nhs 1.30 chair 2.0 chair’s report 1.40 chief officer’s report€¦ · ao accountable officer...

NHS Barking and Dagenham Clinical Commissioning Group Governing Body meeting 18 July 2017

1.30pm Maritime House, 1 Linton Road, Barking

Item Time Lead director Attached, verbal or to follow

1.0 1.1 1.2

1.3

Welcome, introductions and apologies Declaration of conflicts of interest Minutes of the meeting held on 23 May & 29 June 2017 Matters/actions arising

1.30 Chair Attached Attached Attached

2.0 2.1 2.2 2.3

Chair and chief officer reports Chair’s report Chief officer’s report Patient engagement report

1.40 1.45 1.50

Chair CB SW

Attached Attached Attached

3.0 3.1

Governing body assurance Governing body risk assurance framework report 1.55 SM Attached

4.0 4.1

Corporate strategy and planning Corporate objectives 2.05 CB Attached

5.0 5.1

Service transformation and development Urgent care case for change 2.15 SM Attached

6.0 6.1 6.2 6.3

Quality and performance Integrated contract management report Finance report Quality report

2.25 2.35 2.45

TT TT JH


7.0 7.1

7.2 7.3 7.4

7.5

Development/governance Finance and Delivery committee – revised terms of reference Finance & delivery committee chair’s report Audit & governance committee chair’s report Work of the FRPB and Financial Recovery Programme Progress Summary Minutes of sub – committees and relevant fora:

• Primary care transformation programme board• Joint executive committee• Patient engagement forum

2.55

3.00 3.05 3.10

3.15

MP

KP KP TT

Attached


Attached

8.0 AOB 3.20

9.0 Questions from the public 3.25

10.0 Date of next meeting – 26 September 2017 3.30

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Glossary of terms and abbreviations

Term Explanation

AO Accountable Officer

ACS Accountable Care System

ADL Activities of Daily Living

APC Area Prescribing Committee

ASH Accredited Safe Haven

BCF Better Care Fund

BHR Barking and Dagenham, Havering and Redbridge

BHRUT Barking, Havering and Redbridge University Trust

BPPC Better Payment Practice Code

CAPS Clinical Application Services

CCG Clinical Commissioning Group

CCS Complex Care Service

CDOP Child Death Overview Panel

CEO Chief Executive Officer

CFO Chief Finance Officer

CHC Continuing Healthcare

CHS Community Health Services

CHSCS Community Health and Social Care Services

CIL Community Infrastructure Levies

CO Chief Officer

COO Chief Operating Officer

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUIN Commissioning for Quality and Innovation

CSU Commissioning Support Unit

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CTT Community Treatment Team

CVS Council of Voluntary Services

CYPP Children and Young Person Plan

DI Discovery Interview

DOH Department of Health

DTOC Delayed Transfer of Care

ECG Electrocardiogram

EHC Education, Health and Care

ELHCPB East London Health and Care Partnership Board

EMT Executive Management Team

EoI Expression of Interest

EOL End of Life Care

FNP Family Nurse Partnership

FRPB Financial Recovery Programme Board

FRPDM Financial Recovery, Planning, Delivery and Monitoring

FT Foundation Trust

FYE Full Year Effect

GBAF Governance Board Assurance Framework

GP General Practitioner

H4NEL Health for North East London

HCAIs Healthcare Associated Infections

HE NCEL Health Education North Central and East London

HSC Health Scrutiny Committee

HWBB Health & Wellbeing Board

IAPT Improving Access to Psychological Therapies

ICPB Integrated Care Partnership Board

ICM Integrated Case Management

ICSG Integrated Care Joint Health and Social Care Steering Group

IFR Individual Funding Request

IRS Intensive Rehabilitation Service

IST Intensive Support Team

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JAD Joint Assessment and Discharge Service

JCB Joint Commissioning Board

JEC Joint Executive Committee

JHWS Joint Health & Wellbeing Strategy

JSNA Joint Strategic Needs Assessment

KGH King George Hospital

KPIs Key Performance Indicators

LAC Looked After Children

LAS London Ambulance Service

LETB Local Education and Training Boards

LMCs Local Medical Committees

LPC Local Pharmaceutical Committee

LSCB Local Safeguarding Children’s Board

LTC Long Term Conditions

MASH Multiagency Safeguarding Assessment Hub

MLU Mid-wife Led Unit

MSRB Maternity Systems Readiness Board

NEL North East London

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHS National Health Service

NHSE NHS England

NICE National Institute for Health and Care Excellence

OFSTED Office for Standards in Education, Children’s Services and Skills

OD Organisation Development

ONEL Outer North East London

PALS Patient Advice and Liaison Service

PEFs Patient Engagement Forums

PELC Partnership of East London Cooperatives

PMCF Prime Minister’s Challenge Fund

PMO Project Management Office

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POD Point of Delivery

POLCV Procedures of Limited Clinical Value

PPGs Patient Participation Groups

PSED Public Sector Equality Duty

PTL Patient Tracking List

QIPP Quality, Innovation, Productivity and Prevention

RAG Red. Amber, Green

RTT Referral To Treatment

SAB Safeguarding Adults Board

SCB Safeguarding Children’s Board

SCN Strategic Clinical Network

SDPB System Delivery Programme Board

STP Sustainability and Transformation Plan

TDA Trust Development Agency

TSCL The Transforming Services – Changing Lives

UCC Urgent Care Centre

UCL University College London

UCLP University College London Partners

UEC Urgent and Emergency Care

UTI Urinary Tract Infection

VFM Value for Money

WELC Waltham Forest, East London and City

WICs Walk in Centres

YTD Year to Date

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Register of interests 2017/18

Declaration of governing body members

Last updated: July 2017

Name Role Organisation Nature of interest

Amendment and date

Dr Waseem Mohi

Chair Markyate Surgery Together First Limited London Wellbeing Care Ltd Kensington and Chelsea CCG

Sessional GP Shareholder (May 2014) Director GP partner

Peartree surgery, Herts – until 09/16. Added 20/4/14

Dr Ravali Goriparthi

Clinical director Tulasi Medical Centre Tulasi Properties Ltd Health & Happiness Clinic Ltd Barking, Dagenham and Havering LMC Royal College of General

GP Partner. Spouse is practice manager (19/9/06) Director / Shareholder (1/8/16) Director / Shareholder (1/8/12) Member (7/9/09) Member

Lilly Pharmaceutical Company Limited-removed 1/12/16

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Amendment and date

Practitioners

Dr Jagan John

Clinical director King Edward Medical Group LMC (Barking, Dagenham & Havering) North East London Foundation Trust Together First Limited (from May 2014) Health 1000 (December 2014) Prime Minister’s Challenge Healthy London Partnerships

GP Partner, other GPs are family members (2010) Member (2013) GPwSI in Cardiology BD CHS (2011) Shareholder Director Lead (2015) GP lead – self care

Dr Rami Hara

Clinical director Urswick Medical Centre Pharmaceutical companies Together First Limited (from May 2014) London Deanery

GP Principal Speaker fee - Chair and speaker at educational lectures/meetings Shareholder GP registrar trainer

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3


Amendment and date

NHSE Barts Hospital & Queen Mary’s University

GP appraiser (mainly Havering) Undergraduate Tutor (18/10/16)

Dr Gurkirit Kalkat

Clinical director Thames View Health Centre Primary Clinical Partnership Ltd Apex Healthcare Ltd Queen Mary Medical School, London Together First Limited (from

May 2014)

BHR CCGs

GP Principal Director/owner or part owner/ Share holder Director/owner or part owner/ Share holder Honorary Lecturer Shareholder Area Prescribing Chair

Dr Anju Gupta Clinical director

Abbey Medical Centre Together First Limited

GP Principal and CCG lead for diabetes. Practice employs a GP who is the spouse of a BHRUT director Member (2014)

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4


Amendment and date

NELFT NHSE Wilson Mason PLC Barking, Dagenham & Havering LMC

GPwSI – Diabetes (2009) GP appraiser (2013) Spouse employed as an architect and company undertakes NHS work (2015) Member (2015)

Dr Kanika Rai

Clinical director White House Surgery Together First MacMillan London Deanery Queen Mary’s University and Imperial College

GP partner. Sister is a GP a partner and is also a GPwSI dermatology. Brother is also a partner Shareholder (May 2014). Brother is also a director Cancer lead GP for B&D(2015-17) FY2 and GP trainer (2013) Undergraduate tutor (2007)

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5


Amendment and date

Sahdia Warraich

Lay member The Forum for Health and Wellbeing The Forum for Health and Wellbeing Trading Ltd Heathwatch Redbridge London Borough of Redbridge Newham Deanery Healthy Island Partnership

Director Company Director Member (1/4/13) Spouse is a Councillor Trustee Freelance work (22/6/17)

Healthwatch Waltham Forest Removed 11/7/17

Kash Pandya

Lay member - Governance

Essex Ministry of Justice Advisory Committee Her Majesty’s Inspector of Constabulary Brentwood Citizen’s Advice Bureau Havering CCG Redbridge CCG PricewaterhouseCoopers

Lay Member (2010-18) Associate Inspector (2011) General advisor (2009) Lay Member Lay Member Kiren Pandya (son) Management consultant

Hillcroft College for women, Surbiton – removed May 2017. Health & Safety Executive – removed May 2017. Berwin Leighton Paisner (BLP) removed May 2017.

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Amendment and date

Accenture University of Essex Southend on Sea Borough Council

(2013) Anand Pandya (son) Solicitor Independent Audit Committee member (2013-19) Independent Audit Committee Member (2016-18)

Added May 2017

Charles Beaumont

Associate Independent Lay Voting Member for Audit Committee and Individual Funding Request Panel

None None

North Essex Partnership Foundation Trust – removed 25/4/17

Conor Burke

Accountable officer

None

None Your business works (not trading) - removed Jan 2017 Redbridge college – removed Jan 2017

Sharon Morrow Chief operating officer None

None

Tom Travers

Chief financial Officer Royal Free Foundation Trust Wife works in finance department

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Amendment and date

Jacqui Himbury Nurse director None None

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1

Draft Barking & Dagenham Clinical Commissioning Group Governing Body Meeting

23 May 2017 1.30pm

Maritime House Present: Dr Waseem Mohi (WM) Clinical Director and Chair Dr Kanika Rai (KR) Clinical Director Dr Gurkirit Kalkat (GK) Clinical Director Dr Jagan John (JJ) Clinical Director Dr Anju Gupta (AG) Clinical Director Dr Ramneek Hara (RH) Clinical Director Kash Pandya (KP) Lay member - governance Tom Travers (TT) Chief Finance officer Sharon Morrow (SM) Chief Operating Officer Sahdia Warraich (SW) Lay member – patient and public involvement

In Attendance: Marie Price (MP) Director of Corporate Services Anne-Marie Keliris Company secretary Frank O’Neill NELCSU Richard Vann Healthwatch Apologies: Dr Ravali Goriparthi (RG) Clinical Director Conor Burke (CB) Accountable Officer Jacqui Himbury (JH) Nurse Director Marie Kearns (MK) Chair, Healthwatch

Item Action

1.0 Welcome and apologies The Chair welcomed members to the meeting and apologies for absence were noted.

1.2 Declarations of conflicts of interest

The Chair reminded governing body members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of Barking & Dagenham clinical commissioning group. Declarations declared by members of the governing body are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link: http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

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http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

http://www.barkingdagenhamccg.nhs.uk/About-us/Our-governing-body/register-of-interests.htm

1.3 Minutes of the last meeting

The minutes of the meeting held on 28 March were agreed as a correct record.

1.4 Matters/Actions arising

The governing body noted the actions taken since the last meeting.

2.0 Chair & Accountable Officer’s Reports

2.1 Chair’s report The Chair presented his report covering the following areas:

Financial situation

System development

Meetings

The governing body noted the report. 2.2 Chief Officer’s report TT presented the chief officer’s report covering the following areas:

BHR system delivery plan

CCG development

Meetings

The governing body noted the report.

3.0 Governing body assurance

3.1 Governing body assurance framework SM presented a report which outlined the key risks to the clinical commissioning group in achieving its corporate objectives as identified in the governing body risk assurance framework. There are five risks on the GBAF:-

1. Barking, Havering and Redbridge University Hospitals Trust

(BHRUT) emergency care performance

2. BHRUT cancer 62 days

3. Significant risks to the delivery of the CCG’s financial plan

KP commented that the financial risk reducing by September was optimistic and suggested the rating on this should be reviewed. KP suggested exploring the impact of STP developments and how we respond to issues. RH asked whether there is 62 day RTT comparable data for Barts Health and suggested this could be shared with practices to help them make informed decisions. TT agreed to ask CSU to provide this data. JJ asked for a further discussion on the Barts Health risk and how this is being monitored. SM reported that this is being monitored on the collaborative risk register and suggested reviewing this at finance and delivery committee.

TT/CSU SM/TT

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TT reported that Barts Health performance is also monitored through the contract report and concerns have been raised through lead commissioner arrangements, but these have not reached to the level to be raised to the GBAF. The governing body noted the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken. 3.2 BHRUT performance risks

TT presented a report which provided a further update on the key actions

the CCG is taking to seek performance improvements at the Trust. It is

doing this by both holding the Trust to account through its contract and

other mechanisms, as well as providing overall support through wider

system initiatives overseen through the A&E Delivery Board and the joint

RTT Programme Board.

Given the considerable performance improvements at the Trust and the

lifting of ‘special measures’ as reported to the last governing body

meeting, it is proposed that this be the last ‘exception’ report and that

performance at the Trust is reported to this governing body through the

regular quality and contract reports.

KP referred to the high level of ambulance transfers to King George’s

Hospital and asked whether there is a specific reason for this. TT

responded that there has been a general increase across London and

reasons for this increase are being explored.

The governing body

Noted the action being taken to date to mitigate the performance

risks at BHRUT

Noted the significant delivery of the RTT recovery trajectory year

to date.

Agreed that reporting on the Trust’s performance form part of the

standing contracting and quality reports.

4.0 Corporate strategy and planning

4.1 System delivery framework and plan

TT presented a report which updated on progress made to date against

implementation of the System Delivery Framework.

JJ reported that there had been concerns from members that the system delivery plan will impact and change services offered and questioned when this will be communicated. MP responded that the ‘Spending NHS money wisely’ consultation had recently closed and the responses were currently being analysed. She added that the governing body will be required to consider these and the decision made will be communicated to practices and a support package will also be offered. It was noted there had been discussions with the patient engagement forum and patient participation groups. It was noted that over 600 responses to the consultation had been received.

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SW reported that the patient engagement forum had raised concerns and had requested to be involved in any future work to make savings. SM reported that in addition to the £55m savings, providers also have cost improvement plans which will be reviewed by the system delivery board as will local authority savings plans. The Chair agreed that it was important for clear communication to reassure members that any service changes do not affect quality of care. RM agreed, adding that it was important to personalise communications and to not have a ‘one size fits all’ approach. GK referred to a reduction in integrated care services and JJ reported on a reduction in social worker support. SM agreed to raise this issue at the Integrated Care Steering Group. KP thanked all those involved for identifying opportunities for savings and suggested that the totality and impact of changes should be reported to the governing body in the future.

The governing body noted current delivery against the System Delivery

Framework.

SM

5.0 Quality and performance

5.1 Patient experience report SW presented a report which provided a summary of the various feedback that has come through to the CCG from patients and stakeholders highlighting the following areas:

The Patient Engagement Forum (PEF) meeting and activities of

PEF members.

The wheelchair and equipment review

PPGs

Work with the community and voluntary sector groups

Engagement on CCG’s proposals to address our financial

challenges

MP reported that the one team approach is being explored for patient

engagement forums across BHR CCGs. The Chair welcomed this, but

highlighted the importance of continuing local discussions.

JJ questioned whether there are plans for patient communication at an

STP level. MP reported that the recently appointed STP director of

communications is developing a ‘Community Group’. It was

acknowledged that this group felt too big and this would be fed back to the

STP.

The governing body noted the report. 5.2 Finance & activity report TT presented the month 12 finance and activity report highlighting that the CCG had a breakeven position against a year to date planned surplus of

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£3,020k. Agreement was reached across North East London (NEL) to risk share each CCGs’ 1% reserve. In Month 12 both BHR and WELC CCGs’ were able to release their 1% reserve to mitigate the financial position of BHR CCGs. For Barking and Dagenham CCG the total release equated to £7.4m, which included a £4.53m contribution from WELC CCGs. Without the risk share the CCG would have recorded a deficit. As reported throughout the year the main drivers to the variance to plan are RTT backlog clearance, acute contracts (including QIPP performance) and continuing healthcare. These pressures have been partially offset by an underspend in the Programme area, which relates to the use of the 1% risk share and contingency. There are also smaller underspends within Primary Care, Prescribing, Community and Mental Health and Learning Disabilities. Earlier in the year, in recognition of the financial risk faced, the CCG placed itself into turnaround. Given the financial position of the CCGs it is important that decisions from turnaround continue to contribute to future years to ensure ongoing financial sustainability. The reported position includes savings of £5,345k which is in line with the RAG rated Finance Recovery Plan. The challenging financial position continues into 2017/18, with the CCG facing a recurrent underlying opening deficit which is forecast to be £943k. This position includes £3,108k of full year QIPP savings and before the application of business rules, it therefore includes a level of financial risk. Failure to deliver these savings will adversely impact the underlying position. The consequences of an underlying deficit highlights the urgent need for sustainable financial recovery, which needs to be fully integrated into the CCG’s transformation programmes. BHR CCGs developed a System Delivery Framework as a mechanism to drive system recovery. To date £44m of savings opportunities have been identified across BHR CCGs, an update on the progress of the framework was presented to the meeting in a separate paper. The underlying opening deficit has been used in the development of the 17/18 budgets which were presented to the Governing Body in February and March. Budgets have also been reviewed by the Joint Executive Committee (JEC) in April. In addition the Finance and Delivery Committee reviewed the high level of unmitigated risk that is within the 17/18 budgets at its April meeting. The ongoing review and QIPP delivery and the level of unmitigated risk will be critical to understanding the financial position. External audit are currently reviewing, the 16/17 accounts and so the reported position is provisional at this stage. The final accounts are due to be approved at Governing Body on 26 May. The audited accounts are due to be submitted to NHS England on the 31 May 2016. The Chair questioned how much the CCG expects to use from the risk pool. TT reported that we currently have a £15m QIPP target – the whole of the SDP has to deliver balance across the system and if this isn’t

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reached the CCG will draw from the risk pool. He added that the CCG should be putting all effort into finding the required savings rather than relying on the risk pool. The Chair expressed concern that there is no investment into developing localities and the ACS. MP reported that there are early indications that there may be incentives to develop an ACS and the CCG will need to explore these opportunities. SM added, that the FRPB process is following an ‘invest to save’ approach which will support innovation. JJ expressed concern that other CCGs have invested in primary care and the wider community and felt that the CCG had not. He was concerned that as this lack of investment will be to the detriment of the development of the BHR ACS and questioned how we mitigate this. He suggested that business cases need to be three-five years as delivery will be challenging in one year. He also said it will be difficult for GPs when patients request better services and outcomes available in neighbouring boroughs. SM reported that there will be opportunities for investment through the STP but we will still need to lead and influence where we can but focus on BHR. SW questioned whether the STP will create equality. The Chair agrees this is a question which will need to be raised at the STP board but the CCG also needs to ask MPs and Healthwatch to lobby and influence for equality for our patients. KP suggested that the STP needs to be cited on the corporate risk register so that we can influence and mitigate risk with our partners. The governing body agreed the financial position and noted the action taken to achieve it. 5.3 Contracting report TT presented a report which updated on the contract performance for Month 11 2016/17 for Acute, Community and Mental Health services highlighting the following: BHRUT: A year-end agreement for 2016/17 has been reached with BHRUT at a value of £347m across all 12 CCGs. The share for the BHR CCGs is £339.3m.

Barts Health: A year-end agreement of £103m for the 2016/17 contract has been reached with Barts Health against a plan contract value of £97.3m across BHR CCGs. The year-end agreement is -£3.0m over plan for Barking and Dagenham CCG. NELFT: NELFT is performing in line with their contracted standards in both their community services and mental health service contracts, with the exception of the Improving Access to Psychological Therapies (IAPT) access and recovery targets.

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PELC: The first year of a 2 year contract (2016/18) has helped to stabilise PELC’s financial position and enabled its accountability and sustainability. PELC’s performance for the NHS 111 service in recent weeks has fluctuated due to a surge in call demand. Green ambulance re-triage for lower acuity calls have been around 65% of all calls re-triaged. Support for the implementation of the ‘Well Led Review’ recommendations has concluded and the consultants engaged by Commissioners have produced a final report. PELC has recruited its senior management team including a new Chair of the Council as well as Director of Nursing and Governance, Director of Operations and Chief Pharmacist. The CQC conducted an inspection of PELC services during the months of March and April 2017. The inspection report has not been published by the CQC as yet. LAS: The LAS continues to be very challenged in their delivery of the 8 minute response standard, with the year-to-date for Barking and Dagenham CCG at 61.2% against a standard of 75%. The governing body agreed the reported M11 position for the two main acute and two main non-acute contracts. 5.4 Quality report SM presented a report which provided assurance that the CCG continues to measure and monitor the quality of the services we commission from all providers including:

NELFT CQC inspection

BHRUT CQC mortality outlier alert

BH NHS Trust CQC inspections

GP service alerts

Provider quality performance improvements and challenges

addressed through the CQRM

KR raised further concerns with the GP alert process and suggested exploring different ways the process could be run. She also questioned whether CDs are aware of alerts and suggested that a pathway and protocol is required for GP alerts just as there are for specialities. KP welcomed suggestions and reported that internal audit would be in touch with CDs who had raised concerns. JJ raised concern at BHRUT’s CQC mortality rates for UTIs and requested an urgent GB report including what the issues are and how they are being dealt with and suggested that BHRUT internal audit was required. SM reported that BHRUT will be reviewing the data by 1 June. KR reported that sepsis in the main cause of mortality at BHRUT and the last CQRM received a report which was not sufficient and further detail has been requested. GK commented that sepsis is a national issue and GPs are encouraged to attend training on identifying sepsis.

JH JH

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The governing body noted the report.

6.0 Development/governance

6.1 Finance committees - proposals MP presented a report which requested approval for practical changes to the CCG’s financial governance arrangements and amended terms of reference.

The governing body agreed to disestablish the Investment Committee and

to incorporate its functions into the FRPB and approved the revised terms

of reference for the FRPB.

6.2 The East London Health and Care Partnership agreement MP presented the reviewed East London Health and Care Partnership Partnership Agreement (formerly the MoU, renamed to highlight the focus on partnership working) for the governance arrangements of the ELHCP. SW expressed concern that “North” had been dropped from the partnership and believed that local people will feel disengaged and not recognise this as a partnership that represents their area. MP acknowledged that this was not ideal, although this had been agreed at the STP Board, which the CCG is a member of, and would feed this back to the ELHCP. JJ expressed concern that there will be no BHR influence in the decision and questioned what the scope of the partnership was. MP confirmed that Barking & Dagenham CCG are represented. The Chair acknowledged the concerns raised and suggested further discussion at the joint executive committee to discuss how we are interacting, how we are represented and how we are heard. KP suggested that regular feedback will be required for the governing body and the joint executive committee. The governing body agreed to sign up to the partnership agreement. 6.3 Finance & delivery committee chair’s report The Chair presented a report which provided key highlights of the finance and delivery committee held on 27 April 2017. The governing body noted the report. 6.4 Audit & governance committee report KP presented a report which provided key highlights of the audit and governance committee held on 24 April 2017. The governing body noted the report.

6.5 Work of the FRPB and Financial Recovery Programme

TT presented a summary report which provided key highlights of the FRPB and financial recovery programme.

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The governing body noted the report. 6.6 Minutes of sub committees: The governing body noted the minutes of:

Primary care commissioning committee held on 12 April 2017.

Quality and safety committee held on 25 April 2017

Patient engagement forum held on 23 March 2017.

Joint executive committee held on 9 February 2017.

7.0 AOB

The Chair reported that he had received a letter from the Secretary of State for Health congratulating the CCG on the improvement on diagnostic tests and the Chair commended Dr Hara for his work in this area.

8.0 Questions from the public

There were no questions from the public.

9.0 Date of the next meeting

18 July 2017

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1

Draft Minutes of Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups Governing Body meeting held on 29 June 2.30 – 3.30pm. at

Becketts House

B&D CCG Havering CGG Redbridge CCG

Kash Pandya Kash Pandya Kash Pandya

Dr Gurkirit Kalkat Dr Ann Baldwin Dr Anil Mehta

Dr Jagan John Dr Alex Tran Dr Syed Raza

Dr Anju Gupta Dr Maurice Sanomi Dr Shabana Ali

Dr Ravi Goriparthi Dr Gurdev Saini Dr Shujah Hameed

Dr Kanika Rai Dr Ashok Deshpande Dr Sarah Heyes

Conor Burke Conor Burke Dr Jyoti Sood

Sharon Morrow Alan Steward Dr Anita Bhatia

Tom Travers Tom Travers Dr Muhammad Tahir

Jacqui Himbury Jacqui Himbury Dr Mehul Mathukia

Sahdia Warraich Richard Coleman Conor Burke

Louise Mitchell

Tom Travers

Jacqui Himbury

Khalil Ali

8 required for quorum 8 required for quorum 9 required for quorum

quorate quorate Quorate

In attendance: Marie Price Director of Corporate Services BHR CCGs Anne-Marie Keliris Company Secretary BHR CCGs Katy Scammell Public Health Consultant, London Borough of Redbridge Sue Lloyd Public Health Consultant, London Borough of Barking & Dagenham Cathy Turland CEO, Healthwatch, Redbridge Frances Carroll Chair, Healthwatch, Barking & Dagenham Lee Eborall Director, NELCSU Apologies: Barking & Dagenham- Dr Waseem Mohi, Dr Ramneek Hara Havering- Dr Atul Aggarwal Redbridge- Ah-Fee Chan

Minute Action

1.0 Welcome, Introductions and Apologies

Kash Pandya agreed to act as Chairman to this ‘Governing Body in Common’ of Barking & Dagenham, Havering and Redbridge CCGs. The governing body members were welcomed to the meeting. Apologies for absence were noted as detailed above.

1.1 Declaration of Conflicts of Interest

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The Chair reminded governing body members of their obligation to declare any interest they may have on any issues arising at the meeting which might conflict with the business of the three CCGs and the proposals before us. No further conflicts of interest to those recorded in the registers, were raised by members that were present, other than Sahdia Warraich who reported on a change to her declaration which she would report to the governance team but did not directly relate to the item to be discussed at the meeting.

2.0 Spending NHS Money Wisely

The Chair thanked members for attending the governing body meeting in common and reported that the governing bodies were meeting together because this was a joint consultation. The Chair reported on the financially challenged situation of the BHR CCGs and the need to save £55m in 2017/18 and as responsible commissioners the CCGs must live within our means which means we would need to consider difficult decisions. ‘Spending NHS money wisely’ identified a potential £5.2m of savings through restricting or no longer funding a number of treatments and procedures under the following categories:

IVF

Male and female sterilisation

NHS prescribing

Cosmetic procedures

Weight loss surgery

The Chair handed over to the six clinical directors who led the process. Dr Anita Bhatia reported that the six clinical leads, all local GPs, were tasked with looking at a number of proposals, 33 in total, designed to help the local NHS meet what is a considerable financial challenge. The papers for the meeting contained all the detail needed to review the proposals and consider the recommendations, along with the decision making business case, the consultation report, financial impact and the recommendations methodology. The list of proposals in the eight-week public consultation – ‘Spending NHS money wisely’ - amounted to potential savings to the NHS in our area of around £5.2million. Dr Bhatia reassured the governing bodies of the rigour of the approach in the discussions the clinical leads had to make its recommendations and it was noted that these discussions were challenging, and an important piece of work that was taken very seriously. Throughout the process, clinical directors approached decisions as clinicians and put patients first, but against that backdrop of financial challenge and a responsibility to protect the most essential services for local people. The clinical directors had valuable support from a small panel at its meetings, including public health expertise.

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3

Dr Sarah Heyes thanked Dr Bhatia and echoed her comments on the rigour of the discussions and the challenging process. Dr Heyes reported that from the 33 recommendations were grouped around five themes – IVF, Male and female sterilisation, NHS prescribing, cosmetic procedures and weight loss surgery. IVF The consultation included proposals to stop funding IVF altogether, moving from three cycles to none but this was unanimously rejected and agreed a different position. It was recommended moving from three cycles to one. This will bring us into line with 125 other CCGs across the country with a saving of £1.07m. Male and female sterilisation The consultation proposals around male and female sterilisation have been rejected by the clinical leads and the recommendation is not to implement. It was felt there was likely to be an impact on other services within the system such as unplanned pregnancies. Local authority colleagues had expressed the same concerns. NHS Prescribing The proposals consulted on around NHS Prescribing involved a great deal of debate and were able to agree almost unanimously on all of these. It was made very clear that any patients receiving treatment for cancer will continue to be prescribed the drugs they need and any patient with long-term chronic pain will also continue to receive prescribed medicines as they do now. The recommendations on NHS prescribing will achieve a local saving of £1.01m. That figure includes £210,000 for stopping prescribing gluten-free products. Cosmetic procedures The consultation included a wide range of cosmetic procedures and some of these were supported in our recommendations and others were not with the reasons set out in the report. The recommendations amount to a £710,000 saving to the NHS. The proposals around the future funding of abdominoplasty, were not agreed and was deferred. Bariatric, or weight loss, surgery The proposed changes to the criteria around bariatric, or weight loss, surgery were discussed at length and the group recommended tightening up those criteria, which will deliver a saving of £247,000. In total, it was recommended to no longer fund 22 of the 33 proposals, which would see a saving of £3.03million, impacting on 8.87% of the population. The report included the initial and the full Equalities Impact Assessments and it was noted that a patient experience expert was also able to help with any queries around taking full account of statutory protected characteristics.

24

4

Dr Maurice Sanomi reported on the deferred recommendation on the proposals on abdominoplasty or ‘tummy tucks’ and the significant debate of the practical implications of the proposals to stop funding. It was agreed that the current POLCE – procedures of limited clinical effectiveness – policy should be vigorously adhered to by GP colleagues because it already contains sound guidance on who should access this surgery or not. The CCGs will be highlighting the current guidelines to GP colleagues and will review this in six months’ Cathy Turland questioned whether the Department of Health’s consultation on the prescription of gluten free products will impact on the CCG’s consultation. Marie Price responded that the CCG were aware of this consultation but were unable to wait for the outcome of this consultation due to the financial challenges the CCG faces. Cathy Turland questioned whether the equality impact assessment took into account disability, as disabled patients could struggle financially to pay for over the counter medication. Marie Price responded that equality impact assessments do not take into account deprivation or income as this is not one of the protected characteristics, she added that disability was considered. Dr Goriparthi commented that there are many gluten free products available in supermarkets at reduced prices and GPs do not prescribe products for other intolerances i.e. dairy. Dr Mathukia commented that practices will require adequate communications support. Dr Heyes reported that there will be a whole communications package available for GPs and practices. Dr Mathukia welcomed this, adding it was important for this to be extended system wide to include pharmacists and secondary care consultants. Dr Deshpande confirmed that colleagues across the wider system will receive communication on any decision made. Dr Mathukia commented that it was important to be clear which travel vaccinations will no longer be available. Dr Baldwin questioned whether there will be a point of contact for patients who have concerns or complaints. Dr Bhatia responded that the CCG are exploring options to support both patients and practices. CB agreed that clear signposting for patients and practices will be required. CT questioned how local policy fits with Department of Health and whether the Secretary of State for Health decides what can be prescribed. CB responded that the CCGs decides on how its prescribing budget is utilised. CT agreed to write to the CCGs with further questions. Dr John commented that BHR CCGs are not the first CCGs to take these difficult decisions and questioned whether there is any feedback from other CCGs. Dr Gupta responded that one CCG has stopped IVF completely and had received significant challenges which affected the recommendation the panel made. Dr Heyes commented that any significant changes will take time to embed and it was important to encourage patients to take care of their own health.

25

5

Katy Scammell asked whether there are any examples of negative impact on the restrictions of travel vaccinations. It was confirmed that Hepatitis A was still available and this was a concern that the panel had raised but no evidence of negative impact on the restrictions was noted. Katy Scammell questioned whether there is a reason for the low response rate from Redbridge residents. Louise Mitchell responded that the same approach was applied to all boroughs and the figure related to questionnaires returned, adding there were lots of public meetings where patients concerns were also answered. Dr Tahir questioned what process should be followed if practices are challenged on the restrictions. CB responded that any challenge will follow the normal complaints procedure. Dr Heyes reported that the individual funding request process is also available. Dr Tahir questioned if there will be indemnity of individual clinicians and how will they be supported. CB responded that this is not an individual issue for a GP but a commissioning decision by the CCG. The Chair thanked the governing body members for the discussion and questions. He added that normal practice would allow the public to ask questions at the end of the meeting but in order to consider any comments in our decision making this would be brought forward. Lorraine Silver, Chair of the Redbridge patient engagement forum raised the following concerns:

Wastage in many areas including medicines management

Patients who financially cannot afford to buy prescriptions over the

counter

Restriction of gluten free prescriptions

Dr Bhatia acknowledged the concerns raised and reported that the medicines that are being restricted have limited evidence of clinical effectiveness. She also appreciated the concern raised with regard to gluten free products but the CCG needs to be consistent with its approach to prescribing for intolerances. Marie Price referred to low income and reported that the NHS cannot means test. She also acknowledged that NHS wastage was a common theme in the consultation and will be discussing this further at the patient engagement forums. Conor Burke echoed this, adding there are still more savings that need to be achieved this year and welcome the input of all patents in this challenge. Barking & Dagenham CCG governing body approved the recommendations detailed in the decision making business case. Havering CCG governing body approved the recommendations detailed in the decision making business case. Redbridge CCG governing body approved the recommendations detailed in the decision making business case.

26

6

The Chair thanked the clinical director leads for their hard work during and after the consultation.

3.0 Any Other Business

There was no other business.

27

1

Matters arising/ action log from the Barking and Dagenham CCG Governing Body held

on 23 May 2017

Action ref: Meeting date

Action required Lead Required by Status

3.1 GBAF

23 May 2017

Dr Hara requested 62 RTT comparable data for Barts Health and suggested this could be shared with practices to help them make informed decisions. CSU asked to provide.

TT/ CSU

July 2017 Verbal update

3.1 GBAF

23 May 2017

Dr John asked for a further discussion on the Barts Health risk and how this is being monitored. It was agreed to review this at finance and delivery committee.

SM July 2017 Verbal update

4.1 SDF

23 May 2017

Dr Kalkat referred to a reduction in integrated care services and Dr John reported on a reduction in social worker support. Agreed to raise at the Integrated Care Steering Group..

SM July 2017 Raised at the Integrated Care Steering Group meeting on 12 June with a more detailed review planned for 10 July.

5.4 Quality report

23 May 2017

Dr Rai raised further concerns with the GP alert process and suggested exploring different ways the process could be run. She also questioned whether CDs are aware of alerts and suggested that a pathway and protocol

JH July 2017 Verbal update

28

2

Action ref: Meeting date

Action required Lead Required by Status

is required for GP alerts just as there are for specialities. KP reported that internal audit would be in touch with CDs who had raised concerns.

5.4 Quality report

23 May 2017

Dr John raised concern at BHRUTs CQC mortality rates for UTIs and requested an urgent GB report including what the issues are and how they are being dealt with and suggested that BHRUT internal audit was required. SM reported that BHRUT will be reviewing the data by 1 June

JH July 2017 Verbal update

29

To: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group Governing

Body

From: Dr Waseem Mohi, Chair

Date: 18 July 2017

Subject: Chair’s report

Executive summary

The report provides an overview of key activities undertaken by myself and the CCG since the last governing body meeting.

Recommendations

The governing body is asked to note the report.

1.0 Purpose of the report

1.1 To provide an update on my activities since the last meeting and on key CCG news.

2.0 Financial situation

2.1 We are making progress in addressing our financial challenges, but there is still work to do to

ensure that we deliver against our plans and continue to identify opportunities to further close the

remaining gap. My clinical and staff colleagues have worked hard under difficult circumstances to

identify levels of savings opportunities on a scale not seen before in BHR – and not I believe in

many other systems to date.

2.2 This scale of change requires us having to make changes locally that are not easy for any of us.

We did not come into the world of commissioning to stop services for local people, but with a

responsibility as a governing body to deliver within our allocated budget, we have had to make

some difficult choices. We’ve done this in partnership with our system colleagues and by listening

to the public through engagement and consultation. I want to thank everyone who contributed to

our ‘Spending Money Wisely’ consultation. This won’t be the last set of difficult decisions that we

need to take, but I do want to make sure that we take a balanced view by taking on board input

from local people and professionals.

3.0 System developments

3.1 We had a positive board to board session between the BHR CCGs and BHRUT, and to which

NELFT board members also attended. We have agreed on the key areas that we need to focus on

over the next year and beyond to support development of a sustainable health system. I was

heartened to hear the commitment to a focus on primary care provider bodies having a voice as a

major player, given this is where most people experience NHS services.

30

4.0 Networks and localities

4.1 We continue to make good progress, and are further exploring arrangements with regard to the

role of GP federations and GPs as providers in the new landscape and ACS developments. A

productive BHR wide facilitated session for CCG and Federation leads took place on 6 July to

explore how to move things forward at pace.

4.2 As commissioners and given the interests involved, we want to work through the governance

arrangements to enable the system to have the requisite primary care leadership within the

commissioner and provider functions. We will work closely with governance and legal colleagues

to ensure that we develop sound arrangements.

5.0 Meetings

5.1 In addition to the many committee meetings I attend, below is a summary of other meetings I’ve

been to since the last governing body meeting.

5.2 GB away day: we had a positive session with the three CCGs in May, exploring our strategic

direction and considering the functions and leadership required at locality/network, BHR/ACS and

at STP level. It was a lively and positive session with a great deal of consensus about our plans

for the coming year, including our priorities and objectives.

5.3 Weekly BHR CCG GB member meeting (IJEC): our meetings have focussed on progress with

the system delivery and finance recovery plans and updates on key programmes.

5.4 Informal CDs’ meetings: We have informal meetings to catch up on key issues. Our focus has

been on potential new clinical arrangements given ACS/locality/network developments, financial

recovery and transformation programme performance.

5.5 Health and wellbeing board (HWBB): the meeting in May was cancelled. The July meeting

focussed on a wide range of issues including: Care City, Better Care Fund, HWBB annual report,

SEND inspection, three borough integrated sexual health service.

6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capital costs arising from this report. 7.0 Equalities 7.1 There are no direct equality implications arising from this report. 8.0 Risk 8.1 The CCG is managing a number of serious risks which are outlined in further detail in the

assurance section of this agenda.

9.0 Managing conflicts of interest

9.1 There are no conflicts of interest arising from this report.

10 July 2017

31

www.southwark.gov.uk

To: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group Governing Body

From: Conor Burke, Chief Officer

Date: 18 July 2017

Subject: Chief Officer’s Report

Executive summary

This report provides an overview of key activities undertaken by the Chief Officer and the CCG since the

last meeting.

Recommendations

The governing body is asked to:

Note the progress report

1.0 BHR System Delivery Plan

1.1 We continue to make progress on our financial recovery plan, with £43.3m of the £55m target

identified. Further information is provided in the paper later on the agenda.

2.0 BHR Accountable Care System and Sustainability and Transformation Plan (STP)

2.1 Following the refresh of Five Year Forward View STPs were identified as the transitional bodies to

develop new Accountable Care Systems (ACS). Within the NEL STP footprint, a BHR ACS is

assumed and supported and we will need to develop and define what exactly is meant by a BHR

ACS with partners within BHR and STP colleagues over the next few months. The BHR Devolution

Strategic Outline Case gives us a foundation to build on, and both the STP Team and the London

Devolution Team are keen for the BHR system to lead and influence the ACS design.

2.2 Discussions are in train with our local authority colleagues through the newly established Joint

Commissioning Board to explore the role of commissioners in the new system. In parallel, as part

of the System Delivery Plan and with the support of PwC, our two local Trusts have begun

discussions on how they respond and work together as providers within an ACS. This approach

was endorsed at the Board to Board meeting of the BHR CCGs and BHRUT (also attended by

NELFT) on 22 June. Both Trusts at the meeting highlighted the importance of primary care in the

new model and gave a commitment to CCG Chairs to ensure primary care is invited to play a lead

role.

2.3 The Integrated Care Partnership Boards in June and July will be used to bring together the STP,

commissioner and provider discussions/workstreams to develop a system level set of

recommendations for governing bodies/boards consideration.

2.4 On 3 July the East London Health and Care Partnership was officially launched. The Partnership

will support effective collaboration and trust between commissioners and providers to work

together to deliver improved health and care outcomes more effectively and reduce health

inequalities across the local system.

32

3.0 CCG Development

3.1 We held a three CCG governing body away day on 18 May where we discussed the strategic

direction of the NHS and what this means for our ways of working and strategy going forward. We

also discussed our corporate objectives for 2017/18 and these are on the agenda for approval.

4.0 CCG assurance

4.1 At the NHS England assurance meetings on 21 and 23 June discussions focused on the BHR

CCGs’ performance on IAPT, dementia, and 2017/18 QIPP as well as the month 2 financial

position and progress of the financial recovery plan

5.0 Operational Resilience

5.1 Further to the cyber-attack on some NHS organisations in May, neither the CCG nor any of our GP

practices were not affected. The CCG manages the GP IT service for the borough’s GP practices

and following a review of all systems, our IT department are confident all updates and patch

requirements are in place. During the incident the CCGs worked in partnership with our providers

to ensure patients continued to receive urgent care and treatment, and did all we could to help

reduce delays for patients. Barts Health was the most affected trust locally and we worked closely

with them to ensure messages and updates were shared as widely as possible.

5.2 Following the recent incidents in London and Manchester, and the heightened security level that

was put in place, the CCG has reviewed and strengthened all incident plans to ensure that should

a similar major incident occur in our area that we are able to support the response.

6.0 Health and Wellbeing Board update

6.1 At the meeting on 5 July discussions focused on the future practice, direction and vision of the

health and wellbeing board, the Integration and Better Care Fund plan and the future integration

arrangements for the delivery of mental health social care in Barking and Dagenham.

7.0 Meeting attendance

7.1 On 2 June I attended a meeting of London Trust Chief Executives and CCG Chief Officers, hosted

by Anne Rainsberry from NHS England. Discussions focused on operational resilience, STP/ACS

and the emerging integration workstream.

7.2 A forum on Accountable Care was held on 27 June, facilitated by Imperial College Health Partners

and the Health Foundation. At the session they shared research findings and lessons from those

implementing accountable care principles in new models of care across England.

8.0 Equalities

8.1 There are no equalities implications arising from this report.

9.0 Risk

9.1 There are no risks arising from this report.

10.0 Managing of conflicts of interest

10.1 There are no conflicts of interest issues relevant to this report.

11.0 Resources/investment

11.1 There are no additional resource implications/revenue or capitals costs arising from this report and

no impact on sustainability.

33

www.southwark.gov.uk

To: Meeting of the NHS Barking and Dagenham CCG Governing Body

From: Sahdia Warraich, Lay Member - Patient and Public Involvement (PPI)

Date: 18 July 2017

Subject: Patient Engagement Report

Executive summary This report summarises patient and public engagement, feedback and insight gathered since the last meeting. Areas covered:

The Patient Engagement Forum (PEF) Joint PERF/PEF meetings Spending Money Wisely consultation NEL STP launch

Recommendations

The governing body is asked to: Note and comment on the contents of the report

1.0 Purpose of the report 1.1 To provide a summary of the CCG’s engagement with patients, the public and other

stakeholders since the last meeting. 2.0 Patient Engagement Forum (PEF) Update 2.1 The PEF’s last meeting was 18 May. The Forum’s main topic was antibiotic resistance.

Following a presentation by Oge Chesa, Medicines Management Team, members raised questions about how GPs and nurses are updated on issues around antibiotics. Oge reassured the forum that the Medicines Management Team is working with our

providers, hospitals, GPs, microbiologists and other health professionals to ensure they communicate appropriately regarding the prescription of medication.

2.2 The PEF also discussed the Spending Money Wisely consultation. Forum members expressed concerns around the long term impacts of restricting weight loss surgery and the need to protect children from any impacts of restrictions around medicines prescribing.

34

2

3.0 PEFs/PERF Chairs’, Vice-Chairs and Lay members’ meeting: 3.1 The group met on 20 June, with the main topic of discussion being the changing local

NHS structures and their commissioning responsibilities. The group recognised individual CCG patient engagement forums would lack the same degree of strategic influence in the wake of closer BHR collaboration and STP footprint level commissioning of some services. It was agreed that alternating between separate CCG meetings and a joint meeting could maximise the effectiveness of the forums, without losing a focus on different borough needs. A proposal to adopt this structure will be taken to the July PEF/PERF meetings. Subject to agreement, the first joint meeting will take place in September.

4.0 Public consultation “Spending NHS money wisely”: 4.1 On 29 June the governing bodies of Barking and Dagenham, Havering and Redbridge

clinical commissioning groups (CCGs) met in public and agreed to no longer fund certain treatments and procedures as we look to make savings for the local NHS.

4.2 Clinical leads described how during the consultation they had been heartened that local

people largely agree with what we are doing – trying to save the local NHS money at a very difficult time. The clinical panel that made recommendations to the governing bodies carefully considered the outcome of the consultation in reaching their decisions. Not all the proposals consulted on were recommended or subsequently agreed – with some cosmetic procedure proposals not implemented and IVF going from three embryo transfers to one rather than none.

4.3 The full consultation report is on each CCG’s website and can be accessed here -

http://www.barkingdagenhamccg.nhs.uk/Our-work/spending-nhs-money-wisely.htm 5.0 Sustainability and Transformation Plan 5.1 East London Health and Care Partnership, the new name for the NEL STP, launched on

3 July. The first meeting of its Community Group was held on 4 July. Lay members and members of Patient Engagement Forums were invited to attend. The launch was an initial stakeholder engagement event, with the ELHCP looking to increase patient and public engagement over the next few months as the STP starts to be implemented.

6.0 Resources 6.1 There are no resource issues relevant to this report. 7.0 Equalities 7.1 Engagement in the borough should contribute to reducing inequalities in access to

healthcare and support the CCG in meeting its equality objectives. This work is progressed through the CCG’s patient engagement forum structure and in collaboration with patients, the voluntary sector and other key stakeholders.

7.2 The Pan London Equality and Diversity Leads met on 3 July. Feedback from this

meeting will be provided to the next Governing Body.

35

http://www.barkingdagenhamccg.nhs.uk/Our-work/spending-nhs-money-wisely.htm

3

8.0 Risks 8.1 There are no identified risks in relation to this report.

9.0 Managing conflicts of interest 9.1 There are no conflicts of interest relevant to this report. Author: Tracey Bedford, Patient and Public Engagement Advisor, BHR CCGs Date: 28 June 2017

36

To: Meeting of NHS Barking and Dagenham Clinical Commissioning Group Governing

Body

From: Sharon Morrow, transformation director

Date: 18 July 2017

Subject: Governing body risk assurance framework report

Executive summary

The governing body assurance framework (GBAF) has been reviewed to reflect the current significant

risks to the organisation. There are three risks on the GBAF. Risk ratings are based on the June

2017 risk register.

The three risks on the GBAF are :-

1. Barking, Havering and Redbridge University Hospitals Trust (BHRUT) emergency care

performance

2. BHRUT cancer 62 days

3. Risks to the delivery of the CCG’s budget

Recommendations

The governing body (GB) is asked to:

Note and comment on the current risks escalated to the GBAF and that the levels of assurance in

the controls and the mitigating actions being taken are appropriate

Raise and discuss other potential risks that may require escalation to the next GBAF or, where the

risk has reduced, de-escalation.

1.0 Purpose of the Report

1.1 The purpose of the GBAF is to outline the key strategic risks to the Clinical Commissioning Group

(CCG) in achieving its corporate objectives and the controls in place to provide assurance that

the risks are being managed.

2.0 Background/Introduction

2.1 The CCG’s governing body has a responsibility to maintain sound risk management and ensure

that internal control systems are appropriate and effective, and where necessary to take

appropriate remedial action. The CCG’s risk register consists of risks that are local to the

borough and risks that the CCG has in common with its collaborative partners, Havering and

Redbridge CCGs.

3.0 Current risks on the GBAF

3.1 There are three risks on the GBAF. Please refer to appendix 1 for the full details. These fall

under three of our six corporate objectives. (NB: there is a paper on the agenda with the

organisation’s revised corporate objectives and will be aligned to the risk register and GBAF at

the next meeting). The three risks are as follows:

37

of 3

Corporate objective 1 Ensuring that planned care is appropriate, timely and of high quality – with a particular focus on tackling the RTT delays. Risk 1.3: BHRUT cancer performance standard: The Trust has an improvement trajectory in place to recover 62 Day Cancer Standard. This was achieved in March 2017 as per recovery plan (May 2017 for urology). However, the risk of continuity of delivery remains which poses a risk to patient experience and outcomes. Mitigation:

Revised, robust and realistic trajectory (version four) from the Trust to resume delivery of the performance standard by year end and at specialty level (urology) by May 2017

Oversight and assurance of delivery will be monitored via the Planned Care Programme Board from June 2017

Fortnightly operational stock take meeting with the CCG, BHRUT and NEL Commissioning Support Unit

Collaborative capacity and demand plan agreed and completed

Daily monitoring of planned against actual activity. Formal letter issued to the Trust in regard to failure to sustain delivery of the 62 Day standard in April (issued in June) Response received on 12 June and further clarification sought from the Trust week of 19 June by Commissioners.

The Trust has achieved the agreed cancer trajectory at an aggregate level to resume delivery of the performance standard at the end of March 2017 and the specialty level target planned for May 2017. The data to confirm achievement of the May target will be available in July at which time this risk will be reviewed and may be de-escalated from the GBAF.

Collaborative objective 3:

Implementation of the system wide urgent care strategy and redesign of the urgent care pathway

Risk 3.1: BHRUT's on-going failure to deliver A&E performance standards will impact, 1) quality improvement in emergency care, 2) put patients at risk, 3) cause reputational damage and 4) delay the implementation of acute reconfiguration programmes. Trust performance has improved significantly over the past year, prior to the onset of winter pressures. In the context of the current nationally reported pressures the Trust is no longer identified as one of the very high risk Trusts in London. It should be noted however that performance is still fragile. Mitigation:

The A&E Delivery Board is leading the work to support operational delivery. This is chaired by the BHRUT chief operating officer

BHR Urgent and Emergency Care (UEC) programme established with four delivery work streams to deliver improvement and mandatory requirements and address all risks. 17/18 trajectory agreed to meet national standard by March 2018. Plan for formal agreement at A&E Delivery Board 14 June.

BHRUT being held to account via contract meetings including SPR and CQRM

Internal CCG UEC Board monitors implementation (performance, plans risks) Collaborative objective 6: Continued focus on our development as an organisation and health system so that we can meet the challenges ahead and deliver better outcomes, quality and financial efficiency.

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of 3

Risk 6.1: Significant risks to the delivery of the CCG’s financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any acute over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCG’s QIPP plans the CCG will be in breach of its financial control total and c) risk of over performance in acute, continuing care or prescribing activity. Mitigation:

Implementation of our action plan from the Well Led Review

BHR CCGs developed System Delivery Framework and Plan, as a mechanism to drive system recovery

Fortnightly Financial Recovery Programme Board (FRPB) chaired by the Chief Financial Officer

Financial Recovery Planning, Delivery and Monitoring group (FRPDM) established with the responsibility for oversight of the QIPP development process and monitoring delivery against plan, reporting to the Financial FRPB

Financial risk mitigation via our integrated financial strategy across north east London sustainable transformation plan (STP) with continued development through the STP process

Aim to overachieve the QIPP requirement to provide stretch generating schemes and therefore savings over and above the £55m target


3.1 There are no additional resource implications/revenue or capital costs arising from this report.

The cost of operating effective risk management arrangements is met from within existing

resources.

4.0 Equalities

There are no equalities considerations arising from this report

5.0 Risk

5.1 This report also links to the following GB papers being presented at this meeting and provide

greater detail on key risks mentioned above and the organisations mitigations.

GBAF risk ref. 1.3 and 3.1 relates to the Integrated Contract Management report

GBAF risk ref. 6.1 relates to the Integrated Contract Management report and the Work of

the FRPB and Financial Recovery Programme progress report


6.1 There are no conflicts of interest considerations arising from this report.

Attachments:

Appendix 1 - Governing body assurance framework and summary

Author: Pam Dobson, deputy director, corporate services, BHR CCGs

Date: 22 June 2017

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Appendix 1 – NHS Barking and Dagenham CCG

Corporate objective 1: Ensuring that planned care is appropriate, timely and of high quality – with a particular focus on tracking the referral to treatment (RTT) delays.

Risk Description:

Barking, Havering and Redbridge University Hospital Trust (BHRUT) cancer performance standard: the Trust has consistently not

achieved the 62 day cancer waiting time target – with potential clinical risk to the patient pathway impacting on early detection and

survival rates.

Lead director: Louise Mitchell

Risk ref: 1.3

Initial

Risk

Rating

5/2015

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating

30/06/17 Control Assurance

Lik

elih

ood (

4)

x Im

pact (

4)

= S

evere

16

1. Contractual meetings –

Service Performance Review

(SPR) / Clinical Quality

Review (CQRM).

2. Fortnightly cancer

performance recovery board

– BHRUT and CCG.

3. Fortnightly operational

stocktake meeting between

the CCG, BHRUT and NEL

CSU

1. Minutes of monthly

contractual meetings –

SPR / CQRM and

remedial action plans. (I)

2. Minutes of the cancer

performance recovery

board. (I)

3. Weekly cancer

performance pack

reviewed with weekly

update to EMT regarding

potential risks. (E)

Lik

elih

ood (

3)

x Im

pact (

4)

= S

evere

12

The Integrated

Contract

Management

report provides

greater detail on

the

management of

this risk.

Additional remedial

actions agreed for

urology specialty to

return to the 62 day

standard by 31 May

2017. The data to

confirm

achievement of the

May target will be

available in July.

Lik

elih

ood (

2)

x Im

pact (4

) =

Hig

h 8

40

of 7

Collaborative objective 3: Implementation of the system wide urgent care strategy and redesign of the urgent care pathway

Risk Description:

BHRUT's on-going failure to deliver A&E performance standards will impact, 1) Quality improvement in emergency care, 2) Put

patients at risk, 3) Cause reputational damage and 4) Delay the implementation of acute reconfiguration programmes.

Lead director: Alan Steward

Risk ref: 3.1

Initial

Risk

Rating

6/2013

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps

Proposed actions

Target

Rating


Lik

elih

ood (

4)

x Im

pact (

4)

= S

evere

16

1. Accident and Emergency

(A&E) Delivery Board

(formerly the SRG).

2. Urgent and Emergency

Care (UEC) Programme

Steering group

3. Contractual meetings –

SPR / CQRM – and

contractual levers.

4. Winter only - daily surge

calls with the Trust and

reassurance with NHSE

1. Minutes of the monthly

Accident and

Emergency Delivery

Board. (E)

2. Minutes of the monthly UEC Programme Steering Group. (E)

3. Minutes of monthly contractual meetings – SPR / CQRM. (I)

4. Notes of daily surge

call. (E) Lik

elih

ood (

4)

x Im

pact (

4)

= S

evere

16

The Integrated

Contract

Management

report provides

greater detail

on the

management

of this risk.

There are no gaps and the commentary

below provides update.

A&E Delivery Board leading the

transformation programme to deliver

Operating Plan commitments. BHRUT

– with the support of partners – was

delivering the agreed STP trajectory but

winter surge has impacted on this.

The A&E Delivery Board invited ECIP –

the national UEC experts – to review

our plans and progress. Key feedback

was the focus on the patient flow /

discharge and this is now reflected in

our plans.

Continued monitoring and management

through local performance

management framework

Continued liaison with NHSE and the

NHSI to provide assurance on delivery,

particularly through winter surge

arrangements.

Now moving into assurance and

support arrangements for 17/18.

Daily winter calls stepped down to bi-

weekly.

Lik

elih

ood (

4)

x Im

pact (

3)

= H

igh

12

41

of 7

Collaborative objective 6: Continued focus on our development as an organisation and health system so that we can meet the challenges ahead and deliver better outcomes, quality and financial efficiency.

Risk Description:

Significant risks to the delivery of the CCG’s financial plan - legal directions on financial delivery of our QIPP requirements in year and management of any acute

over activity relating to underlying performance: a) Legal Financial directions, b) If we do not deliver against the CCG’s QIPP plans the CCG will be in breach of

its financial control total and c) risk of over performance in acute, continuing care or prescribing activity.

Lead director: Tom Travers

Risk ref: 6.1

Initial

Risk

Rating

8/2015

Controls

Assurances

I = internal

E = external

Current

risk

rating

Evidence for

assurance

Gaps Proposed

actions

Target

Rating


Lik

elih

ood (

4)

x Im

pact (

5)

= S

evere

20

1 Weekly Financial Recovery Planning,

Delivery and Monitoring group (FRPDM)

oversight of the QIPP development

process and monitoring delivery against

plan.

2 Fortnightly Financial Recovery

Programme Board (FRPB) Senior

Executive meetings.

3 Formal escalation route to Finance and

Delivery Committee

4 Clinical engagement and leadership

strengthening via the Joint Executive

Committee (JEC) monthly, FRPB and

F&D committee.

5 Independent review of finances jointly

commissioned with NHSE

6 Monthly NHSE London Assurance

meeting

1 Minutes of FRPDM

meetings and risk log and mitigations for all schemes (I)

2 Minutes of the FRPB

Senior Executive

meetings (I)

3 Minutes of the bi monthly

Finance and Delivery (F&D) committee (I)

4 Minutes of the JEC (I)

5 Report of the independent

review (E)

6 Minutes of the NHSE London assurance meeting (E)

7 Minutes of bi monthly

Governing Body meeting (I)

Lik

elih

ood (

4)

x Im

pact (

5)

= S

evere

20

The Integrated

Contract

Management

report and the

Work of the

FRPB and

Financial

Recovery

Programme

progress report

provides

greater detail

on the

management

of this risk.

1. Further

schemes to

be identified

to cover the

savings gap.

2. Fully

functioning

programme

management

office (PMO).

1. Working with

providers and

STP partners

to identify

additional

schemes

continues

2. PMO project

controls and

monitoring

processes

have been

strengthened.

Alignment of

required

resource is in

progress and

will be in

place by

September

2017.

Lik

elih

ood (

2)

x Im

pact (

5)

= S

evere

10

42

of 7

NHS Barking and Dagenham CCG Governing Body Assurance Framework - overall summary (2015 – 2017)

Lead /

GBAF

ref.

Risk description (summarised)

Previous risk ratings Current

rating

End of year

forecast Target

risk

level Aug

2015

Oct

2015

Dec

2015

Feb

2016

April

2016

June

2016

July

2016

Sept

2016

Nov

2016

Jan

2017

April

2017

June

2017

This

time

Last

time

L Mitchell

1.3

BHRUT’s cancer performance standard: the

Trust has consistently not achieved the 62

day cancer waiting time target.

20 16 16 16 16 16 20 20 20 20 12 12 8 8 8

A

Steward

3.1

BHRUT's on-going failure to deliver the

A&E performance standards 16 16 16 16 16 16 16 16 16

16 16 16 12 12 12

T Travers

6.1

Significant risks to the delivery of the

CCG’s financial. 20 20 20 16 16 16 20 20 20 20 20 20 8 8 10

Risk Summary Number

Total risks last report 3

New risk(s)escalated 0

Risks de-escalated this report 0

Total GBAF risk this report 3

43

of 7

NHS Barking and Dagenham CCG Governing Body Assurance Framework - overall summary (2013 – 2015)

Lead /

GBAF ref. Risk Description

Initial

rating

(June

2013)

Previous risk ratings

Sept

2013

Jan

2014

Mar

2014

June

2014 Sept 2014

Nov

2014

Dec

2014

Feb

2015

May

2015

L Mitchell

1.3

Failure to deliver national performance standards on

cancer at BHRUT 12 9 9 9 16

A Steward

3.1

Failure to deliver quality improvement in urgent and

emergency care at BHRUT 16 16 20 20 20 20 25 25 25 16

Risks de-escalated from the GBAF

Risk description, ref and lead Initial risk

rating

Target risk

level and date

Risk rating when

de-escalated

De-escalated April 2017: Failure to meet the 18 weeks referral to treatment times targets at BHRUT. 5 x 5 = 25

June 2014

1 x 3 = 3

March 2017

2 x 4 = 8

April 2017

De-escalated in April 2017: If the acute contract activity is greater than planned (under payment by results (PbR) this

could result in higher costs. (This risk has been combined with risk 6.1).

4 x 4 = 16

June 2016

4 x 5 = 20

March 2017

4 x 5 = 20

April 2017

44

of 7

How to interpret the CCG governing body assurance framework (GBAF):

45

of 7

Risk ref

This is a risk

identifier

attributed to the

risk by the CCG

risk lead

Lead director

This is the executive lead

with responsibility for:

- managing the risks to the

corporate objectives and

- liaising with the risk lead to

ensure the GBAF is up to

date

Reporting to the CCG

governing body or other

committee on progress

Risk ratings:

The risk rating is derived from conversation between the lead director (or

nominated deputy) and the risk lead. The risk score is calculated using the risk

grading matrix. There are three types of risk rating used in the CCG GBAF.

- initial risk rating: this grades the risk as if there were no remedial measures

in place. This is called the ‘inherent risk’.

- current risk rating: this grades the risk taking into account the remedial

measures. The remedial measures should aim to 1, reduce the likelihood of the

risk materialising, 2, reduce the impact of the risk if it does happen and 3,

reduce both.

- target risk rating: this is the level of risk that the CCG is prepared to accept

and the level of risk that must be aimed for.

Risk description

For each risk note down:

Who can be harmed and how

can they be harmed if the risk

materialises.

Areas to consider are: harm/

injury, objectives, claims or

litigation, service disruption,

staffing and competence,

morale, financial, external

assessment and adverse

media interest

Controls

What is being

done to reduce

the likelihood and

severity of the

risk.

One specific risk

may be mitigated

by a number of

controls

Assurance

Assurances are inevitably ‘bits of

paper’ that act as evidence the

controls are in place. Examples

include:

Job descriptions /organisation charts

Regular reports

Contracts / service level agreements

Policies and procedures

Minutes / agendas / terms of

reference

Gaps in controls

What more can be done to

control the risk and what

controls could be improved

Gaps in assurance

What associated

documentation will

demonstrate that the controls

are in place?

Proposed actions

Where gaps have

been identified, list

the actions required

to put them into

place.

Ensure they have a

named lead and

target date

Risk

Ref

Lead

Director Risk Description

Initial

Risk

Rating

(June 13)

Controls Assurances

Current

risk

rating

Gaps

Proposed

actions

Target

Risk –

1/4/1

4

Control Assurance

3.3 MS

Commissioning

organisations

are not able to

run patient level

validations for

the first quarter

to validate non

contract activity

which will

present a

financial risk

15 Our current control is we have

issued instructions to the CSU

not to pay un-validated

invoices. Where we have a

contract we will pay in line

with the contract and monitor

activity.

Where there is no contract we

will develop an alternative

validation process. Until the

process is developed we will

not pay the invoices.

A regular weekly report

is being developed with

the CSU to report on the

progress.

The audit committee

will be updated on

performance to only pay

validated invoices.

15 A detailed

process for

non contract

invoicing

requires

urgent

development.

A regular

report will

be

produced

for the

audit and

governance

committee

Develop

new

validati

on

process

3

46

To: Meeting of NHS Barking and Dagenham CCG Governing Body From: Conor Burke, Chief Officer Date: 18 July 2017 Subject: Corporate Objectives

Executive summary Each year the CCG agrees corporate objectives that set out our aims for the coming year. We have made progress against a number of last year’s objectives, notably with tackling the delays for referral to treatment (RTT) at Barking, Havering and Redbridge University Hospitals Trust (BHRUT). However considerable challenges remain, particularly in relation to our financial position, for which we received legal directions from our regulator NHS England (NHSE) in March 2017. There have been a number of system wide developments over the past year, with an increased focus on partnership working, both as part of the north east London (NEL) sustainability and transformation plan (STP), now the East London Health and Care Partnership (ELHCP) and within our local patch of Barking and Dagenham, Havering and Redbridge (BHR) through our Integrated Care Partnership Board, System Performance and Delivery Board and embryonic Joint Commissioning Board. Our objectives last year focussed on three main transformation programmes: urgent and emergency care, mental health and planned care – specifically the referral to treatment (RTT) challenge. In addition, we also had a specific objective on primary care transformation, ensuring high quality care from services commissioned as well as continuing to develop our CCG and local system into one enabling us to deliver better outcomes, quality and financial effectiveness. This year we recognise that in order to deliver any of the major improvements that we wish to, we must establish a more sound financial footing through meeting our control totals as directed

by NHSE. We know that we cannot do this in isolation and to tackle the in-year and projected financial challenge in BHR that we must work even more collaboratively in future. The objectives for 2017/18 build on those from last year, with an increased focus on a system approach. They have been revised as follows to cover: 1) financial recovery; 2) development of an accountable care system (ACS); 3) delivery of our transformation programmes for planned, urgent and emergency, complex and mental health care; 4) primary care transformation; 5) high quality safe and compassionate care from all commissioned services.

Recommendations

The governing body is asked to: Consider, discuss and agree the corporate objectives

47

1.0 Purpose of the report 1.1 To update governing body members on the CCG and system strategic direction and to

seek approval for the corporate objectives, which are common across the BHR CCGs.

2.0 Introduction 2.1 This year is the most challenging for the CCG and neighbouring BHR CCGs since our

inception. Havering CCG ended last year in financial deficit and collectively we have a £55m savings challenge this year.

2.2 In tackling our most pressing objective last year - addressing the backlog of patients waiting for more than a year for treatment (RTT) at BHRUT, for which Havering CCG received financial directions, the CCG committed significant staff and financial resources. This led to pressure on our budgets of up to £20 million in-year and contributed to the

deterioration of the BHR CCGs’ financial position.

2.3 We should however be proud of the work led by the CCGs with BHRUT in successfully tackling the most wide-scale waiting time issue in the NHS. The CCGs were also recognised for our work in supporting BHRUT to exit special measures following their CQC inspection last year. It demonstrates that where we commit to working in partnership, positive results can be achieved.

2.4 The financial position remains the most challenging issue for the CCGs and system in

2017/18. Without a more sound financial foundation, we will struggle to implement the changes that will result in better health outcomes for local people. Conversely, we also know that by making changes and working in a more collaborative way with a ‘population based’ focus through an accountable care system that this will also support financial recovery and better use of resources in BHR.

2.5 The CCGs must demonstrate that we are competent commissioners and able to manage

within our means if we are to gain the autonomy we want and need to progress our wider plans.

3.0 The new landscape for the NHS 3.1 In March this year, the refresh of the Five Year Forward View was published: Next steps

on the NHS Five Year Forward View1. The plan makes it clear that there are no new funds above the limited increase in the NHS budget already identified.

3.2 There is a clear commitment to create genuine integrated care, putting in place

population-based health systems to lead to better outcomes and improved efficiency. The plan also sets out the ambition and priority to improve A&E performance.

3.3 The refresh also makes it clear that the STP is a transitional vehicle, leading to the

development of local accountable care systems with new care models and partners working in a more collaborative way. In this respect we are well placed in BHR given the work already underway and agreed through our successful bid for devolution and subsequent business case.

1 Next steps on the Five Year Forward View: https://www.england.nhs.uk/publication/next-steps-on-the-

nhs-five-year-forward-view/

48

https://www.england.nhs.uk/publication/next-steps-on-the-nhs-five-year-forward-view/

https://www.england.nhs.uk/publication/next-steps-on-the-nhs-five-year-forward-view/

4.0 CCG corporate objectives for 2017/18 4.1 Through our positive work across the CCGs and system, we have made progress in a

number of areas as outlined above. So it is proposed that the CCG’s objectives for 2016/17 build on last year’s and are as follows: 1. Secure financial recovery, meeting our control target agreed with NHSE, so that we

begin 2018/19 on a sound financial footing. This will be achieved through Delivery of our system delivery plan and the initiatives within it, including making

difficult decisions Identification of new savings and efficiency initiatives for this year and next Adhering to strict financial discipline and sound financial governance Implementation of all recommendations within the well-led review linked to our

directions, including further integration of our governance across the CCGs.

2. Development of our accountable care system, through a collaborative population based solution to our system challenges of quality and resources. This will be achieved through: Continued development of our joint commissioning approach with BHR local

authorities, with a fully functioning and active commissioning board Further strengthening relationships with our main providers, acknowledging our

respective pressures and the incentives in the system that can currently mitigate against a system rather than individual organisational approach

Playing an active part within the STP, with functions released to the NEL level where it makes sense from a quality and economic perspective to operate at that scale (e.g. maternity)

3. Ensuring that we deliver on the objectives within our CCG and system wide

transformation programmes to improve planned care, complex care, urgent and emergency services and mental health. Implementation of the BHRUT/CCGs referral management system, to cover a

range of specialties in areas such as gastroenterology Continued focus on delivery of the national standards for A&E, meeting required

trajectories for improvement – supported by creation of a joint senior role with a particular focus on the timely discharge of people from hospital

Improving care for patients with complex needs including pressure care, multiple

long term conditions and end of life support Deliver constitutional standards and QIPP requirements within each programme

4. Continued implementation of our agreed Primary Care Transformation Strategy, recognising primary care as the foundation of our accountable care system

This will be achieved through four key workstreams which underpin the delivery of the GP Forward View, namely: Provider Development: ongoing development of primary care networks and

resilience of individual GP practices, leading to a sustainable primary care model and improved CQC ratings

Primary Care Workforce: developing new roles and implementing support packages to address identified recruitment and retention issues

Quality Improvement (QI): developing skills and methods in QI, reducing variation between GP practices and monitoring improvements in patient outcomes, through

49

investments in long-term conditions such as diabetes, latent TB and atrial fibrillation

Reviewing the clinical leadership arrangements to enable a better alignment of talent and skills to deliver the required changes from a commissioner and provider perspective

5. High quality, compassionate and safe care for all commissioned services -

delivering better outcomes. This will be achieved through refreshing our Quality Strategy, confirming our quality

priorities for 2017/20: Implementation of the system pressure care improvement plan Comprehensive quality impact assessments on all proposals/business cases

forming part of the System Delivery Plan

Strengthening collaborative commissioning of care for people living in care homes

Addressing key quality concerns such as: reducing the number of people who die from treatable conditions, and improved infection and prevention control

Implementation of the SEND recommendations for children and the ‘Wood Review’ requirements for safeguarding (working with local safeguarding children boards)

4.2 Each objective and programme has a detailed plan for the year which has been quality

assured and cross-referenced against others through the programme management office (PMO). The relevant committees and governing body will receive regular update reports so that members can be assured on delivery.

5.0 Resources/investment 5.1 There are no specific resource requirements arising from this report.

6.0 Equalities 6.1 There are no specific equalities implications arising from this report.

7.0 Risks 7.1 The CCGs cannot deliver this level of change alone. We rely on collaboration with our

local partners and stakeholders, so our continued focus on developing relationships and a system rather than organisation first approach should help to mitigate this risk.

8.0 Conflicts of interest

8.1 There are no conflict of interest considerations arising from this report. Author: Marie Price, Director of Corporate Services, BHR CCGs Date: 28 June 2017

50

To: Meeting of the NHS Barking and Dagenham CCG Governing Body

From: Sharon Morrow, Chief Operating Officer

Date: 18 July 2017

Subject: Community urgent care - case for change

Executive summary

Urgent and emergency care (UEC) has been a significant challenge for our health economy for many years with key performance targets, particularly in accident and emergency, not being met. The Five Year Forward View refresh gives us a new set of urgent and emergency care key deliverables, which we need to address: − Achievement of the ‘4 hour target’ − Comprehensive front-door clinical streaming − Specialist mental health care in accident and emergency departments (A&E) − Integrated urgent care (IUC) - an enhanced NHS 111 service which means more people

will speak to a clinician and receive a booked appointment where appropriate − An enhanced primary care offer - which will deliver a bookable general practice (GP)

service from 8am - 8pm seven days a week − Standardise non-acute services - including urgent care centres (UCCs) and minor injury

units (MIU) - to urgent treatment centres (UTCs) Local services are inconsistent and fragmented and this confusion can lead to multiple attendances for the same need. Over the last two years we have undertaken several engagement exercises with stakeholders and patient representatives and the clear message from this is that all stakeholder groups view urgent care as complex and confusing and endorse the need to look at simplifying the pathway. This report provides an update for the meeting on the development of a case for change for community urgent care, as the first stage in a process to review and update the existing model

Recommendations The Governing Body is asked to:

Agree the content of the paper

Agree to an engagement process on the community urgent care case for change

Agree to the development of a pre consultation business case

Agree to the timeline for the development of the commissioning plan

51

1.0 Purpose of the Report This report provides an update for the meeting on the development of a case for change for community urgent care, as the first stage in a process to review and update the existing model.

2.0 Background and context 2.1 Urgent and emergency care (UEC) has been a key challenge for our health economy for

many years with a background that includes:

A complex urgent care system with duplication and fragmentation across services

Challenged health economies and challenged acute trusts

Key performance targets, particularly in accident and emergency, not being met

2.2 As part of the Five Year Forward View (5YFV) and subsequent Urgent and Emergency Care Review, NHS England have introduced a new set of urgent and emergency care key deliverables which include:

Achievement of the ‘4 hour target’ Comprehensive front-door clinical streaming Specialist mental health care in accident and emergency departments (A&E) Integrated urgent care (IUC) - an enhanced NHS 111 service which means more

people will speak to a clinician and receive a booked appointment where appropriate

An enhanced primary care offer - which will deliver a bookable general practice (GP) service from 8am - 8pm seven days a week

Standardise non-acute services - including urgent care centres (UCCs) and minor injury units (MIU) - to urgent treatment centres (UTCs)

The General Practice Forward View outlines help for struggling practices, plans to reduce workload, expansion of a wider workforce, investment in technology and estates and a national development programme to speed up transformation of services.

2.3 The BHR health and wellbeing system is facing significant challenges and the CCGs

financial challenge is to find £55m savings in 2017/18. Key to addressing this is the development of an accountable care system (ACS) in which we will further strengthen partnership arrangements. We are developing joint strategic commissioning, conditions for an integrated system provider response and our locality delivery model of care - all intended to best meet the needs of our people. Our jointly agreed new delivery model is comprised of 10 integrated place based localities based on existing GP networks and these are each developing at pace against agreed plans. In many cases UEC services do not align closely with this vision.

2.4 Over the last two years we have undertaken several engagement exercises with stakeholders and patient representatives to gather views on how we can transform urgent care services. This includes the Barking and Dagenham, Havering and Redbridge (BHR) urgent care conference held on 1 July 2015, engagement with the CCG patient engagement forums, a comprehensive UEC co-design research survey which included many patient events. The clear message from all of this engagement is that all stakeholder groups view urgent care as complex and confusing and endorse the need to look at simplifying the pathway. The current urgent and emergency care landscape has a complex mix of service types delivered by multiple providers, with a large proportion of this activity being appointments with a GP. The services include:

52

2 A&E departments provided by BHRUT (in addition some BHR patients use Whipps Cross and Newham hospitals)

NHS 111 service 4 walk-in-centres 7 GP access hubs 3 GP out of hours sites 132 GP practices Community treatment team Minor ailments service

2.5 The current spend on our walk-in centres, access hubs and GP out of hours is a total of

£10.64m per annum, for NHS111 and our UCCs there is a further £3.84m and in 2015/16 the cost of A&E activity was £23.087m at BHRUT and £4.74m at Barts Health - which is a total spend of £42.3m.

2.6 Significant population growth is projected for BHR. Over 143,000 extra people in the next 15 years which is a 19% increase - equivalent to the size of Basildon. There are also changes to the profile with significant housing developments planned such as Barking Riverside, expansion alongside the Elizabeth line and across Rainham within the current financial context.

2.7 A case for change has been developed as the first stage in a process to review community urgent care and transform the model to meet both the community urgent and emergency care Five Year Forward View requirements, to simplify the pathway in response to stakeholder feedback and to respond to the projected population growth within existing resourcing levels.

The case for change covers the following headings: What is urgent care? BHR vision Executive summary National and local context Key urgent care research results Current provision; complex and confusing The case for change Key themes for exploration Next steps

2.8 The planned key milestones for this process are:

Community urgent care case for change to governing

bodies for agreement July 2017

Engagement process on the community urgent care case for change

July – August

Development of a pre consultation business case July – August

Pre consultation business case to governing bodies September

Consultation September to December

Decision making business case to governing bodies January 2018

Development of the commissioning plan January – March 2018

Services in scope

53

3.0 Resources/investment 3.1 There is no investment implication identified at this time and this will be need to be

developed through the pre consultation business case and decision making business case developments.

4.0 Financial Implications 4.1 There is no investment implication identified at this time and this will be need to be

developed through the pre consultation business case and decision making business case development.

5.0 Equalities 5.1 An Equality Impact Assessment (EIA) will be undertaken as part of the pre consultation

business case and decision making business case development. 6.0 Risk 6.1 There is a risk of a growing level of demand for urgent and emergency care and a need

to address the complexity in the system which this case for change can help to mitigate.

6.2 There are limited reputational and political risks associated with engagement on the case for change. Further risk analysis will be conducted alongside development of the pre consultation business case which will include option development; there is a need to avoid predetermining the outcome of a consultation process.

7.0 Managing conflicts of interest 7.1 There are no conflicts of interest considerations arising from this report.

Appendices: 1. Community urgent care case for change

Author: Carla Morgan Date: June 2017

54

Community urgent care

Case for change

Barking and Dagenham, Havering and Redbridge

(BHR) clinical commissioning groups (CCG)

July 2017

55

2

Contents

Key urgent care research results5

What is urgent care?1

National and local context4

BHR Vision2

Current provision; complex and confusing6

Slide 3

Slide 4

Slide 6

Slide 7

Slide 8-10

The Case for Change7

Key themes for exploration8

Next steps9

Slide 11-17

Slide 18

Slide 19

Executive summary3 Slide 5

56

3

“When we need help urgently, we need to know exactly where to go to get the right treatment. Our time should be valued, and we should be treated and sent

home as soon as possible”

What is urgent care?

Urgent care is care needed the same day. This could include

anything from cuts, minor injuries, wound infections or tonsillitis, urinary infections,

mild fevers etc

Urgent care is not emergency care which is provided in a medical emergency when life or long term health is at risk. This could include serious injuries or blood loss, chest pains, choking or blacking out

Definitions developed from Keogh with Healthwatch in 2016 as part of the urgent care co-design preparation

57

Our vision for urgent and emergency care

We want local people to receive the right care in the right place, first time. If they do need to be admitted to hospital, we will get

them home safely and quickly, with the right support to help them to recover their independence.

No time will be wasted.

Our ambition is to radically transform local urgent and emergency care services, removing barriers between health and

social care and between organisations.

BHR urgent and emergency care vision

4

58

5

Executive Summary

The current community urgent care system is complex and confusing

• this is a clear and consistent message from all our engagement work (see slide 7)

• there is lots of variation across our community urgent care services which includes:

− multiple access routes

− inconsistent assessment at first point of access

− multiple services providing appointments with a GP

− different times of provision (7am-11pm weekdays)

− different staff types and diagnostics available in services with the same name (walk-in centres (WICs) and urgent care centres (UCCs))

− a range of providers and limited information sharing between them

− variation in how much people use urgent care services across our local area

• the complexity and variation within the system leads to:

− duplicate attendances for the same health need

− poor clinical outcomes

− multiple transfers of care

− wasted time and resources for both patients and staff

− poor value for money

− ultimately a poor patient experience

These are common issues across the country and ways to address them have been set out in the five year forward view next steps - summarised on the next slide

59

National and local context

The Five year forward view next steps set out the following key deliverables for urgent and

emergency care in 2017/18 and 2018/19

The 5 year forward view key deliverables: BHR status

6

Improve ambulance triage/handover/conveyancing

Achievement of the ‘4 hour target’ Plans in progress

Comprehensive front-door clinical streaming

Patient flow which covers the process from admission through to discharge Plans in progress

Specialist mental health care in A&Es

Integrated urgent care (IUC) - an enhanced NHS 111 service which means more people will speak to a clinician and receive a booked appointment where appropriate and will support care homes

An enhanced primary care offer - which will deliver a bookable GP service from 8am –8pm seven days a week

Standardise non-acute services - including UCCs and Minor Injury Units - to Urgent Treatment Centres

This work will address / enhance these

60

Where people knew

NHS services such as

urgent care centres or

WICs existed, they

were often didn’t know

their exact location

of people said

they had seen

their GP with the

same issue

before going to

A&E.

.

37%

33%

of those who

went to A&E said

that they could

not get a timely

appointment with

their GP

People are

more than

twice as likely

to use their

GP than go to

A&E

This involved:

3,002 telephone interviews (1k per borough)

24/7

Key urgent care research results

7

Around 1 in 3 people told us they were

confused about what NHS services were

available in their local area.

Confusion around services available

B&D 34%

Hav 31%

Red 36%

% c

on

fus

ed

Summary

People are confused There is a mix of awareness and

understanding of what services are

available, what they offer and when

they’re open.

There is good awareness of the

range of non A&E services, but

people are confused about what

each service offers.

51%of people are aware of NHS Choices as a information source

A&E is seen

as a reliable 24/7,

same-day service

People tell us they are prepared

to wait for treatment in A&E

because they are guaranteed to

be seen and get treatment as

quickly as possible.

Long A&E waits are not a

deterrent

Only 6% said they went to A&E

because they thought they got

better care there

Parents with children aged 0-5 (41%), people with a long term illness or disability (35%) and carers (41%) are all significantly more likely to have visited A&E than those who don’t have these roles/conditions.

% of people who did not seek NHS/

professional advice before visiting:

A&E 39%

UCC 44%

The most commonly used services

were

72% GP

69% Pharmacy

31% A&E

26% WICs

of people had

been to A&E

before with the

same issue26%

It needs to be simpler

of people we called had visited a

walk in centre (WIC) in the last

six months

People in Barking and Dagenham and

Havering are more aware of walk in

centres than those in Redbridge

WICs are more commonly

used by those aged 18-34

(34%) and 35-54 (29%).

26%The responses indicate that people

with long term conditions, and so a

greater need for services, are the

most confused about what services

are available.

10 focus groups & 966 one to one interviews

conducted by Healthwatch over the three boroughs in

March 2016

61

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8

The BHR current urgent care system is complex and confusing - locations

Summary of the urgent and emergency care services which currently exist across Barking & Dagenham, Havering and Redbridge (BHR):Total of 19 services (across 7

providers): 2 A&E departments (in

addition BHR patients use Whipps Cross and Newham hospitals)

2 urgent care centres 4 walk-in-centres 7 GP access hubs NHS 111 service 3 GP out of hours sites 132 GP practices minor ailments service Mobile community

treatment team

62

Wee

kday

Wee

ken

d

Borough Access viaService 8-9 9-10 10-11 11-12 13-14 16-17 17-18 19-20 20-21 21-22 22-23 23-24 24-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8

BHR A&E

BHR NHS 111

BHR GP OOHs

BHR Pharmacy

BHR UCC - KGH

BHR UCC - Queens

Hav WIC - Harold Wood

Hav WIC - Orchard VillageRed

Red WIC - Loxford

B&D WIC - Barking community hospital

B&D Access hub: Barking community

Access Hub: Newbury Park

Access Hub: Fullwell Cross

Access Hub: Southdene

Various Sunday opening times from 10am - 5pm

Red

3pm - 7pm / Weekdays

8am - 8pm weekends

8am - 8pm weekends

8am - 8pm weekends

8am - 12.30pm Weekends

8am - 8pm weekends

24/7

10am - 2pm - Weekends

8am - 10pm

8am - 8pm weekends

11am - 4pm Weekends

3.30pm - 8pm Weekends

Access Hub: Rosewood Medical

Centre

12pm - 5pm Saturday

12pm - 4pm Sunday

Hav

Access Hub: North Street

24/7

12-13 14-15 15-16 18-19

24/7

24/7

Borough Access via Service 8-9 9-10 10-11 11-12 13-14 16-17 17-18 19-20 20-21 21-22 22-23 23-24 24-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8

BHR A&E

BHR NHS 111

BHR GP Practice

BHR GP OOHs

BHR Pharmacy

BHR UCC - KGH

BHR UCC - Queens

Hav WIC - Harold Wood

Hav WIC - Orchard VillageRed

Red WIC - Loxford

B&D WIC - Barking community hospital 7-8am

Access hub: Broad Street

Access Hub: Newbury Park

Access Hub: Fullwell Cross

Access Hub: Southdene

6.30pm - 10pm Wkdays




6.30pm - 10pm

Mon/Tues/Weds/Fri


2.30pm - 10pm - Thursday

Red

Hav


Access Hub: Rosewood Medical

Access Hub: North Street

8am - 8pm

B&D

8am - 10pm

Access hub: Upney Lane

8am - 8pm

10am - 2pm / Weekdays 3pm - 7pm / Weekdays

Various opening times from - 6am - 10pm

24/7

8am - 10pm

24/7

8am - 6.30pm

6.30pm - 8am

12-13 14-15 15-16 18-19

24/7

Walk-in Various numbers / call centres call 111 and get a booked appointment slot where appropriate

The BHR current urgent care system is complex and confusing - variation

10pm8am 7am6.30pm

Access route key:

Multiple service names - despite a majority being appointments

with a GP

Multiple access routes (111, call centres, walk in)

Variation in opening hours

Lots of duplicate attendances

Lots of services but not

connected

Variation in diagnostics

63

0

100

200

300

400

500

600

East

No

rth

Wes

t

Cen

tral

No

rth

Sou

th

Cra

nb

roo

k&

Lo

xfo

rd

Fair

lop

Seve

n K

ings

Wan

stea

d&

Wo

od

ford

NHS Barking &Dagenham CCG

NHS Havering CCG NHS Redbridge CCG

444

528 511452

527

446 425383

478

288

All UEC excluding bloods & wound care - per 1000 population (raw)

The BHR current urgent care system is complex and confusing - network area demand

10Activity 2016/17. Includes: ED (lowest 3 HRGs and UCC at Queens, KGH, Whipps Cross & Newham hospitals, WIC at Harold Wood, South Hornchurch, Loxford & Upney lane, all GP Out of hours (PELC and federations).

HaveringPhlebotomy and wound care are delivered by the

WIC - this has been adjusted in the second graph

CCG Networks

Raw list

size

Weighted

list size

WIC

activity

Out of Hours

(total

activity)

Access

Hub

UCC

activity

A&E

activity

All UEC

Total

Community

UC: WIC,

OOH, Hub &

UCC

Total

WIC,

OOH &

Hub

Community

UC activity

per 1000

population

All UEC

activity per

1000

population

East 73,929 69,770 6,280 4,699 3,590 6,193 12,075 32,837 20,762 14,569 281 444

North 73,353 71,258 6,252 5,263 5,697 7,880 13,714 38,806 25,092 17,212 342 529

West 73,796 67,050 9,620 3,889 6,950 5,645 11,622 37,726 26,104 20,459 354 511

Central 91,068 87,335 9,120 6,671 5,559 7,009 14,679 43,038 28,359 21,350 311 473

North 96,779 97,012 20,275 7,654 5,471 7,142 16,551 57,093 40,542 33,400 419 590

South 86,859 84,649 11,371 5,891 4,575 5,236 12,597 39,670 27,073 21,837 312 457 Cranbrook

& Loxford 101,624 88,050 6,966 4,570 8,306 7,862 15,458 43,162 27,704 19,842 273 425

Fairlop 59,192 54,743 1,136 3,963 5,588 3,851 8,143 22,681 14,538 10,687 246 383

Seven Kings 62,164 71,937 2,615 3,627 4,834 6,939 11,715 29,730 18,015 11,076 290 478 Wanstead

& Woodford 70,412 78,312 407 3,476 5,101 1,576 9,703 20,263 10,560 8,984 150 288

Unregistered 8,462 119 1,676 8,150 3,764 22,171 18,407 10,257

Out of Area 10,598 10,689 1,411 6,516 7,138 36,352 29,214 22,698

Total 718,764 691,804 93,102 60,511 58,758 73,999 137,159 423,529 286,370 212,371

Average 298 458

NHS Barking &

Dagenham

CCG

NHS Havering

CCG

NHS

Redbridge

CCG

There is variation in the use of urgent care services

across our networks

B&D Havering

Havering

Redbridge

RedbridgeB&D

64

The case for change - local population growth projections

11

15904

13865

11998

15136 15115 14597

21422

18990

16621

0

5000

10000

15000

20000

25000

Growth 2017-22 Growth 2022-27 Growth 2027-32

BHR growth over the next 15 years

Barking and Dagenham Havering Redbridge

Over the next 15 years this is over 143,000 extra people - equivalent to the size of Basildon - 19% increase

65

The case for change - primary care

Primary Care

Primary care - the first place to consider for your urgent health needs as your practice provides care closest to home with the best continuity of care. This is beneficial especially for those with complex or long term conditions as a patient’s GP practice takes a more holistic view of care including preventative and other health services, such as immunisations and health checks

BHR commissioners agree that acute hospital care should be reserved for acutely ill patients with the majority of care delivered nearer to home.

Primary Care Capacity

The GMS primary care contract states that practices should provide care for long term condition and life limiting illness management, episodes of ill health and support people at the end of their lives.

None of the GP contracts state how many appointments are provided, however ‘reasonable access’ should be provided. We know that general practice receive only 7% of the NHS budget - but they provide over 90% of NHS activity - pound for pound this is

high value Our co-design survey reported GPs as the most commonly used service (72%). We also know that there is wasted capacity within primary care arising from people not attending their booked appointments - audits

conducted with Redbridge practices in late 2014 saw this at between 11% and 13% at a cost of £1.2m Establishing the access hub urgent evening and weekend GP appointment service has delivered significant improvement to access.

Friends and Family Test

BHR practices are consistent with national and London averages

GP Friends and family test London B&D Hav Red

% would recommend 88% 85% 88% 90%

% would not recommend 7% 8% 2% 5%

Primary Care Strategy

However primary care has challenges; and key themes for the development of general practice are that it should be accessible, coordinated and proactive (with a focus on prevention).

The CCGs’ vision for primary care is to combine general practice care (with other services such as community pharmacy, community optician, dentistry and community-based health and social care) into a locality or network care model with more productive general practice at its foundation and GPs overseeing care for their patients. Locality-based care will be proactive, with a focus on prevention, support for self-care, active management of long-term conditions and the avoidance of unnecessary hospital admissions

12

66

The case for change - emergency care

Our emergency services are under pressure

The Five Year Forward View refresh tells us ‘Each year the NHS provides around 110 million urgent same-day patient contacts. Around 85 million of these are urgent GP appointments, and the rest are A&E or minor injuries-type visits. Some estimates suggest that between 1.5 and 3 million people who come to A&E each year could have their needs addressed in other parts of the urgent care system. They turn to A&E because it seems like the best or only option.’

High level of demand is seen at our A&E departments which is increasing (approximately 7% per year at KGH and 5% per year at Queen’s over the last four years). This rate is above demographic growth which has been at around 1.4%

Despite considerable improvements, BHRUT has consistently failed to meet the 4 hour target over the last 3-4 years

Recruitment is a challenge within our ED departments leading to high use of locums There is an establishment of 18 ED consultants - with 10 in post (46% vacancy rate) There is an establishment of 223 ED nurses - with 170 in post (24% vacancy rate)

At Queen’s and KGH hospitals - 16.6% of patients attending did not have any investigation or treatment

The re-direction trial at Queen’s hospital has demonstrated that up to 30% of patients attending ED do not require a same day urgent care service

A&E and ambulance services need to concentrate their skills on serious and life threatening conditions

13

67

14

The case for change - children

Three main conditions were:• Feverish symptoms (febrile) (does not include co-morbidity or complex health conditions

e.g. diabetes, sickle cell)• Gastro - constipation, haemorrhage, abdominal pain and other • Respiratory including asthma

Children – from new-born to 18 years of age

There has been a significant increase in 0-5s using A&E services over last 2 years (19% increase - 8,000 patients).

There is significant growth projected in the number of children within BHR - 47,400 in the next 5 years alone.

The emergency department lead paediatric consultant, conducted an audit from a sample of 100 attendances. This identified 32 children did not need emergency care at A&E.

Parents with children

aged 0-5 (41%),

people with a long

term illness or

disability (35%) and

carers (41%) are all

significantly more

likely to have visited

A&E than those who

don’t have these

roles/conditions.

Source: ONS 2014 based sub-national population projections

Key items from the childrens services programme• Children are proportionately higher users of urgent and

emergency care• Often access more than one service for the same

complaint• Evidence that in some cases, parents are accessing

multiple services for a ‘second opinion’68





Evidence of repeat attendances for the same health need (duplicate attendance) from our engagement work

The clinical implications - duplication can lead to many negative clinical results:• No continuity of care• Increased clinical risk• Child or adult protection implications

Quantification of duplicate attendances - we know that some NHS capacity is wasted due to repeat attendances for the same health need.

This can be caused by the variation in services meaning people’s first choice service cannot meet their health needs due to the different staff types, diagnostics or technology in place; however some of this is also driven by patient behaviour to seek a second opinion

Unconnected IT systems mean the full extent of duplication cannot be quantified - however, where we can compare datasets, the level of duplicate attendances was just over 5%; and most of these within 24 hours of the first attendance 3.3%. The highest number of attendances within a 72 hour period was 6 attendances

Antibiotic prescribing• In recent B&D GP practice audit, attendances outside the practice were tracked for 1 week. The greatest number of

patients attending different services on the same day had a final outcome of having been prescribed antibiotics. GPs anecdotally report patients seeking antibiotics outside of the practice as a clinical concern and a driver of duplication

• There is clinical evidence to demonstrate that if patients take too many antibiotics they become resistant to the effects • BHR are amongst the highest prescribers in London with only 1 CCG above us

Unregistered population - walk-in services can encourage patients to avoid registering with a GP - 9% of patients attending our 4 WIC services are not registered with a practice - with significant variation between 15% and 3%. The unregistered population miss the benefits provided by the GP practices such as continuity and holistic care 15

of people said they had seen their GP with the same issue before going to A&E

37%of people had been to A&E before with the same issue

26%

% of people who sought NHS/professional advice before visiting:

A&E 39% UCC 44%

The case for change - clinical

• Delay in the patient journey• Contribute to antibiotic resistance

69



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It’s confusing so people go to the wrong place first time and need to be directed on to another service by staff who may also find the system confusing and therefore default to advising patients to go to ‘A&E’

16

A&E is the well known and trusted 24/7 service and people know that they will be seen within 4 hours, so this can become a default service for many people

24/7

A&E is seen

as a reliable 24/7,

same-day service

People tell us they are prepared

to wait for treatment in A&E

because they are guaranteed to

be seen and get treatment as

quickly as possible.

Long A&E waits are not a

deterrent

Patient expectation - this could be: seeking a prescription to ‘cure’ the illness,

even though a similar medicine may be available over-the-counter

expecting to receive antibiotics and accessing multiple services until these are prescribed

expecting to be seen on the same day regardless of urgency

Dependence on clinical opinion or lack of confidence to self care. This could be: lack of confidence or understanding of the

normal progress of symptoms (e.g. a cold can last up to 14 days)

reassurance that nothing more serious is wrong - particularly true for parents of young children

The case for change - common drivers of duplication

70

17

The case for change - value

• The current spend on our walk-in centre, access hub, urgent care centres, NHS 111 and GP out of hours is a total of £14.49m per annum and in 2015/16 the cost of A&E was £23.087m at BHRUT and £4.74m at Barts Health – which is a total spend of £42.3m

• There is lots of duplication in our urgent care system (approx. 5% of all attendances) - clearly this represents poor value -financial, resources, quality and patient experience

• Currently ‘Walk in’ services such as A&E, UCC and walk-in centres do not have common assessments and therefore patients may be seen in urgent care facilities when their need is not urgent. The re-direction trial at Queen’s hospital demonstrated up to 30% of ED presentations do not require a same day urgent care services

• Inefficiencies in the patient pathway also arise from a lack of digital connectivity between these services and the GP record

• Across our contracts there are variable contract and payment terms. This is both expensive to manage and the unit price for these services can range from around £15 for an NHS 111 call to £153 for an low acuity A&E attendance.

Local Authority funding

reduction

Public Health budget

reduction

£

£

BHR CCG 17/18 budget gap of over

£55m

Funding and efficiency challenges

Context: BHR CCGs have a 2017/18 in year financial challenge of £55m of savings. The system-wide budget gap is over £250m over the next five years

BHR UEC spend

£42.3m

71

Key themes for exploration

18

Simplify the system for patients - provide a clear and defined service structure so that patients can be confident about where to go for what e.g. illness/ injury… urgent or emergency and to reduce duplication and inappropriate attendances

Move towards bookable appointments - the national requirement is bookable from 8am-8pm daily

Consistent assessment consistent assessment and re-direction when booking and at the front door of

services where people walk in such as A&E appointments bookable through centralised systems (phone and online) to increase

self care and remove inappropriate appointments

Plan for the changing profile of population growth

Provide more local services - this is an opportunity to review the location of where and how services are delivered

Improved provision for children (newborn - 18 years) as they represent the greatest proportion of attendance growth

72

Next steps

Case for change key stages and timeline

19

May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18

FRPDM 10/5/17

EMT proposal 11/5/17

UEC, Primary Care and Estates

workshop19/5/17

High level proposal to FRPB 25/5/17

Develop case for change

Case for change to GBs

Consultation plan and

engagement on C4C

Develop pre-consultation

business case

PC-BC to GBs

Consultation Mid Sept - Mid Dec

Consultation analysis

Decision making paper to GBs Late Jan

Service alignment/ procurement

IUC 111 go live

Service go live

Community urgent care case for change to July Governing Bodies Subject to outcome of Governing Body discussions, development of a business

case for community urgent care in BHR including stakeholder engagement

73

To: Meeting of the Barking and Dagenham Clinical Commissioning Group Governing Body From: Tom Travers, Chief Finance Officer Date: 18 July 2017 Subject: Integrated Contract Management Report

Executive summary

This report follows the existing format but will be the last of its kind, as the recommendations of the Deloitte Well Led Review to create an integrated performance report including finance, activity, performance of services and Quality Innovation and Productivity schemes is presented to the CCG.

This current report concerns the CCG’s main providers - Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), Barts Health NHS Trust (Barts Health), North East London Foundation Trust (NELFT), Partnership of East London Cooperatives (PELC) and the London Ambulance Service (LAS). Activity and performance data at Month 1 vary in their reliability upon which to base an accurate assessment or risk and develop sound mitigations: as data flows in subsequent months, in particular validated SUS data from acute providers, reliability and the ability to forecast, improve.

The main points of note are:

• BHRUT has exited special measures, which is a key step forward for local patients and the

health system as a whole.

• BHRUT is also ahead of trajectory to return to RTT compliance.

• The cyber-attack in May severely impacted on the operational capability of Barts Health NHS

Trust.

• The IAPT target was not achieved in the last quarter of 2016/17 by NELFT.

• The achievement of the required performance trajectory in call answering by LAS remains a

challenge. BHRUT: Following the Care Quality Commission (CQC) inspection at the end of 2016, which found evidence of significant and transformational improvement at Queen’s and King George Hospitals, the CQC made a recommendation, endorsed by NHS Improvement, that the Trust be removed from special measures. Having been placed in special measures in December 2013, the CQC’s recommendation was accepted and the Trust was taken out of special measures in March 2017. The agreed 2017/18 contract value with BHRUT is £346m (for the 12 CCGs within North East and North Central London), inclusive of CQUIN and agreed QIPP. The QIPP is balanced between that at commissioner and that at provider, financial risk. Barking and Dagenham CCG’s contract value is £92.3m. Joint working between the BHR CCGs and Trust on the development of QIPP schemes continues at both a local and STP level. Due to the expected data quality issues with month 1 data, the CCG has reported a breakeven plan. This is expected to be reviewed once the month 2 reporting cycle has been completed. CCG and BHRUT colleagues are working closely to come to a view on the likely risks inherent in the 2017/18 period, from the very earliest stage. A key change for 2017/18 is the increased reliance on the achievement of the A&E performance

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2

trajectory, in order for the System to gain access to STF funding, 30% is now linked to delivery against the trajectory. Since recommencement of RTT data reporting in October 2016, BHRUT has consistently been ahead of the recovery trajectory and is expected to meet the national standard of 92% for 18 Weeks RTT Incomplete Pathways before September 2017. This therefore means the Trust is highly likely to have returned to RTT compliance ahead of schedule. Following the issuing of Contract Performance Notices to BHRUT in 2016/17 regarding non-compliance with MRSA and Clostridium Difficile contract standards, the Trust has achieved compliance with the standards for the last 3 reported consecutive months. The unprecedented global ransomware cyber-attack on 12 May 2017 resulted in approximately 120 elective outpatient appointments being cancelled at BHRUT in order to release capacity for non-elective activity. BHRUT took action to mitigate the impact of the attack including manually fixing all Trust PCs to ensure effective running of clinical systems. The CCG’s Quality Team has visited the Trust post attack and was assured by the steps taken by the Trust to minimise its impact. The Trust is also conducting a post-event review. Barts Health: The agreed 2017/18 contract value is £93.5m across all BHR CCGs and the share for Barking and Dagenham CCG is £22.3m. No QIPP has been agreed at provider risk and significant further work is required to meet the requirements of the System Delivery Framework. Due to the cyber-attack on 12 May 2017 and issues with the Trust’s IT systems, Barts Health has been unable to submit month 1 activity data. The Trust is addressing the issue and has agreed with the Co-ordinating commissioner (Newham CCG) that both month 1 and month 2 activity flex data will be available on 27 June 2017. The CCG has reported a breakeven financial forecast position at financial reporting period of month 2. The May cyber-attack followed 2 previous IT incidents that took place in January 2017 (affecting Newham Hospital’s Pathology system) and April 2017 (affecting pathology and imaging services). On 9 June 2017, BHR CCGs wrote to the Co-ordinating commissioner outlining concerns relating to the Trust’s resilience against IT system failures, and the impact on patient care and clinical risk. An extraordinary Contract Review Group (CRG) was held with the Trust on 16 June with a further CRG scheduled for 6 July 2017, at which further assurance will be sought from the Trust. NELFT: NELFT is performing to Quarter 4 (Q4) contracted standards in their community services and mental health service contracts with the exception of the Improving Access to Psychological Therapies (IAPT) access target. The Care Quality Commission (CQC) published their inspection report and rated NELFT as “Requires Improvement” in September 2016. A quality summit has subsequently been held. The Commissioners’ response is being led by the Nurse Director. PELC: Key activity trends experienced in this contract include an increase in 111 activity in Month 1 maintaining a trend set in 2016/17, a continuing reduction in activity in Out of Hours and relatively stable activity at King George UCC. 111 KPIs continue to be met. LAS: The 2017/18 LAS contract is commissioned on a pan-London basis. BHR CCGs have yet to sign the contract. It is managed by Brent CCG as the host commissioner. A paper from the CSU has been presented to BHR CCGs on the 2017/18 LAS contract proposal, with details of the outstanding issues for agreement and the key implications linked to the proposed contract. These mainly relate to the contractual terms and the proposed application of contractual penalties for non-delivery of the commissioners’ LAS-related demand management initiatives.

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3

The LAS contract value for Barking and Dagenham CCG is £8.5m and this is a £0.7m increase on the 2016/17 contract value which includes CQUIN. The month 1 2017/18 LAS performance for Barking and Dagenham CCG is reported at 65.8% of Category A calls responded to within 8 minutes against the 75% target. In order to achieve the LAS pan-London demand management reduction of 6.4% for both Categories A&C activities in 2017/18, Barking and Dagenham CCG has been allocated a planned demand management reduction figure of 711.

Recommendations

The Governing Body is asked to:

Note the performance of contracted services, the risks therein and note the commissioner actions to

address them.

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4


The purpose of this report is to inform the Governing Body on the contract activity and performance for M1 2017/18 for acute where available, community, mental health contracts including the LAS contract, and agree any actions required.


This is a report from Co-Director, System Delivery Framework, to inform the Governing Body of the position of acute, community and mental health contracts including the LAS contract at M1 2017/18.

3.0 Contract updates

BHRUT – Contract Value for Barking and Dagenham CCG - £92.3m The performance and constitutional standard data is Trust wide, whereas the activity and finance data is CCG specific.

All performance tables included in this report for acute services contain nationally published validated data.

Where more up to date data is available, this is referenced in the commentary of the report.

BHRUT Activity Summary

Below is a summary of the BHRUT M1 activity forecast at Point of Delivery (POD) level (for activity tables

refer to Appendix 2)

Urgent Care The total emergency care activity (all A&E activity and the urgent care centre (UCC) at Queen’s Hospital is under performing against plan at 199 (0.3%). The UCC is under performing at 3,197 (38.7%) while A&E activity is forecast over plan at -2,998 (-5.2%).

The 2016/17 month 1 forecast activity for A&E was over plan at (-3.3%) and

UCC (48.3%) under plan.

This indicates there has been a year-on-year decrease in A&E activity at month 1 in 2017/18 in comparison with same period in 2016/17.

There is also a year-on-year increase in month 1 UCC activity in 2017/18.

This represents a decrease in total emergency activity in 2017/18 compared with same period in 2016/17.

Non-elective excess bed days is forecast to be under plan at 1,534 (34.3%) and this is partially offset by non-elective non-emergency activity which is forecast at -987 (-27.5%) over plan.

Planned Care The most significant variance from plan is day cases at -1,802 (-20.8%) over plan, in comparison with the same period in 2016/17 at a forecast over performance of -213 (-1.9%) at M1.

This is slightly offset by forecast activity under performance in regular attenders at 279 (14.2%). The offset in 2016/17 was elective excess bed days at 536 (74.6%) under plan.

Outpatients Total outpatient activity forecast is over plan at -18,269 (-17.5%).

The majority of the over performance is seen in outpatient follow ups which is forecast at -11,358 (-24.0%) over plan and in outpatient first appointments

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5

which is forecast at -4,508 (-13.7%) over plan.

Outpatient procedures firsts is also forecast over plan at -1,606 (-19.4%).

This has increased from the reported 2016/17 forecast under spend of 4,866 (4.0%) at M1.

Other Activity The main driver of the over performance reported is the block component (mainly palliative care). The block component is forecast at -2,892 (-619.6%) over plan and is being shadow monitored in 2017/18.

3.1 A&E

Current Position

A&E (all types): BHRUT reported a validated performance of 86.06% in April 2017 and unvalidated performance of 82.73% for May 2017. April’s performance shows that it is below the expected improvement trajectory of 86.30%. Attendances at BHRUT in April 2017 compared with April 2016 have increased by 4.52%, while breaches have reduced by 22.05%. There have been persistent increases in daily A&E attendance. Over the last six months (October 2016 to April 2017), averaging 789 attendances a day, compared to 762 attendances for the six months prior to this period (April 2016 to September 2016). This is a comparative increase of 3.5% in daily attendance over stated periods. Drivers for this growth can be identified as - increased attendances in late evenings, increased pressure on resus beds with potential impact on operational efficiency, increases in the proportion of ‘blue light’ ambulance conveyances as well as ambulance conveyances and this could be a driver for the increased demand on resus beds. The leading causes of A&E breaches remain as follows - wait for the first clinician, wait for A&E triage and bed management. It is noted that BHRUT continues to face challenges linked to increase in demand on A&E and the availability of a suitably skilled workforce in ED in 2017/18, as reported in 2016/17.

Risks to Delivery

Risks to the delivery of the A&E target are as follows:

• Higher A&E attendances compared to 2016/17. • ED staffing issues, in particular, low proportion of medical rotas (Consultant and Middle-Grade

Doctors and bank nursing) that are filled with permanent staff. • Recruitment and development of staff to support appropriately skilled workforce for the enhanced

urgent care pathway. • Delayed discharge from poor patient flow through the hospital. • High-acuity of patients and increase in blue light conveyances.

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Mitigating Actions

The work streams of the Patient Flow Programme that support the improvement trajectory include Enhanced UCC (urgent care centre) & Redirection; Streamlining Complex Discharges & Discharge to Assess and Early Discharge Planning and Seven Day Services. Ongoing actions within the work streams include:

• Recruitment and development of ACPs (Advanced Clinical Practitioners) to support the non- admitted pathway/Enhanced UCC.

• Continuation of redirect at the front door of Queen’s for patients not in need of acute care.

• Maximising use of SAFER (Senior review, All patients to have an expected discharge date, Flow

of patients, Early discharge, Review) bundles of care on wards.

• Standardising use of Expected Discharge Dates to proactively manage patients to discharge.

• The trial of front loading therapies at the start of the patient journey to support early discharge.

• Rehabilitation beds are available to flex up to 10%, with pilot underway to flex criteria to support

flow.

• Trust full capacity protocol in place to further support discharge where required, involving cancelling training/development and elective procedures to support the non-elective pathway.

• Weekly and monthly (multi-agency) Length of Stay (LoS) reviews underway to challenge

assessments for longer LoS patients.

• In June the System Performance and Delivery Board for BHR, agreed a sum of £400,000 to support improvement actions in ‘discharge to assess’ and BHRUT, under the direction and monitoring of the A&E Delivery Board.

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The Table below shows the latest available A&E Performance position in 2017/18.

National

StandardPerformance Mar-17

2016/17

YTDApr-17

Unvalidated

May - 17

2017/18

YTD

Performance 89.08% 87.09% 89.72% 87.61% 88.60%

Performance 85.24% 81.39% 81.41% 76.12% 78.67%

Trust Performance 86.48% 83.25% 84.05% 79.99% 81.93%

Performance Vs Standard

Performance Vs Trajectory

Performance 92.23% 90.90% 92.32% 90.99% 91.61%

Performance 85.89% 82.18% 82.19% 77.19% 79.60%



Trajectory 91.50% 86.30% 86.40%


Trust Performance 0 6 0 0 0

Performance Vs National Standard

Performance 25.06% 25.76% 25.13%

Performance 27.80% 26.92% 29.32%

Trust Performance 27.14% 26.63% 28.22%


Performance 87.58% 89.23% 87.95%

Performance 82.44% 85.83% 84.72%



Performance 109 1434 91117

Performance 496 5568 360 415

Trust Performance 605 7002 451532


Performance 3 12 00

Performance 0 29 0 2

Trust Performance 3 41 0 2


Performance 88.52% 87.59% 90.23%

Performance 93.31% 90.98% 93.22%



Ac

cid

en

t &

Em

erg

en

cy

an

d A

mb

ula

nc

e H

an

do

ve

r

A&E All Types Performance

BHRUT

95%

KPI Site

Queens

BHRUT

% Ambulance Handovers within 15

mins: KPI 1

Number of Ambulance Handover-30

minute breaches

King George H

Number of Ambulance Handover-60

minute breaches

King George H

0Queens

% Ambulance Handovers within 30

mins: KPI 2

King George H

BHRUT

Queens

0Queens

BHRUT

BHRUT

100%

King George H

Queens

King George H

Queens

BHRUT

95%

0BHRUT

King George H

100%Queens

BHRUT

A&E Type I Performance

% Patient records captured

electronically: KPI 4

King George H

90%

No. of waits from decision to admit to

admission (Trolley waits) over 12

hours

3.2 Referral to Treatment (RTT) and Diagnostics

Current Position

The latest RTT data available at the time of writing this report is shown and validated in the table below for March 2016/17. In April 2017, the reported performance for incomplete pathways was 89.11% against a planned recovery trajectory of 82.90%. BHRUT recommenced RTT data reporting in October 2016 and has consistently been ahead of the recovery trajectory and is expected to meet the national standard of 92% for 18 Weeks RTT Incomplete Pathways before September 2017. This means that the risk relating to 18 Weeks RTT Incomplete Pathways shifts from assuring delivery to ensuring the delivery in line with the agreed contract values, affordability within the contract sum and ensuring clear plans to stand down capacity within the provider in order for services to remain affordable. The total number of patients waiting >18 weeks reduced to 3,803 in April 2017/18 from 4,351 in March 2016/17, as the RTT Programme continued to treat patients with long waits. A total of 4 patients had waited >52 weeks on an incomplete pathway in April, representing a continuing

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reduction in the number of >52 weeks waiters. The Planned Care programme, following from the RTT Programme Board, will continue to monitor each patient who has waited >48 weeks (an indicator to inform of the potential risk of breaching >52weeks), to understand the reason for the delay and seek assurance that each patient has a plan to progress their pathway. The Trust continues to be compliant on the diagnostics standard for April 2017.

Risks to Delivery

The key risks to delivery of the RTT Plan is:

Activity and financial over performance against the agreed contract sums

Increased levels of system capacity that cannot be funded by the CCGs long-term

Mitigating Actions

The commissioner and BHRUT are working closely to manage the demand for out-patient care.

In June 2016/17, the System Delivery Board (SDB), approved the proposals of the two

organisations joint Senior Responsible Officers (SRO’s) to establish a business case for whole

system planned care demand management, building on the joint success of delivering the RTT

backlog.

The CCGs will track and manage treatment levels through the BAU contract management

processes

The Tables below show the latest available performance positions for both RTT and Diagnostics in 2017/18

National

StandardPerformance Feb-17 Mar-17

2016/17

YTDApr-17

2017/18

YTD





Trust Performance 19 3 4

KPI

18 Weeks RTT Admitted

Site

18 Weeks RTT Non-Admitted

18 W

eeks

18 Weeks RTT Incomplete Pathways 92%

Incomplete >52 week waits

BHRUT

National

StandardPerformance Feb-17 Mar-17

2016/17

YTDApr-17

2017/18

YTD



Trajectory 99.00% 99.00%


6 Weeks Diagnostic Waits BHRUT 99%

Dia

gn

osti

c

Wait

s

KPI Site

3.3 Cancer Waits

Current Position

The latest cancer data available at the time of writing this report is shown and validated in the table below for April 2017. Validated March data shows that the Trust achieved 7 out of 8 cancer standards. The Trust failed the 62-day urgent GP referral to treatment standard, having met the standard in the previous month in line with the agreed recovery plan (achieving 81.99% against standard of 85%). The main driver for the non-compliance was urology.

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As the standard was not met in April 2017/18, the commissioners, on 7 June 2017, wrote to the BHRUT requiring: 1. Confirmation of the anticipated combined and specialty level performance positions for May 2017. 2. A full and comprehensive rationale for the reasons for failure to achieve the recovery positions at specialty level also setting out any interdependencies and associated risks, providing patient numbers for all. On 12 June, BHRUT responded to the commissioner’s letter stating that urology will be compliant by September 2017. The commissioners and BHRUT are working closely together to agree on a feasible and sustainable solution which will deliver the standard at an aggregate and at speciality level. In addition, the Planned Care Team meets fortnightly to review progress in delivery of the BHRUT cancer recovery plan.

Risks to Delivery

The key risks to delivery of this standard are:

• Lack of capacity within core specialties (urology, lower/upper GI, lung) to deliver additional activity to reduce existing backlogs.

• Conversion of patients who have waited >62 days to be moved from the ‘suspected’ to ‘confirmed’ waiting list impacts on capacity at tertiary providers.

Mitigating Actions

• Daily performance reporting in place. • Ongoing, fortnightly operational teleconferences between BHRUT and CCG. • Additional support on MDT and histopathology to be provided via NHSE funding. • Independent clinical input for urology via NHSE is awaited. • Planned Care Programmer Board established across BHR health economy – first meeting on 29

June 2017. Following the formal communications between the commissioners and the Trust relating to the non-compliance of the 62 Day GP Referral cancer waiting time standard, both parties are making arrangements to agree the terms for the recovery of the standard. Meeting set for 29 June 2017.

The Table below shows the latest available performance cancer position in 2017/18

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National Standard Performance Oct-16 Nov-16 Dec-16 2016/17 YTDPerformance 69.43% 70.44% 66.27% 69.40%Performance Vs StandardPerformance 66.27% 67.08% 64.00% 65.17%Performance Vs StandardPerformance 93.76% 93.32% 91.89% 93.48%Performance Vs Standard75%95%75% Ambulance Clinical Category A calls resulting in emergency response arriving within London Ambulance Service (LAS)KPI SiteCategory A calls resulting in emergency response arriving within Category A calls resulting in emergency response arriving within

3.4 Quality

Current Position

The latest available data is for March 2016/17. MRSA - There were no reported cases of MRSA bacteraemia occurrence in March. In total there were 7 reported cases in 2016/17. There were no cases reported in April 2017.

C.difficile - There were 2 reported cases of C.difficile reported in April 2017. It must be noted that in 2016/17, there were 29 reported incidents. The annual 2016/17 threshold was 30.

Mixed Sex Accommodation (MSA) - There were no MSA breaches in April. There were 7 cases reported in 2016/17. Venous thromboembolism (VTE) The year-to-date performance in 2016/17 met the standard (95%) at 95.47%

Risks to Delivery

MRSA This standard has zero tolerance threshold. Any breaches at any point in the year would jeopardise the standard. All MRSA bacteraemia infections are subject to root cause analysis investigations to identify lapses of care, and these cases are reviewed at the monthly Joint Infection Prevention Committee (IPC) meeting and penalties applied where applicable. This risk has materialised, and the tolerance of 0 was surpassed for 2016/17. C.difficile All C.difficile infections are subject to root cause analysis investigations to identify lapses of care, and these cases are reviewed at the monthly Joint IPC meeting. Mixed Sex Accommodation (MSA) This standard has zero tolerance threshold. Any breaches at any point in the year would jeopardise the standard. Venous thromboembolism (VTE) The standard for this indicator is 95%.

Mitigating Actions

Each case of C.difficile is reviewed via a multi-disciplinary Root Cause Analysis (RCA) meeting incorporating clinical, microbiology, pharmacy, CCG, IPC and nursing teams. An action plan is held by each ward to facilitate learning outcomes and ensure patient safety. The Trust has implemented a plan to improve the performance of the 95% admission assessments for VTE. The CQC improvement plan requires BHRUT to report on progress in reducing the risk of VTE in the hospital by ensuring that VTE prophylaxis is offered to patients at high risk and that patients are re-assessed when their clinical or mobility conditions change. This is reinforced by NICE Quality Standards and should be incorporated into BHRUT's VTE Prevention Policy.

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3.5 Friends and Family Test (FFT)

Current Position

The Trust’s performance for A&E FFT experienced deterioration in April 2017 with a turnout of 78.13%. This is against the performance trend over the last 6 months which averaged above 81.20. During 2016/17, apart from the month of April, 80% or more of A&E patients responding to the survey would recommend the A&E service to their friends and family. The Trust performance for inpatients has been maintained consistently through 2016/17, being above 92% of patients who would recommend the service for most of the year. Performance for April 2017 was 92.80%.

Risks to Delivery


• Response rates of the FFT surveys. • Trust capacity to conduct surveys for the FFT.

Mitigating Actions

The Trust has been working in partnership with “I Want Great Care” for Friends and Family Test Surveys since April 2016, with the aim of providing:

• Real-time feedback. • Different ways for patients to provide feedback, either hardcopy or online. • New simpler booklet style surveys. • One set of questions across many areas to provide benchmarking capability.

This also includes initiatives such as recruitment of further patient experience volunteers to assist patients, the introduction of new electronic tablets to capture FFT responses and the introduction of new FFT feedback boards displaying monthly results in a user-friendly way. The Trust also has a newly formed Patient Partnership Council (PPC) and acts as the patients’ forum which is a key mechanism to oversee patient and public involvement in the work of BHRUT. FFT performance continues to be scrutinised at Divisional Performance Reviews, which are chaired by the Chief Operating Officer.

The table below shows the latest available FFT performance figures in 2017/18

Row Labels Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17

Accident and Emergency

Average of Percentage_Recommended 82.18% 81.88% 80.62% 80.03% 80.33% 78.13%

%_Not_Recommended 7.46% 7.75% 8.03% 7.25% 8.37% 10.21%

Inpatient

Average of Percentage_Recommended 92.65% 92.41% 91.75% 90.85% 92.06% 92.80%

%_Not_Recommended 1.52% 1.35% 1.76% 1.58% 1.63% 1.17%

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3.6 Summary Level Hospital Mortality Indicator (SHMI) – September 2015 to October 2016 (latest reported data)

Current Position

The last nationally recorded information shows that BHRUT's Summary Level Hospital Mortality Indicator (SHMI) rate is 106.8 for the period September 2015 - October 2016 and Hospital Standardised Mortality Ratio (HSMR) is 109.34 for December 2016 for the last 12 months. This is latest data for both indicators. SHMI and HSMR should be interpreted with care and the data should be used as an alert to prompt further investigation rather than as a judgement tool in performance and practice. The data at the time of publication will be six months in arrears and is published by the Health and Social Care Information Centre (HSCIC). SHMI and HSMR are routinely monitored at the CQRM – detailed work on sepsis rates is in the planning stage.

Risks to Delivery

The key risks to accuracy and interpretations of these indicators and their values are :

• Accurate reporting of data, which are always contested. • Staff recruitment, retention and training, which could adversely impact on patient care.

Mitigating Actions

The Mortality Assurance Group (MAG) have reviewed and rebuilt arrangements for mortality review within the Trust, restructuring the process to ensure:

• The identification of avoidable deaths. • Lessons learned from problems in care and contributory factors. • Mortality reviews are recognised as an untapped resource for quality improvement.

Progress to date includes:

• Quarterly mortality data reports to Trust Executive Committee, Clinical Quality Review Meeting, Quality Assurance Committee and Trust Board.

• Mortality Review Checklist introduced June 2015 for ‘first cut’ reviews at the time of death. • Understanding avoidable mortality based on HOGAN score. • Established mortality database, over 2500 deaths recorded to date. • Progression of the Divisional Mortality Dashboards, shared with divisional teams August 2016. • Rebuild of MDT MAG – focused remit to review data and drive actions.

The Trust carries out reviews of and identifies learning from, all deaths within the organisation through the MAG, which updates the CQRM. The Trust has introduced the mortality review checklist as this is an established method of data collection, which incorporates the Hogan Scoring System, to assess the quality of care and treatment being provided and to give an early warning signal if an avoidable death is suspected. Data accuracy is determined by Clinician Input. All pro-formas are reviewed weekly by the Clinical Outcome Manager and Associate Medical Director and escalated appropriately.

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Barts Health Trust (BHT) - Contract Value for Barking and Dagenham CCG - £22.3m

All reporting reflects the Trust wide position

There is no activity data on month 1 due to the cyber-attack and a financial breakeven position is forecast at month 2.

3.7 A&E

Current Position

A&E (all types): Barts Health Trust (BHT) did not achieve the A&E national standard in April 2017,

achieving 81.81% and the reported final year-to-date position in 2016/17 was 86.06%. Barts Health has

now resumed daily A&E performance reporting, this was suspended from 12 May 2017 to 11 June 2017,

when the full data became available again.

This has resulted in twice monthly assurance meetings with regulators. Following a meeting with Steve

Russell (Executive Regional Managing Director for London at NHS Improvement) and Anne Rainsberry

(Regional Director for London, NHS England) in April, the Trust and WEL system have reviewed and

consolidated the A&E Improvement Plans across the whole system. Building on the current governance

structure of Urgent Care Working Group (UCWG) and A&E Delivery Board, a PMO approach is to be

taken to managing the programme across both acute and community settings to deliver the required

trajectory.

Progress in meeting that trajectory has been impaired by the IR35 (tax legislation designed to combat tax avoidance by workers supplying their services to clients via an intermediary, such as a limited company, but who would be an employee if the intermediary was not used) issues and difficulties in recruiting locums and both the diagnostics IT issue.

Risks to Delivery

The BHT and WEL system has been categorised as Group 2 in the National Groupings of Urgent and Emergency Care (UEC) systems, with a low level of performance and high breach volumes that require regional intervention and support.

Progress in meeting that trajectory has been impaired by the IR35 issues and difficulties in recruiting locums and both the Diagnostics IT issue.

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Mitigating Actions

Twice monthly assurance meetings with regulators have been commenced.

Building on the current governance structure of UCWG and A&E Delivery Board, a PMO approach

is to be taken to managing the programme across both acute and community settings to deliver

the required trajectory.

Barts Health has reset the recovery plans for each of its sites and revised the STF performance

trajectory for 2017/18 delivering 90% by September 2017 and with a more ambitious recovery

trajectory to achieve and sustain 95% by March 2018.

Targeted actions with a national focus include freeing up bed capacity through:

• Improving access to home care or care home places.

• 7 day discharge capabilities including trusted assessor and discharge to assess.

• Comprehensive front door streaming.

• Improved support for care homes.

• Access to clinical advice within the 111 service.

• Reducing ambulance conveyances through hear and see & treat care.

• Standardising urgent care pathways.

• Rolling out increased access to GP appointment at weekends and evenings. The national importance of this programme is demonstrated by the allocation of the 30% performance element of the STF for 2017/18 focused on the urgent and emergency care agenda. National funds have also been allocated to support improvements in social care, streaming and 111. The revised trajectory has been signed off by commissioners and included in the operating plan submission uploaded on the 30 March 2017.

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The Table below shows the latest available A&E Performance position in 2017/18.

3.8 Referral to Treatment (RTT) & Diagnostics

Current Position

The Barts Health Trust Board took the decision to suspend national RTT reporting from October 2014

due to a lack of confidence in the quality of the data being submitted following the migration of the old

Whipps Cross site Patient Administration System (PAS) to Cerner. As a result of the cyber-attack the

Cerner upgrade due at Newham Hospital was brought forward, resulting in an increase in the number of

un-validated patients, delaying confirmation of the final PTL number.

KPI National Standard

Performance Feb-17 Mar-17 2016/17

YTD Apr-17

Ac

cid

en

t &

Em

erg

en

cy a

nd

Am

bu

lan

ce H

an

do

ver

A&E Type I Performance 95%

Trust Performance

76.17% 80.46% 81.02% 77.99%



A&E All Types Performance

95%

Trust Performance

82.58% 85.72% 86.06% 81.81%


Trajectory 92.30% 90.30%


No. of waits from decision to admit to admission (Trolley waits) over 12 hours

0

Trust Performance

0 0 2 0


% Ambulance Handovers within 15 mins: KPI 1

100% Performance 50.89% 48.60% 46.30%

Performance 31.16% 28.30% 30.47%

% Ambulance Handovers within 30 mins: KPI 2

100% Performance 99.94% 92.81% 92.46%

Performance 86.23% 77.70% 78.49%

Number of Ambulance Handover-30 minute breaches

0


Performance 141 303 1645 266

Trust Performance

141 463 1906 418


Number of Ambulance Handover-60 minute breaches

0

Performance 0 1 1 2


Trust Performance

15 31 184 14


% Patient records captured electronically: KPI 4

90% Performance 87.80% 89.98% 89.39%

Performance 84.87% 88.74% 87.81%

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As it stands, BHR CCGs cannot be clear on the total number of their patients, as is the case with all

CCGs, waiting for care at Barts Health. This represents a significant quality of care and financial risk.

Risks to Delivery

A Phased Data Quality Plan was put into place, as part of which 4.2m pathways were extracted from the

PAS system. Following the application of national and local rules as well as manual validation, a cohort of

25,000 patients remained whose pathway status was unknown. A patient contact exercise followed and

of the 25,000 patients, 3,500 patients fed back that they were actively waiting for an appointment,

however these pathways were not apparent on the PTL.

The Trust concluded that a full review of its electronic logic was required utilising alternative logic

available through Cymbio applications and the Trust was required to undertake another significant

validation programme of 69,831 pathways. Despite the IT Cyber-attack the Trust has been able to

complete this exercise with only 2 weeks delay to the original timeline of end of May 2017, however

resources allocated to validating the BAU Patient Tracking List (PTL) were diverted to supporting the

backlog of paper records onto the Patient Administration System (PAS) and has resulted in an inflated

PTL and a requirement for further validation.

The number of over 52 week waits has also significantly increased both as a consequence of the addition

of validated pathways and the inability to validate due to lack of access to electronic patient records. In

addition, the IT problem forced an early migration from the Newham black box resulting in a further 10k

pathways needing validation.

RTT training remains a risk and the Trust was asked by commissioners and NHSE on the 30th May, to

escalate this to the Director of Operations and to secure a date for the first training sub group meeting.

Mitigating Actions

All patients on both outpatient and admitted pathways affected by the IT problem have been rebooked on

the Whipps Cross and Newham sites and partially on the Royal London and St Barts sites. Plans are in

place to rebook all outstanding patients by July 2017.

A return to national reporting remains reliant on other interdependencies and actions within the RTT

recovery action plan. The Trust aims to produce a trajectory and roadmap to national reporting for sign-

off with internal and external stakeholders. Due to the dependency against actions relating to data quality,

validation and training, a completion date can only be set once these project elements are complete.

Demand and capacity modelling has been received for orthopaedics and this is currently being reviewed

by the CSU. Specialty and site level recovery trajectories are still to be clarified and understood.

As part of the joint Trust/IST PTL assurance process, the Trust plans to carry out a series of sampling

exercises equivalent to approximately 3k validations to ensure the integrity of the data.

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Current Position

The national standard for 6 weeks diagnostic waits was achieved in March 2017 (M12) with performance of

99.59%. This represented achievement of the standard for the ninth month in succession.

Barts Health has not submitted diagnostic data for April 2017. Due to the cyber-attack, the Trust is in a

process of recovery and has agreed a later submission of this data with UNIFY.

The Table below reflects the latest available diagnostics data position in 2017/18

National

StandardPerformance Jan-17 Feb-17 Mar-17 2016/17 YTD

Trust Performance 99.21% 99.42% 99.59% 99.21%


Trajectory 99.17% 99.17% 99.17%


KPI

Dia

gn

osti

c

Wait

s

6 Weeks Diagnostic Waits 99%

3.9 Cancer Waits

Current Position

The latest available data as shown in above table is for M12 2016/17. At Barts Health: The cancer 2 week wait performance for March was 97.85% compared to the standard of 93% and this has been met consecutively for the last 22 months. The 62 day urgent referral performance for March was 85.99% compared to the standard of 85%. Overall year view shows that this standard was met for 9 out of 12 months. At the Whipps Cross site: The cancer 2 week wait performance for March was 98.1% compared to the standard of 93% and this has been met consecutively for the last 23 months. The 62 day urgent referral performance for March was 93.8% compared to the standard of 85%.

Risks to Delivery

Risks to delivery continue to include:

• Diagnostic delays.

• Capacity delays.

• Late referrals from other providers.

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Mitigating Actions

In response to the sustained poor performance in 2014/15 and 2015/16, Commissioners took a number of actions to turn around the cancer delivery at the Trust in 2016/17 and these included:

• Serving a Contract Performance Notice (CPN) which required the development of a Remedial Action Plan (RAP) for Cancer, RTT and Diagnostics. These are reported to the BH National Standards Performance Committee where senior level representation from WEL CCGs, NHS Improvement, NHSE Specialised Commissioning and the CSU hold the Trust to account.

• Many of the actions in the RAP have been completed and those that weren’t, were rolled forward

into the Service Development and Improvement Plan in the 2016/17 Contract. To oversee the Cancer Improvement Programme the Trust has put in place permanent senior clinical and managerial resources; a Clinical Director of Cancer Performance & Improvement, a ‘managerial’ Director of Cancer Performance & Improvement, a General Manager for Cancer Performance and Data Analysts. The SDIP programme includes a number of service developments and enhanced quality requirements:

• GP direct access or ‘straight to test’ diagnostic tests with targets for reduced reporting times. • Reducing variation within pathways. • Implementation of the Macmillan/NCSI ‘Recovery Package’. • Adoption of stratified follow-up and self-management programme.

The 62 day trajectory for 2017/18 and 2018/19 continues to profile a non-compliant position for two months, based on actual outcomes, these months are now August and January where the highest impact of patient choice delays are expected. Barts Health is working with BHRUT to improve late inter-provider transfers. There are monthly Contract Technical Sub-group meetings, led by the WEL CCG collaborative, where performance is scrutinised. The WEL CCG collaborative has engaged in NCEL sector fora with other commissioners, providers and other regional partners to improve inter trust referral transfer performance. The Trust continues to mitigate the impact of the IT problem and is working to compliance and the agreed STF trajectory for Q1.

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The Table below show the latest available performance positions for cancer wait in 2017/18

National

StandardPerformance Jan-17 Feb-17 Mar-17 2016/17 YTD















Trajectory 83.50% 85.71% 86.46%





Performance Vs Standard - - - -

KPI

Can

cer W

aits

All Cancer Two Week Wait (2 Week Cancer

Wait)93%

Two Week Wait for Breast Symptoms

(where cancer was not initially suspected)93%

31 Day Cancer Wait 1st Definitive Treatment 96%

31 Day Standard for Subsequent Cancer

Treatments - Surgery

62 Day Cancer Wait Screening Service 90%

62 Day Cancer Wait Consultant Upgrade No threshold

94%


Treatments - Anti cancer drug regimens98%


Treatments - Radiotherapy94%

62 Day Cancer Wait GP Referral 85%

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North East London Foundation Trust (NELFT)

3.10 Community Health Services (CHS) – 2017/18 Contract Value for Barking and Dagenham CCG

£29.9m

Current Position

This section is focuses on the latest quarterly performance data. Monthly review of performance occurs within the quarterly business cycle and significant exceptions will be reported to Governing Body when they occur. NELFT Key Performance Indicator (KPI) and CQUIN performance is reported quarterly in line with contractual targets and the quarterly service and performance review (SPR) closedown process. Performance Management (Q4) Q4 performance data has been received with an initial review of performance data undertaken at SPR on 26 May 2017. The highlights are set out below: KPIs:

• All KPI targets have been achieved in Q4. • Community Treatment Team (CTT) numbers of new patients referred and conversion rate targets

met. Number of referrals is 34% above the required target for new patients referred in the quarter, with acute conversion rate of 7% against maximum of 12%.

• Intensive Rehabilitation Service (IRS) numbers of patients referred continues to over-perform across BHR, in Barking and Dagenham this represents 30% above target to date.

• No reported cases of MRSA or Clostridium difficile. CQUINs:

• NHS Staff health & wellbeing – NHS staff survey (based on 3 staff survey questions on health and wellbeing, MSK and stress). The required 5% improvement based on 2015/16 results was not achieved with relevant partial payment and withholding rules applied.

• NHS Staff health & wellbeing – Achieving an uptake of flu vaccinations by clinical frontline staff by 75%. Initial review highlights 50% of front line staff had been vaccinated. This CQUIN was not achieved with the relevant financial withholding applied.

RTT: • No reported breaches of the 18 week Referral to Treatment (RTT) complete/incomplete pathways

across NELFT paediatric and adults services. Other Highlights:

• Patient experience and satisfaction across CTT in Q4 was 95% based on 5x5 survey results. • Patient experience and satisfaction across IRS in Q4 was 100% based on 5x5 survey results. • Patient experience and satisfaction across Community beds in Q4 was 87% based on 5x5 survey

results. • Looked After Children (LAC) Initial Health Assessments (IHAs) completed with 4 weeks = YTD

average 90%. • Child Protection Medicals completed with 48 Hours = 97%. • CTT / LAS attended 337 calls and kept 238 (70%) of patients at home against plan of 260. • Admission avoidance at Queen’s Hospital via CTT acute hub remained high with 251 referrals

against a plan of 132, with 95% of referrals preventing an acute admission. • IRS inreach into orthopaedic and geriatric wards at BHRUT identified and managed out of the

acute 326 suitable patients for community support against a plan of 325 in the quarter. • Percentage of Community Matron Care plans that have been agreed by patient /carer remains

high during the quarter, at 99%. • Community Rehab Average Length of Stay (ALoS) remains within the benchmark position of 21

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days with average Q4 position for Foxglove at 17 days and Japonica at 19 days. • Occupancy rates for the general rehab beds remains high and consistent with previous years,

averaging 93% across both Foxglove and Japonica wards.

North East London Foundation Trust (NELFT) 3.11 Mental Health Services (MHS) – 2017/18 Contract Value for Barking and Dagenham CCG

£27.1m

Current Position

This section is focuses on the latest quarterly performance data. Monthly review of performance occurs within the quarterly business cycle and significant exceptions will be reported to Governing Body when they occur. The 2016/17 Q4 initial review will be presented to SPR on 7 July 2017. The Q4 performance for selected KPIs is set out below. It should be noted that the Barking and Dagenham IAPT service has achieved the IAPT Recovery but missed the Access target for two consecutive quarters.

KPI Name Borough Target Q3 Performance Q4 Performance

IAPT Access Barking and Dagenham

3.75% 3.70% 3.50%

IAPT Recovery Barking and

Dagenham

50% 51.3% 50.30%

IAPT Waiting times: percentage of people referred to the IAPT programme begin treatment within 6 weeks of referral

Barking and

Dagenham

75% 100% 100%

IAPT Waiting times: percentage of people referred to the IAPT programme begin treatment within 18 weeks of referral

Barking and

Dagenham

95% 100% 100%

It should be further noted that the Barking and Dagenham CAMHS service has breached a KPI:

KPI Name Target Q4

Performance

Comments Penalty

Routine referral to

treatment waiting times

for BHR LAC placed in

borough to Tier 3

CAMHS.

95% within 4

weeks of becoming

a LAC

75% There were three

routine LAC

referrals one of

who missed the

target.

Penalty

£26,605

All other mental health KPIs have been met, including the important new EIP target of 50% of people experiencing a first episode of psychosis being treated with a NICE approved care package within two weeks of referral. The Q4 performance is 76.5%.

Q4 performance:

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As reported at Q2 and Q3, high pressures on inpatient occupancy of the psychiatric acute wards at Goodmayes Hospital continue. Rising demand on NELFT beds to levels consistently above 100% occupancy occurred during 2016 until remedial actions were taken by NELFT (above 100% occupancy means that patients who are on trial home leave have their beds used by other patients). Whilst the mitigating actions have moderated the bed pressures, the occupancy does still remain high. This persistent high demand for inpatient beds reflects trends across London. At times this requires placements by NELFT with alternative providers. CQUINs: NHS Staff health & wellbeing – NHS staff survey (based on 3 staff survey questions on health and wellbeing, MSK and stress). The required 5% improvement based on 2015/16 results was not achieved with relevant partial payment and withholding rules applied.

• NHS Staff health & wellbeing – Achieving an uptake of flu vaccinations by clinical frontline staff by 75%. Initial review highlights 37% of front line staff had been vaccinated. This CQUIN was not achieved with the relevant financial withholding applied.

• Improving physical healthcare to reduce premature mortality in people with severe mental illness - Cardio metabolic assessment and treatment for patients with psychoses. The NELFT Q4 performance on this element of CQUIN is to be determined by a national audit; the results of which are still awaited.

Risks to Delivery

a) There remains a key risk in relation to the IAPT Access and Recovery targets.

b) The Early Intervention in Psychosis (EIP) is a new target, with a high risk of achievement failure

due to small numbers in patients in the service, which can be fewer than 10. This small demand can have a significant impact on provider percentage performance achievement, for only one patient breach.

c) Pressures on occupancy in the psychiatric acute ward beds are posing significant operational

challenges.

Mitigating Actions

a) IAPT: The CCG clinical lead continues to support work to achieve IAPT targets with the provider

and GPs.

b) EIP: There is an applicable contractual penalty in the event of quarterly failure. In order to develop an understanding of the reasons why targets may be missed, we require NELFT to report on all cases where EIP patients were not seen within the specified standard timescale. This enables us to identify whether entering treatment after two weeks is a data recording issue, service delivery issue, or whether the specific circumstances of the particular cases suggest valid clinical reasons for delay.

c) Under the leadership of the Nurse Director, commissioners are supporting NELFT and seeking assurance that the requirements to improve quality and safety identified in the CQC report are being met. Placements into out of area hospitals if required due to capacity constraints are paid for by the provider trust (NELFT) rather than the CCGs. Such placements are reported for quality assurance purposes to commissioners. Detailed discussions continue with NELFT to ensure that the pressures in the acute care pathway are understood and a plan to mitigate them agreed.

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The PELC contract covers GP Out-of- Hours (OOHs), 111 and Urgent Care Centre (UCC) King Georges Hospital (KGH) Following the ‘Well Led Review’ and Action Plan in 2016/17 PELC has achieved a level of financial sustainability based on the contract agreed for 2016/18. Enhanced support to the WLR Action Plan ended in 2016/17 and PELC have taken forward actions including recruitment to senior posts, including a new Chair. Further development of WLR themes e.g. of internal governance is continuing. Key activity trends can be summarised as; increase in 111 activity in Month 1 2017 maintaining trend set in 2016/17, continuing reduction in activity in Out of Hours and relatively stable activity at King George UCC.

3.12 PELC Performance

Current Position

111

111 call volumes have increased by 34% in April 2017 compared to the same time last year. In part this

increase reflects telephony developments which now allocate mobile network calls correctly to BHR but

there is an underlying increase in 111 usage.

Selected KPI: PELC’s performance for calls answered within 60 seconds at 96.8% comfortably met the

95% target. Call abandonment rates are within target.

The percentage of calls disposed to Green Ambulance despatch, which have been clinically re-triaged

has been consistently improving and has been achieving over 65% in recent weeks as it continues to

support LAS and prevent non-essential attendances to ED.

Out of Hours (OOH)

The activity has again decreased in OOH in April 2017 by -8.26% in Barking and Dagenham CCG,

compared to same period in April in 2016/17 (note that whilst OOH calls are routed through 111, they are

only a proportion of 111 calls and changes in overall 111 activity can occur in a different trend compared

with OOH).

Performance against KPIs has improved in April and all KPIs were reported Green or Amber. Amber KPI

relate to ‘call backs’; calls are prioritised based on clinical acuity and any delays in call backs to patients

are risk assessed.

UCC

Activity at King George Hospital (KGH) has increased by 3.16% in April 2017 compared to the same

period in 2016/17. However achieving a sustained increase in patients directed to UCC rather than A&E

is proving challenging. Overall utilisation at King George Hospital (KGH) UCC was 30.33% in April 2017.

Patients attending UCC are streamed by PELC at point of entry. A CCG led audit of streaming has been

undertaken and opportunities to improve streaming and UCC utilisation have been jointly explored with

the provider.

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Risks to Delivery

• Maintaining organisational development required by the Well Led Review may prove challenging

now that external support has ceased

• Improving activity within UCC and increased direction of patients following screening to UCC

rather than A&E is stalling and risks failing to support A&E improvement sufficiently

• Integrated Urgent Care Procurement may potentially lead to a change in provider (dependent on

outcome of bidding process for the contract) and will require a different delivery model; both

circumstances will raise risk to service continuity. This is a medium term risk, new service due on

April 2018.

Mitigating Actions

• Assurance in respect of provider governance underpinning service delivery is within scope of

SPR/CQRM • Commissioners are working closely with provider on service improvement, potentially further

incentivising increases in activity to UCC • Robust mobilisation plan will be developed with NE London procurement project

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London Ambulance Service (LAS) Contract Value for Barking and Dagenham CCG – £8.5m (2017/18)

3.13 LAS performance

LAS Performance for Barking and Dagenham CCG

Current Position

LAS Performance Pan-London The 2017/18 LAS contract is commissioned on a pan-London basis. BHR CCGs have yet to sign the contract. The lead CCG remains Brent. BHR CCGs’ allocation of the pan-London 2017/18 LAS contract value is £28,539,368. A paper from the CSU was presented to the BHR CCGs on the implications linked to the proposed contractual terms. The contractual terms relate firstly to the STP rejecting the LAS proposed billing arrangements for over/under performance being sent to the STP rather than individual CCGs directly and secondly, to improve patient care, the commissioners’ proposal for the transfer time to the preferred place of death for patients on an End of Life (EoL) pathway to be undertaken by LAS within the patient’s last 48hours, instead of 24hours in the 2016/17 contract.

LAS performance pan-London continues to underperform against the national target at month 1 of 2017/18. Category A performance in April 2017 is reported at 73.7%. The LAS is aiming to achieve the pan-London national standard of 75% by 1 October 2017.

The 2017/18 pan-London contract activity plan is based on 2016/17 activity with 6% uplift for growth. A further 3% growth will be paid at 75% marginal rate on a cost / volume basis reconciled by STP area on a quarterly basis and cost applied to individual CCG at the rate of demand generated. Cost per case is payable at £211 for activity above the baseline (2016/17 + 6%). CQUIN is not payable on over performance. Over- performance is capped at 9% total (the 6% plus the 3%). If activity exceeds this then all parties commit to formally renegotiating the contract to determine the causes and assess the full range of potential options to address. Should activity fall below the funded 6%, up to 2% (reducing the 6% to 4%) will be withdrawn at the 75% marginal rate. Again, this is payable on a cost per case basis or £211. If activity is lower than 4% then both parties commit to contract renegotiation as above.

In order to facilitate the change in billing, freeze data submission dates and quarterly closedown dates have been agreed.

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26

LAS and Barking and Dagenham CCG The LAS contract value for Barking and Dagenham CCG is £8.5m and this is a £0.7m increase on the 2016/17 contract value and includes CQUIN. The April 2017/18 LAS performance for Barking and Dagenham CCG is reported at 65.8% of Category A calls responded to within 8 minutes against the 75% target (see graph above). There has been a -4.8% increase in total demand in April 2017/18 (inclusive of incidents, Hear & Treat and Surge) when compared to the same in 2016/17. In month 1 of 2017/18, Barking and Dagenham CCG actual activity positions for both Categories A and C activities are 1,237 and 1,135 respectively (the phasing for the activity plan is in the process of being finalised).

In order to achieve the LAS pan-London demand management reduction of 6.4% for both Categories A&C activities in 2017/18, Barking and Dagenham CCG has been allocated a planned demand management reduction figure of 711 (368 for Category A and 343 for Category C respectively).

Risks to Delivery


• Non-delivery of commissioners demand management plans resulting in increase in LAS activity.

• Delivery against the pan-London 6.4% demand management target.

• 111 conversions to 999 calls across London

• Increase in ambulance handover times / job cycle time.

• Use of different UCC protocols used in the 2 UCCs at Queen’s Hospital and KGH.

Mitigating Actions

BHR CCGs Demand Management

The CSU’s June 2017 paper serves to inform and support decision making.

LAS NEL Demand Management

The second NEL Demand Management meeting with the LAS was held in April 2017 to discuss challenges in the footprint and plans to reduce activity. The following areas were covered at the meeting and at subsequent forums:

Care Homes

• A number of schemes are underway in the STP to reduce call-outs to the LAS and unnecessary conveyances to A&E.

• Educate and training of Care Home staff on best practice taking place e.g. ‘Significant Seven’ training programme in BHR CCGs.

Frequent Callers

• Ensuring that CCGs have the required forums for discussing and managing frequent callers via the Urgent Care Network.

• Awaiting details of NEL Stakeholder Engagement Managers to obtain latest data.

ACPs

• Work underway to improve the utilisation of Alternative Care Pathways (ACPs) across the STP, which includes reviewing access criteria and failed referrals.

• MiDoS will be the platform to host the ACPs and the NEL CSU Directory of Services Team is working on developing the tool and familiarising the LAS Clinical Hub (CHUB) with its functionality.

• The initial plan is to promote the top ACPs per CCG e.g. Rapid Response and GP Out of Hours, and get these on the home page of the MiDoS tool, and eventually in ambulances via mobile devices. In the interim, the STP is looking at producing ‘business cards’, which captures this for

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27

ambulance crews.

• The STP is also looking at placing ACP representatives (possibly with an LAS manager) at A&E to greet arriving ambulances and discuss whether the patient could have been treated by the ACP.

111

• The PELC services in the STP aim to monitor and re-triage green ambulance dispositions, where a target of 60% is taken through enhanced assessment.

• Also, in the STP, 111 callers are asked whether they have contacted other urgent care services including LAS services within the previous 24 hours. PELC is the only 111 provider that currently captures this data. Between April and August 2016, 1,282 calls were received by PELC that had been previously in contact with 999 services. When LAS is operating under surge Red currently, it is recognised that LAS redirects identified callers to 111 for assessment where appropriate.

Analysis by the LAS is also underway to understand the case mix of patients that are conveyed to EDs in the STP. Addressing hospital handover delays continue to be a key focus for the Trust, and an action plan has been developed to address issues relating to the Trust’s handover to green performance. The Trust continues to be involved and participates in discussions with system wide partners to improve overall hospital handover performance.

The BHR health economy continues to have in place services that support demand management and

prevent conveyances. These schemes include the Community Treatment Team (CTT), the CTT/LAS

Falls Car, and service developments at A&E to support resilient ambulance handover times.


4.1 Resources/investment in each service/provider are highlighted for each individual provider as

required, under the relevant sections of this report.

4.2 There are no financial, social or environmental impacts arising from this report.

5.0 Equalities

5.1 There are no equalities implications arising from this report.

6.0 Risk 6.1 Risks and mitigations for each service are highlighted for each individual provider, under the relevant

sections of this report.


7.1 There are no conflicts of interest to note, related to this report.

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Appendix 1

BHR CCGs Open Contract Performance Notices to BHRUT in 2017/18

Provider CPNs/AQNs/Exception notice

Issue Current Status

BHRUT RTT Incomplete pathway - CPN

Percentage of service users on incomplete pathway waiting no more than 18 weeks, Trust not achieving target.

An update on performance will be reviewed at the July 2017 CQRM meeting between the Commissioner and the Trust. Recommendations from the CQRM will subsequently be made to the next SPR meeting.

BHRUT A&E - CPN Trust non-achievement of the national target


BHRUT Cancer 62 day – Exception Notice

Trust continued failure to achieve the 62 day standard within agreed timescales

A 2nd Contract Exception Report Notice was issued to the Trust in January 2017 for failure to meet the recovery trajectory for 62 day cancer standard. A urology specific recovery plan was agreed with the Trust (approved and monitored via the Cancer Performance Recovery Board). A letter was issued to the Trust on 7 June 2017 requesting recovery plans and trajectories for specialties which are at risk of not meeting the standard from April 2017 onwards. Trust plans are awaited. The Exception Report Notice will remain open pending Trust achievement of the 62 day standard.

BHRUT Cancelled operations - CPN

Trust breached the zero tolerance threshold for the number of Service Users who have operations cancelled who have not been treated within 28 days

A Contract Performance Notice remains open for Trust performance below the national standard. Following a request at SPR in January 2017, the Trust provided a report to SPR in April 2017 on the work being undertaken by the Trust to reduce the rate of cancelled operations. SPR further agreed that cancelled operations would be routinely reported via the RTT Programme Board going forward. Latest data (Q4 of 2016/17) indicates Trust achievement of 99.64% against the 100% standard. The Contract Performance Notice will remain open pending Trust achievement of the standard.

BHRUT MRSA (Methicillin-Resistant

Trust has breached the zero tolerance thresholds for

Commissioners and the Trust agreed at SPR in March 2016 that the CPN relating to MRSA performance would remain open until such time as the

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29

Staphylococcus Aureus) - CPN

incidences of MRSA. Trust achieve 3 consecutive months of achievement against the threshold. April 2017 data indicates 3 months consecutive achievement with 0 cases reported in February 2016 - April 2017. Pending formal recommendation from CQRM, the CPN will be recommended for closure by SPR.

BHRUT Mandatory Training - CPN

Provider failing monthly targets for Mandatory Training in the following areas; Safeguarding (Adults and Children), Information Governance, Appraisals.


BHRUT Clostridium difficile (C-Diff)

Monthly cumulative breaches above the agreed trajectory.

Commissioners and the Trust agreed at SPR in March 2016 that the CPN relating to C-Diff would remain open until such time as the Trust achieve 3 consecutive months of achievement against the threshold. April 2017 data indicates 3 months consecutive achievement with 0 cases in February 2016 and 2 cases each in March and April 2017 (below the threshold of 2.5 cases). Pending formal recommendation from CQRM, the CPN will be recommended for closure by SPR.

Barts Health

Serious Incidents - CPN

Serious Incidents investigated and closed on STEIS within 60 working days threshold of 90%

A CPN was issued to the Trust in February 2017 for consistent failure to achieve to standard at the Whipps Cross site, with a monthly average of 19 overdue SI reports throughout 2016/17.

The CQRM is monitoring the status of this performance notice.

Barts Health

Complaints - CPN

Complaints responded to within 25 working days or the timeframe agreed with the complainant - 80% threshold

A CPN was issued to the Trust in February 2017 for consistent failure to achieve to standard at the Whipps Cross site.


Barts Health

Duty of Candour - CPN

Duty of Candour threshold of 100%

A CPN was issued to the Trust in February 2017 for consistent failure to achieve to standard at the Whipps Cross site.


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Appendix 2

Month 1 Activity Summary Tables

BHRUT

Urgent Care

Planned Care

Outpatients

Other

103

To: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group

Governing Body

From: Tom Travers, Chief Financial Officer

Date: 18 July 2017

Subject: Finance Report Month 2

Executive Summary The Month 2 Finance Report should be read in conjunction with the report from the Chair of the Financial Recovery Programme Board (FRPB). In Month 2 Barking and Dagenham CCG reported a year to date deficit of £0.46m and a forecast deficit of £2.79m. This is in line with the CCG’s operating plan. At Month 2, there is £3.4m QIPP slippage reported in the forecast position. This has been mitigated by the use of acute reserves and the release of contingency. The likely level of risk that the CCG is facing at Month 2 is £7.5m. These are mitigated by opportunities totalling £2.4m, resulting in a net risk of £5.1m. If these risks materialise this will result in the CCG’s deficit increasing to £7.9m. The major risks are further slippage on QIPP and acute SLA over performance. A further risk identified is that there is limited acute data available at Month 2 and the data received has some data quality issues. Prescribing data is received two months in arrears, which means that no data is available until Month 3 reporting. CHC data is also limited at the start of the financial year. This is not unusual at Month 2 reporting and means that the CCGs have reported to plan for Month 2. This position may be revised in future months when more data becomes available.

Recommendations

The Governing Body is asked to: Agree the financial position noting the risks within it.

104

1 Purpose of Report

The purpose of this report is to brief the Governing Body on the overall financial position as at the end of May 2017 (Month 2).

2 Background/Introduction

As at the end of Month 2 the CCG reported a deficit of £0.46m with a forecast year end deficit of £2.79m against resource limit. These deficits are in line with the plan. 3 Report Content

105

MONTH 2 FINANCIAL INDICATORS

Indicator Target Actual Variance Rating this

month

Key Messages

£'000 £'000 £'000

Financial position year to date (464) (464) 0 Amber

At month 2 BHR CCGs have reported an in year deficit of £0.464m, which is in line with plan. Month 1 flex data received from BHRUT has a number of errors which have been raised with the trust. A number of associate trusts (including Barts Health) have not submitted a full set of data. These data issues pose a risk at month 2 reporting.

Financial position forecast outturn (2,790) (2,790) 0 Amber

The forecast outturn deficit remains in line with plan as a £2.79m deficit. However this position includes a forecast savings slippage of £3.4m. An over spend of £0.3m is also forecast within the IT directorate. This slippage has been negated by the release of the commissioning reserve and the majority of contingency. Any further slippage or contract overspends will result in the CCG not delivering its planned deficit position

Savings Year to date 758 797 39 Green The year to date savings position shows an over achievement of £39k. The position has been calculated using proxy data given the issues raised with regard to acute data.

Savings forecast outturn 12,479 9,051 (3,428) Red The savings forecast outturn projects a £3.4m slippage. This position is broadly in line with the level of assured savings schemes

Risks and Opportunities Net Opportunity

(5,098) Red The likely risks facing the CCGs at month 2 amount to £7.5m; these are mitigated by opportunities of £2.4m, resulting in a net risk of £5.1m

Worst Case Forecast outturn (2,790) (7,888) Red If the risk position fully materialises the CCGs will record an in year £7.9m deficit.

106

REVENUE POSITION

Annual

Budget

YTD

Budget

YTD

Actual

YTD

Variance

Forecast

Outturn

Variance

to FOT

£'000 £'000 £'000 £'000 £'000 £'000

BHRUT 92,230 14,381 14,381 0 92,465 (235)

Barts Health NHS TRUST 22,298 3,632 3,632 0 23,095 (797)

Homerton 2,202 351 351 0 2,202 0

Other Acute Trusts 11,642 1,814 1,854 (39) 11,707 (65)

Other Acute 20,017 3,328 3,349 (21) 20,037 (20)

Acute Reserves 3,191 14 0 14 914 2,277

Acute QIPP Commitments (2,572) 0 (33) 33 (486) (2,086)

Acute Commissioning Total 149,008 23,520 23,534 (14) 149,934 (926)

Mental Health 30,208 4,965 4,947 18 30,185 23

Community 31,703 5,433 5,335 98 32,189 (487)

Continuing Care 16,565 2,757 2,766 (8) 16,547 18

Primary Care & Prescribing 32,555 5,507 5,493 14 32,546 9

Primary Care Co-Commissioning 30,048 5,008 5,008 0 30,048 0

Other Programme Services 10,016 1,302 1,315 (13) 10,333 (317)

Programme Reserves 3,844 53 53 0 2,201 1,644

Other QIPP Investments / Disinvestments 41 (94) 0 (94) 5 36

Running Costs 4,552 759 759 0 4,552 0

Total BHR CCGs Expenditure 308,538 49,210 49,210 (0) 308,539 (0)

2017/18 Allocation (305,748) (48,746) (48,746) 0 (305,748) 0

2017/18 Control Surplus / (Deficit) (2,790) (464) (464) 0 (2,790) 0

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MAIN EXPENDITURE VARIANCES Acute Contracts

Due to the limitations of acute data at Month 2 the variances reported against BHRUT and Barts Health relate to QIPP slippage. The most significant being £0.8m QIPP slippage reported against Barts Health.

The lead commissioner for Barts Health has reported that Barts will provide Month 1 and Month 2 activity and cost data in time for Month 3 reporting.

There is also forecast QIPP slippage of £2.1m against other acute QIPP commitments. The QIPP slippage is partly mitigated by an acute reserve generated as a result of contract agreements being less than the operating plan assumptions. This has released £2.3m into the forecast position.

Community

There is a year to date underspend of £0.1m. This relates to the final 16/17 CQUIN reconciliation with NELFT.

The annual QIPP target with NELFT is £0.8m. It is assumed that there will be slippage against the QIPP, resulting in a forecast overspend of £0.5m.

Other Programme Services / Reserves / QIPP Investments and Disinvestments

The main budgets held under “Other Programme Services” includes budgets for Better Care Fund (BCF), 0.5% uncommitted risk reserve, Property Services and other programme services. This area is reporting a £0.3m overspend against the IT directorate.

There has been £1.7m released into the financial position as a result of the partial release of contingency and savings shown against QIPP investments.

Further detailed information across all contracts is found in the Performance Report.

108

RISK ANALYSIS

Full Risk

Value

£000s

Probability

of risk

being

realised

%

Potential

Risk

Value

£000s

RISKS

Acute SLAs 5,320 50% 2,660

Continuing Care SLAs 332 50% 166

QIPP Under-Delivery 4,997 64% 3,220

Prescribing 862 50% 431

Other Risks 996 100% 996

TOTAL RISKS 12,507 7,473

MITIGATIONS

Uncommitted Funds (Excl 1% Headroom)

Contingency Held 1,379 100% 1,379

Mitigations relying on potential funding 996 100% 996

TOTAL MITIGATIONS 2,375 2,375

NET RISK / HEADROOM (10,132) (5,098)

Forecast Outturn Underspend / (Deficit) 0 (2,790)

RISK ADJUSTED CONTROL TOTAL (10,132) (7,888) Acute SLAs

The risk relates to acute pressures in excess of the agreed contracts. This encompasses baseline, demographic and non demographic growth.

Continuing Care and Prescribing

The risk reflects the risk of demographic growth and price increases above plan. QIPP Under Delivery

Outstanding risk is based on the RAG rating from the latest System Delivery Framework report. Other Risks

Increases in market rent. It is assumed this risk will be fully mitigated by national funding. If this funding isn’t received it will represent a risk to the CCGs.

Mitigations

Due to the financial position the CCG is facing, the only mitigation available to offset the risk is release of the contingency.

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UNDERLYING POSITION

2017/18

Forecast at

M02

Remove

Non

Recurrent

Budget

(b/f

surplus)

Other Non

Recurrent

Spend

Non

Recurrent

QIPP

schemes

2017/18

exit

underlying

position

FYE of

QIPP

FYE of

Investments

2018/19

opening

underlying

position

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

Total Allocation 305,748 -845 0 0 304,903 0 0 304,903

Total Spend 308,538 -3,435 -3,337 2,715 304,481 -2,359 334 302,456

Surplus / (deficit) -2,790 2,590 3,337 -2,715 422 2,359 -334 2,447

Purpose

The underlying position details the recurrent spend against the allocation received – this is different to the forecast position at Month 2.

Methodology

The start point is the Month 2 forecast. Non recurrent budgets and spend are removed, including the impact of the Identification Rule (IR) changes, HRG 4+ changes and non recurrent investments.

Non recurrent QIPP is added into the position to give an exit underlying position for 2017/18 – at Month 2 this is forecast to be a surplus of £0.4m.

The full year impact of 17/18 QIPP schemes and investments are reflected post the exit 17/18 position to give the opening underlying position going in to 2018/19. At Month 2 it is expected that this will be a surplus of £2.4m

Risk to the Underlying Position

The underlying position is based on Month 2 data. Overspends reported against acute and other contracts will impact on the underlying position.

Further QIPP slippage will negatively impact the underlying position.

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OVERVIEW

No Indicator Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12

1. Financial position year to date Amber

2. Financial position forecast outturn Amber

3. Savings Year to date Green

4. Savings forecast outturn Red

5 Risks and Opportunities Red

6 Worst Case Forecast outturn Red The table above shows the Financial dashboard on a month by month basis. This will be further developed in future months and will be used to make comparisons against historical performance.

Information relating to the Statement of Financial Position, Invoice payment metrics and the cash position can be found in the appendices.

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Financial Summary

The financial position of the CCG is extremely challenging. The forecast QIPP slippage at Month 2 means that the CCG has released available contingencies into the position to enable the reported position to be at plan. Clearly this means that any acute or other over performance and any further QIPP slippage represents a high risk to the CCG and will result in the financial position moving away from plan. 4 Resources/Investments

n/a

5 Equalities n/a

6 Risk Financial risk is reported in section 3 of the report.

7 Managing conflicts of interest n/a

Attachments: 1. Appendix 1 – Statement of Financial Position 2. Appendix 2 – Invoice Payment Performance Measure 3. Appendix 3 – Cash to Income and Expenditure Reconciliation 4. Appendix 4 – Cash Position and Forecast Year End Value

Author: Tom Travers, Chief Finance Officer Date: June 2017

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Appendix 1

£000 £000 £000 £000

Mar

2017

May

2017

Mar

2018

Annual

Change

Non-current assets

Property, plant and equipment - - - -

Intangible - - - -

Other financial assets - - - -

Trade and other receivables - - - -

Total Non Current Assets - - - -

Current Assets

Inventories - - - -

Trade and other receivables 3,535 4,671 3,061 (474)

Other financial assets - - -

Cash and cash equivalents 25 (609) 50 25

Total Current Assets 3,560 4,062 3,111 (449)

Total Assets 3,560 4,062 3,111 (449)

Current Liabilties

Trade and other payables (24,249) (26,612) (21,525) 2,724

Provisions (1,868) (1,868) (974) 894

Borrowings - - - -

Total Current Liabilites (26,117) (28,480) (22,499) 3,618

Net Current Assets/(Liabilities) (22,557) (24,418) (19,388) 3,169

Trade and other payables - - - -

Provisions (6) (6) - -

Borrowings - - - -

Total Non-Current Liabilites (6) (6) - -

Total Assets Employed (22,563) (24,424) (19,388) 3,175

Financed by:

Taxpayers Equity

General Fund (22,563) (24,424) (19,388) 3,175

Revaluation reserves - - - -

Total Taxpayers Equity (22,563) (24,424) (19,388) 3,175

Barking & Dagenham CCGStatement of Financial Position

Position as at 31st May 2017

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Appendix 2

Number Value Number Value Number Value

£'000 £'000 £'000

Non-NHS Creditors

Total Bills paid in the year 682 4,268 859 5,454 1,541 9,722

Total Bills paid within target 672 4,267 797 4,980 1,469 9,247

Percentage of Bills paid within target 98.5% 100.0% 92.8% 91.3% 95.3% 95.1%

NHS Creditors

Total Bills paid in the year 114 16,277 210 17,074 324 33,351

Total Bills paid within target 114 16,277 196 16,744 310 33,021


All Creditors

Total Bills paid in the year 796 20,545 1,069 22,528 1,865 43,073

Total Bills paid within target 786 20,544 993 21,724 1,779 42,268


Barking and Dagenham CCG

Invoice Payment Performance Measure


May-17 CumulativeApr-17

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Appendix 3

£000

May

2017

Actual

Cashflows from Operating Activites

Net operating cost before interest operating surplus/deficit (49,209)

(Increase)/decrease in trade and other receivables (1,136)

Increase/(decrease) in trade and other payables 2,363

Provisions utilised -

Net cash inflow/(outflow) from operating activities (47,982)

Cash flow from investing activities

Interest received

(Payments) for property, plant and equipment -

(Payments) for intangible assets -

(Payments) for other financial assets -

Proceeds of disposal of assets held for sale (PPE) -

Proceeds of disposal of assets held for sale (Intangible) -

Proceeds from disposal of other financial assets -

Net cash inflow/(outflow) from investing activities -

Net cash inflow/(outflow) before financing (47,982)

Capital element of payments in respect of finance leases and On-SoFP PFI and LIFT -

Net parliamentary funding 47,348

Capital receipts surrendered

Capital grants and other capital receipts (excluding donated / government granted cash receipts)

Cash transferred (to)/from other NHS bodies

Net cash inflow/(outflow) from financing activities 47,348

Net increase/(decrease) in cash and cash equivalents (634)

Cash and cash equivalents (and bank overdraft) at beginning of the period 25

Cash and cash equivalents (and bank overdraft) at YTD (609)

Reconciliation of Cash Drawings to Parliamentary Funding

Total cash received from DH (Gross) 43,000

(Less)/plus: transfers (to)/from other resource account bodies -

Plus: cost of Co-Commissioning (central charge to cash limits) -

Plus: drugs reimbursement (central charge to cash limits) 4,348

Parliamentary funding credited to General Fund 47,348


Cash to income and expenditure reconciliation


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Appendix 4

£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

April May June July August September October November December January February March Total

2017 2017 2017 2017 2017 2017 2017 2017 2017 2018 2018 2018 2018

Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast

Receipts

Balance bfwd 25 1,675 81 159 139 151 154 157 170 173 176 188 25

-

NCB Drawdown 22,000 21,000 22,400 21,600 22,100 21,400 21,400 22,100 21,400 21,400 22,100 21,400 260,300

Other 389 145 - - - - - - - - - - 534

PCS Payments Reimbursements - - - - - - - - - - - - -

VAT 28 36 - - - - - - - - - - 64

Total 22,442 22,856 22,481 21,759 22,239 21,551 21,554 22,257 21,570 21,573 22,276 21,588 260,923

Payments

Creditors NHS 16,277 17,083 16,339 16,335 16,852 16,335 16,335 16,852 16,335 16,335 16,852 16,335 198,270

Creditors BACS 4,384 5,517 5,891 5,192 5,143 4,969 4,969 5,143 4,969 4,969 5,143 4,969 61,262

Creditors CHAPS 2 58 - - - - - - - - - - 60

Salary CHAPS - - - - - - - - - - - - -

Cleared Payable Orders 7 20 - - - - - - - - - - 26

Salaries & Wages 55 55 52 52 52 52 52 52 52 52 52 52 630

Pensions 12 12 12 12 12 12 12 12 12 12 12 12 144

Tax & NI 29 30 28 28 28 28 28 28 28 28 28 28 339

Standing Orders/Direct Debits - - - - - - - - - - - - -

Foreign Payments - - - - - - - - - - - - -

Other 0 - - - - - - - - - - - 0

Total 20,767 22,775 22,323 21,620 22,088 21,397 21,397 22,088 21,397 21,397 22,088 21,397 260,732

Balance cfwd 1,675 81 159 139 151 154 157 170 173 176 188 191 190


Cash position and Predicted Year End Value


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Executive summary

This report provides assurance to the governing body that the Clinical Commissioning Group (CCG) continues to measure and monitor the quality of the services we commission from all providers. The report is divided into two sections. Section 1 provides a system wide overview of specific quality indicators that underpin and assure all the CCG commissioning activities, such as assurance on the robustness of the quality impact assessment process to ensure the system delivery plan is safe to implement. Section 2 focuses on the priority operational quality issues and challenges that the CCG continues to manage to ensure patient safety and that also support a positive patient experience.

Recommendations

The governing body is asked to:

Discuss and review the quality matters outlined in this report

Suggest any additional actions that are required for further improvements or assurance


1.1 This report is presented to the governing body to ensure that members are fully briefed and

assured on all the quality challenges and issues that the CCG is addressing through our range of

commissioning activities.

1.2 This covers both strategic and operational quality issues and details how they are managed so

that the people we commission services for receive the best possible care, delivered in a way that is safe and effective while providing value for money and a positive patient experience.

2.0 Introduction 2.1 Improving experience for patients continues to be a CCG priority, and many of our specific quality

improvement and assurance activities are aimed at doing this, particularly our actions that deliver improved provider quality performance, which we assure and monitor through our established contract monitoring processes.

2.2 This report is divided into two sections:

Section 1 - System wide quality performance which includes the CQC provider quality performance concerns and assurance of the robustness of our Quality Impact

To: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group Governing Body

From: Jacqui Himbury, Nurse Director

Subject: Quality Report

Date: 18 July 2017

117

Assessment (QIA) process and that we continue to implement our care home (with nursing) strategy.

Section 2 – The quality performance of our main providers and the issues we are currently reviewing and addressing at the Clinical Quality Review Meetings (CQRM).

3.0 Section 1: System Quality Performance

3.1 CQC Provider Quality Performance Challenges

3.1.1 NELFT CQC inspection. NELFT has reported the current status of the Strategic Quality Improvement Plan to the June Trust Board meeting and confirmed that there are fourteen exceptions remaining, with nine improvement actions recently closed. NELFT has recently established locality CQC meetings which will focus on preparation for re-inspection and to guarantee sustainability into the future. These locality meetings will ensure that there are audit checks and assurance processes in place.

3.1.2 NELFT reports that they have a solution around monitoring and reporting against care planning

and risk assessment which is under discussion with their IT department to ensure that the solution is embedded and maintained. We have sought assurance at the June CQRM on the Clinical Risk Training Programme, both in terms of the content of the training and the expected level of participation. NELFT has advised that their biggest change since the CQC inspection is an improvement in staff culture in terms of understanding the consequences of actions and risk awareness.

3.1.3 We have also continued to improve the service performance review/CQRM process and can

assure the governing body that the quality team and CSU contracting colleagues will continue to work together to monitor the performance and quality of the services provided by the Trust.

3.2 BHRUT CQC inspection. As reported in previous papers, BHRUT exited “Special Measures” in

March 2017 following the publishing of the recent CQC report which rated the Trust as “Requires

Improvement” overall.

3.2.1 The Trust’s improvement programme provides the detail on implementation of the next steps with

the aim of improving the CQC rating from ‘Requires Improvement’ to ‘Good’ within the next 18 months. To achieve this current “Must Do” and “Should Do” actions from the March 2017 CQC report are aligned to the existing improvement programmes. Where no immediate concerns, risks or issues exists these areas will be moved to business as usual systems and processes overseen by the improvement portfolio leads with oversight by commissioners through the CQRM.

3.2.2 The current enhanced surveillance level of contract monitoring and quality assurance processes we have in place will remain, until we are assured that the required improvement the Trust has achieved is sustained. We will continue to support the Trust with all the quality improvement plans and initiatives to ensure the pace of improvement does not slow down.

3.3 Bart’s Health NHS Trust CQC inspections. As reported in previous papers, the CQC issued

the Trust with seven requirement notices because of the breaches to the fundamental standards

that were not being met. Included within the regulations are twelve “Must Do” and twenty one

“Should Do” recommendations that the Trust must meet.

3.3.1 The Trust reports progress against the Whipps Cross improvement plan, including discharge improvements linked to better transport arrangements, a focus on reducing cancelled operations, some recent senior appointments and roll out of the SAFER bundle at each CQRM. At The Royal London Hospital, there had been work to address staffing ratios and consistency of security arrangements in maternity services while improving high dependency contingency arrangements. All ‘Must Do’ actions following the Newham Hospital inspection have now been implemented.

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3.3.2 A quality summit will be held to formalise a related improvement plan and the Trust has been encouraged by positive media coverage following the CQC report publication that reflected the progress made. The Quality and Safety Committee (QSC) will review the emerging improvement plan in more detail in due course.

3.3.3 The Trust Board papers notes forthcoming CQC inspections ahead of an overall CQC provider report being issued: A review of St Bartholomew's Hospital in May 2017, followed by a 'Well Led' domain review in early June, which will focus on the effectiveness of 'ward-to-Board' governance and processes.

3.4 PELC CQC Inspection. PELC have recently undergone a CQC inspection and have received

verbal feedback. They are awaiting imminent publication of the report and when this is available a detailed update will be included in this report.

4.0 System Quality Improvement Actions

4.1 Care Homes (with nursing) Strategy 2017 – 2020. As reported in previous papers, the CCG

has been performance managing three different care homes where quality risks have been

identified. All three have had ongoing enhanced quality assurance monitoring by Multi Agency

Surveillance Groups, and all three have now had their restrictions lifted. These three return to

routine surveillance and quality monitoring.

4.2 The care home CQRM process is currently being established with appropriate representation

from Continuing Healthcare and CSU colleagues. This will provide a report to the QSC at each

meeting to assure members that the issues and challenges we identify are being managed safely

and proactively. This process will include the routine monitoring of all performance information

including attendances at emergency departments, number of reported falls and pressure ulcer

prevalence.

5.0 Quality Impact Assessment (QIA) process. As reported in previous papers, due to the

significant scale of our financial challenge and the development of the System Delivery Plan,

each cost reduction project and investment business case goes through an initial QIA process,

and if indicated a comprehensive QIA is completed. Since March 2017, approximately 30 project

plans have been reviewed by the quality team following this process. The QSC are assured that

the process is robust and that if any quality/patient safety issues are identified appropriate action

is taken to mitigate or reduce the risks.

6.0 Section 2: Operational Quality Improvements and Challenges

6.1 Provider quality performance improvements and challenges addressed through the CQRM

6.2 BHRUT Mortality Outlier Status. As reported in previous papers, BHRUT was flagged as a

mortality outlier by the Dr Foster Unit in December 2016, February and March 2017, for urinary

tract infections (UTI), patients admitted with septicaemia (except in labour) and more recently

deaths caused by biliary sepsis. In response, the CQC have issued three alerts requesting that

the Trust take action to understand and explain why the actual number of deaths for these

conditions is greater than the expected number of deaths. The CQC requested that the Trust

explore potential common factors which might explain the apparent raised mortality. The Trust

was required to review the groups of patients coded with these primary diagnosis between

specified dates, and evidence analysis undertaken on a sample of at least 30 individual cases for

each alert. The reviews of sepsis and UTI have been completed.

6.2.1 The findings reported at the June CQRM noted one case of probably avoidable UTI mortality,

which represents 3% of cases which is in line with the national average. This case related to

failure to remove an indwelling catheter for a care home resident with resultant immediate

admission to hospital with sepsis. The case requires wider review in respect to planning for

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catheter change, referral and detection of deterioration within the care home. The Trust have

indicated that the avoidable mortality scoring is subjective and have cited concern from the Royal

College of Physicians who feel it is better to extract learning points from mortality reviews.

However, the Trust continues to build their Mortality Faculty to deliver extensive detailed reviews

by Q3 to meet the NHSE publication date. This work builds on the current checklist review

established in 2015 which has reviewed 3700 deaths and reported across a range of quality

indicators.

6.2.2 The Trust has identified three key findings from their mortality reviews:

That patients are presenting in a considerably poor condition and often have significant

comorbidities. Deterioration is clear prior to admission and this suggests earlier clinical

intervention may have halted progression of the condition. Identification of people who are

approaching the end of their life if they are able to communicate this on admission, however

communication and planning from community care settings could be improved. The engagement

of commissioners, GPs, community providers and care homes is needed in this area and is being

pursued.

In the mortality review timeframe (June 2016), the use of bundles of care was poor. A number of

examples show excellent senior review, however evidence of delivering all key tasks required in

sepsis varied. Weekly testing and reporting on care bundles was established in May 2017 to

drive improvement, and now shows >90% compliance. Performance is being monitored monthly

at the CQRM.

Documentation of patient condition and assessment was variable in the review. This relates to

care bundle use and accurate clinical coding. Clinicians and the coding team have been

presented with the results and have been involved with improvement actions. Consultant sign off

on primary diagnosis and comorbidity is now in place.

6.2.3 BHR CCGs have been invited to participate in the new Mortality Faculty which will closely monitor

actions to reduce mortality and ensure compliance to the ‘Learning from Death’ reviews. BHRUT

has requested support from the CCG in respect to care provided outside of the Trust, and

proposes engagement with GPs and the community provider in this work.

6.2.4 Commissioners have requested that the Trust produce an improvement plan with a recovery

trajectory that will reduce mortality to ensure the Trust return to the expected Summary Hospital-

leveI Mortality Indicator (SHMI) baseline of 100. The Trust have given commissioners assurance

that the plan will be presented to the July 2017 CQRM for commissioner sign off. Enhanced

quality surveillance will continue for this indicator at each CQRM and a report on progress will be

presented to each QSC meeting.

6.2.5 A clinically led meeting has been arranged between the CCG and the Trust to review the draft

improvement plan and to agree the next steps for implementing total pathway reviews.

6.3 BHRUT. Safer Staffing. As noted in previous papers, recruitment and retention of staff, across

all disciplines continues to be a risk that the Trust are managing, and this risk is reported monthly

to their Board through an escalation process from their Quality Assurance Committee.

6.3.1 In June 2017, the Trust presented the current status of the recruitment for the nursing workforce,

particularly at band 5 level, which remains one of the Trust’s key risks and challenges. The Trust

has refocused their recruitment from EU and international campaigns to developing a “grow your

own” programme to recruit more locally; by developing and embedding a strong and identifiable

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employer brand that is visible in the local community, setting out how BHRUT manages its people

in line with their PRIDE values.

6.3.2 The Trust will continue to commission the maximum number of places on pre-registration courses

with partners, and will introduce the Nursing Associate role to support the development of a future

professional workforce.

6.3 BHRUT – Never Event. BHRUT reported their third Never Event in May. This was a retained

swab which was discovered two days after surgery. An initial investigation notes that the swab

was retained following the formal counting process, and an immediate safety action was put in

place to hold observation audits of theatre practice on 3-5 June. The Never Event has been

reported to NHS Improvement. The Investigation report on the previous SI (retained dental

micro-drill bit) was reviewed at the April 2017 SI Panel and approved. The actions from this

report will be monitored to completion through the SI Panel process, and the final report will be

noted at CQRM.

6.4 NELFT - Safer Staffing. As reported in previous papers, the Trust has reported that vacancy

rates are showing significant improvement across the Trust, with a reasonably static rate of 17%

against a target of 10%. Staff turnover increased in March 2017 from 15% to 17%, and this

continues to be a cause of concern for commissioners, as the target is 10%. The Trust has a

trigger point for safe staffing; where vacancy factors of 30% or above are reported, a quality visit

is conducted by the Director of Nursing to assess the safety of the service. As of March 2017, no

new wards have hit the trigger for a quality visit. The Trust has a watch list for wards at risk for

staffing issues, as identified by incident reports for red flag staffing events such as, where

bank/agency staff do not arrive or are cancelled late. These incidents are closely monitored and

used as a risk measure. In March 2017, out of approximately 2,100 shifts, 11 (0.52%) were

reported as ‘adverse events that affect staffing levels’ incidents.

6.4.1 The Trust has established an agreed reporting and quality assurance framework to ensure all

quality and patient safety risks are reported to their board on a monthly basis. This reporting

mechanism demonstrates an improvement in the way the Trust manage quality risks, escalating

as necessary. Improvements are still required and this is evidenced in their recent well led

review conducted by KPMG, which is with the commissioners for review.

6.5. Bed Occupancy. The ward occupancy rate for adults of working age has risen again (reported

as >99% in February 2017). Older adults’ ward occupancy has risen for men and women. Older

women remain within target while older men are above the target. 93.4% and 86.8% respectively.

This shows that despite the remedial actions taken by NELFT to relieve pressures, the demand

for inpatient care remains high.

6.5.1 Adult average length of stay (ALOS) has fallen for each borough for the third month and are

within the 25 day threshold. This reflects the actions that NELFT has been taking to ease the

pressures on beds. However, older adult (ALOS) in B&D and Havering are no longer within the

threshold.

6.6 Bart’s Health. The Trust continues to progress slowly in improving their performance across a

range of quality indicators and continue to be contractually and supportively managed by the lead

commissioners. This report focuses on exception reporting for Whipps Cross Hospital (WXH) as

this is our main local hospital site. The quality indicators that we are supporting the Trust to

improve are:

A high number of Never Events with repeated incidents and poor evidence of learning. Following Redbridge CCG escalating concerns to the lead commissioner contractual action has been taken. BH have now developed and implemented a

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remedial action plan which includes a standardised risk assessment process for Never Events. The Trust reported at the April 2017 CQRM that during 2016/17 there were 13 Never Events reported, 2 of these events occurred at Whipps Cross Hospital. There were no Never Events reported at WXH between November 2016 and March 2017, however, a Never Event was declared in April 2017. This was a Redbridge CCG patient.

Non-compliance with the National Framework for the management of serious incidents. In December nineteen serious incident (SI) reports were overdue, which was a deteriorating position compared to the November data. Whipps Cross Hospital have confirmed that the governance team lack the capacity and capability to ensure all the serious incidents are closed on time. The Medical Director is now leading the improvement plan and a revised compliance trajectory has been agreed. Data reported at the June CQRM shows 14 open SIs (within the deadline) with only 3 overdue. This is a significantly improved position.

Inadequate complaints management and little evidence of organisational learning. As above a remedial action plan has been submitted by the Trust and was reviewed in January 2017 by commissioners. Commissioners were not assured that the plan would deliver the required improvements and escalated this quality risk to the Contractual Review Group. The Trust has subsequently shown significant improvement in reducing the number of overdue complaints from 62 in Q3 to 34 in Q4, with 3 complaints overdue in April. The governance team are reviewing complaints at day 15 to determine any risks to achieving the deadline and appropriate escalation for issues related to lack of response. The Trust have assured commissioners that the performance target of 80% of all complaints responded to within 25 working days will be delivered by the end of Q1 2017/18. Year to date performance at the time of writing this report was 64%.

Friends and Family Test rate for the emergency department. The Trust has submitted an amended improvement action plan with a revised trajectory for compliance. This has been accepted by commissioners. The Trust has recruited a lead for patient experience and commissioners anticipate this could support improvements. Work has been on-going to improve the response rate in the Emergency Department at Whipps Cross to achieve the improvement trajectory agreed with the CCG. Data presented at the June CQRM provides a trajectory to improve FFT rates for the ED to 20% by August 2017. The Trust’s reported response rate is 3% as of February 2017. The CCG is offering additional support to this provider working collaboratively with NHSI.

Non-compliance with regulation 20 the Duty of Candour (DoC). The requirement is

100% compliance and for November 2016 the Trust reported 65% compliance. This

breach of contract has also been escalated by Waltham Forest CCG to the Contract

Review Group as a breach of regulation. Data reported for January 2017 shows the

overall Trust at 69.2% compliance, with the WXH site at 54.5%. The improvement plan

includes a daily review of incidents to ensure level of harm is correct and escalation for

review at compassionate care and patient safety meetings is timely. Additional

governance resource has been dedicated to support staff to ensure all elements of DoC

are completed, and to ensure that performance reports are accurate. Further training to

increase awareness around DoC, medical and nursing staff priority groups is planned to

be completed before the end of June 2017.

6.7 Bart’s Health IT Disruption. In January 2017, Barts Health IT service became aware of failures

in their IT systems at Newham University Hospital which suggested a computer virus had

affected their pathology and imaging systems, making them inoperable, and also affected file

share systems which prevented user access to documents and files. The effect of measures to

protect from further infiltration was that planned cardiac cases were cancelled and pathology

results were reported manually. This was declared as a Major/Serious Incident, which was due

to report on 12 April 2017 although the report has not yet been submitted.

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6.7.1 On April 20 2017, Barts Health IT service reported a Major/Serious Incident into simultaneous

failures of a number of hard drivers storing clinical data, which affected diagnostics systems and

chemotherapy systems. This incident appeared to reach deeper into Trust clinical systems,

again affecting pathology and imaging systems across the Trust, although it has not been

confirmed that this was caused by similar malware. An immediate response was to advise GPs

to send requests for fracture and chest x-rays to the Royal London Hospital, rather than the Mile

End Hospital until further notice. This incident appears to have similar features to the January IT

disruption, which raises concerns about the IT system’s resilience. It also raises concerns that

organisational learning across sites requires improvement.

6.7.2 On 12 May 2017, the global cyber-attack caused major disruption to Barts Health pathology and

diagnostics systems. A Major/Serious Incident was declared. Barts Health reported that 80

operations were cancelled, 30 of these at Whipps Cross Hospital, and that all of these patients

had been rebooked. The immediate impact of that was that current patients had their operations

cancelled to accommodate these cancellations.

6.7.3 In addition 980 screening mammograms were delayed, with 5 cancers diagnosed, 300

surveillance mammograms were delayed, and all reported initially without access to archive

scans for comparison (as archives were not accessible). No cancers in this group have been

reported to date and films for second reporting have been taken as historic archives are restored.

BH reported that 3,000 screening mammograms appointments were delayed. As these are

rebooked, new cancer diagnosis will be assessed for clinical harm potentially caused by the

delay. The Trust anticipates that this would be a low number.

6.7.4 For Maternity, the IT systems failure had less impact, as patients’ paper records were available.

However, some mothers had their foetal anomaly screening delayed, and maternity follow-ups

post-delivery were pushed back. The Clinical Harm Team undertook a review to assess any

clinical harm in maternity services and to date, have found no evidence of patient harm. A

specific focus was on delays to foetal anomaly screening; to date, none have been identified.

Impact on RTT

6.7.5 Barts Health reported a major impact on their ability to validate their RTT/PTL following the cyber-

attack, and that they could not report a validated position from March 2017. At the Clinical Harm

Review Panel in June, it was noted that 167 patients had been waiting longer than 52 weeks, but

that this could not be substantiated until data was fully restored. Barts Health anticipated having

an accurate PTL by the end of June.

6.7.6 Barts Health plan to return to RTT reporting in October 2017, but were identifying risks to this as:

the upgrade to the Newham system, further cyber-attacks, data quality issues and training for

clinicians on RTT rules.

Clinical Harm Process

6.7.7 Barts Health clinicians explained at the External Clinical Harm Review Panel in June 2017 that

reviews for potential clinical harms would be carried out on patients impacted by the cyber-attack

in a similar manner to the RTT clinical harm review process. A Quality Assurance Triumvirate

has established a task and finish group to identify and review clinical harm caused by the global

cyber-attack. The clinical harm reviews will focus on the following:

Inpatients – patients who required repeat diagnostics/imaging, with higher risk of ionising

radiation; and patients who may have suffered an adverse outcome related to a delay.

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Accident & Emergency – patients who suffered delays to treatment, with focus on delayed

fracture management and cardiac procedures; where revisions of treatment were made

consequent on delayed diagnosis

Cancer Patients – patients who had cancer operations cancelled; administration of

chemotherapy and treatment delays; delays related to deferred MDT discussions and the

potential impact on the 31 and 62 day cancer constitutional targets.

RTT and Outpatients – Treatment cancellations and impact on 18 week pathways; where

surgery was delayed or deferred, or where interventional procedures were delayed of deferred.

GP Alerts System – review of the dedicated email inbox (which was closed for a time following

the attack) where local GPs had raised concerns of possible harm from delays.

Additional areas for review – The Trust will also review the impact of delays on breast cancer

screening, the prolonged impact on Cancer MDT and 52 week breeches. A maternity review will

be conducted to assess the impact on maternity patients, to include post-delivery follow ups.

Radiology Safety Netting – The Trust has put in place a Radiology Safety Netting process. To

date, 1,100 MRIs and 600 CT scans have been recovered from the recent archives and are being

reported. Further imaging recovery is on-going. A log is being kept within Radiology for all

patients from this period, who are being monitored for new diagnoses and/or repeat ionising

radiation. A clinical harm review will take place for all of these patients.

6.7.8 Comprehensive oversight and risk management will be maintained through the use of the Trust’s

Datix reporting tool. Where Incidents were recorded on paper, these are being added to the

electronic system. The Trust will present information on any clinical harm from the IT disruptions

via the Clinical Harm Review Panel.

IT Resilience Recovery Plan - June 2017

6.7.9 The Managing Director of Whipps Cross Hospital, provided an overview of the current status of

the IT resilience recovery plan at the Whipps Cross CQRM on 15 June 2017. The recovery plan

which was being tracked daily is now at a point where weekly tracking is required and 96% of the

actions are complete. In terms of risk, the ability to rebook the backlog of patients should be

complete by the end of July. Barts Health has commissioned an external review into the IT

disruptions.

BHR CCG Actions

6.7.10 BHR CCGs have written to the lead commissioners asking for assurance that Barts Health has

mitigated the risks. BHR CCGs has expressed concerns that despite moving to manual paper

systems during the IT disruption; that data restored from backups may be incomplete, so cases of

potential clinical harm may not be immediately identified. It is clear that the Trust has found it

challenging to restore imaging archives, and that data required for reporting has also taken some

time to restore. The Trust have agreed to review the process and will provide additional

assurance as requested by commissioners at the July CQRM.

7.0 Resources/investment 7.1 There are no additional resource implications/revenue or capitals costs arising from this report.

8.0 Sustainability

8.1 If we achieve the quality improvements detailed in this report the positive impact will be on sustained quality improvement and an improvement in patient experience.

124

9.0 Equalities 9.1 This report has considered the CCG’s equality duty and where relevant has identified relevant

actions which address any likely impact on equality and human rights. 10.0 Risk

10.1 Failure to ensure that there are improvements to the quality performance of commissioned

services may result in a failure to manage and mitigate risks with potential harm to patients and

reputational damage to the CCG. The CCG quality surveillance and management system

provides mitigation to this risk. The management of this risk is assured by the Quality and Safety

Committee.

10.2 Some patients may not be receiving the quality of care at the level which the CCG commissions,

and therefore may have a poor experience of using the services we commission.

10.3 Mitigating actions for the above risks have been specified in the body of the report.


11.1 There are no conflicts of interest raised in this report.

Author: Jacqui Himbury, Nurse Director and Christine Kane, Deputy Director Quality Date 26 June 2017

125

To: Meeting of the Barking and Dagenham Clinical Commissioning Group Governing Body

From: Marie Price, Director of Corporate Services

Date: 18 July 2017

Subject: Finance and Delivery Committee – Update to Terms of Reference

Executive summary

The CCGs have been revising arrangements for governance of financial decisions and risk given

the deterioration in the financial position and recent finance/governance review.

The Barking and Dagenham, Havering and Redbridge (BHR) governing bodies have agreed to

consolidate the functions of the Investment Committee into the Financial Recovery Programme

Board (FRPB) and its terms of reference (TOR) have been amended.

A number of further changes to finance and delivery committee arrangements were recommended

as part of the recent Deloitte review and were proposed to the Finance and Delivery Committees

(FDC) which met (in common) on 28 June and considered and agreed the following changes to the

TORs:

Additional member: One of the recommendations of the review was that the FDC include

an additional member. It was agreed that one of the lay members be included as a

member. The lay members across the three CCGs currently act on behalf of each other

with respect to some decisions – such as investments where there is a conflict of interest for

other members. It was proposed and agreed that the lay member invited to join this

committee in common is also able to act for all three CCGs. The Accountable Officer will

also attend meetings of the committee as appropriate.

Chairing: It is suggested that the Chair of Havering CCG act as the FDC Chair, with the lay

member for governance as deputy chair.

Procurement Oversight Group (POG): The revised TORs also outline that the POG will

report to this committee.

Additional changes have been made to reflect the name of current plans – i.e. System Delivery

rather than QIPP and senior responsible officer (SRO)/clinical responsible officer (CRO) in line with

the leadership arrangements for programmes and projects.

The revised TORs are attached.

Recommendations

The Governing Body is asked to:

Approve the revised terms of reference

Author: Marie Price, Director of Corporate Services Date: 04 July 2017

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Clinical Commissioning Group Governing Body

Finance and Delivery Committee Terms of Reference

Meeting Finance and Delivery Committee

Constitution The Clinical Commissioning Group (CCG) governing body (‘the governing body’) hereby resolves to establish a committee of the governing body to be known as the Finance and Delivery Committee (‘the Committee’).

NB: This committee is specific to the CCG and retains individual decision making authority, but meets in common with fellow BHR CCGs.

Role of the committee

The Committee shall provide assurance that all aspects of financial management are operating effectively, through focus upon key financial risk areas. The Committee will ensure that CCG is delivering its financial targets within the System Delivery Plan (SDP). It will review and agree mitigating actions, for projects escalated to the committee as high risk.

Membership

Members:

Two clinical directors (CD), including the CD finance lead

Lay member, governance

Chief finance officer

Transformation programme directors

Lay member (PPI) from one of the BHR CCGs and able to represent all three CCGs

Regular attendees

CCG Deputy Chief finance officer

CCG Director of Delivery and Performance

Additional Attendees

All clinical directors will be invited to attend. Individuals may be invited to attend all or part of the meeting, as and when appropriate. These are expected to include SROs, CROs and assurance leads for areas such as contracting, finance and analytics. Other individuals may be invited to attend all or part of the meeting depending on the specific range of risk areas identified. The accountable officer will also attend meetings as appropriate.

Chair The Committee shall be chaired by the Havering CCG Chair with the lay member for governance as the deputy chair.

Quorum

The quorum of the Committee is three of the six members, to include at least one lay member or the chief finance officer and one clinical director.

A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee.

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Decision-making

The chair of the Committee will work to establish unanimity as the basis for decisions of the committee. If, exceptionally, the committee cannot reach a unanimous decision, the chair will put the matter to a vote, with decisions confirmed by a simple majority of those voting members present, subject to the meeting being quorate.

The Committee will ensure that any conflicts of interest are dealt with in accordance with the CCG standards of business conduct policy.

Duties of the Committee

The Committee shall provide assurance to the governing body that there are robust and integrated mechanisms in place to ensure detailed review and oversight of the CCG’s financial position.

The Committee shall:

Review and consider the financial and delivery plans and make

recommendations to the governing body.

Review significant risks identified by the Committee, the Chief

Finance Officer, Executive or Governing Body. Facilitate deep

dives into finance and activity data where required.

Report to the governing body on the overall status of financial and

operational performance, assessing potential shortfalls and risks

and recommend governing body level mitigating actions to

address them.

Review plans and progress reports on the delivery of SDP

initiatives and ensure that plans are supported by robust activity

and financial information. Review in detail SDP schemes that have

been escalated to the group as high risk, and ensure that

mitigating actions are in place to enable recovery.

Receive reports on progress against action plans already in place.

Review and consider detailed monitoring reports and year end

forecasts relating to financial performance and performance of the

CCG against core standards, national and local targets and the

operating plan as required.

Frequency of meetings

Meetings shall be held bi-monthly and not less than five times a year.

In accordance with standing orders the Chair may call an extraordinary meeting of the committee at any time.

The Committee also has the right to meet with another CCG Committee if there are matters of common concern for discussion e.g. the audit & governance committee

Notice of meetings

Meeting dates are set by the company secretary for each financial year in advance. Changes to meeting dates or calling of additional meetings

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should be provided to members and attendees within five days of the meeting.

A minimum of five working days’ notice and dispatch of meeting papers is required. Notice of all meetings shall comprise venue, time and date of the meeting, together with an agenda of items to be discussed and supporting papers.

Administration and minutes of meetings

The company secretary, or whoever covers these duties, shall be secretary to the Committee and shall attend to take minutes of the meeting and provide appropriate support to the chair and Committee members.

Reporting responsibilities

The Committee shall:

submit a summary of key points and recommendations to the

governing body.

submit to the governing body complete copies of minutes of all

meetings;

submit an annual report of its work to the governing body.

The pan BHR Procurement Oversight Group will report to the Committee.

Authority

The Committee is authorised by the governing body to investigate any activity within its terms of reference. It is authorised to seek any information it requires in this regard from any employee and all employees are directed to cooperate with any request made by the Committee. The Committee is authorised by the governing body to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

The Committee will be responsible for determining any additional or reconfigured sub-structural arrangements to support fulfilment of the Committee’s remit.

Other

The Committee shall at least quarterly, review its own performance and terms of reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the governing body for approval.

Agreed at Barking & Dagenham CCG’s Finance & Delivery Committee May 2015. Approved at Barking & Dagenham CCG’s Governing Body meeting June 2015.

NB: This will be updated following consideration at July GBs

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To: Meeting of the NHS Barking and Dagenham Clinical Commissioning

Group Governing Body From: BHR CCGs Finance & Delivery Committee Vice Chair Date: 18 July 2017 Subject: Feedback report from the June 2017 BHR CCGs Finance & Delivery

Committee meeting Summary The Finance & Delivery Committee meeting minutes are provided to each of the 3 CCGs Governing Body meetings. To provide additional assurance to the Governing Bodies, this brief feedback report provides key highlights from the meeting:- Finance risk report - Committee members were given an update on the financial risks and it was noted that the financial position of the CCGs remains extremely challenging. System Delivery Framework - Committee members received an update report which outlined the current status of QIPP savings. Contracts position / deep dives An update on the RTT national standard was provided along with an update on the NHS Standard Contract and the changes affecting the interface between primary and secondary care. Committee members also received a deep dive on ENT, Gastroenterology and Urology referrals. Locality/Network updates The Lead CDs from each borough provided updates on the areas they are focusing on. Recommendation:

The Governing Body is asked to note this feedback report and the June committee minutes which provide more detail on all the matters considered.

3 July 2017

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Draft Minutes of the BHR CCGs Finance & Delivery Committee held on 28 June 2017 at Imperial Offices, Romford

Members:

B&D CCG Havering CGG Redbridge CCG

Dr Atul Aggarwal (AA) CCG Chair and F&D Committee Chair

Dr Jyoti Sood (JS) Clinical Director

Dr Gurkirit Kalkat (GK) Clinical Director

Dr Alex Tran (AT) Clinical Director

Dr Muhammad Tahir (MT) Clinical Director

Kash Pandya (KP) Lay Member, Governance



Tom Travers (TT) Chief Finance Officer



Sharon Morrow (SM) Chief Operating Officer

Alan Steward (AS) Chief Operating Officer

Attendees: Dr Ann Baldwin (AB) Clinical Director, Havering CCG Dr Gurdev Saini (GS) Clinical Director, Havering CCG Dr Anil Mehta (AMe) Chair, Redbridge CCG (Dialled in) Dr Syed Raza (SR) Clinical Director, Redbridge CCG Conor Burke (CB) Chief Officer, BHR CCGs Tracy Welsh (TW) Deputy Chief Operating Officer, representing LM Ali Kalmis (AK) Director, Acute Contract Management- CSU Frank O’Neill (FO) Interim Director Finance – CSU Jeremy Cridland (JC) Associate Director, Business Intelligence - CSU Anna McDonald (AMc) Business manager, BHR CCGs Apologies (members) Dr Waseem Mohi (WM) Chair, B&D CCG and F&D Committee Dr Maurice Sanomi (MS) Clinical Director, Havering CCG Dr Mehul Mathukia (MM) Clinical Director, Redbridge CCG and Chair of F&D Committee Dr Sarah Heyes (SH) Clinical Director, Redbridge CCG Louise Mitchell (LM) Chief Operating Officer, Redbridge CCG Apologies (attendees) Dr Kanika Rai (KR) Clinical Director, B&D CCG Dr Ravi Goriparthi (RG) Clinical Director, B&D CCG Dr Anju Gupta (AG) Clinical Director, B&D CCG Dr Ashok Deshpande (AD) Clinical Director, Havering CCG Dr Anita Bhatia (AB) Clinical Director, Redbridge CCG Rob Adcock (RA) Deputy Finance Officer, BHR CCGs

1.0 Welcome and apologies Action

The Chair welcomed everyone to the meeting and apologies were noted.

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1.1 Declarations of interests

The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of BHR CCGs. No additional declarations of interest were declared. The register of interests held for BHR CCGs Governing Body (GB) members and staff is available from the Company Secretary.

1.2 Minutes of the last meeting

The minutes of the meeting held on 27 April 2017 were agreed as an accurate record with one minor amendment.

1.3 Matters arising/actions log

The open actions were reviewed:- Ref 2.1 Clarity on the RTT national standard – AK confirmed that the national standard for RTT is still included in the standard national contract. The target is achievement of 92% by 2020 which providers are expected to meet. AK confirmed there isn’t a financial penalty attached and that her team are working with BHRUT to achieve the target. CB reiterated that the CCGs have agreed with our providers that they are contractually obliged to meet the target. Action Closed. Ref 2.2 Review other CCGs ToR for clinical cabinets – The Chair confirmed that BHR CCGs clinical cabinet has now been established. Action closed. AK to invite SH to attend a meeting with Barts Health re their QIPP – AK has contacted SH to agree a convenient date. Action closed. The remaining actions related to items on the agenda.

2.0 Finance reports / risks

2.1 Finance risk overview report TT presented the month 2 report based on month 1 data. The financial position of the CCGs remains extremely challenging. A £12.9m QIPP slippage was reported which has been mitigated by the use of acute reserves and the release of contingency. The likely level of risk that the CCGs are facing at month 2 is £26.8m and if the risks materialise, it will result in the deficit increasing to £29.8m. TT stressed that this is not a position that the CCGs can be in. The major risks are further QIPP slippage and acute over performance. There is limited acute data available at month 2 and the data that has been received has some quality issues which has been identified as a further risk. KP raised his concerns about the lack of data and about the quality of the data received and asked when the CCGs could expect to receive more reliable data. AK said she understands the concerns raised and explained that the data received for months 1&2 is in the process of being validated and there are a number of processes to go through before assurances can be given. It was acknowledged that the recent cyber attacks have had an effect on coding at the Trusts. KP asked for assurance that NHS England (NHSE) has been sighted on the data

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issues and TT confirmed that it was specifically mentioned at the assurance meeting with NHSE on 21 June 2017. CB reminded Committee members of their responsibility to determine what action needs to be taken and when adding that a positive steps need to be have been taken by September 2017 to inform any change to reported outturns. KP suggested this should be focus for the finance sub-group meeting on 27 July 2017. AB raised concerns about the QIPP target for NELFT and TT explained the action that is being taken. Dr Mehta joined dialled into the meeting. Committee members noted the risk overview report and the monthly dashboard. 2.1.1 Finance risk register SM presented the risk register and reported that there are currently 12 red rated risks mostly relating to finance. The highest rated risks to the CCGs are: -Risks to the delivery of the CCGs’ budget -Risk to the delivery of the CCGs’ QIPP plans -Barts Health A&E performance -Co-commissioning - Personal medical services (PMS) contracts -Re-basing PMS to general medical services (GMS) contracts SM explained that each risk is being reviewed by the risk owner and the register will be reviewed at EMT on a monthly basis. KP said he found the new format very useful but added that he would like to see a timeline/numbers included in the narrative. SM to feed back to Pam Dobson (PD). AB raised the issue in regard to hospital appointment letters not being received etc that has been in the news recently which she said could have caused a high number of DNAs (did not attend). AK to contact AB outside of the meeting to establish the severity of the problem. TW added that DNA rates are being looked at and said she would include this issue too. It was agreed that Trusts should be looking at others ways to communicate with patients such as SMS text messages rather than just relying on letters. KP referred to the risk regarding the NELFT IT funding transfer. TT explained the mediation process that is taking place and what the next steps will be if the issue remains unresolved. AMe referred to the BHRUT radiology risk and asked if the quantity is known. AMc to ask the risk owner and respond back to AMe.

The Committee reviewed the risks and agreed that the actions are

appropriate to reduce the impact to the CCGs. No additional risks were

added.

2.2 System delivery framework The Committee noted the report and the assurances conveyed on the 21 June 2017 position and also the key differences since the report was last presented.

TT/KP/ WM/AA/AMe SM AK TW AMc

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3.0 Contracts position / deep dive reports

3.1 Payments made to GP Federations TT presented the report that had been requested at the last meeting. The report provided a summary of the payments made to the Federations during 2016/17 and the Federations performance. TT drew particular attention to the final paragraph on ‘year-end reconciliation’ which informed members that as at the end of May 2017, it has still not been possible to fully reconcile the year-end payments. In order to do this the CCGs are reliant on data that details the amount of capacity and activity that was provided from December through to the end of March. Some data has been received from the Federations but it is incomplete so the year-end reconciliation cannot be finalised. This is being picked up with the Federations directly. TT confirmed that the Federations are on the same tariff and explained the reasons for the variations in the totals. AS confirmed that the CCGs are working with the Federations, looking at the current patterns of activity at the hubs and ways to increase it. Contract meetings with the Federations are being set up and quarterly reviews will be undertaken with the first is scheduled for July. AS confirmed that payments to the Federations are made on a monthly basis. Concerns were then raised about the risks associated with payments being made when the full data has not been received. CB said we need to be looking at whether the service is effective and if it’s delivering its primary objectives. AMe said he feels there is a lot of duplication that needs looking into as patients are seen in the evening at the hubs and then going to their GP practice the next day. AS confirmed that the Community Urgent Care group is already looking at these issues. AA asked TT when he expected to receive the missing data and TT responded saying he will bring an updated report back to the next meeting. 3.2 BHR CCGs contracts position FO presented the report which included key message for each CCG. However, he explained that not all the activity has been received and that some of it is inaccurate. He gave assurance to the Committee that meetings with BHRUT are taking place regarding activity and the meetings will be on-going through the year. KP said it was difficult to comment on the report knowing that the data is not accurate and this was acknowledged by other Committee members. AK said her team are currently looking at month 1 freeze data. KP said one of the key things for the Committee is to decide when to escalate concern about the data issues. 3.3 2017/19 NHS Standard Contract – changes affecting the interface between primary and secondary care AK presented the report which provided information on the six changes introduced in the 2017/19 NHS Standard contract (fit notes, out-patient clinic letters, patient queries, discharge summaries, out-patient prescribing and shared care protocols) and the actions taken by BHR CCGs’ and BHRUT to implement the changes. AK reported that a meeting with BHRUT had taken place earlier in the day where she reiterated the importance of these changes to primary care. AA asked AK how she will know if the Trust is delivering on the new changes and AK assured the Committee that working groups will be set up. AA suggested this is something that should go to the CCGs Clinical Senate followed by

TT

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a report back to the Committee to provide the necessary assurance. AMe said this needs to be prioritised as GPs are continuing to receive more and more requests for diagnostics. AT added that there isn’t the capacity in general practice to keep up with the number of requests received each day. AK asked if there is a forum where GPs and Trusts can discuss their issues and AA replied that is the purpose of the new Clinical Senate. AK suggested that service level discussions need to take place there. AA raised the question of how the issues can be quantified and suggested that AK could work with one CD from each CCG on this. AK to bring a follow-up report back to the next meeting. 3.4 ENT, Urology and Gastroenterology referrals - deep dive JC presented the analysis report that was requested at the last meeting. The key messages in the report were:- ENT: The total GP referred outpatient first activity has reduced in 2016/17. The majority of this decrease is seen at BHRUT with some activity moving into the other providers. The timing of these changes in activity suggests that these shifts are due to the redirection of referral activity that commenced in May 2016/17 as part of the RTT System Recovery plan. As of Feb-March 2016/17 GP referred activity has not returned to the levels previously seen. Urology: The total GP referred outpatient first activity has reduced in 2016/17. As with ENT the majority of this decrease is seen at BHRUT. The largest increase in activity is seen within NHS providers (particularly the Homerton). The independent sector is showing a decline in activity as two providers have stopped the Urology service. Similarly to ENT, as of Feb-March 2016/17 GP referred activity has not returned to previously observed levels. Gastroenterology: Both GP and consultant referred ‘outpatient first’ activity has increased in 2016/17. This change in activity was seen earlier and occurred from July 2015/16 with decreases at BHRUT initially being balanced with activity at other NHS providers and the independent sectors but not Barts Health. GP referred activity has shown higher levels at all providers from July 2016/17 although this may be for different reasons. The new Gastro Virtual Pathway (Medefer) appears to have had an effect on BHRUT referrals but more time is needed to see if this is disproportionate to the effect on other providers. TW added that the Planned Care Transformation team has requested a piece of work on consultant to consultant referrals. AA thanked the CSU for the helpful report and added that he would like to know how many patients are being seen in the community for ENT. AK agreed to circulate the information after the meeting a ‘post meeting note’. It was acknowledged that we don’t have a community urology service. In regard to gastroenterology it was noted that referrals though Medefer are low. TW added that a survey has been undertaken to determine why GPs aren’t referring through Medefer yet. Conor Burke left the meeting. 3.5 BHR joint delivery arrangement review – draft PwC report TT explained that PwC had been commissioned to undertake this piece of work to get an independent view of the joint delivery arrangements between the CCGs and BHRUT in order to address the 2017/18 financial

AK AK

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challenge. TT talked though the main highlights in the interim report and explained that it would be updated following the board to board meeting with BHRUT that took place on 22 June 2017 and the conclusion of the equivalent piece of work with NELFT. KP said that an action plan is now required which will be jointly managed by the CCGs and BHRUT. TT confirmed that an action plan will be drawn up based on the recommendations which will be agreed with the Trust and he advised the Committee that PwC has started the scheduled piece of work with NELFT. He added that the interim report has been shared with BHRUT but not with NSHE or NHSI as they will receive the final report. AA gave his view that the System Delivery Performance Board (SDPB) should take this forward. KP said he would like the recommendations and the outcome brought back to the next meeting. He added that he is in the process of trying to set up a meeting with the Audit Chairs from BHRUT and NELFT.

TT

4.0 Update to the Committee Terms of Reference (ToR)

TT explained that the ToR have been re-drafted based on the Deloitte Well-led review. The main changes suggested are:- -One PPI lay member be invited to join as a member from one of the BHR CCGs and who is able to represent all three CCGs -Lay member for Governance to be the Chair of the Committee -Accountable Officer to attend as appropriate - Review of Committee effectiveness to be carried out quarterly instead of annually. KP proposed that AA be the Chair and said he would be happy to act as vice-chair in AA’s absence. AB asked if the issue of conflicts of interest and clinicians needing to leave meetings could be reviewed. It was agreed that it isn’t an issue for this Committee and relates more to the Financial Recovery programme Board (FRPB). The Committee agreed to the proposed changes with the exception of the suggested Chair which the Committee proposed should be AA. TT to take discuss with Marie Price in advance of the ToR going to the July Governing Body meetings for final approval.

TT

5.0 Locality/Network updates

B&D CCG – GK reported that the initial focus has been setting up the network. They held their second council meeting on 27 June. A plan of action is being drawn up and they have a dashboard in place. They are looking at setting up a community minor surgery service. One of the main problems is funding for locality developments. AK asked how they propose the minor surgery services service will fit in with PoLCE and the service restrictions and GK responded that this is being worked through. SM added the Integrated Steering Group is looking at how services are being aligned at locality level.

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Havering CCG – AB gave an update on their network progress so far. Their areas of focus are diabetes, Atrial Fibrillation (AF) and workforce/back office. They are also exploring moving to a single clinical system across Havering as well as working on a number of other projects but are still unclear about project support, who makes the decisions and what the networks can and can’t do. AS confirmed there has been a good level of engagement from the networks into the localities. Locality work is focussing on how people are discharged into the community and there has been good support on this from NELFT and the Local Authority. AB added they are also working closely with the Federation and AA reported that there is a Locality/Federation meeting scheduled for 6 July. Redbridge CCG – MT reported they have had two leadership meetings and are starting to see individual development of the localities. He said it is very encouraging that the leads are taking advantage of the opportunities and are starting to review services. They are getting more and more data from the acute sector but are struggling with the data sets received from community services and there are still boundary issues. AK asked MT to send her an e-mail about the issues with the data sets from NELFT.

MT

6.0 Items for noting

6.1 Procurement Oversight meeting minutes The Committee noted the minutes.

7.0 Any other business

KP referred to a new consultation on the proposed new charging systems to replace PbR which he said the Committee needs to respond to. AK said it is only in draft at the moment and confirmed the consultation runs from 3 July until 25 August 2017. She agreed to circulate the consultation document via AMc. AA asked for it to be circulated to the LMC as well.

AK/AMc

8.0 Dates of next meetings: F&D Sub- group - 27 July 2017 F&D Committee – 29 August 2017

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To: Barking & Dagenham, Havering and Redbridge CCGs

From: Kash Pandya, Chair of Audit & Governance Committees

Date: July 2017 Governing Body meetings

Subject: Feedback from the 24 May 2017 Audit & Governance Committee meetings

The Governing Body’s (GB) attention is drawn to the following key matters discussed at the Audit and Governance Committee meetings on 24 May 2017:

The Committee considered reports from the both internal and external auditors on the governance arrangements and the financial statements for 2016/17. The Committee noted that unqualified audit opinions were proposed by the external auditor for all the three CCGs, though for Havering a qualification to the regulatory opinion was also proposed as the CCG's spend in 2016/17 had exceeded its resources limit. All three CCGs were also to be given qualified value for money conclusions because of the Legal Directions issued against them by the NHSE. The Committee were pleased that the auditors had not identified any errors in the accounts and the annual reports and thanked all staff involved with their preparations for their efforts. The Committee recommended that the BHR CCGs approve and adopt their accounts and annual reports for 2016/17. (This was subsequently done at the BHR GB meetings on 26th May and the external auditors completed their audit on 30th May).

The Committee approved both a revised conflicts of interest policy (that incorporated gifts, hospitality and sponsorship) and a raising a concern (whistleblowing) policy for the BHR CCGs based on new guidance. Mandatory training on the new conflicts of interest policy and briefing arrangements for all GB members and staff is currently being finalised.

The Committee welcomed the proposed improvements to the BHR CCGs risk management arrangements. The Committee decided that it would review the risk register every 6 months.

The Committee recommended that a report be prepared for the BHR CCG's GBs on the benefits secured from their Better Care Fund investments with local authorities and the learning points for the future, where necessary.

Kash Pandya

BHR Audit & Governance Committee Chair

05.06.17

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Draft Minutes BHR Audit Committee 24 May 2017 v1

DRAFT Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs Audit &Governance Committee held on 24 May 2017 at Becketts House 9.30-12.00

Present –Members

Kash Pandya (KP) BHR audit chair, lay member for Audit & Governance

Khalil Ali (KA) Lay member PPI Redbridge CCG

Charles Beaumont (CBe) BHR co-opted member for Audit & Governance

Sahdia Warraich (SW) Lay member PPI Barking & Dagenham

In attendance-Officers

Tom Travers (TT) BHR chief financial officer

Rob Adcock (RA) BHR deputy chief financial officer

Nick Christolides (NC) NELCSU interim financial controller Pam Dobson (PD) 1 item Deputy Director of Corporate Services

Angela Ward (AW) BHR company secretary

In attendance-auditors

Kevin Suter (KS) External auditor, Ernst & Young

Stephen Bladen (SB) External auditors, Ernst & Young

John Elbake (JE) Internal auditors , RSM

Apologies

Richard Coleman (RC) Lay Member PPI Havering

Marie Price (MP) BHR Director of Corporate Services

Conor Burke (CB) BHR Chief Officer

Nick Atkinson (NA) Internal Auditor RSM

Action

9.00- 9.30

Committee Members held a short private meeting and IA and EA then joined for a short private session.

26/17 Welcome and Apologies for absence

Apologies for absence were received from Richard Coleman, Marie Price, Conor Burke and Nick Atkinson.

27/17 Declaration of Interests (DOI)

No further declarations of interests were declared other than those on the three registers presented.

28/17 Minutes of meeting held on 14 February 2017.

The minutes of the previous meeting were agreed and would be signed by the Chair as a correct record.

29/17 Matters Arising

The log indicated a number of completed actions and updates that were being provided at the meeting, in addition;

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05.4/17 Well Led Review-attention was drawn to a briefing from MP that advised there was a working group looking at the recommendations next week and an action plan would come to the next committee. 10/17 IG Toolkits- Training was being arranged for June (PD) and there would be a meeting to discuss further, including the costs. 18/17 IA- TT and RM had met and the Directorate Risk Register was now in place and the request for a review be completed before the July deadline noted. An update on the recent ransome-ware Cyber-attack from RM was provided and members were pleased to note that the CCGs were not impacted bar a potential server patch issue where there was a decision not to switch off due to loss of clinical data. The team were congratulated on a well managed incident. SW raised the impact on our patients from Barts Health IT issues particularly those receiving critical care and the Q& S Committee would request if any SIs had arisen. TT advised that such impacts and power outage were also picked up by review of the Business Continuity Plan and resilience testing and these new issues would be picked up at the next exercise. Although systems were in communication with each other the firewalls would prevent spread. 18.2 /17 IA CSU Report- The Chair could request a copy of the WF CHC personal budgets report via their audit chair if necessary. 21.1/17 Tender Waivers- Due to the time constraints at this meeting the procurement strategy was deferred to the next meeting.TT confirmed a final review was in hand by GS.

MP KP/TT/MP/PD AW/JH MP/LW MP/KP TT

30/17 Havering CCG

TT provided a short summary of the annual report that included some new mandated requirements. He confirmed it was a comprehensive cover of a number of necessary statements and there had been work with EA on the content and alignment with the financial statements. CBe pointed out an error on P16 around the year end position which was to be corrected immediately after this meeting. The other two CCG reports would be checked for accuracy. For the financial statements TT confirmed the core numbers and bottom line had not changed since the draft financial statements although there had been a classification change around the CSU across all CCGs and formatting changes. Member’s earlier feedback had been accounted for. Internal Auditors Annual Report/HOIAO JE confirmed that all reports for the three BHR CCGs included the same Head of Internal Audit Opinion for this financial year - ‘The organisation has an adequate and effective framework for risk management, governance and internal control. However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure it remains adequate and effective’. This included work on QIPP and CSU work undertaken on IT controls and Cyber Security. The status of management action against IA recommendations was commended, noting 100% achievement by year end. Areas for partial opinion were highlighted. The findings of the interim Service Auditor Report (Deloittes) had been reviewed and a draft bridging letter had been received for the final month with no significant issues to report.

NC/MP

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The report covered IA’s own performance and added value achieved that included the sharing of Health Matters bulletins. Also provided was a summary of performance indicators, agreed with the Committee, and their achievement. The Chair in noting the challenging year and a light management structure, congratulated staff on achieving the 100% response by year end. KA requested a piece of work in year to review the impact of the BCF, both on health and social care, to determine VFM. The Chair questioned specific reporting on BCF/S75 agreements and delivery of objectives. TT said there were elements reported eg. BCF figured in the Urgent & Emergency Care QIPP and referred to reducing elective activity/holding back further growth and work could be done to strip out more direct impact and this would be considered further with leads. Noting the current amber/red status of QIPP and partial assurance, there would be a further update at the July meeting.JE would check whether the CSU IT security issues had been sorted. The Chair noted the April 2017 edition of Health Matters and asked TT to run through the sections to determine if any issues impacted the CCG noting many areas had been covered already by the CCGs. The Internal Auditors were thanked for their report. External Auditors results report KS reported on a good set of accounts in a challenging year by the finance team with the ambition to complete the work by Friday 26th May. An unqualified opinion was proposed.. On the financial statements there were just a few further areas to complete but the key challenge was completing the work on co-commissioning. Although a national process had been agreed and we submitted information in January there had been slow progress in clarifying responsibility for accruals. Although these were delegated budgets they were not in our control. It was confirmed this had been escalated at a number of levels including the NAO but communications did not appear to be working with for example, London finance. The Chair agreed to raise with the national Audit Chair if necessary as the account closures were being delayed. The Chair was reminded of a similar delay on Service Auditor reporting some years back. It was confirmed RA and TT had escalated this issue a number of times and KA added that the PCC had found the paucity and quality of information difficult to work with. KS drew attention to the usual key areas of audit focus covering risk of fraud in revenue and expenditure recognition and management over-ride of controls. Testing was on reasonableness of estimates, journals and general satisfaction with evidence to provide assurance on a unqualified, true and fair, opinion. Havering had overspent against its resource limit. KS stated that, whilst understanding the progress made in mitigating the RTT backlog clearance, he had no option but to issues a S30 referral to the SoS on 8 May. This reflected the factual position that led to a qualified regulatory opinion being given as monies were spent without statutory powers to do so. Under VFM responsibilities it was clear that good progress had been made that led to the RTT Legal Directions being removed this year. This was a very positive message, However the CCG had to incur additional spend under these Directions to retrieve the

TT JE TT

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RTT position, leading to the £4.76m overspend. Therefore the auditors were planning on giving a qualified VFM conclusion. On reviewing the CCG’s Operating Plan for 2017/18, a significant level of QIPP was noted for the year ahead and looking at the whole health economy there was a very large issue, so the CCGs were not alone in their challenge. It was noted that not all QIPP areas appeared fully supported by full project plans yet and the CCG were advised to keep going, keep producing replacement ideas for areas of non-delivery, look ahead for opportunities for next year. Areas such as Prescribing coded blue were to be kept under review as whilst processes were in place there was no assurance until figures came through. TT confirmed it was coded blue due to the planning process and was in provider contracts and therefore risk was with the provider. Planning assurances vs delivery assurances was key. TT highlighted a difference with auditors on one point under the conclusions. It related to reference to weakness in financial arrangements rather than the CCG view of it being performance. KS stressed the need to use regulatory wording. KA again raised the importance of gaining evidence to review outcomes as commissioners we needed to ensure our money was well spent. The Chair questioned impact of the S30 referral and KS did not expect it to raise any further issues as the CCG was in Legal Directions and therefore it aligned. Members discussed the need for reference in the annual reports to turnaround referencing strong strategic direction and commitment, Board to Board meetings on the £35m and clinician to clinician work on 13 specialties. The Chair added that the VFM conclusion was disappointing but understandable due to the Legal Directions but asked that the Management Letter emphasise the positives not a lack of effort. KS would reflect on this further before finalising his letter. KS added that he was completing testing that day and was preparing for the Friday sign-off by TT and KP. Finalised Annual Reports Apart from the issue raised by CBe, there was little further to add to previous drafting. MP and her team were thanked for the finalised reports. Finalised Financial Statement The Chair firstly thanked the Finance Team and both the Internal and External Audit teams for their very good work. The Chair would recommend to the Havering GB that they adopt the Annual Report and the Annual Accounts for the year 2016/17, highlighting that all observations of the CFO, Audit Committee Members, Internal Audit and External Audit had been considered in the documentation, subject to a change of one sentence on P16 of the Annual report that would be corrected after this meeting (since completed).

31/17 Barking & Dagenham

TT provided a short summary of the annual report that included some new mandated requirements. He confirmed it was a comprehensive cover of a number of necessary statements and there had been work with EA on the content and alignment with the financial statements. NC would check the statements in the annual report were correct on the year end position. For the financial statements TT confirmed the core numbers and bottom line had not changed since the draft financial statements although there had been a classification

NC

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change around the CSU across all CCGs and formatting changes. Member’s earlier feedback had been accounted for. Internal Auditors Annual Report/HOIAO JE confirmed that all reports for the three BHR CCGs included the same Head of Internal Audit Opinion for this financial year - ‘The organisation has an adequate and effective framework for risk management, governance and internal control. However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure it remains adequate and effective’. This included work on QIPP and CSU work undertaken on IT controls and Cyber Security. The status of management action against IA recommendations was commended, noting 100% achievement by year end. Areas for partial opinion were highlighted. The findings of the interim Service Auditor Report (Deloittes) had been reviewed and a draft bridging letter had been received for the final month with no significant issues to report. The report covered IA’s own performance and added value achieved that included the sharing of Health Matters bulletins. Also provided was a summary of performance indicators, agreed with the Committee, and their achievement. The Chair in noting the challenging year and a light management structure, congratulated staff on achieving the 100% response by year end. The Internal Auditors were thanked for their report. External Auditors results report KS reported on a good set of accounts in a challenging year by the finance team with the ambition to complete the work by Friday 26th May. An unqualified opinion was proposed. On the financial statements there the same issue applied around co-commissioning information and this was currently being chased and would be escalated if necessary as outlined above. KS drew attention to the usual key areas of audit focus covering risk of fraud in revenue and expenditure recognition and management over-ride of controls. Testing was on reasonableness of estimates, journals and general satisfaction with evidence to provide assurance on an unqualified, true and fair, opinion. A qualified VFM conclusion was being proposed. The Letter of Representation will refer to an accrual, referred to last year, of a provision made for R & D ‘Life Study’ work involving the CCG, NELFT and BHRUT. There was lack of clarity of ownership of the debt between NELFT and BHRUT and the CCG was taking a prudent approach with holding a provision. The Chair noted this was not material and supported the CFO in making this provision and requested an update in September of the position. The significant level of challenge on QIPP was again repeated and the need for completed project plans and advice given on focus for the CCG. Finalised Annual Reports There was nothing further to add on the annual reports but the summary line on year end position would be checked for accuracy (since complete). MP and her team were thanked for the finalised reports.

TT

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Finalised Financial Statement The Chair firstly thanked the Finance Team and both the Internal and External Audit teams for their very good work. The Chair would recommend to the Barking & Dagenham GB that they adopt the Annual Report and the Annual Accounts for the year 2016/17, highlighting that all observations of the CFO, Audit Committee Members, Internal Audit and External Audit had been considered in the documentation.

32/17 Redbridge CCG

TT provided a short summary of the annual report that included some new mandated requirements. He confirmed it was a comprehensive cover of a number of necessary statements and there had been work with EA on the content and alignment with the financial statements. For the financial statements TT confirmed the core numbers and bottom line had not changed since the draft financial statements although there had been a classification change around the CSU across all CCGs and formatting changes. Member’s earlier feedback had been accounted for. Internal Auditors Annual Report/HOIAO JE confirmed that all reports for the three BHR CCGs included the same Head of Internal Audit Opinion for this financial year - ‘The organisation has an adequate and effective framework for risk management, governance and internal control. However, our work has identified further enhancements to the framework of risk management, governance and internal control to ensure it remains adequate and effective’. This included work on QIPP and CSU work undertaken on IT controls and Cyber Security. The status of management action against IA recommendations was commended, noting 100% achievement by year end. Areas for partial opinion were highlighted. The findings of the interim Service Auditor Report (Deloittes) had been reviewed and a draft bridging letter had been received for the final month with no significant issues to report. External Auditors results report KS reported on a good set of accounts in a challenging year by the finance team with the ambition to complete the work by Friday 26th May. An unqualified opinion was proposed. On the financial statements there were just a few further areas to complete but the key challenge was completing the work on co-commissioning as referred to above. KS drew attention to the usual key areas of audit focus covering risk of fraud in revenue and expenditure recognition and management over-ride of controls. Testing was on reasonableness of estimates, journals and general satisfaction with evidence to provide assurance on an unqualified, true and fair, opinion. A qualified VFM conclusion was proposed and there were no specific references in the Letter of Representation. However, the resultant accruals arising from co-commissioning, referred to as delayed above, would sit with Redbridge CCG as the host of the delegated co-commissioning so therefore there was risk of delay in these accounts sign off to meet the deadlines. The Chair questioned the penalties and TT confirmed this could be counted against the CCGs performance assessment

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framework. The Chair requested TT escalate to David Slegg if there was a continued risk of delay and KS was to keep the Chair informed. Finalised Annual Reports There was nothing further to add to previous comments other than a request to ensure plain English (e.g. Deep Dives was not an understood term). Finalised Financial Statement The Chair firstly thanked the Finance Team and both the Internal and External Audit teams for their very good work. The Chair would recommend to the Redbridge GB that they adopt the Annual Report and the Annual Accounts for the year 2016/17, highlighting that all observations of the CFO, Audit Committee Members, Internal Audit and External Audit had been considered in the documentation.

33/17 Update on GBAF and risk in 2017/18

PD attended and confirmed she had taken account of comments from the last Audit Committee and the IA review. She had now met with all risk owners, and questioned if the risk description was correct and the impact of the risk. The mitigation was reviewed and tangible actions sought and target dates set of when reduction of risk was expected. The risk registers would be updated to align with the agreed corporate objectives and CD responsibilities. A summary would be added to list risks in severity order against the corporate objectives. Work was ongoing to keep pace with changes to the management structure and transfer of risks. The Chair welcomed the risk review and requested a twice yearly report to the Committee, beginning July. KA questioned whether a learning element to share risk and remedial action could be incorporated to avoid repetition. PD would consider this further. The Chair was pleased to note that all Directorates had a risk register and that EMT were discussing it the following week. He requested a July review of the register. As agreed earlier there would be a meeting to discuss and scope the June risk training. KS added that the key to good risk management was management behaviour and gaining continuity in a challenged environment. The Chair thanked PD for her update.

MP/PD

34/17 Policy Approval

Conflicts of Interest, Gifts & Hospitality and Sponsorship Policy This new policy had taken account from recent guidance and was based on a useful national template. It had also taken account of the IA recommendations from their February review. IA supported the policy and added it was important to record refusal of gifts etc. Under COI, KA suggested that consideration could be given to including co-opted patients/public involved in the procurement processes. It was noted there was a separate declaration form around procurement, and that process should be referenced in the procurement policy and to whom was included, but this would be checked. The policy was required to be in place by 1 June and there would be communication to all listed as affected by the policy. A national training module was being developed and this would be rolled out to staff in the autumn and become part of CCG mandatory training. It was confirmed that the Audit Chair remained the COI Guardian.

AW

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The policy was approved by the Committee. Raising a Concern Policy This was the new term for Whistle-blowing and again the policy took account of new guidance. LCFS had received a copy and were satisfied with the content. Again the Guardian, was the Audit Chair and there were details of reporting to LCFS in the policy. SW raised the consequences if staff saw something and did not report this and CBe referred to references to ‘don’t do nothing’. The Chair welcomed any further additions that members offered and added that training would be important for full understanding. Communication of the policy would be rolled out to all concerned during June. It was noted that an annual report was required and this would be to the Remuneration and Workforce Committee by year end. The Committee agreed the policy.

35/17 Update on Financial position

At month 1- There was no actual data yet but everything was on plan. A focus of the system delivery performance board was ensuring QIPP remained on target. A risk model was being developed and he was able to report on very positive partnership work. The letter of engagement required PWC to provide their analysis by month end and a draft had been received for comment. This Committee would receive that next time. KA raised the impact of purdah on decision-making and TT confirmed that the timetable was affected for only one procurement. The Chair advised that the CCG had received directions that the annual reports and accounts could not be made public until purdah was lifted and the website had been adjusted and GB papers would be received at a Part 2 meeting. KA asked for consideration to be given if there was the easing of 18 week wait targets as reported on and flagged impact on finance. Tender Waiver- Home-Start Havering-The Committee noted this had been considered by FRPB and this was a sole provider issue. KA asked that good VFM should be captured in all procurements at the outset.

TT

36/17 CSU Quality Assurance Plan

JE provided the Plan that indicated that the CCG’s risk management processes had been evaluated to inform the Plan. Priorities had been discussed with a number of leads and SLAs reviewed. The Plan had 4 sections

Information Technology

Clinical Systems

Data/Analytics/Performance

Operational Processes The main focus areas for the CCGs were cyber-security, provider quality management, GP IT services, CHC. The Quality Assurance Group had recommended the plan to the Audit & Governance Committee for approval. There had been three key considerations for the Assurance Group laid out in the report. This had also been reviewed by the CFOs group. The £77k costs were to be divided between the 12 CCGs served by the CSU dependant on usage not equally. The Chair asked the CFO to consider if the CSU had adequate workforce resources to deliver and JE confirmed that it had included a recruitment review.

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KA referred to the current consultation on spending wisely and whether there could be a process to capture any impact e.g. on IFRs, finance, quality & safety and the patient response. It was noted all such plans had an equality impact assessment and TT would consider further. The Committee approved the CSU Quality Assurance Plan

37/17 Any Other Business

There was no other business.

38/17 Chairs Key Messages to GB

The Chair would be referring to completion of the Annual Reports and Annual Accounts for 2016/17, the issuing of qualified VFM conclusions for all three CCGs, a provision made in Barking & Dagenham accounts, agreement of two policies, review of risk management processes, approval of the CSU Assurance Plan and a request for a review of BCF value for money.

39/17 Items for Information

The Committee noted the minutes of the Assurance Group meeting held on 3 March 2017.

40/17 Date of Next Meeting

The next meeting was arranged for 11 July 2017.

Signed………………………………………………..Date………………………….

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To: Meeting of the Barking and Dagenham CCG Governing Body

From: Tom Travers, Chief Financial Officer

Chair of Financial Recovery Programme Board (FRPB)

Date: 18 July 2017

Subject: Work of the FRPB and Financial Recovery Programme Progress Summary

Executive summary

During 17/18 BHR CCGs are required to deliver £45m of savings in year. As of 9 May over £33m of

savings scheme opportunities have been approved by the CCG. A pipeline of new opportunities has

been identified and a series of workshops to develop further opportunities is in progress.

Recommendations

The Governing Body is asked to note the report


1.1 To update the Governing Body on the progress of the 2017/18 Financial Recovery Programme

and work of the FRPB.


2.1 The financial challenges facing the BHR health system, following agreement of 2017-19 NHS

contract values, are now significant, requiring BHR CCGs to save £45m to deliver a planned

£10.2m deficit across BHR. Work is continuing under the direction of the Financial Recovery

Programme Board (FRPB) to deliver savings schemes to meet this target.

2.2 Under the FRPB’s terms of reference a high level summary of the progress on the financial

recovery will be regularly provided to the governing bodies.

3.0 Progress to date

3.1 Significant progress continues to be made on the savings programme: 47 savings schemes are

now approved by the CCG and the total assured savings figure is £33,173,000.

3.2 Work is continuing within the CCGs and with providers to identify new savings opportunities. A

program of workshops involving CCG clinical directors and provider clinicians to develop the

identified opportunities into viable projects is ongoing, as is work to identify new opportunities via

the NHS RightCare program which benchmarks CCGs’ performance against comparator CCGs.

Following a joint executive meeting with colleagues from BHRUT in April, three system wide

initiatives are being developed: Discharge to Assess, Pressure Ulcer Avoidance and

Management and Referral Management. Each is reported through the System Delivery and

Performance Board and monitored through the weekly Joint Delivery Meeting between the CCGs

and BHRUT.

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3.3 Work is being undertaken to review current and planned investments to ensure that where

possible investment funds deliver an optimal financial return on investment given the competing

pressures of immediate financial recovery and sound long term investment in the health of our

population. In addition work has begun to review the CCGs’ contract portfolio and procurement

pipeline to identify any areas for potential saving.


4.1 There are no additional resource implications/revenue or capitals costs arising from this report.

5.0 Equalities

5.1 There are no additional equalities implications arising from this report. All savings schemes are

required to have an equalities impact assessment completed as part of the approval process.

6.0 Risk

6.1 There are no risks arising from this report. Risks to project delivery are held in individual project

risk registers.


7.1 There are no conflict of interest in regards to this paper.

Author: Jeremy Kidd, Head of PMO

Date: 26.06.17

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Primary Care Transformation Programme Board

16 January 2017 Becketts House

Present:

Councillor Mark Santos, Chair (MS) Cabinet Member for Health and Social Care, London Borough of Redbridge

Conor Burke (CB) Chief Officer, BHR CCGs

Dr Gurkirit Kalkat (GK) Clinical Director, Barking and Dagenham CCG

Sahdia Warraich (SW) Lay Member, Barking and Dagenham CCG

Dr Shabana Ali (SA) Clinical Director, Redbridge CCG

Khalil Ali (KA) Lay Member, Redbridge CCG

Cathy Turland (CT) Healthwatch Redbridge

Dr Anil Mehta (AM) Chair, Redbridge CCG

Rob Adcock (RA) Deputy Chief Finance Officer, BHR CCGs

Alison Goodlad (AG) Head of Primary Care, North East London, NHS England

Dr Daniel Weaver (DW) Chair, Havering Health Ltd

Sarah See (SS) Director, Primary Care Transformation, BHR CCGs

Dr Arun Sharma (AS) Chair, Together First Ltd

Dr Imran Umrani (IR) Director, Redbridge GP Alliance Ltd

Gladys Xavier (GX) Deputy Director of Public Health, London Borough of Redbridge

Paul Roche (PR) Primary Care Programme Manager NEL STP

Karen Stubbs (KS) Director & COO, HealthBridge Direct Ltd

In attendance

Sarah Perman (SP) Deputy Director, Primary Care Transformation, BHR CCGs

Natalie Keefe (NK) Head of Primary Care Transformation, BHR CCGs

Ross Graves (RG) Prederi, Programme Support

Paul Olaitan (PO) Programme Manager, BHR CEPN

Jordanna Hamberger (JH) Senior Localities Lead, Havering CCG

Jenny King (JK) (minutes) Business Manager, Primary Care Transformation, BHR CCGs

Apologies

Anne-Marie Dean (AD) HealthWatch, Havering

Dr W Mohi (WM) Chair, Barking and Dagenham CCG

Item Title Action

1. Welcome and introductions

After a hiatus due to the ‘refresh’ of the programme, MS welcomed all to the meeting and introductions were made. Apologies were noted.

2. System financial delivery

CB gave an update on the BHR financial position and the plan to deliver financial sustainability. He outlined the financial challenges facing the BHR health care scheme and highlighted that good headway is being made. The main hurdle relates to next year’s financial position and the saving of £55m identified as a result of the arbitration from the contract negotiations. The challenge is to draft a plan for delivery of the £55m by 28 February 2017 as required by our regulators. It is important to note that the plan needs to be signed off by system commissioner & providers; £35m of the plan needs to demonstrate how that value will be taken out across BHRUT. The plan will require input/agreement from all the providers, evidence continuous impact for the next 12 months starting 1st April, incorporate schemes associated with transformation, decommissioning and the cessation of services currently in the system.

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In order to reach the 28 February deadline, a mechanism will be established to facilitate arrangements, identify priorities and develop robust business cases. It was agreed at a recent meeting of all the BHR Chief Executives to recommend to the Integrated Care Partnership Board (our overarching system governance arrangement) to establish a BHR System Delivery and Performance Board (SDPB). The Board will be comprised of representatives providers and commissioners and will be responsible for system level delivery, planning and implementation of the financial recovery programme. This is a new way of working and will inevitably require further discussion regarding board members, terms of reference, decision making criteria and how workstreams and providers will be held to account. To this end a programme director has been engaged to facilitate arrangements and liaise with members to take the objective forward, adhering to the very tight timescale. CB stated that it will be the responsibility of the SDPB to oversee the work that is being carried out across the system and to support, enable and develop primary care. One of the critical enablers to this relates to the primary and community response to handling the demand management. AS queried whether London Ambulance Service (LAS) will be included in the board. CB stated that LAS is represented through the A&E delivery arrangements which would in effect report into this board. AS had a concern regarding the need for primary care to focus on demand management as he felt that this was a piecemeal way of dealing with what is a much bigger issue. CB understood the sentiment but reiterated that there is a requirement for all the organisations to make savings. MS thanked CB for an informative update.

3. Governance and delivery structure

Governance and delivery structure Given the ‘refresh’ of the programme, MS gave an overview of the governance and

delivery structure. As the strategy is now approved, the focus of the board has changed from developing the strategy to implementing the strategy. Going forward the role of the board would be to implement the GP Forward View and supporting programmes (e.g. SCF), collaborative arrangements for STP Primary Care QI programme board and system financial recovery. MS indicated that there are three overarching worksteams under the programme; workforce, provider development and quality improvement. SS clarified that in terms of governance, provider networks have their own accountable boards and are not managed by the Primary Care Transformation Programme – that is they are part of the delivery models, such as GP Federations, but are independent provider units (not managed by CCGs).

Terms of Reference SS stated that there had been slight changes to the membership in order to support attendance at meetings across the system. Feedback from the local authorities is that they would prefer a representative for each borough – this is likely to be the Director, Public Health. A representative from CEPN was now included in the membership. A suitable meeting date/time needs to be identified as Monday afternoon is not convenient for many GPs.

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DW queried whether it would be beneficial to have individual federation representative rather than the three areas. SS agreed this was the intention and will make the necessary amendments to the TOR so that this is clear to all. AS suggested linking the objective settings to financial recovery so that the results of projects incorporated both financial and quality. CB confirmed that GPs, NELFT and voluntary sector organisations are expected to put forward joint propositions relating to how they will deliver planned health and wellbeing. Commissioning for outcomes and integrated solutions will be on a place based geographical basis. The terms of reference was agreed, subject to incorporating the comments made above. Action: Update TOR accordingly.

SS

4. Programme overview SS presented the BHR Programme Overview Slides which set out the objectives, role of the GP Networks, current network status, approach and priorities for quarter 4 2016/17 and financial year 2017/18. Each of the networks will have a non-commissioning chair and a vice-chair who will sit on a council/board at borough level, this group will steer the work undertaken in this programme within the respective boroughs. The chair of the council/board will join this programme board and ensure the flow of information between the practice networks and federations with the transformation programme board. They will also be representative of the NEL Quality Improvement Programme Board. Discussion took place and it was recognised that the saving of £55m was a huge task during 2016/17 but ultimately that is what is required. It was agreed that the Board needs to have a clear focussed message to encourage GP engagement and ensure the challenge is met in a confident manner. Providing practices with training, information and support to enable them to do more for themselves has proved successful in other boroughs. GX stated that this is an excellent opportunity to work together as public health commission services from primary care too. SA queried whether the arbitration process would provide BHRUT the ‘higher ground’ to challenge primary care in future. CB responded that there will be challenging times ahead and there needs to be a move to develop joint plans relating to capacity, activity and managing demand in a better way.

5. Agree summary PIDS and review delivery highlights for each workstream

NK presented the summary PIDS for each workstream providing further detail; namely provider development, quality improvement and primary care workforce. Provider development has 4 workstreams: GP network development, sustainable GP practice, pathway redesign and patient access.

Discussion on Urgent Primary Care needs ensued and KA suggested that it would be helpful to have a mechanism in place to measure patient feedback to ensure the service they are visiting is adequate. Taking on board patient comments would impact patient design with maximum effect and prevent historic mistakes being repeated. SS reassured that positive patient feedback had been received from the hubs and will be taken into account when redesigning Urgent Primary Care Services going forward.

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There was also a concern regarding high levels of DNAs. NK confirmed this was an issue, in some practices DNA rates were higher than the national average, and was an area that could be looked at through the text messaging service. SS pointed out that the hub model had a much lower rate of DNAs than practices, possibly due to the fact that appointments were made/available on the day. KS suggesting making patients aware of the actual cost of a DNA and the general cost of using a NHS health service; there is evidence that this strategy has been effective in other areas. SP advised that as part of the Urgent and Emergency Care Programme, there is a review of the OOH provision access across BHR which is going to be taking place with the final report being available at the end. SP provided an update on the Quality Improvement Programme, rollout access across the patch, recruitment for training local QI facilitators, working with UCL partners and the Clinical Effectiveness Group (CEG). All agreed it is also important to involve non clinical staff in QI. SP confirmed that there will further opportunities for non-clinical staff in future via Care City / CEPN. SP confirmed that the CCG is working closely with Community Educational Provider Network (CEPN) to ensure coherence in terms of the way we work noting their Programme manager is now part of the Transformation Programme Board.

6. Budget SS presented an update on budget and investment. In response to a query from KA relating to the Primary Care Investment Fund, SS clarified that as per the December Operating Plan submission, investment per head would remain at £5 inclusive of £3ph required under the GPFV. KA felt it would be beneficial to financially reward patient representatives for attending meetings as patient input was key. SW agreed with this sentiment as well as the provision of refreshments at meetings. SS stated it was the decision of individual practices if they wish to invest in the PPG.

7. STP Primary Care Approach

PR presented a paper relating to the STP Primary Care Quality Improvement Care Approach across North East London. In brief, he reported that there are 2 main areas in terms of the STP plan; one relating to the strategic frameworks; access to care and proactive care and the other delivery of the GPFV. He further advised that there are 3 main workstreams:-

QI – sharing learning and examples of good practice

Workforce

Provider development PR then went through the TOR for the North East London Primary Care Quality Improvement Partnership Board. It is intended to have representation from both commissioners and providers for all 7 CCGs and he reiterated the importance of building on our knowledge and developing common views.

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KA & GX would like patient representative to be included as these were not currently involved. PR acknowledged that thought should be given to how practices are represented on the Partnership Board as it develops. Action: Draft patient engagement strategy for next meeting.

PR

8. Review risk register

The risk register was presented and noted.

9. A.O.B. None

Date of next meeting: 5th April 2017

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Joint Executive Committee

20 April 2017 MINUTES

Present Title

Dr Waseem Mohi Chair – Barking and Dagenham CCG (meeting Chair)

Dr Gurkirit Kalkat Clinical Director – Barking and Dagenham CCG

Dr Kanika Rai Clinical Director – Barking and Dagenham CCG

Dr Rami Hara Clinical Director – Barking and Dagenham CCG

Dr Ravi Goriparthi Clinical Director – Barking and Dagenham CCG

Dr Jagan John Clinical Director – Barking and Dagenham CCG

Dr Anju Gupta Clinical Director – Barking and Dagenham CCG

Sharon Morrow Chief Operating Officer – Barking and Dagenham CCG

Dr Atul Aggarwal Chair – Havering CCG

Dr Maurice Sanomi Clinical Director – Havering CCG

Dr Ann Baldwin Clinical Director – Havering CCG

Alan Steward Chief Operating Officer – Havering CCG

Richard Coleman Lay Member – Havering CCG

Dr Anil Mehta Chair – Redbridge CCG (meeting Chair)

Dr Mehul Mathukia Clinical Director – Redbridge CCG

Dr Shabana Ali Clinical Director – Redbridge CCG

Louise Mitchell Chief Operating Officer – Redbridge CCG

Conor Burke Chief Officer – BHR CCGs

Tom Travers Chief Financial Officer - BHR CCGs

Marie Price Director of Corporate Services – BHR CCGs

In attendance

James Gregory Interim Director - Programme Management Office

Christine Kane Assistant Director – Quality – BHR CCGs

Apologies

Dr Sarah Heyes Clinical Director – Redbridge CCG

Dr Shujah Hameed Clinical Director – Redbridge CCG

Dr Muhammad Tahir Clinical Director – Redbridge CCG

Dr Jyoti Sood Clinical Director – Redbridge CCG

Dr Syed Raza Clinical Director – Redbridge CCG

Dr Anita Bhatia Clinical Director – Redbridge CCG

Khalil Ali Lay Member – Redbridge CCG

Ah-Fee Chan Secondary Care Consultant – Redbridge CCG

Kash Pandya Lay Member – BHR CCGs

Dr Alex Tran Clinical Director – Havering CCG

Dr Ashok Deshpande Clinical Director – Havering CCG

Dr Gurdev Saini Clinical Director – Havering CCG

Jane Gateley Director of Strategic Delivery

Jacqui Himbury Nurse Director – BHR CCGs

Sarah See Director of Primary Care Improvement – BHR CCGs

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1.0 Welcome, Introduction and apologies The Chair welcomed members to the meeting and apologies were noted.

2.0 Declarations of interest There were no new declarations of interest declared.

3.0

Minutes from the previous meeting The minutes from the previous meeting were agreed.

Note

4.0

Finance Budget 2017/18 Tom Travers gave an overview of the new integrated budget paper that provides the commissioning financial position for the three CCGs, which is a QIPP requirement for 2017/18 of £45.1m and a deficit of £10.2m.Tom advised that the full value of the net financial risk totals £40.8m, with a mitigated risk value of £21.7m. The full unmitigated risk based on assessment of current plans could result in the CCGs delivering an end of year deficit of up to £31.9m. Dr Mohi asked how the planned £10.2m deficit is mitigated. Tom advised that this is supported by the STP taking on additional QIPP to support the CCGs and that the expectation by NHS England is that this will be the final position for 2017/18. It was noted the line for ACO investments should be changed to ACS and that this is the budget provision for invest to save initiatives as part of this. Richard Coleman asked on the progress of reconciling the BHRUT, NELFT and Barts Health Cost Improvement Plans with our QIPP plans. Tom advised that this was in progress. Dr Aggarwal questioned the activity in Appendix D – Forecast Outturn for 2016/17. Tom confirmed this was the number of referrals made for all providers. Tom outlined the new national process for systems in financial recovery, the Capped Expenditure Programme, and how the principles for affordability will change going forward. Tom advised that some modelling has already been done internally as to what that may mean for the CCGs and that we are already looking at early opportunities using those principles, such as looking at current contracts that are coming to an end, so that we be in a position to respond when required. Dr John raised concerns on the implications of the new process on patient care and the viability of the system as a whole.

Note Note

5.0 System Delivery update James Gregory updated members on the progress and latest position of the System Delivery plan. The key next steps are to work with Barts and NELFT to identify any additional opportunities.

6.0 6.1

Items for information Collaborative risk log Members were asked to note the risks outlined.

7.0

Date of next meeting Thursday 8 June 2017, 1.30-3.30pm at Becketts House. The next informal JEC will be held on Thursday 4 May at 2pm at Becketts House.

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B&D Patient Engagement Forum

Thursday, 18 May 2017

5pm-7pm

B&D CCG offices, Maritime House, Barking

Present:

Nicholas Hurst, B&D PEF Chair (Chair)

Sharon Morrow, Chief Operating Officer B&D CCG

Sahdia Warraich, Lay member, B&D CCG

Ron Wright, B&D PEF Vice-Chair

Boba Rangelov, PPE Advisor, BHR CCGs

David Elliott, PEF member

Mary Parish, PEF member

Ken Humphries, PEF member

Peter Hopper, PEF member

Christine Brand, PEF member

Dorothy Stokes, PEF member

Apologies:

Miriam Greenwood, PEF member

Gemma Hughes, Deputy Chief Operating Officer

In attendance:

Oge Chesa, Deputy Chief Pharmacist, Medicines Management Team

Denise Baker, Medicines Management Team

1. Welcome, introductions and apologies

Chair welcomes everyone to the meeting and apologies were accepted.

2. Notes and matters arising

Minutes were accepted as a correct record of the meeting. All actions were

completed.

3. Antibiotics’ resistance

Chair welcomed OC to the meeting. OC gave a presentation on chosen subject.

OC highlighted an opportunity to apply to become an Antibiotics guardian. MP asked

how GPs and nurses are informed and updated about this. OC replied that they have

disseminated information to all GPs and practices and they are getting the message.

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An inappropriate diagnostics leads to inappropriate prescribing and then

inappropriate admission to hospital.

OC stated that we are working with our providers, hospitals and also GPs,

microbiologists and other health professionals to ensure they communicate

appropriately regarding prescription of medication.

ACTION: BR to give contact details of new PPE Advisor to DB to provide this for

PEF.

RW suggested sending the link of the film presented during the presentation to PEF

ACTION: OC and DB to send the link to new PPE Advisor.

4. Consultation “Saving NHS money wisely”- further discussion

SM gave a brief overview of the proposals. Today was another chance for PEF to

give a consolidated response. Following the consultation the business case will go to

the Governing Body for them to consider the feedback and make decision. No

decisions have been made yet, as the consultation is still happening. BR confirmed

that the Communications Team has agreed to extend the consultation for another

two hours (as PEF meets today 5pm-7pm). Chair noticed that looking at the figures

which were provided by the Communications Team and also the Governing Body

papers, the BHR CCGs still need to find the way to save a large amount of money.

SM replied that an opportunity of saving 47 million pounds has been identified. The

areas have been identified where we can achieve around £31 million savings.

PEF asked if there is a deadline to achieve those savings. SM replied that 31 March

2017 was a deadline to meet the saving target. However, there is still a savings gap

and it will be difficult to achieve this in one year and monitoring bodies are aware of

this. Most savings will happen through Service Transformation programmes, working

with GPs, appropriate referrals, restricting access to some services and also

stopping some services, inappropriate and overprescribing. It is a continuous

process and we are working with our providers on this.

RW asked why PEF is not informed or consulted about more detailed plans how to

save 90% rather than just talking about 10% savings, which is just a small amount,

looking at the total of £55 million. SM said that many services will not change and will

stay the same.

DE stated that not much money will be saved by stopping weight loss surgeries but

much more could be saved further down the line if surgery was available.

SW asked how they will be checking patients who live in one borough but got

prescriptions in another one. SM replied that the cost of prescribing is attributed to

the GP practice and the Medicines Management Team is monitoring this.

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ACTION: CCG to come back to PEF in one of the future meetings in order to provide

detailed breakdown regarding saving plans.

PH asked how CCG can be confident that they will make savings when assessment

has not been done. SM replied that there is a project initiation document and the

CCG’s confidence is based on the robustness of the plan. There is a regular review

of the actions agreed throughout the year to check that the plan is delivering as

expected.

SM explained that the schemes have been introduced in 2016/17, and some of the

savings were a full year impact of plans that had been implemented in 2016/17. We

are assessing the risks about delivery and we will forecast at the end of the year if

we are going to deliver what is planned.

SW stated that it is very much postcode lottery which treatment people can receive.

Croydon CCG has stopped completely IVF. SW also said that there should be a

standard across London not to be different from one CCG to another. SW also said

that not having the standard, inequalities are created and there is no fairness.

SM said that all CCGs have a legal responsibility to balance budgets.

CB asked how saving plans link up with STPs. SM said that BHR CCGs have been

given additional help from NE London CCGs (who have increased their QIPP plan by

£10million), to cover some of the shortfall in BHR.

In respect of “Spending NHS money wisely” SM also said that we held stakeholders’

events across three boroughs, drop in sessions and all GPs had an opportunity to

comment on the proposals. PEF members asked for the following responses to be

considered as part of the consultation process:

1. PH stated that children should be protected/exempt from any proposals that

could impact on their wellbeing as parents/ carers may have to make difficult

choices about whether children can have medicines based on affordability.

The proposals to restrict access to Over the Counter medicines and gluten

free products were mentioned as an examples. MP and SW said that people

on low income and benefits will be affected the most, as nearly 90% of people

in B&D get free prescriptions. This should be taken into consideration when

making decisions.

2. Consideration should be given to the impact of reducing access to weight loss

surgery and the longer term impact of this proposal.

ACTION: BR and SM to send key comments from today’s PEF meeting to the

Communication Team.

5. Governing Body papers

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The reports discussed were: BHRUT performance risks, System Delivery

Framework, Chair’s report and Patient Experience Report.

BHRUT has been taken out of the special measures and Chair said that this should

be congratulated. SM said that the BHRUT performance will still be monitored by

BHR CCGs but no regular reports will be submitted at Governing Body meetings in

future.

BR gave an update on PPG survey. The response from the practices was excellent,

with 50% of practices participated. BR will send the reports to senior directors

tomorrow.

SW updated on recent PEF/PERF Chairs, Vice-Chairs and Lay member’s meeting.

There is a proposal to hold only one PEF in future. This will align with future BHR

CCGs plans. They have been asked to think how this would work in future.

Chair said that it is questionable how much Practice Managers are interested in

PPGs. BR replied that this varies, as there are PPGs very well managed and

organised and there are some that still need more support.

ACTION: New PPE Advisor to send PPG survey report to PPGs and PEF.

6. The B&D Healthwatch report-Enter and View

Chair congratulated Healthwatch on their reports – the latest report was about their

visit to Mandarin ward A. (The report was circulated before the meeting).

7. Forward planner

The topic agreed for July’s meeting is Gastroenterology RTT. Further discussion for

July’s PEF suggested (Pain management RTT and Orthopaedics RTT). SW said that

it is important to make sure not to lose those items from the Forward Planner.

BR reminded everyone that changes might be implemented regarding PEFs/PERF,

so to bear that in mind when discussing Forward Planner in July.

8. AOB

Chair thanked BR for her excellent work with PEF over the last couple of years and

wished her a success in her new role in Ealing CCG. BR also informed PEF that she

has met with the new PPE Advisor. Chair also mentioned a revolutionary new

treatment for Stroke patients. Prior to this meeting, BR sent to all three PEFs/PERF

news from NHS England about this.

9. Close and date of next meeting

Chair thanked everyone for their attendance and the meeting was closed. Next PEF

meeting is on Thursday, 13 July 2017 5pm-7pm in Maritime House, Boardroom,

B&D CCG offices.

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