others are for CCGs to consider working in collaboration.

CCGs will need to submit one GPFV plan to NHS England on 23 December 2016, encompassing the specifc areas outlined in this guidance. Plans will need to refect local circumstances, but must – as a minimum – set out:

• How access to general practice will be improved

• How funds for practice transformational support (as set out in the GPFV) will be created and deployed to support general practice

• How ring-fenced funding being devolved to CCGs to support the training of care navigators and medical assistants, and stimulate the use of online consultations, will be deployed.


https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf


1.2 InvestmentThe NHS England allocations for primary care (medical) were published for fve years.

This sets out that in 2017/18 and 2018/19 there will be an increase in funding for core local primary medical allocations of £231 million and then a further £188 million on top respectively. In addition to those allocations, other primary care funding is available for specifc purposes as part of the £500 million plus sustainability and transformation package announced in the GPFV, as detailed below, as well as specifc extra funding to support improvements in access to general practice, and improvements in estates and technology.

1.2.1 Elements of the sustainability and transformation packagea) Transformational support 2017/18 and 2018/19 from CCG allocationsCCGs should also plan to spend a total of £3 per head as a one off non-recurrent investment commencing in 2017/18, for practice transformational support, as set out in the GPFV. This equates to a £171million non- recurrent investment. This investment should commence in 2017/18 and can take place over two years as determined by the CCG, £3 in 17/18 or 18/19 or split over the two years. The investment is designed to be used to stimulate development of at scale providers for improved access, stimulate implementation of the 10 high impact actions to free up GP time, and secure sustainability of general practice. CCGs will need to fnd this funding from within their NHS England allocations for CCG core services.

b) Online general practice consultation software systemsThe £45 million funding for this programme (over three years), announced in the GPFV, will start to be deployed in 2017/18 with £15 million devolved to CCGs along with rules and a specifcation, and a further £20 million in 2018/19.

The allocations to each CCG will be based upon the estimated CCG registered populations for 2017/18 and 2018/19, which can be found in the “GP Registration Projections” tab of Spreadsheet fle B.

CCGs can calculate their share of the funding in 2017/18 by multiplying the £15 million total by their registered population fgures in column X within the “GP Registrations Projections” tab of the Spreadsheet fle B, and then dividing by the total number of registered patients in England of 58,173,725.

Likewise, CCG shares for 2018/19 can be calculated by multiplying the £20 million total by their registered population fgures in column Y, and dividing by the total number of registered patients in England of 58,592,211.

CCGs will be accountable for this spend to deliver the specifcation outlined. Further details on the specifcation and monitoring arrangements will be shared in due course.


https://www.england.nhs.uk/wp-content/uploads/2016/01/pc-medical-allocations.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/01/ccg-allocations.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/01/ccg-allocations.pdf

https://www.england.nhs.uk/2016/04/allocations-tech-guide-16-17/




c) Training care navigators and medical assistants for all practicesThe £45 million funding for this programme (over fve years) announced in the GPFV, totals £10 million in 2017/18 and £10 million in 2018/19, with £5 million already allocated in 2016/17. Again, this funding will be devolved to NHS England local teams or delegated CCGs based on their share of registered patients as a percentage of the England total.

The allocation for 2017/18 for each CCG area will be their total estimated registered population for that year, shown in column X of the “GP Registration Projections” tab of Spreadsheet fle B divided by the total estimated registered patients in England, of 58,173,725 multiplied by the £10 million total.

Likewise, the allocation for each CCG area is the estimated CCG registered lists fgure in column Y of the “GP Registration Projections” tab of Spreadsheet fle B divided by the total of patients in England of 58,592,211 multiplied by the £10 million total.

CCGs will be accountable for this expenditure to deliver the specifcation outlined for this work, with details on the specifcation and monitoring arrangements being shared in due course.

d) General Practice Resilience ProgrammeThe £40 million non-recurrent funding for the General Practice Resilience Programme (over four years) announced in the GPFV, has already begun to be deployed, with £16 million already allocated in 2016/17. Funding for this programme in 2017/18 totals £8 million, and a further £8 million in 2018/19.

This funding will be delegated to NHS England local teams on a fair shares basis as set out in the published guidance document , which contains the details of the allocations. NHS England local teams should ensure these amounts are included in their plans.

A number of other elements of the package are being held centrally. Some schemes have already started and announcements will be made in due course as to how further funding for these will be spent and distributed, or how centrally commissioned arrangements can be accessed. Commissioners of GP services should not currently factor any of the funding for these schemes into their plans.

1.2.2 Funding to improve access to general practice services This funding is being targeted at those areas of England which had successful pilot sites in 2015/16, known as the “Prime Minister’s Challenge Fund” or “General Practice Access Fund” sites.

CCGs should plan to receive £6 per weighted patient for each of these sites in 2017/18 and £6 per weighted patient in 2018/19.

The programme will expand in 2017/18, bringing the total investment up to over £138m million. This funding will be recurrent. There will be further funding coming on stream in 2018/19, totalling £258 million. This additional funding will be allocated across all remaining CCGs to support improvements in access, as £3.34 per head of population and as set out in the ‘improved access’ section of this document.




https://www.england.nhs.uk/ourwork/gpfv/resilience/

https://www.england.nhs.uk/ourwork/gpfv/resilience/

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/09/gp-resilience-programme-guidance.pdf


It has been agreed that, given some of the unique characteristics of London, the funding for London schemes will be available to be deployed to support improvements across the whole of the geographical area. Further information will be available through NHS England (London).

Further background details on improving access to general practice are available here.

1.2.3 Estates and Technology Transformation Fund (primary care)CCGs were invited to bid for funding from 2016/17 onwards as set out in guidance issued in May 2016. Details of the process and milestones are also included in that guidance.

CCGs will receive confrmation that a bid has been successful shortly.

1.2.4 Other funding for general practiceThere will also be some non-recurrent funding held nationally to support GPFV commitments in a number of areas, including growing the general practice workforce, premises and the national development programme. In addition, there will be increases in a number of national lines to support the promised increase in investment in general practice set out in the GPFV. This includes:

• increases in funding for GP trainees funded by Health Education England; • Increases in funding for nationally procured GP IT systems; • Increases in the section 7A funding for public health services, which support payments to GPs for

screening and immunisation services; and• 3,000 new fully funded practice-based mental health therapists to help transform the way

mental health services are delivered.

The GPFV also assumes that there will continue to be increases in CCG funding to general practice (currently totalling around £1.8 billion in 2015/16) at least equal to, and ideally more than, the increases in CCG core allocations which are 2.14% in 2017/18 and 2.15% in 2018/19.

1.3 Care redesignAs part of their GPFV plan, CCGs should have a clear, articulated vision of the care redesign that will deliver sustainable services today and transformed services tomorrow. This will be part of their STP’s vision. This should include details of the changes to be made to redesign services for improved outcomes, including the ways in which greater use will be made of selfcare, technology and a wider workforce, and other actions to address challenges with general practice capacity.

CCGs should agree a plan for implementation of these changes across all member practices and other providers, with an indication of how this has been developed in co-production with primary care providers themselves.


https://www.england.nhs.uk/ourwork/futurenhs/pm-ext-access/


1.3.1 Improved accessAs outlined in the investment section, NHS England will provide additional funding, on top of existing primary medical care allocations to enable CCGs to commission and fund extra capacity to ensure that everyone has access to GP services, including suffcient routine and same day appointments at evenings and weekends to meet locally determined demand, alongside effective access to other primary care and general practice services such as urgent care services.

CCGs will be required to secure services following appropriate procurement processes.

Recurrent funding to commission additional capacity and improve patient access will increase over time. In 2017/18 CCGs with General Practice Access Fund Schemes, and a number of additional geographies identifed across the country which will accelerate delivery of improving GP access, will receive recurrent funding of £6 per head of population (weighted) to commission improved access. In 18/19, this will expand to enable remaining CCGs to improve access, with £3.34 available in 2018/19 for those remaining CCGs. In 2019/20 all CCGs will receive at least £6 per head extra recurrently for those improvements in general practice.

In order to be eligible for additional recurrent funding, CCGs will need to commission and demonstrate the following:

Timing of appointments: • commission weekday provision of access to pre-bookable and same day appointments to general

practice services in evenings (after 6:30pm) – to provide an additional 1.5 hours a day;• commission weekend provision of access to pre-bookable and same day appointments on both

Saturdays and Sundays to meet local population needs;• provide robust evidence, based on utilisation rates, for the proposed disposition of services

throughout the week; and• appointments can be provided on a hub basis with practices working at scale.

Capacity: • commission a minimum additional 30 minutes consultation capacity per 1000 population, rising to

45 minutes per 1000 population.

Measurement:• ensure usage of a nationally commissioned new tool to be introduced during 2017/18 to

automatically measure appointment activity by all participating practices, both in-hours and in extended hours. This will enable improvements in matching capacity to times of high demand.

Advertising and ease of access: • ensure services are advertised to patients, including notifcation on practice websites, notices in

local urgent care services and publicity into the community, so that it is clear to patients how they can access these appointments and associated service;



• ensure ease of access for patients including: o all practice receptionists able to direct patients to the service and offer appointments to

extended hours service on the same basis as appointments to non-extended hours services o patients should be offered a choice of evening or weekend appointments on an equal footing

to core hours appointments.

Digital: • use of digital approaches to support new models of care in general practice.

Inequalities: • issues of inequalities in patients’ experience of accessing general practice identifed by local

evidence and actions to resolve in place.

1.3.2 Effective access to wider whole system services• Effective connection to other system services enabling patients to receive the right care from the

right professional, including access from and to other primary care and general practice services such as urgent care services

During 2017/18 CCGs should ensure 100% coverage of extended access (evening and weekend appointments) is achieved in GP Access Fund sites and a number of additional geographies identifed across the country which will accelerate delivery of improving GP access.

In 2018/19 and 2019/20, we expect this roll out to continue. Remaining CCGs will be required to start access improvement in 2018/19, with funding at £3.34 per head of population for the year, and achieve 100% coverage from April 2019, when funding will reach at least £6 per head of population in 2019/20.

CCGs will need to provide plans outlining their approach to improved access by 23 December 2016 as part of their GPFV plan. This should include trajectories on improved access coverage for their local population.

There are currently signifcant inequalities in different groups’ experience of access. Whilst making changes designed to improve access, CCGs should ensure that new initiatives work to reduce inequalities as well as improve overall access.

1.3.3 Time for Care Programme In July 2016, NHS England set out plans to establish a new national development programme for general practice – Time for Care. CCGs will want to consider identifying a senior person to lead local work to release staff capacity in general practice. They will be an important part of championing the 10 High Impact Actions to release time for care, support the planning of care redesign programmes and act as a link with NHS England development leads. Where appropriate, they will also support local practices in submitting expressions of interest for the Time for Care and General Practice Improvement Leaders programmes.


https://www.england.nhs.uk/ourwork/gpfv/gpdp/

https://www.england.nhs.uk/ourwork/gpfv/gpdp/releasing-time/

https://www.england.nhs.uk/ourwork/gpfv/gpdp/capability/

https://www.england.nhs.uk/ourwork/gpfv/gpdp/capability/


CCGs should have clear plans for how they will support the planning and delivery of a local Time for Care development programme, to implement member practices’ choice of the 10 High Impact Actions. This could include details of:

• how this piece of practice development is being aligned with other developments locally such as technology and estates investment, workforce development and improved collaboration between providers, and

• the investment being made by the CCG to create headroom for practices to engage in development.

1.3.4 Deployment of funding for reception and clerical staff training, and online consultation systemsCCGs are not required to submit a plan to the national NHS England team prior to beginning to spend funds allocated for training in active signposting and document management, or supporting the purchase of online consultation systems. However, they will be required to report on their use of this funding on a regular basis, as part of wider arrangements for monitoring GPFV activity.

The funding will be allocated equally between all CCGs on a capitated basis. The frst tranche of funds were transferred in September 2016, but future allocations will be made near the beginning of each fnancial year.

It will usually be preferable for practices to undertake training or innovation adoption in local cohorts, rather than on an ad hoc basis. CCGs may wish to consider pooling funding with others in their STP footprint. Reporting of GPFV activity will allow CCGs to indicate where this is being done.

As part of their GPFV plan, CCGs should describe how these two new funds will be used for member practices, and may wish to do this collaboratively across the STP footprint. This should include evidence that the plan:

a) has been developed in consultation with general practices themselves;b) will be delivered in alignment with other development activities such as local Time for Care

programmes, and wider workforce and technology strategies;c) includes plans to use early adopters to help spread innovations in workforce and technology; andd) provides assurance that this funding is ring-fenced for the intended purposes.

1.4 WorkforceIn their GPFV plans, CCGs will want to include a general practice workforce strategy for the local system that links to their service redesign plans. These should be clear about the current position, areas of greatest stress, examples of innovative workforce practices, the planned future model and actions to get there.

For example, the plans could include:

• a baseline that includes assessment of current workforce in general practice, workload demands and identifying practices that are in greatest need of support;


https://www.england.nhs.uk/ourwork/gpfv/gpdp/reception-clerical/

https://www.england.nhs.uk/ourwork/gpfv/gpdp/consultation-systems/


• workforce development plans which set out future ways of working including the development of multi-disciplinary teams, support for practice nursing and establishing primary care at scale;

• commitment to develop, fund and implement local workforce plans in line with the GPFV and that support delivery of STPs;

• initiatives to attract, recruit and retain GPs and other clinical staff including locally designed and nationally available initiatives;

• actions to ensure GPs are operating at the top of their license, for example through use of clinical pharmacists in a community setting and upskilling other health care professionals to manage less complex health problems;

• actions which facilitate an expanded multi-disciplinary team and greater integration across community services to optimise out of hospital care for patients including access to premises, diagnostics, technology and community assets.

NHS England has retained some national funds to support workforce developments as indicated in the investment section. This includes:

a) International recruitment: NHS England will produce a framework for CCGs along with other partners to recruit doctors internationally and will fund several overseas recruitment projects for up to 500 doctors nationally. Further information will be available by the end of December 2016.

b) Clinical pharmacists in general practice: in addition to the clinical pharmacist recruited in phase one, additional funding will be available (as set out in the GPFV) for providers over the next three years to assist in costs of establishing the role in practices. Further information will be made available by December 2016.

c) HEE and NHS England will produce frameworks and models to support the expansion of physician associates, medical assistants and physiotherapists.

1.5 WorkloadGuidance for the General Practice Resilience Programme sets out indicative funding allocations of £8 million each year for 2017/18 and 2018/19 for NHS England Regional teams to deliver a menu of support to help practices become more sustainable and resilient. Local teams should work in partnership with STPs and CCGs to ensure this funding is used to target support at areas of greatest need and work in line with the processes set out in the operational guidance to deliver upstream support for practices. Local teams will keep their assessments of practices to be selected for support under six-monthly review and by July and January of each fnancial year will be able to confrm their list of practices prioritised for support and that agreed action plans for delivery of support to these practices are in place.

For people living with long term conditions, self care is usual care. STP footprints should ensure that people living with long term conditions reporting low levels of support or confdence to self care (or for those STPs using the Patient Activation Measure, low levels of activation) undertake regular personalised care and support planning and are signposted to tailored support. Personalised care and support planning should take place in general practice and should produce a single care plan, which is owned by the patient and shared with the system.





Commissioners should also have established pathways of care that integrate with community pharmacy. For example, we would expect CCGs to have considered the value provided by a community pharmacy based minor ailments service and also the contribution to better medicines use by patients with long terms conditions – both of which are expected to have a positive impact on patient experience and practice workload.

1.6 Practice infrastructureCCGs should have clear local estates and digital roadmaps which lay out the plans to create the infrastructure to support new models of care. These should deliver against the requirements set out in recent guidance (Local Estates Strategies: A Framework for Commissioners and the GP IT Operating Model 2016/18).

Estates and technology schemes funded or part funded by the Estates and Technology Transformation Fund must meet the specifed core criteria. NHS England will work with CCGs to agree the pipeline of investments.

Digital Roadmaps, as highlighted in the GP IT Operating Model 2016/18, should set out priorities and deliverables for each year. Interoperability must feature as must the pursuit of innovative technologies to transform triage and consultations with patients to alleviate workload pressures.



Annex 7

Cancer services transformation planning requirements

2017/18 2018/19 Metrics

Strengthen existing tobacco controls and smoking cessation services, in line with reducing smoking prevalence to below 13% nationally by 2020

Strengthen existing tobacco controls and smoking cessation services, in line with reducing smoking prevalence to below 13% nationally by 2020

Smoking prevalence in adults in routine and manual occupations (PHOF 2.14; annual; PHE)

Increase uptake of breast, bowel and cervical cancer screening programmes

Increase uptake of breast, bowel and cervical cancer screening programmes

Cancer screening uptake rates (PH Outcomes Framework 2.20i-iii; annual; PHE)Stage at diagnosis

Drive earlier diagnosis by:A. Implementing NICE

referral guidelines, which reduce the threshold of risk which should trigger an urgent cancer referral

B. Increasing provision of GP direct access to key investigative tests for suspected cancer

Drive earlier diagnosis by:A. Implementing NICE

referral guidelines, which reduce the threshold of risk which should trigger an urgent cancer referral

B. Increasing provision of GP direct access to key investigative tests for suspected cancer

A. Stage at diagnosisB. GP direct access to tests

used for suspected cancer in Diagnostic Imaging Dataset (offcial statistics; monthly; NHS England statistics)



2017/18 2018/19 Metrics

Commission suffcient capacity to ensure 85% of patients continue to meet the 62 day standard by:A. Identifying any 2017/18

diagnostic capacity gapsB. Improving productivity or

implementing plans to close these immediate gaps

Commission suffcient capacity to ensure 85% of patients continue to meet the 62 day standard and to begin to meet the 28 day faster diagnosis standard by:A. Identifying any 2018/19

diagnostic capacity gaps.B. Improving productivity or

implementing plans to close these immediate gaps

62-day cancer waiting times (offcial statistics, monthly, NHS England statistics)Stage at diagnosisA. Submission of planning

trajectories for activity (diagnostic tests; endoscopy tests) (annual, NHS England)

B. Diagnostic Waiting Times (offcial statistics; monthly; NHS England Statistics)

Ensure all parts of the Recovery Package are available to all patients including:A. Ensure all patients have a

holistic needs assessment and care plan at the point of diagnosis and at the end of treatment

B. Ensure that a treatment summary is sent to the patient’s GP at the end of treatment

C. Ensure that a cancer care review is completed by the GP within six months of a cancer diagnosis

Ensure all parts of the Recovery Package are available to all patients including:A. Ensure all patients have a

holistic needs assessment and care plan at the point of diagnosis and at the end of treatment

B. Ensure that a treatment summary is sent to the patient’s GP at the end of treatment

C. Ensure that a cancer care review is completed by the GP within six months of a cancer diagnosis

Local data collectionCurrently piloting collection of HNA data using COSD (PHE)Developing national quality of life metric

Ensure all breast cancer patients have access to stratifed follow up pathways of care and prepare to roll out for prostate and colorectal cancer patients

Ensure all breast, prostate and colorectal cancer patients have access to stratifed follow up pathways of care

Local data collectionExploring how data may be collected nationallyDeveloping national quality of life metric

Ensure all patients have access to a clinical nurse specialist or other key worker

Ensure all patients have access to a clinical nurse specialist or other key worker

CNS question in CPES (Q17 Cancer Patient Experience Survey, annual, NHS England Statistics)



Annex 8

Mental health transformation planning requirements

1. Mental health transformation 61

1.1 Overview 61

1.2 Transformation funding 62

1.3 Summary table of key deliverables for mental health transformation 63



1 Mental health transformation

1.1 OverviewLocal areas must plan to deliver in full the implementation plan for the Five Year Forward View for Mental Health, including commitments to improve access to and availability of mental health services across the age range, develop community services, taking pressure off inpatient settings, and provide people with holistic care, recognising their mental and physical health needs. As part of this, local areas must also ensure delivery of the mental health access standards for Improving Access to Psychological Therapies (IAPT), Early Intervention in Psychosis (EIP) and eating disorders.

Additional funding underpinning the delivery of the Five Year Forward View for Mental Health must not be used to supplant existing spend or balance reductions elsewhere. This new money builds on both the foundation of existing local investment in mental health services and the ongoing requirement to increase that baseline by at least the overall growth in allocations to deliver the Mental Health Investment Standard. Savings arising from new services (such as integrated Improving Access to Psychological Therapies/Long Term Conditions and Mental Health liaison in A&E) resulting from this new investment need to be reinvested to maintain services and ensure delivery of the commitment to treat an additional one million people with mental illness by 2020/21.

CCGs should commit to sharing and assuring fnancial plans with local Healthwatch, mental health providers and local authorities. Details of deliverables and actions are summarised below but areas should make reference to fuller guidance set out in Implementing the Five Year Forward View for Mental Health.



1.2 Transformation fundingMental health transformation funding is available for the specifc deliverables within the implementation plan. For 2017/18 and 2018/19 the new commitments which are supported by identifed funding are:

• Commission additional psychological therapies from a baseline of 15% so that at least 25% of people with anxiety and depression access treatment by 2020/21, with the majority of the increase integrated with physical healthcare.

• Increase access to evidence-based specialist perinatal mental health care, in line with the requirement to meet 100% of need by 2020/21, and ensure that care is in line with NICE recommendations.

• Deliver ‘core 24’ standard liaison services for people in emergency departments and inpatient wards in at least 50% of acute hospitals by 2020/21.

Small amounts of transformation funding may be available locally, if not nationally delivered, in 2018/19 against the following sets of deliverables:

• Deliver community based alternatives to secure inpatient services such that people requiring services receive high quality care in the least restrictive setting.

• Deliver increased access to Individual Placement Support for people with severe mental illness in secondary care services by 2020/21; increase access to IPS by 25% on 2017/18 baseline in 2018/19.

Details of amounts of funding available both from the transformation fund and within CCG baselines are set out in Implementing the Five Year Forward View for Mental Health.



1.3 Summary table of key deliverables for mental health transformation

Deliverable Key actions for commissioners and providers

How this will be measured

Increase access to high quality mental health services for an additional 70,000 children and young people per year.

• Implement local transformation plans to expand access to CYP services by 7% in real terms in each of 2017/18 and 2018/19 (to meet 32% of local need in 2018/19).

• Ensure that all areas take full part in the CYP IAPT workforce capability programme and staff are released for training courses.

• Commission 24/7 urgent and emergency mental health service for children and young people that can effectively meet the needs of diverse communities, and ensure submission of data for the baseline audit in 2017.

• Access to evidence based treatment for children and young people will be measured through the MHSDS (number of CYP who have started and completed treatment) and NHSE fnance tracker to monitor additional funding.

• Data will be provided from HEE and the CYP IAPT programme at CCG and provider level.

• 24/7 urgent and emergency response times will be measured through a baseline audit and, subsequently through the MHSDS.

Community eating disorder teams for children and young people to meet access and waiting time standards.

• CCGs should commission dedicated eating disorder teams in line with the waiting time standard, service model and guidance.

• Commissioners and providers should join the national quality improvement and accreditation network for community eating disorder services (QNCC ED) to monitor improvements and demonstrate quality of service delivery.

• Waiting times and access to evidence based care will be measured through UNIFY from 2016/17 and the MHSDS from 2017/18.





Increase access to evidence-based specialist perinatal mental health care.

• Commission additional or expanded specialist perinatal mental health community services to deliver care to more women within the locality.

• Ensure staff are released to attend training or development as required.

• Provision of specialist community services will be monitored through MHSDS and NHSE fnance tracker.

• Baseline provision against treatment pathway and outcomes will be measured through CCQI self-assessment and subsequent validation.

Commission additional psychological therapies for people with anxiety and depression, with the majority of the increase integrated with physical healthcare.

• CCGs should commission additional IAPT services, in line with the trajectory to meet 25% of local prevalence in 2020/21. Ensure local workforce planning includes the number of therapists needed and mechanisms are in place to fund trainees.

• From 2018/19, commission IAPT services integrated with physical healthcare and supporting people with physical and mental health problems. This should include increasing the numbers of therapists co-located in general practice by 3000 by 2020/21.

• Increased access rates: through quarterly publications and other reports within the IAPT data set.

• Therapists working in general practice: through the annual IAPT workforce census.





Expand capacity so that more than 50% of people experiencing a frst episode of psychosis start treatment within two weeks of referral with a NICE-recommended package of care.

• Commission/provide an early intervention service that provides NICE-concordant care to people aged 14-65 years, meeting the relevant access and waiting time standards in each year.

• At least 25% of EIP teams should meet the rating for ‘good’ services in the CCQI self-assessment by 2018/19.

• The RTT component of the standard will be measured through the UNIFY collection in 2017/18, moving to MHSDS as soon as possible.

• The NICE-concordant component of the standard will be measured in the CCQI provider self-assessment.

Reduce suicides by 10%, with local government and other partners.

• CCGs and providers should contribute fully to local multi-agency suicide prevention plans, following the latest evidence and PHE guidance.

• Suicide rates will be published by CCG in the MH dashboard, using ONS statistics.

Commission effective 24/7 Crisis Response and Home Treatment Teams as an alternative to acute admissions.

• Commissioners must have conducted a baseline audit of CRHTTs against recommended best practice and have begun to implement a funded plan to address any gaps identifed.

• Providers must routinely collect and monitor clinician and patient reported outcomes and feedback from people who use services.

• Plans for CRHTTs to be monitored through the CCG Improvement and Assessment Framework.

• Delivery of effective CRHTTs in line with standards to be assessed and validated by CCQI.

• CCG funding for crisis services to be monitored through NHSE fnance tracker





Eliminate of out of area placements for non-specialist acute care.

• Commissioners and providers must deliver reductions in non-specialist acute mental health out of area placements, in line with local plans, with the aim of elimination by 2020/21

• Commissioners must ensure routine data collection and monitoring of adult mental health out of area placements, including bed type, placement provider, placement reason, duration and cost.

• Plans for reducing OAPs to be monitored through milestone indicator in the CCG IAF.

• Out of area placements to be measured through an interim CAP collection (from autumn 2016), moving to the MHSDS (from April 2017).

Deliver integrated physical and mental health provision to people with severe mental illness.

• CCGs should commission NICE-recommended screening and physical health interventions to cover 30% of the population on GP register with severe mental illness (SMI), and 60% in 2018/19.

• Providers to meet the physical health SMI CQUIN requirement.

• NHS England to measure physical health checks in primary and secondary care through a clinical audit of people with SMI to have received a cardio-metabolic assessment and treatment within inpatient settings, EIP services and community-based teams.





Ensure that 50% of acute hospitals meet the ‘core 24’ standard for mental health liaison as a minimum, with the remainder aiming for this level

• Commissioners and providers must implement funded service development plans to ensure that adult liaison mental health services in local acute hospitals are staffed to deliver, as a minimum, the ‘Core 24’ service specifcation.

• Funding will be made available for mental health liaison via a two-phase bidding process. The frst phase of bidding will be run in autumn 2016 for funding in 2017/18 (wave 1) and 2018/19 (wave 2). The second phase of bidding will be run in autumn 2018 for funding in 2019/20 (wave 3) and 2020/21 (wave 4). A&E Delivery Boards (formerly known as System Resilience Groups) will be invited to bid in late October.

• Health Education England will commission an annual workforce survey of liaison mental health services to monitor compliance with workforce elements of the ‘core 24’ standard.

• Access and waiting times for liaison services will be assessed and monitored through CCQI, and in due course the MHSDS.

• Outcome measures in line with RCPsych standards will also be collected and monitored through CCQI assessment against standards and the MHSDS.

Increase access to Individual Placement Support for people with severe mental illness

• Using local fndings from the national IPS baseline audit, CCGs should plan for improving access to IPS employment support for people with SMI across their STP area from 2018/19.

• STP footprints will be invited to bid for transformation funding in autumn 2017, with bids submitted by December 2017.

• NHS England will commission a national baseline audit for IPS services in Q3/4 2016, supported by regional assurance of CCG plans.





CCGs will continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia.

• Achieve and maintain a diagnosis rate of at least two-thirds, making sustained gains towards the national ambition with a view to halving the number of CCGs not meeting the ambition by March 2019.

• Increase the number of people being diagnosed with dementia, and starting treatment, within six weeks from referral; with a suggested improvement of at least 5% compared to 2015/16 (subject to local agreement).

• Monthly monitoring and reporting of CCG diagnosis rates using QOF data.

• Regular monitoring and reporting of referral to treatment times using MHMDS data and self-report data from the new CCQI tool.

• Annual monitoring of care plan reviews using QOF data.

Ensure data quality and transparency.

• Commissioners must assure that providers are submitting a complete, accurate data return for all routine collections in the MHSDS, IAPT MDS and to any ancillary UNIFY collections.

• Providers must engage with CCQI to complete and submit self-assessment tools and subsequent validation in relation to all evidence-based treatment pathways.

• Ensure a locally agreed suite of quality/outcome measures is in place which refects mental, physical and social outcomes, in line with national guidance.





Increase digital maturity in mental health.

• Commissioners should support full interoperability of healthcare records ensuring mental health services are included in local digital roadmaps, plans and suffcient investment is made in functionalities and capabilities

• Commissioners should support further expansion of e-prescribing across secondary care mental health services.

• Next and subsequent iterations of the digital maturity index.

• Next and subsequent iterations of the digital maturity index.


22 September Month 2016

NHS Providers | ON THE DAY BRIEFING | Page 1

2017-2019 OPERATIONAL PLANNING & CONTRACTING “PLANNING GUIDANCE” – ON THE DAY BRIEFING Today the national bodies NHS England (NHSE) and NHS Improvement (NHSI) have published their “planning guidance” 2017-2019 NHS Operational planning and contracting. This briefing paper summarises the proposals, and gives NHS Providers view on them. The planning guidance outlines the expectations of the national bodies for system level planning over the next two years, focussing on contracting and sustainability and transformation plans (STPs) as well as introducing a range of new national business rules. Alongside the planning guidance the draft standard contract has also been published today (summarised in a separate briefing document, to follow on our website) as well as the draft National Tariff prices and draft national CQUINs.

WHAT HAS BEEN PUBLISHED TODAY? • 2017-2019 Operational planning & contracting “planning guidance”

• Technical guidance for NHS planning 2017/18 and 2018/19

• Draft standard contract for consultation

• Draft Tariff prices for 2017/18 and 2018/19

• Specialised services commissioning intentions and Specialised CQUIN Scheme Guidance for 2017-2019

KEY PROPOSALS The key proposals from the planning guidance focus on several areas – changes to contracting processes, STP financing measures and performance metrics, and some further details on sustainability and transformation funding. The key deadlines and information on publication dates relating to these items can be found in Annex 2.

STP planning, control totals and performance metrics

STP areas are required to submit local financial plans showing how their systems will achieve financial balance within the available resources, with NHSI and NHSE expecting both the commissioner sector and the provider sector to each be in financial balance in both 2017/18 and 2018/19. The position of each provider’s plan (on finance, activity and workforce) has to be consistent with the STP footprint financial plan for 2017/18 and 2018/19 that will be submitted on 21 October 2016 and with the system control for that STP area (see below for more detail), with the aggregate of all operational plans in a footprint needing to reconcile with the overall STP position. All organisations will be held accountable for delivering both their individual control total and the overall system STP control total.

Page 1 of 11Agenda Item 12.0b - NHSP Briefing - 2017 to 2019 Planning Guidance.pdfOverall Page 161 of 190

https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/

https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/

https://improvement.nhs.uk/uploads/documents/Technical_guidance_sep2016_v9_21sep_FINAL.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/09/1-consult-doc-flsf.pdf

https://improvement.nhs.uk/resources/proposed-national-tariff-prices-1718-1819/

https://www.england.nhs.uk/wp-content/uploads/2015/12/spec-comm-intent.pdf

https://www.england.nhs.uk/wp-content/uploads/2015/12/spec-cquin-guid.pdf


From April 2017 each STP will have a financial control total derived from all the individual control totals for CCGs and provider organisations in that geography. It will be possible to flex individual organisation’s control totals within that system control total via an application to NHS England and NHS Improvement, the purpose being to allow better balance, integration and planning across different organisations. STPs can also propose to NHS England and NHS Improvement a subdivision or cross-STP boundary arrangements of their geography, with separate system control totals (and governance arrangements) for each sub-division, if they feel it is better suited to operational collaboration and risk management. The document notes STP leaders “will have strong governance processes to ensure clarity as to how different organisations are contributing to agreed system working, how progress will be tracked, and how organisations will work together to manage cross-cutting transformational activity.”

Drawing on existing data collections from the assurance frameworks, NHSI and NHSE will also publish core baseline STP metrics in November, encompassing, as a minimum, the following metrics:

• Finance • Performance against system control totals

• Quality • Operational Performance

• A&E performance

• RTT performance

• Health outcomes and care redesign • Progress against cancer taskforce plan

• Progress against mental health FYFV implementation plan

• Progress against the General Practice Forward View

• Hospital total bed days per 1,000 population

• Emergency hospital admissions per 1,000 population

STP areas will need to agree trajectories against these areas for 2017-19.

Sustainability and transformation funding (STF)

The planning guidance and its technical annex outline the following on future allocations of the STF funding:

• £1.8bn of sustainability funding will again be available in 2017/18: a £1.5bn general fund allocated on the basis of emergency care; a £0.1bn general fund allocated to non-acute providers; and a £0.2bn targeted fund.

• NHSE and NHSI have reviewed the approach to the STF for 2017/18 to 2018/19 in the light of experiences in 2016/17, and made changes based on an impact assessment model at an individual provider level. Based on this work they have allocated individual providers an indicative share of the STF and a provisional control total for 2017/18 and 2018/19. These are being communicated in a letter to each provider on 30 September 2016.

• The operating rules will be subject to agreement with the Department of Health and HM Treasury. However, as in 2016/17, the payment of STF will depend on providers meeting their financial control totals and meeting the core access standards.

• The baseline for 2017/18 trajectories will be the same as the agreed trajectories for 2016/17. Any provider whose plan for 2016/17 did not deliver one or more of the national standards for operational performance will not be able to reduce this baseline, and will have a trajectory to reach the national standards during 2017/18.



• If a provider does not deliver its performance trajectory during 2016/17 as a result of “exceptional circumstances outside of its control”, it can use an appeals process to NHS England and NHS Improvement.

From 2017/18 onwards, the guidance states streams of transformation funding will increasingly be targeted towards “the STPs making most progress”. This funding will be focused on delivery of specific national programme objectives “rather than spread thinly everywhere”. To minimise the administrative burden, NHSE and NHSI will “ensure that the different application processes for different programmes are more co-ordinated.”

Contracts and the contracting round

The document reaffirms that the contracting round will be completed by the end of this calendar year, and the contracts signed within this contracting round will last two financial years, starting from April 2017. With regard to the process for signing off contracts, the document states:

• “We expect all contracts to be signed by 23 December”.

• “Access to formal arbitration must be a last resort… and [resorting to arbitration] will be seen as a clear failure of collaboration and good governance.”

• “NHS Improvement and NHS England will intervene where necessary, using their oversight and regulatory powers to resolve any cases where organisations refuse to do.”

• “To enable a more collaborative approach to contracting [there will be] increased access to technical advice on contract and tariff issues… [and] escalation to NHS England and NHS Improvement Chief Executives (or delegated national directors) for commissioners and providers that do not agree their contracts” on time.

• “Where a provider refuses to follow the NHS arbitration process, they may forfeit a proportion of their Sustainability and Transformation Fund (STF) monies, and where a CCG fails to comply with the process, quality premium and transformation monies may be forfeited.”

Regarding the content on the contracts, the planning guidance outlines the following:

• The 2017-19 planning and contracting round “will be built out from STPs”. Two-year contracts will reflect two-year activity, workforce and performance assumptions that are agreed and affordable within each local STP. They must include “how they support delivery of the local STP, including clear and credible milestones and deliverables”

• It also requires that plans include:

• The planned contribution to savings at an STP level,

• How risks have been jointly identified and mitigated

• The impact of new care models, including where appropriate how contracts with secondary care providers will be adjusted to take account of the introduction of new commissioning arrangements (MCPs, PACs)

• The technical guidance published alongside the main planning guidance states that providers plans must be “stretching from a financial perspective: planning to deliver (or exceed) the financial control total agreed with NHS Improvement, thus qualifying the provider for receipt of STF; taking full advantage of efficiency opportunities including those identified by the Carter review and the agency rules.”

Where providers accept their financial control totals and any associated conditions and are therefore eligible for payments from the Sustainability and Transformation Fund, contract sanctions for key performance standards will continue to be suspended until April 2019.



Nine ‘must dos’ for 2017-19

These are the same as outlined in 2016/17 planning guidance, and they remain for the priorities for 2017/18 and 2018/19. Commissioner and provider plans need to demonstrate how they will deliver these nine ‘must-dos’.

2017/18 and 2018/19 ‘Must dos’

1. STPs – includes: Implement agreed STP milestones, on track for full achievement by 2020/21, and achieve agreed trajectories against the STP core metrics set for 2017-19.

2. Finance – includes: Deliver individual CCG and NHS provider organisational control totals and achieve local system financial control totals. Also implement local STP plans, moderate demand growth, increase provider efficiencies, including Carter proposals

3. Primary care – includes: Implement the General Practice Forward View., ensure local investment meets or exceeds minimum required levels., Increasing the number of doctors working in general practice, improve weekend and evening access, and Support general practice at scale and the expansion of MCPs or PACS,.

4. Urgent & emergency care – includes: Deliver the four hour A&E standard and standards for ambulance response times. By November 2017, meet the four priority standards for seven-day hospital services for all urgent network specialist services. Implement the Urgent and Emergency Care Review.

5. Referral to treatment times and elective care – includes: Deliver the NHS Constitution standard that more than 92 per cent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment. Deliver patient choice of first outpatient appointment, and achieve 100% of use of e-referrals by April 2018 in line with the 2017/18 CQUIN. Implement the national maternity services review

6. Cancer – includes: Implement the cancer taskforce report. Deliver the NHS Constitution 62 day cancer standard. Make progress in improving one-year survival rates and ensure all elements of the Recovery Package are commissioned.

7. Mental health – includes: Deliver in full the implementation plan for the mental health five year forward view for all ages. Ensure delivery of the mental health access and quality standards including 24. Increase baseline spend on mental health and eliminate out of area placements for non-specialist acute care by 2020/21.

8. People with learning disabilities – includes: Deliver Transforming Care Partnership plans with local government partners, reduce inpatient bed capacity. Reduce premature mortality by improving access to health services, education and training of staff, and by making necessary reasonable adjustments for people with a learning disability or autism.

9. Improving quality in organisations – includes: Implement plans to improve quality of care, particularly for organisations in special measures.



Other key items

National Tariff

Draft Tariff prices for the next two years have been published today and are available here. Subject to consultation, cost uplifts in the national tariff will be set at 2.1% for 2017/18 and 2.1% for 2018/19. As previously announced, the efficiency deflator will be set at 2% in both years. The proposal for follow up outpatient activity to move to a single block payment was not widely supported by either commissioners or providers during the Tariff Engagement over the summer. As a result NHSI and NHSE “intend as an alternative to increase the percentage of follow-up costs bundled into first attendances as follows:

• 30% - adult surgical specialties and some medical specialties e.g. diabetes, cardiology and general paediatric medicine;

• 20% - other medical specialties;

• 10% (i.e. no change) – oncology, haematology, paediatric specialties and areas where Best Practice Tariffs apply e.g. transient ischaemic attack.”

Education and Training Tariffs

To “provide stability to providers”, Health Education England (HEE) will not be introducing changes to the education and training tariff currency design before April 2019. There are three possible exceptions to this:

• The non-medical placement tariff. The Department of Health consultation on education funding reforms could lead to structural changes from September 2018;

• Dental undergraduate tariff, where the Department of Health is proposing changes to the structure of the tariff from April 2018; and

• The potential expansion of the standardised education and training tariff for primary care placements.

CCG Business Rules and Allocations and “Risk reserve”

In 2016/17 CCGs had to ensure the 1% non-recurrent investment was uncommitted at the beginning of the year in order to create a risk reserve for the NHS worth c£800m. For 2017/18 and 2018/19 both commissioners and providers are required to help create the risk reserve. As in 16/17, release of the risk reserve to each local system will be dependent on delivery of its control total, subject to a satisfactory national risk profile. The risk reserve will be created from three components, totalling c. £830m:

• CCGs will again be asked to ensure that 1% of their allocation is planned to be spent non-recurrently, but only half of this – equivalent to £360m – has to be uncommitted at the start of the year, with the other half being available for immediate investment;

• NHS England will add c.£200m to this;

• 0.5% of the local CCG CQUIN scheme will also be held within the risk reserve, contributing £270m. Where systems are delivering their control total, this element of the risk reserve will be released for investment by the providers to whom the CQUIN is payable, with no other conditions attached.


https://improvement.nhs.uk/resources/proposed-national-tariff-prices-1718-1819/


Other salient items include:

• Commissioner allocations may be refreshed to reflect the impacts of new tariff pricing and updated Identification Rules for specialised services. Any adjustments will be published on 30 September.

• In deficit CCGs are expected to achieve at least breakeven position in-year and plan for return to cumulative underspend over the Spending Review period. Where this is not possible, they will be required as a minimum to improve their in-year position by 1% of allocation per year plus any above average allocation growth until the cumulative deficit has been eliminated and the 1% cumulative underspend business rule is achieved.

CQUINs

The current CQUIN scheme enables providers to earn up to 2.5% of annual contract value if they deliver objectives set out in the scheme. For 2017/18 and 2018/19, the full 2.5% will continue to be available to providers. NHS England is intending to make two changes to the scheme.

Continuing the arrangement of the current year, 1.5% of the 2.5% will be linked to delivery of nationally identified indicators. The indicator set has been streamlined, and with different indicator sets for different provider types. For acute and community services, the proposed national indicators cover six areas; there are five in mental health, and two in ambulance services. The national indicators include:

• NHS staff health and wellbeing (all providers)

• proactive and safe discharge (acute and community providers);

• reducing 999 conveyance (ambulance providers)

• NHS 111 referrals to A&E and 999 (NHS 111 providers);

• reducing the impact of serious infections (acute providers)

• wound care (community providers);

• crisis liaison (acute and mental health providers);

• physical health for people with severe mental illness (community and mental health providers);

• transition for children and young people with mental health needs (mental health providers);

• advice and guidance services (acute providers);

• e-referrals (acute providers, 2017/18 only;) and

• preventing ill health from risky behaviours (acute providers 2018/19 only; community and mental health providers, both years)

The remaining 1% will be assigned to support providers locally. 0.5% of this will be available subject to full provider engagement and commitment to the STP process. To support the introduction of system-wide risk pooling at STP level, the remaining 0.5% will be held as a reserve to cover risks in delivery of the relevant system control total. Where the system as a whole is on track to deliver within its system control total, this 0.5% will be payable to providers.

Specialised Services commissioning intentions and CQUINs

NHS England’s commissioning intentions for specialised services are published today alongside the planning guidance. These set out national priorities for the six programmes of care, and region-specific priorities, as well as priorities for clinical and service reform, quality improvement and peer review including the payment system for secure mental health and critical care. The specialised services CQUIN scheme will remain as now with 2% of contract value for all acute providers, 2.5% for mental health providers, and 2.8% for Hep C lead providers.



The scheme provides a limited number of CQUINs per contract, proportionate to the financial value of CQUIN investment. The largest acute and mental health provider will have between ten and five CQUINs respectively, with an average three CQUINs per contract. NHS England will seek further views on the proposed specialised CQUIN indicators as part of the wider CQUIN engagement exercise in October, and will publish any changes to the final scheme at the end of October.

NHS PROVIDERS VIEW ON THE PLANNING GUIDANCE We welcome the action NHS England and NHS Improvement have taken to create a more effective planning cycle for 2017/18-2018/19. There are clear themes in the planning guidance of:

• Setting a more realistic, though stretching, ask on provider efficiency with a 2% headline efficiency requirement

• Providing greater planning certainty and stability through a two-year tariff, contract and consistent list of ‘must do’ performance commitments

• Supporting collaboration between providers and commissioners to reduce the time spent on transactional contractual disagreements and coming to earlier agreement on contracts

• Signalling further moves towards system-based working, including the development of STP metrics and control totals.

We acknowledge the aims of this new approach in reducing the transactional costs in the system and creating more time and focus on the delivery of longer-term transformation of services. However, there are several significant practical and policy issues to address if the aims of the planning guidance are to be realised.

Deadlines for agreeing contracts The aim to have contracts signed off earlier is laudable and many providers are already accelerating their internal planning process to meet this new deadline. However, there is a clear trade-off between developing a plan quickly, and developing a well thought-through plan that has appropriate clinical input and board oversight. We would not wish to see providers or commissioners penalised for following good governance and planning processes where this entails missing a brought-forward deadline. Many providers are also exploring complex new contracting arrangements that involve alliances between social care, primary care and third sector providers. Developing these contracts requires considerable time and resource, and partners in these alliances may not always be bound by the requirements of the NHS planning timeline. We welcome the assurance that commissioners will still have the ability to let new longer-term contracts and revise existing contracts accordingly, but contracting teams have finite time available and will be developing both these longer term contracts and the standard annual or biannual contract in parallel. It would be helpful if NHS England and NHS Improvement could provider a clearer signal on whether resources should be prioritised in developing the standard contract over the next three months, or these longer-term contracts that may have greater benefits for patients. There is welcome recognition in the guidance that less time should be spent in adversarial and transactional contracting disagreements between CCGs and providers in the forthcoming contracting round. It would be helpful to see how NHS England will provide oversight on whether opening offers from CCGs in the contracting round are credible and supportive of a good faith negotiating process. It must also be recognised that many of the challenges in agreeing contracts between CCGs and providers in 2016/17 did not always arise from local issues but sometimes from seemingly conflicting guidance from the national bodies. We will be seeking greater clarity from NHS England



and NHS Improvement on how we will avoid issues where CCGs and providers simply can not agree a contract due to their commitments to organisation control totals and risk reserves. Finally, while the planning guidance is clear in its view that failure to avoid arbitration is a failure of collaboration and good governance, we would argue that it would be a greater failure of governance for autonomous provider boards to sign-up to contracts that are neither fair nor deliverable, and this must be respected as part of the dispute resolution process and wider discussions with NHS Improvement and NHS England.

National tariff and standard contract As noted earlier we welcome the retention of a more credible 2% efficiency factor. We strongly opposed the introduction of a single block payment for outpatient activity, and welcome the changes that have been made to this policy. However, the proposed changes to the payment system are still relatively blunt and will potentially penalise providers offering outpatient follow-ups at clinically appropriate levels.

Provider finances and control totals The planning guidance sets out how sustainability and transformation funding and control totals will operate over the next two years. We will be continuing our discussions with NHS Improvement over the longer-term strategy for control totals and how providers will be supported to return to greater autononomy in financial decision-making and control. We will also be working closely with Health Education England to understand how changes to education and training funding will affect provider income over the course of the parliament. Although there is initial stability to provider income from education and training in 2016/17 from non-recurrent top-up payments, changes to the HEE budget in 2017/18 and 2018/19 may result in significantly increased pass-through costs to providers. The planning guidance reiterates that the target NHS provider deficit for 2016/17 should be no more than ₤580m with a goal of ₤250m, and that any slippage against this target will lead to higher cumulative efficiency asks on providers in 2017/18-2018/19 as we will have ‘unrealised and undelivered efficiency opportunity from previous years.’ We will continue our influencing work with the national bodies to argue that the planning guidance must-dos must in fact be doable, and there is little to be gained by setting unachievable financial or performance targets that are then missed.

STPs Following the introduction of STPs in last year’s planning guidance, this year’s planning guidance potentially cements STPs as a new unit of financial and performance monitoring and management, in addition to their initial primary purpose as a planning vehicle. Greater clarity is needed on what the long term strategic direction for STPs will be, what accompanying regulatory and legistlative changes are needed, and what support will be provided for the development of clearer and more accountable governance structures. Further information is also needed on what support will be provided to STP leaders who will now see their duties and responsibilities grow.

Allocating STP-wide, or sub-STP-wide, financial control totals may in some areas support the appropriate sharing of financial risk and resource to improve services for patients, and the benefits of system-based working and collaboration are considerable. However, there is significant complexity involved in designing these systems. A given



mental health provider for example may now find itself with an individual control total, an STP control total, a separate contractual arrangement for the specialised services it offers, and on-going negotiations with partner providers and commissioners on transfers of services that will affect all the control totals within the STP as well as the aggregate STP-position. Resolving these issues is not impossible, nor is this the wrong thing to aim for, but it will be a significant challenge for local health systems to achieve this within the next few months. It is also unclear whether reporting of A&E and RTT performance at STP level is simply additive and an aggregate of individual organisational reporting, or whether this is intended to allow greater flexibility in how services are delivered at individual organisations as long as the STP-wide performance is on trajectory.

Our next steps Separate details will be circulated on how we will be involving our members in our engagement programme with NHS England and NHS Improvement on specific issues in the planning guidance, such as the longer-term approach to education and training funding and the operation of CQUINS, and wider issues including the governance issues surrounding STPs. If you have any questions please contact Edward Cornick (Policy Advisor – NHS Finances) [email protected]


mailto:[email protected]


ANNEX 1: NHS Providers press statement

Welcoming the release today of the NHS 2017/19 planning guidance, Chris Hopson, chief executive of NHS Providers, said: “This year’s planning and contracting round was one of the most difficult and frustrating in NHS history. We therefore welcome the desire of NHS England and NHS Improvement to improve and refine this year’s process. The much earlier publication of the national planning framework allows frontline organisations to start their planning much earlier in the year, although this will bring some challenges. “A two year planning and contracting period will help make the best use of resources. The clarity on key elements of the NHS landscape like the tariff, CQUINs, business rules and the standard contract will all help and are to be welcomed. We recognise the hard work of NHS England and NHS Improvement, which have worked at high speed, to get us here. “The tariff is sensible and will help providers - together with the continuing £1.8 billion support – to eliminate or significantly reduce deficits. This year's quarter 1 results has shown, despite the huge pressure on providers from rising demand and the stretch on social and primary care, that extra investment in providers delivers concrete results for patients. “We also welcome the recognition that the NHS is in transition from a service focussed on individual organisations to one focussed on local health and care systems. “We also welcome the recognition that the NHS is in transition from a service focussed on individual organisations to one focussed on local health and care systems. The guidance sets out helpful, but appropriately flexible, guidance on how these two year 2017/19 operational plans interact with Sustainability and Transformation Plans. “There are some aspects that need further exploration over the next weeks but these should not detract from the positive steps taken so far to help the NHS manage a very challenging financial challenge and plug the gap. In particular, we need to be sure that numbers of small but unfunded commitments are not added later in the year. This is critical as the gap between what the NHS is being asked to deliver and the funding available remains. But this guidance provides a helpful basis to enable the NHS to now plan how to meet the more challenging times we face.” Ends



Annex 2: Planning timeline

Key deadlines for planning and contracting processes and information publication dates Date

Planning Guidance published + Technical Guidance issued 22 September

Draft NHS Standard Contract, national CQUIN scheme guidance and National Tariff draft prices issued 22 September

Initial STF 2017/2018 guidance issued to providers 30 September

Commissioner allocations, provider control totals and STF allocations published 21 October

NHS Standard Contract consultation closes 21 October

Submission of STPs 21 October

National Tariff section 118 consultation issued 31 October

Final CCG and specialised services CQUIN scheme guidance issued 31 October

Commissioners (CCGs and direct commissioners) to issue initial contract offers that form a reasonable basis for negotiations to providers

4 November

Final NHS Standard Contract published 4 November

Providers to respond to initial offers from commissioners (CCGs and direct commissioners) 11 November

Submission of full draft 2017/18 to 2018/19 operational plans 24 November

National Tariff section 118 consultation closes 28 November

Where contract signature deadline of 23 December at risk local decisions to enter mediation 5 December

Contract mediation 5 – 23 December

National Tariff section 118 consultation results announced w/c 12 December

Final National Tariff published 20 December

National deadline for signing of contracts, submission of final approved 2017/18 to 2018/19 operational plans, aligned with contracts (Final contract signature date for avoiding arbitration) 23 December

Submission of joint arbitration paperwork by CCGs, direct commissioners and providers where contracts not signed By 9 January

Arbitration outcomes notified to CCGs, direct commissioners and providers Within 2 working days after panel

Contract and schedule revisions reflecting arbitration findings completed and signed by both parties By 31 January


Trust Board

Meeting Date: 29th

September 2016 Agenda Item:

Subject: Finance Report for the period to 31st

August

For Publication: No

Author: Sam Garrett, Head of Financial

Planning & Reporting

Approved by: Paul Ronald, Deputy

Director of Finance & Performance

Improvement

Presented by: Keith Loveman, Director of Finance


To inform the Board of the current financial position and the outstanding matters which may

impact the final position reported for the full year.

Action required:

To review the financial position set out in this report, consider whether any additional action is

necessary, or any further information or clarification is required.


The overall Trust position reported in August for the year to date is a surplus of £639k, which is

ahead of the Plan of £400k by £239k. The reported position for the month is a surplus of £150k,

ahead of the Plan of £50k by £100k. The overall NHS Improvement (NHSI) Risk Rating, the FSRR,

reports as a 4. Key figures are summarised below:

FSRR 4 In Month Plan £000

In Month Actual £000

YTD Plan £000

YTD Actual £000

Overall Surplus (Deficit)

50 150 400 639

Pay Overall 11,296 11,307 56,780 56,349

Agency 745 709* 4,005 3,678 *

Secondary Commissioning

2,082 2,313 11,642 10,281

*Although currently within the NHSI Agency Expenditure Cap, this is due to NHSI phasing. Current activity levels and forecasts suggest

the cap may not be achieved in the full year.

This position remains broadly in line with previous reporting, and has been driven by the level of

vacancies; the resulting pay saving is partly offset by a shortfall in the CRES program, in particular

continued high agency usage. Spend on secondary commissioning (placements and packages,

both health and social care) remains high, and above plan.

Although the position is favourable year to date, this is expected to reverse during the latter half of

Page 1 of 6Agenda Item 13.0 - Financial Summary to end August 2016 - Public Board.pdfOverall Page 173 of 190

the year reflecting planned investment requirements.

This position excludes income from the Sustainability and Transformation Fund (STF), which in

principle remains neutral in effect.


Effective use of resources, in particular to meet the continuing financial requirements of the

organisation.

Summary of Implications for:

Finance – achievement of the 2016/17 planned surplus and Risk Rating

Seen by the following committee(s) on date: Finance & Investment / Integrated Governance /

Executive / Remuneration / Board / Audit


1. Background to Financial Plan 2016/17

1.1 The Financial Plan reflects settlement of all key contracts and that, within Hertfordshire, the

agreed contract reflects commissioners’ support for the national parity of esteem ambition,

providing additional income for developing services in 2016/17. The Trust also benefits from the

lower national efficiency requirement in 2016/17 of 2%. Against this there are growing

pressures in both demand for services, the challenges in recruiting and retaining staff, and the

growing impact of issues in the wider system both locally and nationally. The Plan is

summarised in Fig. 1a below:

Fig. 1a Description 2015/16 Plan 2015/16 Actual 2016/17 Plan**

Income 198.8 205.9 211.4

Pay -129.3 -132.6 -136.1

Other Direct Costs -27.2 -30.9 -27.8

Overhead Costs -29.8 -32.9 -36.9

EBITDA 12.5 9.5 10.6

EBITDA Margin 6.86% 4.6% 5.01%

Financing -11.5 -9.5 -10.0

Surplus 1.0 0.0* 0.6

* Excludes impairments

** This is before any amounts due under the Sustainability and Transformation Fund

1.2 The Plan assumes achievement of a surplus of £0.6m, (lower than the 2015/2016 Plan which was

£1.0m, but compares to a break-even position achieved in 2015/16); and a NHSI FSRR of 3

(against 3 in 2015/16). The key risks to the achievement of the Risk Rating are:

1.2.1 Securing planned income from commissioners and the achievement of at least 90% of

the available CQUIN.

1.2.2 The achievement of the CRES target of £6.3m, in particular, the planned reduction in

agency pay spend, and in external placements.

2. Performance Summary and Risk Rating

2.1 The year to date Trust position for August is a surplus of £639k, which is ahead of the Plan of

£400k by £239k. The reported position for the month is a surplus of £150k, which is ahead of

the Plan of £50k by £100k. The forecast remains to achieve the control total, reflecting planned

investments. This position excludes income from the Sustainability and Transformation Fund

(STF), which in principle remains neutral in effect.

2.2 This position remains broadly in line with previous months of the year, and is driven by the level

of vacancies; the resulting pay saving is partly offset by a shortfall in the CRES programme, in

particular continued high agency usage; pay is now marginally above plan, as a result of agency

spend, though remaining significant vacancies contribute to substantive pay being below plan.

Spend on secondary commissioning (placements and packages, both health and social care)

remains high, and above plan, with increases in August for External Acute, due to continued bed

pressures, but decreases for social care residential, as service users move on to more

independent settings.

2.3 Although the position is favourable year to date, this is expected to reverse as vacancies

continue to be filled, and with significant one-off expenditure due later in the year, on areas


such as enhancing the environment, and on information technology to support efficiency and

effectiveness.

2.4 The Trust’s overall Risk Rating, the Financial Sustainability Risk Rating (FSRR), reports as a 4

overall in the month.

3. Trading Position

3.1 Employee Pay Costs totalled £11.3m in August, £11k above Plan; year to date totalled £56.3m,

below Plan of £56.8m by £431k. This position reflects the net impact of leavers and new

starters, and is affected by vacancies, offset by ongoing agency usage above Plan. Of the

overall total spend in the month, £9.3m (82.5%) was on Substantive Staff, £709k (6.5%) on

Agency, and £1.3m (11%) on Bank. This reflects a small increase in agency spend in the

month, and an increase in substantive pay.

3.2 Fig. 3a

shows overall

actual against

planned pay

spend for the

last 12 months.

This illustrates

pay reducing in

Quarter 3 of

2015/16, and

then increasing

again from

January, in line

with

recruitment to

posts funded

from the 2015/16 investment by commissioners in additional posts. Although there is a peak

in March, this is due to higher levels of bank and agency pay accounted for at the yearend.

Planned pay has increased significantly from Quarter 4 2015/16 to Quarter 1 2016/17 in line

with the 2016/17 investment by commissioners in additional posts, with the actual spend on

Plan or below this financial year.

3.3 There remain high levels of vacancies, c. 540, of which a number are covered by bank and

agency. Action is being taken to address recruitment including:

3.3.1 Focused Recruitment and Retention Group

3.3.2 Actions taken on retention including work on Wellbeing, staff social club, staff

lottery

3.3.3 Overseas recruitment – c. 40 offers out

3.3.4 Targeting local universities


3.7 The most significant area of non-pay spend above Plan remains Secondary Commissioning,

which totalled £2.3m in August, above Plan by £230k; £11.6m year to date, above Plan by

£1.4m. There has been an improvement in some areas, such as Controlled Access Placements;

areas of most concern are Acute and PICU placements, with Acute increasing in August, and

Residential Social Care, though this did decrease in August.

3.8 Work continues via the Supporting Service Users in the Right Environment (SSURE) Project to

review service users, ensuring they are in the most appropriate setting, and working with

providers to encourage recovery-orientated principles.

4. Statement of Financial Position

4.1 Receivables decreased by £256k in August, as main contract commissioners are now up to date

with their payments.

4.2 Payables and accruals increased by £1.1m, due to fewer invoices being received over the

summer period.

4.3 Cash balances have decreased by £2.0m in the month, including cash inflow from operating

activities of £2.1m (including £320k STF funding), and cash outflow from investing activities of

£100k.

4.4 Cumulative capital spend for 2016/17 is £2.1m, including income from asset sales of £300k,

and VAT recovery on the Lambourn Grove project of £214k.

5. Forward Look

5.1 HCS (Health and Community Services – HCC) have issued notification that the social care

resources to the Trust will be reduced by £1m (c. 4.4%) from 1 April 2017. This will be

significantly challenging, and work is ongoing to fully understand the potential impact on

services and statutory responsibilities for social care delegated to the Trust through its

contractual agreements.


Current Trading - Income Statement for Period Ended 31-August-2016 31/08/16 APPENDIX F2

10 3 05-Jan-1900 6 05-Jan-1900

Actual in

month Aug-

15

Actual YTD

to 31-Aug-

15 Description 2016/17 Plan Month Aug - 16 Year to Date Aug - 16

Actual Plan Variance Actual Plan Variance

31 31 Number of Calendar Days 365 31 31 153 153

0 0

12,936 63,974 Contract #1 Hertfordshire IHCCT 163,557 13,775 13,630 146 68,294 68,149 146

1,536 7,634 Contract #2 East Anglia LAT 18,686 1,536 1,557 (21) 7,680 7,786 (105)

626 3,775 Contract #3 North Essex (West Essex CCG) 9,122 763 763 0 3,817 3,817 0

168 842 Contract #4 Norfolk (Astley Court) 2,020 126 168 (42) 783 842 (59)

715 2,351 Contract #5 IAPT Essex 6,694 555 558 (3) 2,754 2,789 (35)

15,981 78,577 Contracts 200,079 16,756 16,676 79 83,329 83,382 (54)

42 193

Clinical Partnerships providing mandatory svcs (inc

S31 agrmnts) 993 127 83 45 621 414 207

185 957 Education and training revenue 2,147 191 179 12 985 894 91

458 2,234 Misc. other operating revenue 2,488 199 207 (8) 1,050 1,041 9

476 2,242 Other - Cost & Volume Contract revenue 5,006 467 417 50 2,268 2,086 183

72 353 Other clinical income from mandatory services 755 106 63 43 441 315 127

47 186 Research and development revenue 24 48 2 46 175 10 165

17,261 84,741 Total Operating Income 211,491 17,894 17,627 267 88,869 88,141 728

(8,609) (43,616) Employee expenses, permanent staff (131,066) (9,319) (10,901) 1,582 (46,441) (54,799) 8,358

(1,218) (5,856) Employee expenses, bank staff (3,294) (1,279) (274) (1,005) (6,231) (1,374) (4,856)

(1,214) (5,714) Employee expenses, agency staff (1,454) (709) (121) (588) (3,678) (606) (3,072)

(54) (263) Clinical supplies (538) (39) (45) 6 (199) (224) 26

(2,370) (11,498)

Cost of Secondary Commissioning of mandatory

services (24,531) (2,313) (2,082) (230) (11,642) (10,281) (1,361)

(219) (1,061) Drugs (2,627) (201) (219) 18 (998) (1,094) 96

(13,684) (68,009) Total Direct Costs (163,511) (13,859) (13,642) (217) (69,188) (68,380) (809)

3,577 16,732 Gross Profit 47,980 4,035 3,984 19,681 19,761

20.72% 19.75% Gross Profit Margin 22.69% 22.55% 22.60% 22.15% 22.42%

Overheads

(54) (222) Consultancy expense (15) (14) (1) (13) (153) (6) (147)

(55) (427) Education and training expense (451) (69) (38) (32) (333) (188) (146)

(354) (1,905) Information & Communication Technology (4,103) (405) (342) (63) (2,072) (1,710) (362)

(474) (2,245) Hard & Soft FM Contract (4,081) (321) (340) 19 (1,680) (1,700) 20

(1,274) (5,365) Misc. other Operating expenses (14,524) (1,145) (1,197) 52 (5,707) (5,669) (38)

(52) (307) Non-clinical supplies (620) (29) (52) 22 (227) (258) 31

(239) (1,185) Rents (2,904) (217) (244) 27 (1,167) (1,198) 31

(0) (0) Reserves (7,314) (586) (607) 21 (2,264) (3,062) 798

(261) (1,417) Travel, Subsistence & other Transport Services (3,341) (280) (278) (2) (1,390) (1,392) 2

(2,764) (13,073) Total overhead expenses (37,352) (3,067) (3,099) 32 (14,994) (15,183) 189

813 3,659 EBITDA 10,628 968 886 82 4,687 4,578 109

4.71% 4.32% EBITDA Margin 5.02% 5.40% 5.02% 5.27% 5.19%

(431) (2,155) Depreciation and Amortisation (5,480) (437) (457) 20 (2,166) (2,283) 117

(41) (191) Other Finance Costs inc Leases (473) (40) (39) (0) (197) (197) (0)

3 10 Gain/(loss) on asset disposals (0) (0) (0) (0) (0) (0) (0)

11 48 Interest Income 105 8 9 (1) 57 44 13

(377) (1,883) PDC dividend expense (4,180) (348) (348) (0) (1,742) (1,742) (0)

(22) (513) Net Surplus / (Deficit) 600 150 50 100 639 400 239

-0.13% -0.61% Net Surplus margin 0.28% 0.84% 0.28% 0.72% 0.45% Page 6 of 6Agenda Item 13.0 - Financial Summary to end August 2016 - Public Board.pdfOverall Page 178 of 190

1


Report of the Report from the Audit Committee

Agenda Item 14

Meeting Date 29 September 2016 Presented By Catherine DugmoreNon-Executive Director

1. Purpose of the Report:

This paper provides a summary report of the items discussed at the Audit Committee meeting on 21 September 2016.

2. Items Discussed:

The Agenda for the meeting included: Clinical Audit Programme Internal Audit progress report and tracking status report Counter Fraud progress report External Audit update Trust Risk Register and Board Assurance Framework Evaluation of both Internal and External Audit Effectiveness Outcome of the evaluation of the effectiveness of the Audit Committee Quarter 1 NHSI Formal Feedback letter Use of Waivers in Quarter 1 and 2 CQC Registration Compliance Service User Finance Policy

The committee received a progress report on the Clinical Effectiveness Programme. The annual programme had increased by 20% by using time and resources more effectively and at times using smaller data samples which returned the same results. The committee noted that in respect of DNAs for CAMHS little progress had been made although 56% of service users had a reason why they had not attended completed in their Electronic Patient Record.

The committee received an update on the Internal Audit work noting that there were four completed reports for consideration which were:

Data Quality, RAG rated green, substantial assurance, with two low and one medium recommended actions.

CQC Action Plan RAG rated amber green, reasonable assurance, with two low and one medium recommended actions.

Financial Forecasting and Budgetary Control rated amber green, reasonable assurance with three low and two medium actions.

Service User Money and Property which was an advisory report which was not RAG rated.

Internal Audit also presented a status report on the number of recommendations that had been completed, were overdue or their target date had not yet been reached.

The report highlighted that there were 17 recommendations of which 41% of the actions had been completed, 12% the date had not been reached, 18% were being implemented and 29% (5 actions) were outstanding. It was noted that the 5 actions had been implemented since the report had been issued.

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The Counter Fraud progress report highlighted the significant activity of the Local Counter Fraud Specialist (LCFS) in the Trust. A number of ongoing investigations were discussed which included the use of e-Rostering where the online responsibilities of managers had been delegated inappropriately to more junior staff. These investigations highlighted the importance of keeping passwords confidential. The control issues relating to e- Rostering were noted and discussed by the Committee. LCFS will be performing a proactive piece of work examining the controls around e-Rostering. It was agreed that LCFS would liaise with management regarding the learnings from this work so that they can be incorporated into the roll out of e-Rostering into the community services.

The committee noted that November was Fraud Awareness month.

External Audit provided an update on their work noting that they were in the process of putting together their audit plan which would be brought to the December meeting. They highlighted that there was to be a new accounting manual which would look very different to what is currently used. They also referred to the emerging issues around governance in relation to the Sustainability and Transformation Plans and the potential impact of these on the audit process.

The Trust Risk Register and Board Assurance Framework were presented noting that these had been discussed at the Integrated Governance Committee and the July Board meeting. Work is currently underway on a refreshed version.

The committee noted that the contracts for both internal audit including counter fraud and external audit had been extended for a year and were due for review, although both had an option of extending for a further year. A process for the Evaluation of Internal and External Auditors was discussed and agreed which would be brought back to the December meeting for consideration. The Committee agreed that in view of the status of the contract and the change in the internal audit lead partner, the Trust would initiate a tender process for internal audit and LCFS for the financial year commencing 1 April 2017.

The committee noted that there had been one Waiver in Quarters 1 and 2 which related to the provision to service users of fitness instruction in the Trust's Gyms.

CQC Registration Compliance was discussed by the committee noting the progress against the CQC inspection recommendations. Oversight of the action plan is provided by the IGC and the report had also been presented to the Trust Board at their July meeting.

Finally the committee discussed the draft Service User Finance Policy and noted the importance of ensuring that it cross referenced with the Trust's Safeguarding Policy in relation to financial abuse.

3. Matters for escalation to the Board:There were no matters for escalation to the Board.

4. Committee decisions for Board to note:The Trust would initiate a tender process for internal audit and LCFS5. Decisions for Board approvalNone

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www.hpft.nhs.uk



Subject: Single Oversight Framework Update For Publication: Yes

Author(s): Helen Potton, Company Secretary Approved by: Helen Potton, Company Secretary

Presented by: Helen Potton, Company Secretary


To update the Trust Board on the Single Oversight Framework.

Summary and Recommendations to the Board of Directors

Following a period of consultation NHS Improvement (NHSI) have published their Single Oversight Framework (SOF) which brings together the regulation responsibilities of both Monitor and the Trust Development Authority (TDA). It sets out a framework for overseeing providers which in part, seeks to support them to improve or maintain a CQC rating of good or outstanding.

The attached paper sets out an overview of the framework to enable the Board to understand and discuss the changes and implications for the Trust.

It also includes a self-assessment which indicates that the Trust would be in segment 1 which gives providers maximum autonomy.

The Board of Directors is asked to consider and discuss the contents of the report and self-assessment.

Relationship with the Business Plan & Assurance Framework (Risks, Controls & Assurance):Robust governance is an essential part of the assurance framework. Understanding the changes to the regulatory environment and the likely impact upon the Trust is essential to ensure that the governance framework is effective.

Summary of Financial, Staffing, IT & Legal Implications:There are no overt implications

Equality & Diversity and Public & Patient Involvement Implications:There are no overt implications

Evidence for Essential Standards of Quality and Safety; CNST/RPST; Information Governance Standards, other key targets/standards:The self-assessment provides assurance of the Trust’s commitment to quality and good governance.

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Single Oversight Framework

1 Introduction

Following a period of consultation NHS Improvement (NHSI) have published their Single Oversight Framework (SOF) which brings together the regulation responsibilities of both Monitor and the Trust Development Authority (TDA). It sets out a framework for overseeing providers which in part, seeks to support them to improve or maintain a CQC rating of good or outstanding. A copy of the full document can be found at http://dmtrk.net/2J9J-WB7F-4ARCQR-FT5VO-1/c.aspx.

2 Five ThemesThe SOF sets out five themes which will form the focus for NHSI in carrying out their oversight role:

Quality of CareThis will be assessed using the CQCs most recent assessments of whether a provider's care is safe, effective, caring and responsive, in combination with in year information where available.

Finance and use of resourcesThey will oversee a provider's financial efficiency and progress in meeting its financial control total, reflecting the approach taken in Strengthening Financial Performance and Accountability. They are co-developing this approach with the CQC

Operational performanceThey will support providers in improving and sustaining performance against NHS Constitution standards including access to mental health services. These NHS Constitution standards may relate to one or more facets of quality i.e. safe effective, caring and/or responsive.

Strategic changeThey will consider how well providers are delivering the strategic changes set out in the Five Year Forward View with a particular focus on their contribution to Sustainability and Transformation Plans (STPs), new care models and where relevant implementation of devolution.

Leadership and improvement capability (well-led)This will build on the joint CQC and NHSI well-led framework, developing a shared system view with CQC of what good governance and leadership look like, including an organisations ability to learn and improve.

The first three of these themes relate directly to sector outcomes, whereas strategic change recognises that organisational accountability and system-wide collaboration are mutually supportive. The final, well led theme is crucial in ensuring that providers can deliver sustainable improvement.


http://dmtrk.net/2J9J-WB7F-4ARCQR-FT5VO-1/c.aspx

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3 Assessment

Across each theme, NHSI will utilise a range of qualitative and quantitative information to monitor organisations. This is summarised in the table below:

These arrangements are further supported by a range of more detailed indicators and metrics to determine ‘trigger points’ for NHSI intervention with a graduated approach to earned autonomy for providers in a similar way to the previous regulator, Monitor (See Appx 1 & 2 attached for triggers and specific metrics of the SOF). In essence the outcome from monitoring will ‘segment’ providers on a rating scale of 1 to 4, with 1 being the best, and within each segment a level of support from NHSI will be enabled.

4 What are Segments?The segments for the provider sector are structured as:

Segment Description 1 Providers with maximum autonomy − no potential support

needs identified across our five themes – lowest level of oversight and expectation that provider will support providers in other segments

2 Providers offered targeted support − potential support needed in one or more of the five themes, but not in breach of licence (or equivalent for NHS trusts) and/or formal action is not needed

3 Providers receiving mandated support for significant concerns – the provider is in actual/suspected breach of the licence (or equivalent for NHS trusts)

4 Special measures − the provider is in actual/suspected breach of its licence (or equivalent for NHS trusts) with very serious/complex issues that mean that they are in special measures


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The SOF enables a significant degree of flexibility to NHSI in identifying the potential support needs of a provider and how they will work with them. This will include:

- Extent that SOF measures are triggered;- Associated circumstances for the provider;- Degree of understanding of key drivers;- Capability of provider and credibility of plans; and- Ongoing delivery against recovery trajectory.

5 What does ‘support’ mean?As the needs emerge NHSI will tailor any support required to those specific needs reflecting the graduated approach to earned autonomy. The levels of support offer are described as:

Universal Voluntary use of tools to improve specific aspects of performance

Targeted Voluntary use of support in specific areas with agreed programmes

Mandated Potential support for complex issues with mandated series of improvement actions

The potential application of support against the relevant segment for a provider is graduated as follows:

Segment Levels of support

1 Universal support e.g. tools, guidance, benchmark information made available for providers to access

2 Universal support (as for segment 1) Targeted support as agreed with the provider to address issues and help move the provider to segment 1 either offered to provider (and accepted voluntarily) or

requested by provider

3 Universal support (as for segment 1) Targeted support as agreed with the provider (as for segment 2) Mandated support as determined by NHS Improvement to address specific issues, help move the provider to segment 2

or 1 compliance required

4 Universal support (as for segment 1) Targeted support as agreed with the provider (as for segment 2) Mandated support as determined by NHS Improvement to help minimise the time the provider is in segment 4 compliance required

6 What will be different for the Trust?Whilst significant elements of the SOF already sit within the regulatory framework for the CQC and previously the TDA and Monitor, the framework does indeed bring the approach to oversight into a combined framework for all provider organisations.


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This in effect means that there is no difference between NHS Foundation Trusts and NHS Trusts. NHSI is clear that it will be flexible in how it carries out its role and the need to respond quickly and proactively to unexpected issues in individual providers. It is important to note that the SOF is also clear that a Foundation Trust will only be in segments 3 or 4 where is has been found to have been in breach or suspected breach of its licence. Thus whilst there are a number of triggers which inform the placement within a segment allocation to 3 or 4 will only be in those circumstances.

Concerns were highlighted in the consultation that, particularly with targeted support, a provider would be obliged to accept the support offered. However, NHSI have indicated that in respect of both universal and targeted support this will only be signposted, offered and made available, but will not be mandated. The approach to application of the framework will become clearer over time and whilst elements of support are set out as voluntary, where these will be of assistance in improving performance and achieving best practice, it will be important to ensure these are taken into account by the Trust.

7 What does not change?The key element for the Trust is that our approach should remain open and transparent and that the relationship with NHSI needs to continue on this basis. We have benefitted from working at and building on the support provided by our relationship team at Monitor and with the CQC and as a learning organisation would want to maintain this.

Self-AssessmentTo enable HPFT to understand the potential impact of the SOF and the indicative segment that it would sit in, we have undertaken a self-assessment based on evidence currently available. Appendix 1 sets out the specific indicators for the Trust and an update on each metric.The five themes are set out below together with the self-assessment.

1 Quality of CareOne of the triggers for Quality of Care is where the CQC has rated the provider with an inadequate or requires improvement. The Board will be aware that whilst HPFT received a Good in its CQC inspection under “Safe” it received requires improvement with four domains achieving that score. Since the inspection HPFT has put in place a robust action plan which the Board received an update on at its meeting in July. The Board will recall that the CQC identified a number of actions which have now been completed and that an external review is due to take place in October/November to confirm that the areas identified as requires improvement have moved to good.The Quality Indicators suggest that information is available and mostly reported upon and would not trigger a concern.

2 Finance and use of resourcesThere have been some changes to the finance and use of resources metrics. Agency spend has been introduced into this score from quarter 3. Previously they had indicated that this would only take place in shadow form. The Trust is already completing a monthly return on agency spend and is within the trajectory although the Board will be aware that there is a risk that it will become more challenging to remain within the cap as the year progresses.

A review of the financial metrics scoring indicates that HPFT would score 1 overall.


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3 Operational performanceThere are currently three indicators which HPFT will be measured upon on a quarterly basis. Two are already reported on and are being achieved; the third is the subject of a CQUIN.

4 Strategic changeNHSI have produced guidance on how they expect well-led providers to work with partners and collaborate locally. The guidance can be found at www.improvement.nhs.uk/uploads/documents/Guidance_on_good_governance_in_a_LHE_context_final.pdfand sets out the expectations on providers when considering local health economy (LHE) working and collaboration around scope, appropriate level, engagement approach, rationale and accountability. In view of the significant Director level involvement in the STP this should be an area of strength for HPFT.

5 Leadership and improvement capability (well-led)Providers must demonstrate three main characteristics:

Effective boards and governance Continuous improvement capability Use of Data

HPFT have recently been the subject of a governance review which was presented to the Public Board meeting in July. Whilst there are areas for improvement the overall findings of the review were positive indicating that HPFT was well-led and had an effective board with an appropriate governance framework. The Good to Great Strategy and the plans to achieve this demonstrate HPFT’s desire to continuously improve.HPFT collects, uses and where required submits robust data.

Likely Segment outcomeFollowing the self-assessment it is considered that there is sufficient evidence to indicate that HPFT would be in segment 1 as there have been no potential support needs identified across the five themes.


http://www.improvement.nhs.uk/uploads/documents/Guidance_on_good_governance_in_a_LHE_context_final.pdf

http://www.improvement.nhs.uk/uploads/documents/Guidance_on_good_governance_in_a_LHE_context_final.pdf

www.hpft.nhs.uk

Appendix 1Quality of care (safe, effective, caring, responsive) monitoring metricsMeasure Type Frequency Source UpdateStaff Sickness Organisational health Monthly/quarterly NHS Digital (publicly

available) This information is produced on a monthly and quarterly basis and is included in the performance reports on a monthly basis and goes to Trust Board on a quarterly basis. At the end of Q1 the sickness absence rate was 3.92%. At the end of August the rate was 4.01%.

Staff turnover Organisational health Monthly/quarterly NHS Digital (publicly available)

This information is produced on a monthly and quarterly basis and is included in the performance reports on a monthly basis and goes to Trust Board on a quarterly basis. At the end of Q1 the turnover rate was 14.14%. At the end of August the rate was 13.92%.

Executive team turnover Organisational health Monthly Provider return Chief Nurse leaving. Director Service Delivery & Customer Experience relatively new in post. Remainder of team in post in excess of a year. No interims currently in place.


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Measure Type Frequency Source UpdateNHS Staff Survey Organisational health Annual CQC (publicly available) This is produced on an

annual basis. The survey will commence in October 2016 and the outcome of the survey will be received in February/March 2017.

Proportion of temporary staff Organisational health Quarterly Provider return We produce data on a monthly and quarterly basis which shows bank and agency fill rates and the percentage of bank and agency as a proportion of the overall pay bill. This information goes to Trust Board on a quarterly basis. As at the end of Q1 10.9% of the pay bill was spent on bank staff and 6.9% on agency. At the end of August YTD 10.9% was spent on bank staff and 6.45% on agency.

Aggressive cost reduction plans Organisational health Quarterly Provider return It is not clear what the measure will be for this metric and further information will be required.

Written complaints - rate Caring Quarterly NHS Digital (publicly available)

Our KO41 return is the submitted to NHS Digital and is available publically.

Staff Friends and Family Test % recommended - care

Caring Quarterly NHSE (publicly available) Stable rate in high 80%

Occurrence of any Never Event Safe Monthly NHS Improvement (publicly available)

We haven’t had one.


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Measure Type Frequency Source UpdateNHS England/NHS Improvement Patient Safety Alerts outstanding

Safe Monthly NHS Improvement (publicly available)

We have no outstanding alerts and meet our deadlines.

CQC inpatient/mental health and community survey

Organisational Health Annual CQC (publicly available) CQC community survey which is due to be published shortly.

Mental health scores from Friends and Family Test - % positive

Caring Monthly NHSE (publicly available) We report on this as part of our patient experience reports currently 88%.

Admissions to adult facilities of patients who are under 16 years old

Safe Monthly NHS Digital (publicly available)

This would be considered an SI and reported to Board and is not an issue for us.

Operational performance metricsStandard Frequency Standard UpdatePatients requiring acute care who received a gatekeeping assessment by a crisis resolution and home treatment team in line with best practice standards (UNIFY2 and MHSDS)

Quarterly 95% 100% as per Quarter 1 return100% for July and August.

People with a first episode of psychosis begin treatment with a NICE-recommended package of care within 2 weeks of referral (UNIFY2 and MHSDS)

Quarterly 50% 57.6% as per Quarter 1 return75.8% July69% August

Ensure that cardio-metabolic assessment and treatment for people with psychosis is delivered routinely in the following service areas: a) inpatient wards b) early intervention in psychosis services

Quarterly

90% 90% 65%

This is not currently routinely reported but is one of this year’s CQUINs and will be measured by audit.


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Finance and use of resources metrics


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