nhs wirral clinical commissioning group governing … · 4.1 director of commissioning’s report...

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING – A Formal Meeting in Public

Tuesday 10th March 2020

Council Chamber, Wallasey Town Hall

3pm – 5pm

AGENDA

Ref No.

No Time Item Action Papers

GB19-20/0046

1. 3pm PRELIMINARY BUSINESS/ADMINISTRATIVE ITEMS (Chair) 1.1 Welcome & Apologies for

Absence Lorna Quigley

Graham Hodkinson

1.2 Chair’s Announcements To Inform

1.3 Declarations of Interest

1.4 Minutes and Action Points of Last Formal Meeting

• 14th January 2020

• Action Points

To Approve

1.4 a WCCG Governing Body PUBL

No Outstanding actions

1.5 Matters Arising To Inform

GB19-20/0047

2. 3.45pm RISK MANAGEMENT

2.1 Risk Register (Paul Edwards)

To Discuss/ Approve 2.1 Risk Register

March 2020 GB.pdf

GB19-20/0048

3. 3.55pm FINANCE

3.1 Chief Financial Officer’s Report (John Doyle)

To Assure /

Note 3.1 a Report cover

sheet Finance Commit 3.1 b Wirral CCG

Finance Committee Re

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Ref No.


3.1.1 Finance Committee Chair’s Report (January) (Lesley Doherty)

3.1.2 Audit Committee Chair’s Report (January) (Alan Whittle)

To Assure /

Note

To Assure /

Note

3.1 c Copy of Appendix 1 - Board R

3.1 d Copy of Appendix 2 - Month 1

3.1.1 Governing Body Finance Chair's Repor

3.1.2 Governing Body Chair's Report Audit C

GB19-20/0049

4. 4.10pm PERFORMANCE AND COMMISSIONING

4.1 Director of Commissioning’s Report (Nesta Hawker)

4.1.1 Primary Care Co Commissioning Report (PCCC) Chair’s report (January) (Sylvia Cheater)

To Assure /

Note

To Assure /

Note

4.1 a Director of

Comm Governing Bod 4.1 b GB Report DoC

Feb-20 vSG.docx

4.1.1 PCCCC Chair

Report 7th January 20

GB19-20/0050

5. 4.20pm QUALITY & PATIENT SAFETY

5.1 Director of Quality & Patient Safety’s Report (Lorna Quigley)

5.1.1 Quality and Performance Committee Chair’s Report

(January) (Ian Huntley)

To Assure /

Note

To Assure /

Note

5.1 a Director of Quality and Patient Sa

5.1 b Director of Quality and Patient Sa

5.1.1 Q&P Committee Vice Chair report 28 J

GB19-20/0051

6. 4.30pm GOVERNANCE AND ENGAGEMENT

6.1 Director of Corporate Affairs’ Report (Paul Edwards)

To Assure /

Note 6.1 a Cover sheet - Director of Corporate

6.1 b Director of Corporate Affairs - Ma

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Ref No.


GB19-20/0052

7. 4.40pm MEDICAL

7.1 Medical Director’s Report (Dr Simon Delaney)

To Assure /

Note

7.1 a Governing Body MD Cover Sheet Marc

7.1 b MD GB 3.20.docx

GB19-20/0053

PUBLIC HEALTH

8.1 The Local Plan (Julie Webster)

To Assure /

Note 8.1 a Governing Body Cover Sheet February

8.1 b Governing Body Report#Local Plan#Fe

GB19-20/0054

9. 4.50pm COMMITTEE MINUTES

9.1 Committee Meeting Minutes

• Quality and Performance Minutes December 2019 and January 2020.

• Finance Committee

Minutes from December 2019 and January 2020.

• Audit Committee Minutes

from November 2019.

• Collaborative Commissioing Forum from November 2019.

To Note

To Note

To Note

To Note

9.1 a Ratified Quality Performance minutes

9.1 b Ratified Quality Performance minutes

9.1 d ratified Finance Com minutes 17.12.19

9.1 d ratified finance Com minutes 28.1.20.d

9.1 e Ratified audit Committee minutes 21

9.1 f Collaborative Commissioning Forum

GB19-20/0055

9. 4.55pm ANY OTHER BUSINESS

Communications from this meeting

Date and Time of Next Meeting:

Tuesday 14th April 2020 (Formal), Council Chamber, Birkenhead Town Hall Please send any apologies to [email protected]

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mailto:[email protected]

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Governing Body Meeting Attendees’ Guidance

Under the direction and guidance of the Chair, all members are responsible for ensuring that the meeting achieves its duties and runs effectively and smoothly. Before the meeting • Prepare for the meeting in good time by reviewing all reports (the amount of time allocated for each agenda item can be used to guide your preparation); • Submit any reports scheduled for consideration at least 10 working days before the meeting to the Governing Body Chair (using the standard report template); • Ensure your apologies are sent if you are unable to attend to the Governing Body Chair and meeting support. *some members may send a nominated representative who is sufficiently senior in order to talk through agenda papers in their absence, however, it is understood that deputies do not have voting or decision making authority. At the meeting • Arrive on time; • Mobile phones to be on silent as it is recognised that individuals may be on call; • Focus on the meeting at hand and not the next activity or on your emails; • Actively and constructively participate in the discussions; • Think about what you want to say before you speak; explain your ideas clearly and concisely and summarise if necessary; • Make sure your contributions are relevant and help move the meeting forward; • Respect the contributions of other members of the group and do not speak across others; • Ensure you understand the decisions, actions, ideas and issues agreed and to whom responsibility for them is allocated; • Accept corporate ownership of decisions made; • Do not use the meeting to highlight issues that are not on the agenda; • Re-group promptly after any breaks; • Take account of the Chair’s health, safety and fire announcements (fire exits, fire alarm testing, etc). Attendance • Members are expected to attend all meetings held each year. After the meeting • Follow up on actions; • Inform colleagues appropriately of the issues discussed. Standards • All documentation will be prepared using the standard Governing Body templates. A named person will oversee the administrative arrangements for each meeting; • Agenda and reports will be issued 7 days before the meeting; • An action schedule will be prepared and circulated to all members after the meeting; • The minutes will be available at the next meeting. Also under the guidance of the Chair, members are also responsible for the meeting’s compliance with relevant legislation and policies, up-to-date versions of which are available on the CCG website, or via the communications team.

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NHS WIRRAL CLINICAL COMMISSIONING GROUP

Governing Body Meeting Minutes of Meeting – Public Session

Tuesday 14th December 2020

Council Chamber, Wallasey Town Hall Present: Dr Paula Cowan (PC) (CHAIR) Chair Simon Banks (SB) Chief Officer Michael Treharne (MT) Chief Financial Officer Nesta Hawker (NH) Director of Commissioning & Transformation Paul Edwards (PE) Director of Corporate Affairs Lorna Quigley (LQ) Director of Quality & Safety Alan Whittle (AW) Lay Member (Audit & Governance) Sylvia Cheater (SC) Lay Member (Patient Champion) Dr Sian Stokes (SS) GP Lead – Long Term Conditions Dr Saket Jalan (SJ) GP Lead – Unplanned Care & Medicines Management Dr Lax Ariaraj (LA) GP Lead – Planned Care Dr Simon Delaney (SD) Medical Director Lesley Doherty (LD) Registered Nurse Dr Bennett Quinn (BQ) Members Council Representative Graham Hodkinson (GH) Director of Care and Health In Attendance: Karen Duckworth (KD) Acting Senior Corporate Officer Chris Harrop (CH) Turnaround Director Ian Huntley (IH) New Ley Member (Quality & Safety) - Observer

Ref No. Minute Action

GB19-20/0037

Preliminary Business 1.1 Apologies for absence: Apologies were noted from Julie Webster, Karen Prior and Dr Richard Sturgess 1.2 Chairs Announcements/Opening Remarks The Chair welcomed all attendees and the members of the public present at today’s meeting. The Chair stated that she had spoken to the public attendees and none wished to address the Governing Body. 1.3 Declarations of Interest

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The Chair reminded the Governing Body members of their obligations to declare any interest they may have on any items arising at that might conflict with the business of NHS Wirral Clinical Commissioning Group (CCG). There were no declarations of interest raised by the members present. The Conflicts of Interest Register is available either via the secretary to the Governing Body or the CCG website at the following link: https://www.wirralccg.nhs.uk/media/3842/copy-of-conflicts-of-interest-staff-listing-august-2017.pdf 1.4 Comments/questions from members of the public None 1.5 Minutes & Action Points from previous meeting held on the 12th November 2019 Minutes The minutes of the previous meeting held on 12th November 2019 were reviewed by the members and were agreed to be a true and accurate record of the meeting, Action Points No outstanding actions. 1.6 Matters Arising There were no matters arising. 1.7 Patient Story LQ shared Poppy’s story, who has special educational and learning needs. Governing Body members all valued the story. It was highlighted that the themes around Poppy’s story link an identified risk currently on the CCG’s risk register in relation to Special Educational Needs and Disability (SEND). This risk recognises the need to ensure the Wirral system is working well together with robust processes, ahead of an expected inspection of this area.

GB19-20/0038

2.1 Risk Register

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https://www.wirralccg.nhs.uk/media/3842/copy-of-conflicts-of-interest-staff-listing-august-2017.pdf


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PE updated members with regards to the current risks and drew members’ attention to those risks which focus on A&E Performance and Ambulance Turnaround times. PE requested that members support the proposed amendment to scores around A&E which had been debated at the Quality and Performance (QP) Committee. This proposal was to raise consequence to 5, based on the potential risk of harm resulting from patients being managed on corridors, but reduce likelihood to 4, based on robust management and clinical approaches to mitigating risk. Members supported this, with the request to ensure the situation was continually assessed to monitor for any evidence of increased risk of harm. PE and LQ outlined the various mechanisms already in place to support this. LQ highlighted that an extract from the Wirral University Teaching Hospital Foundation NHS Trust risk register had been requested and they also have this risk identified (labelled as ‘inability to provide effective care’) and the scores are consistent with the CCG’s. NH also highlighted that in the previous week the hospital was under extreme pressure and actions were put in place by the system in order to react to additional pressures. PE stated that the deterioration the performance in Ambulance turnaround times and handovers is closely linked to A&E performance; however, North West Ambulance Service has a good oversight of the whole system to monitor and manage pressures and flag any issues with local areas. At QP, risks were proposed to remain the same and Governing Body supported this, as whilst potential for harm was recognised, no evidence of actual harm was present. AW made any observation that many of the scores had reduced over the year, which shows that the mitigations that are in place are working and this in turn provides assurance as to the effectiveness of the CCG’s risk management approach.

GB19-20/0039

3.1 Chief Financial Officer’s report MT provided members with an update regarding the Month 9 position, following on from the Month 8 as reported within the agenda papers. The financial position at Month 8 is a £14.6m deficit. The planned position was break-even which means the CCG are £14.6m away from plan. MT stated that this position is supported by the release of £2.7m of contingency. The reported forecast out turn remains as a break even position at this stage of the financial year. However, MT pointed out that this is subject to £13.975m worth of potential risk, some of this related to CCG’s QIPP programme.

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MT updated members of the Month 9 financial position, which reflects a worsening position of a further £1.2m from Month 8, due to pressures within provider performance, prescribing and commissioned out of hospital care. MT confirmed that a detailed paper will be submitted to the Finance Committee to highlight the impact of these pressures in year (against the net risk position as reported to NHS England of £13.975m) and on planning/forecasting for 2020/21. CH queried at what point the CCG will be able to formally change the forecast position. MT advised that the process would usually happen at Month 9 in line with an agreed protocol, however, the regulators have asked that this be pushed back until after month 10. 3.1.1 Audit Committee Chair Update The Chair’s report for November was noted by members and AW highlighted that following the appointment of the new Information Governance Lead from MLCSU, the Committee felt more assured in this area.

GB19-20/0040

4.1 Director of Commissioning Report NH provided the following updates from the Director of Commissioning report:

• A&E – The agreed trajectory for A&E performance was not met in September or October and the October position deteriorated significantly compared with September 2019. NH acknowledged that one of the contributory factors to A&E performance is availability and flow within the bed base. The system, with support from Emergency Care Intensive Support Team (ECIST), is focussing on improving the numbers of Long Length of Stay (LLOS) patients and improving the approach to early discharge planning. Weekly ward based long stay reviews are continuing to take place on the wards with the highest numbers of long stay patients and alongside this, therapy led discharge is being rolled out across all wards. This gives therapists the responsibility for leading discharge planning. A number of wards are trialling the ‘perfect board rounds’ with therapy led board rounds and, if successful, the aim will be to roll out across all wards and ensure sustainability.

• Ambulance – There is a correlation between ambulance performance and A&E performance as when the Emergency Department is under increased pressure, crews are at increased risk of delayed handover and turnaround times which consequently impact their ability to respond to calls in a timely manner. An improvement trajectory has been agreed, which outlines achievement of all categories in Quarter 4

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2019/20, with the exception of Category 1 mean, which will be achieved in Q2 2020/21. Full roster changes will be implemented in order to achieve the standards. The performance improvement plan is monitored by Northwest Strategic Partnership Board (NHS Blackpool CCG, lead commissioners, NHS England and Improvement). Additional paramedics have been recruited to support across West Cheshire and Wirral.

• NHS 111 – There are concerns around performance standards for the North West 111 service (managed NHS Blackpool CCG) have deteriorated and the expected improvements have not been achieved. There is a request to the Quality and Performance Committee to obtain further granular detail in order to assess what is happening to improve performance.

• Referral to Treatment (RTT) - WUTH continue to have zero 52 week breaches and there is ongoing work to review the whole wait list which is also reducing. Changes have been put in place in order to track patients better and the quality of work has improved.

• Cancer - The CCG is now the only CCG in Cheshire and Merseyside to meet the 62 day target for consecutively for 8 months and WUTH have been one of the 5 trusts in England to have been identified as maintaining excellent cancer performance.

• Improving Access to Psychological Therapies (IAPT) – The September and October data shows that the CCG has achieved 2 of the national standards for access to first treatment 6 week and 18 week waits. There have been improvements on the overall access standard, following a dip in the summer, but this has not yet met the required trajectory and therefore further action is being taken to map resources for appointments required for the actual numbers of clients that need to enter into service to meet this. Also, the issues with the legacy aspects are also now improving since the transition from the old provider. Going forward there will the Quality and Performance Committee will review statistical data and monitor trends in this regard.

Members noted the report and actions to improve performance. 4.1.1 Primary Care Co-Commissioning Chairs Report (PCCC) The Deputy Chair’s report for November was noted by members and AW drew attention to the Committee is making good progress in preparing for the transition to full delegation of Primary Care Commissioning and that the Committee is preparing to develop a risk register taking into account full delegation with the help of PE.

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GB19-20/0041

5. 1 Director of Quality and Patient Safety report LQ updated members with regards to Health Care Associated Infection (HCAI) and advised that Quarter 3 data will not be published until late January 2020, therefore the report contains the last three months data. LQ advised that Methicillin-resistant Staphylococcus aureus (MRSA) had no reported in Wirral from September to November 2019. However, LQ highlighted that there had been 1 case reported within December which will be with the next reporting cycle. LQ went onto advise that C-Difficile will start to show a spike due to the recent Norovirus outbreak at Wirral Hospital’s University Teaching Hospital NHS Foundation Trust (WUTH). LQ confirmed that new guidance will be in place in January 2020 around Mixed Sex Accommodation breaches, and it was noted that the Quality and Performance Group will be seeking further assurance from WUTH that any breaches not mitigated by this guidance are understood and being addressed, but also that there are measures in place to protect patient privacy and dignity in all cases. Progress against the new guidance will managed through the Quality and Performance Committee. LQ advised that the Friends and Family Test are seeing good results within most organisations, however, it was noted that for Cheshire and Wirral Partnership NHS Foundation Trust (CWP), continue to have low response rates (3%), therefore work is required in generating more returns. LQ highlighted that within the Serious Incidents reported, there have been 3 ‘never events’ involving Wirral patients at Alder Hey Hospital, Royal Liverpool and Broadgreen University Hospital and Liverpool Heart and Chest, which will be scrutinised through the Quality and Performance Committee and reviewed by the Serious Incident Review Group (SIRG). Members noted the report. LD fed back that it was good to see the breakdown of the details around infections in order to have better debate and discussion. SS queried if there were any updates regarding Escherichia Coli (E.coli). LQ updated that Wirral is an outlier for this infection and Cheshire and Mersey Partnership have appointed a Senior Responsible Owner (SRO) to look at the reported themes. There is currently a reduction target of 50%, and although improvements are being made, more work is needed. 5.1.1 Quality and Performance Committee Chair’s update

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Members noted the Chair’s reports and no comments were made.

GB19-20/0042

6.1 Director of Corporate Affairs’ report PE asked members to note the report and highlighted the extensive staff and public engagement work around the Healthy Wirral Plan, which had significant reach through a variety of engagement approaches. 6.1.1 Assurance Framework PE highlighted how NHS Wirral CCG’s Strategic Aims have now been aligned to those of Wirral Health and Care Commissioning (the partnership between the CCG and Wirral Council’s Commissioning functions), following discussion at Informal Governing Body in October 2019. He drew attention to papers that show the historic and new Strategic Aims, together with the revised Assurance Framework which aligns risks and mitigations to the new Strategic Aims. Governing Body members approved the revised approach to the Assurance Framework. Members also agreed to two changes to the Assurance Framework itself. Firstly, an extension to the deadline for Constitution changes on risk D5 was supported because the approval process is still in progress between the CCG and NHS England. Secondly, members agreed that the gaps in controls on risks E1 and E4 are updated to reflect that the offered support for strengthening provider collaboration has now been agreed to by Healthy Wirral providers and the work has begun. AW commented that this was a good assurance document as it has shown active management of risks of over time.

GB19-20/0043

7.1 Medical Director’s Report SD asked members to note the report and highlighted the key activities, highlighting that further engagement and collaboration with secondary care is crucial, although every effort to engage is being made by the CCG. He also stated that streaming in A&E is improving, although there is still a lot of work required to achieve the agreed target. SD also advised that work is underway so that the Urgent Treatment Centre (UTC) will house a Point of Care Testing (POCT) laboratory, which should be up and running the end of January 2020. The proposed changes will provide infrastructure to accommodate the expected increase in streaming numbers.

In addition, SD confirmed that the Direct Access Fibroscan service is now up and running and can now be booked directly by GPs. Members noted the report and the range of positive clinical developments.

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GB19-20/0044

Committee Meeting Minutes Members noted the following ratified minutes:

• Quality and Performance Minutes from September, October and November 2019.

• Senate Minutes from September and November 2019.

• Audit Minutes from September 2019.

• Finance Committee Minutes from September, October and November

2019.

GB19-20/0045

Any Other Business PC thanked MT for the work undertaken over the last 4 years and wished him well for the future.

Date and Time of Next Public Meeting Date and time of next public meeting: Tuesday 10th March 2019, 3pm – 5pm, The Council Chamber, Wallasey Town Hall. Please forward any apologies to [email protected] Prior to this meeting, the Governing Body will meet alongside the Joint Strategic Commissioning Board, which will commence at 1pm.

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Master

Risk ID Date added Source Committee

Risk Description Organisational Objectives (reference to detail)

Consequence

Likelihood

Matrix Score

Key Control Established Key Gaps in Control (reference to evidence)

Assurance on Controls (reference to evidence)

Gaps in Assurance (reference to evidence)

Consequence

Likelihood

Previous Risk

Rating

Owner Date of next review

Date of last review Last review

14-15G Apr-19 CCG QP Risk to patient safety due to corridor waits Quality / Patient Safety 5 4 20.00 A&E Delivery Board established and meeting regularly with representation

from the CCG.

Clinical Quality and Performance Group

Service Development Improvement Plans (SDIPs) agreed that will give additional leverage in contractual

management.

Regular Board to Boards held with WUTH where this risk is discussed.

Quality Surveillance Group Process

None Minutes from the A&E Delivery Board

Minutes from Contract Meetings.

Written SDIPs in place.

Minutes from Board to Boards.

Review of the delivery of the Improvement Action Plan.

Potential patient safety issues.

Poor patient experience.

Long length of stay impact on patients long term care

needs.

4 5 20.00 NH/LQ March 2020 QP

February 2020 QP April 2019 : Quality review visits undertaken, ECIST visits are taking place on the 30th April 2019. Implementation of the RCP Report and Peer Review undertaken.

June 2019 update: Improvement seen in turnaround time. CQC targeted inspection has taken place March 2019. Actions implemented as per review.Quality review visit undertaken for assurance in relation to actions. 10th June. Deep dive into urgent care to take place in July’s Q&P. Risk rating to reconsidered in Julys Q&P.

July 2019 update: Following the deep dive into urgent care by QP Committee, there is a request for the risk rating to be reconsidered.

July QP Meeting update: Following the A&E Deep Dive, members were impressed by the range of measures and actions in place that collectively aim to address Urgent Care performance. In spite of this, members felt that these had yet to result in sustained improvement. As a result, members agreed to retain current risk scores but to assess risk again in Quarter 3 to establish if the actions have had the desired effect.

05/12/19 Improved streaming in place, including Paediatrics now being streamed. Interim UTC to start on 16/12/19. Long length stays remain an issue and this has been escalated by the A&E Board with actions on top of the winter plan, to aim to tackle this.

December QP Meeting Update: Members discussed in depth this risk in light of recent deteriorating performance within the Emergency Department at WUTH. Members concluded that whilst there was some evidence of potential harm, this was deem to be not clinically significant. Therefore it was agreed to raise the consequence level to 5 (recognising the potential for more significant harm) but to reduce the likelihood of this occurring to level 4, because robust mitigation are in place to safeguard against major patient safety issues.

January 2020: There is now a national focus on this area. Performance to be continue to be monitored.

January 2020 QP Meeting Update: Discussed at QP and members agreed as there was no change to the risk of patient harm, for the scores to remain the same.

February 2020:The position remains the same and will continue to be monitored.

28/02/2020: A number of actions are being taken as outlined above in previous updates. The Emergency Care Intensive Support Team (ECIST) have been supporting the system to implement robust weekly Long Length of Stay (LLOS) reviews with the aim of unblocking some of the issues creating delayed discharge. Whilst this has provided further oversight into what these patients are waiting for, it has yet to make a material difference to the number of LLOS patients within the acute. It is acknowledged that improvements to ward based care as a whole will result in improvements for LLOS patient cohorts as well as facilitating more efficient and timely non-complex discharges. Availability of beds will eradicate the need for corridor waits.

16-17C Reviewed April 2019

CCG QP Increase in potential patient safety issues leading to moderate or severe harm at acute provider organisation.

Quality / Patient Safety 4 2 8.00 Monthly Serious Incident Review Group, of which minutes are also reviewed at

QP Committee.

System Improvement Board.

CQPG Meetings.

None. Minutes of Serious Incident Review Group.

Minutes of the System Improvement Board.

Minutes of CQPG Meetings.


4 3 12.00 LQ March 2020 QP

February 2020 QP September 2019 update: A Quality Review was conducted on August which provided some assurance on the actions completed by the Trust. Following a review of the documentation from the review, this is going to be shared with the Provider for comments.

24/09/19 QP noted actions and agreed not to change scores.

10/10/19 Documentation following the review of the department has been shared with the Provider for comments. CQC are with the Provider organisation at present and we are therefore awaiting feedback from this inspection.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed to reduce the likelihood to 2 as some of the most important issues have been progressed following the review of the department.

26/11/19 Suggested amendment to scores (as above) agreed at November QP.

January 2020: Awaiting feedback from CQC inspection.

February 2020: CQC report is awaited and no recorded episodes of harm.

February 2020 QP: LQ updated that the report is now with the provider organisation and the CCG are awaiting a copy of this report.

16-17D Reviewed April 2019

CCG QP Risk of potential patients harm due to non achievement of RTT (Referral to Treatment).

Quality / Patient Safety / Commissioning

3 2 6.00 RTT Strategic Board.

Data Trackers in place.

Oversight and Activity Management Group.

Contract Meetings.

System Improvement Board.

Data Trackers not rolled out all specialties.

Minutes from the RTT Strategic Group.

Performance Data.

Minutes from Contract Meetings.

Minutes from System Improvement Board.


Processes not universal.

3 3 9.00 LQ March 2020 QP

February 2020 QP August 2019 QP meeting update: The QP Committee reviewed the RTT harm review paper and agreed that this risk could be reduced. The likelihood of the risk was reduced to a 2 as the risk is being managed and the consequence as a 3 to ensure that the risk remains highlighted for discussion.

September 2019 update: MK advised that there were no further updates to be added to the risk this month.

24/09/19 QP noted actions and agreed not to change scores.

15/10/19 The position remains the same and will continue to be monitored.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed for the scores to remain the same as the risk is being managed appropriately. To remain on the risk register as a 'watching brief'.

January 2020: The position remains the same and will continue to be monitored.


February 2020: The position remains the same and will continue to be monitored.

28/02/20: Gap in assurance identified with other provider organisations who the CCG has an associate contract with. Work is being undertaken within the Contracts Team to ensure measures in place to prevent this from occurring in the future.

17/18F Reviewed April 2019

CCG QP Managing effectiveness of staff and development. All 3 3 9.00 PDR process. Awaiting development of new PDR process.

Action plan in place as per the key controls established.

PDR compliance rate.

Compliance reports provided.

Implementation of new PDR process to allow accurate compliance

reporting.

3 3 9.00 PE March 2020 QP

February 2020 QP September 2019 update: The workforce team have apologised for the delay in producing the PDR template suitable for the ESR system and advised that time will be dedicated to producing the template within the next two weeks.

10/10/19 Draft template of new PDR template has been shared and a meeting has been arranged with the Workforce Team and Corporate Affairs Manager on 24th October 2019, to test the system prior to roll out to all staff.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed no changes to be made at present until PDR system has been agreed with the CSU.

05/12/19 Discussions have been taking place around integrating PDR processes with the Electronic Staff Record (ESR). It has emerged that this is now proving technically difficult, so the CSU are developing an alternative proposal.

January 2020: New proposal for system has been received from the CSU. To be trialled by CCG staff to assess the effectiveness of the new approach. Further update to be provided in February 2020.

February 2020: In light of the national changes to Agenda for Change Terms and Conditions, Midlands and Lancashire Commissioning Support Unit (MLCSU) have been looking to develop a new system of recording appraisals within ESR. This is in preparation for appraisal dates linking directly to pay progression. MLCSU have now suggested an alternative appraisal approach is put into place, which MLCSU staff themselves are now using. Therefore, the CCG will be trialling the new approach with a small number of staff throughout February, in the first instance, to assess the effectiveness of the new approach and iron out any problems.

February 2020 QP: LL updated that the deadline for feedback to be provided with regards to the new approach is due to be received by 28/02/2020.

17/18H Reviewed April 2019

CCG QP Failure to meet Category 1 and Category 2 ambulance response times leading to potential patient safety issues.

Commissioning/Quality 4 4 16.00 Strategic Board in place that oversees ambulance performance on behalf of

several CCGs including Wirral.

Incidents Meeting.

None. Minutes of Strategic Board.

Minutes of Incident Meeting.

Delivery again the Improvement Trajectory.



4 5 20.00 NH March 2020 QP

February 2020 QP September update 2019: latest data available is July 2019 which shows targets for category 1 and 2 have not been met. Performance July is slightly better than June. Improvement plans in place. It is likely that performance will deteriorate August/September as handover times and turnaround times have increased which will likely have a knock on effect on cat 1 and 2 calls. This will be closely monitored.

24/09/19 QP noted actions and agreed not to change scores. Given the ongoing performance concerns the members asked that a deep dive at QP be expedited.

10/10/19 Deep dive to be undertaken. This is scheduled on the workplan for QP for November 2019.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed to reduce the likelihood to 4 as there is no evidence of harm.


05/12/19 Due to winter pressures ambulance handover times and targets for category 1 and 2 have deteriorated.

December QP Meeting Update: Members discussed in depth this risk in light of continued poor performance of the ambulance service. Members concluded that scores should remain the same as the risk of potential harm remains present, but at this stage there has been no significant risk to patient safety.

January 2020: No further update to position - Next update therefore due in February 2020.


February 2020 QP - Committee members noted that further assurance relating to risks is being requested, negotiations are ongoing with regards to a regular report relating to Emergency Department safety.

28/02/2020: A Contract Performance Notice has been issued on the category 2 performance by the Blackpool Commissioners. An improvement trajectory has been agreed, which outlines achievement of all categories in Quarter 4 2019/20, with the exception of Category 1 mean, which will be achieved in Q2 2020/21. Full roster changes will be implemented in order to achieve the standards. The performance improvement plan is monitored by Northwest Strategic Partnership Board (Blackpool CCG, lead commissioners, NHSE and NHSI). Additional paramedics have been recruited to support across West Cheshire and Wirral. There is a correlation between ambulance performance and ED performance as when ED is under increased pressure, crews are at increased risk of delayed handover and turnaround times which consequently impact their ability to respond to calls in a timely manner.

18/19C Reviewed April 2019

CCG QP Failure to meet Ambulance Turnaround target of 30 minutes.

30 minute target includes time from when the ambulance arrives on the hospital grounds to the time the patient is handed over to A&E and the ambulance is made ready to respond to the next call.

Arrowe Park hospital are amongst the six worst performing hospitals in the North West on turnaround.

Commissioning 4 4 16.00 WUTH and NWAS are jointly implementing all aspects of NHS

Improvement's handover guidance. A monthly meeting is held between WUTH,

NWAS an CCG to monitor progress. This feeds into A&E Delivery Board.

WUTH are one of six trusts in the North West that have been selected to

participate in a rapid improvement programme with NWAS.

None. Ambulance Handover Action Plan

Minutes of A&E Delivery Board.

Minutes of Urgent Care Operational Group.



4 5 20.00 NH March 2020 QP

February 2020 QP September 2019 update – Performance has started to deteriorate with Wirral becoming one of the worst performing Trust’s in the region again. Reverse cohorting is in place and nurses are supporting the corridor to minimise delays to handover and turnaround times however it remains a significant issue. ECIST are

supporting with long stay patients and streaming. The number of long stay patients has increased significantly over recent weeks correlating to deterioration in handover times and an increase in corridor waits. As a result a daily multi organisation response is in place to review patients with extended length of stay and a senior lead is given responsibility for progressing their discharge. It is anticipated that as discharges increase, occupancy will drop and the pressures in ED will be significantly reduced. Streaming also includes internal options to assessment and specialty level support this will also reduce ED pressures. 24/09/19 QP noted actions and agreed not to change scores. Given the ongoing performance concerns the members asked that a deep dive at QP be expedited.

10/10/19 Deep dive to be undertaken. This is scheduled on the workplan for QP for November 2019.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed to reduce the likelihood to 4 as there is no evidence of harm.


05/12/19 Performance has deteriorated due to hospital pressures. Escalation protocols are being adhered to.

December QP Meeting Update: Members discussed in depth this risk in light of continued poor performance of the ambulance service. Members concluded that scores should remain the same as the risk of potential harm remains present, but at this stage there has been no significant risk to patient safety.

January 2020: No further update to position - Next update therefore due in February 2020.


February 2020 QP - Committee members noted that further assurance relating to risks is being requested, negotiations are ongoing with regards to a regular report relating to Emergency Department safety.

28/02/2020: Performance has deteriorated due to winter pressures. Ambulance handover performance is reviewed on a regular basis both in Wirral System meetings and with NHS E / NHS I.

19/20A Jul-19 CCG Finance CCG has been set a balanced position control total, but this would require a £24m QIPP which is clearly not deliverable. In addition, the Wirral system has the opportunity of receiving £20m of external funding, but only if Provider control totals are met.

Consequently the CCG with partners, has adopted a collaborative place based approach to help WUTH deliver it's control total in order to receive the external funding, which includes a explicit subsidy of £4.5m, and 'ring fences' WUTH income from being targeted by the CCG QIPP.

The impact of this is that the CCG is facing a deficit of £14.8m, resulting in a system deficit of £13.6m (as opposed to a system deficit of £33.6m). Discussions with NHS England/Improvement have clarified that the system control total remains as £1.2m surplus. which presents a significant risk in terms of the CCG achieving a break even position

Financial 4 2 8.00 Turnaround Director and Healthy Wirral Finance Lead appointed for some time.

Regular Financial reporting to Finance Committee and Governing Body which will now also incorporate the system

wide financial reporting as each Board and Health Wirral Partners Board.

Production of a Wirral system Financial Recovery Plan

Negotiations have taken place with NHS E / I to seek a revision to the control

total.

Additional savings/mitigations yet to

be fully identified with significant risk on the ability to implement.

Minutes from Finance Committee and Governing Body

Minutes from the Healthy Wirral Partners Board

The regulator has revised the control total deficit to £13.975 million in line

with the CCG's financial plan.

Poor patient experience. 4 5 20.00 JD March 2020 Finance

February 2020 Finance

August 2019 update: A meeting has taken place with the regulators on the 6th August 2019 who have reiterated the requirement of the system to meet the sum of the individual organisational control totals (£1.2m surplus). A further submission is to be made 13th September 2019 which will need to demonstrate the recovery and mitigation actions to be implemented, in order to eradicate the net risks of £14m. Work is currently ongoing in this area.

September 2019 update: work is ongoing to finalise the update for the 13th September 2019 and preparation for the 25th September meeting. conversations are being had with the regulations in advance of the submission and meeting to ensure the regulators are briefed and aware of our current position.

October 2019: Meeting took place on 25th September 2019 in respect of overall system performance including finance. Generally well received by the regulators but recognised that further scrutiny and meetings will be taking place on finance.

16th October - Letter was received from Graham Urwin in respect of financial position and reiteration that the system needs to do all it can to achieve its control total, including the CCG's control total of nil. Regulators anticipate revised FRP on 1st November 2019 detailing how this will be achieved.

04/12/19 Revised FRP submitted to regulators, who still wish to see the Wirral System to achieve a breakeven position. The current overall potential system deficit is £24.1 million, due to over performance in a number of areas. The CCG continues to explore all opportunities to manage its year end position.

January 2020: The 2019/20 financial year end position for the Wirral System has now been fixed at circa £20million net of WUTHs £4.4 million Provider Sustainability Funding which will now not be received. The CCG element within this overall system position is a deficit of £13.975 million, which will need to be delivered.


February 2020: The position remains the same at present. Previously the £13.975 million was the CCG's risk adjusted deficit. This has now been formally approved by NHSE/I and will now be reported as a formal forecast outturn.

February 2020: Negotiations have taken place with NHS E / I to seek a revision to the control total and the regulator has revised the control total deficit to £13.975 million in line with the CCG's financial plan. In line with this likelihood score reduced to 2 from 5. Interim CFO meeting with Finance Committee representatives on 10/03/2020 to discuss mitigation.

Page 1 of 2

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Master

19/20/C Aug-19 CCG Finance Implications of an independent review being commissioned by the CCG of a provider that became unsustainable and went into administration.

Financial / Quality 3 4 12.00 Regular discussion with NHS Resolution and have been seeking advice from Hill Dickinson's to minimise the impact of

litigation against the CCG.

Independent Review commissioned by NHS E / I.

Review team have been identified and Terms of Reference established.

None identified at present (awaiting report).

Report from the Independent Review commissioned by NHS E / I.

3 4 12.00 JD/LQ March 2020 QP

February 2020 QP 10/10/19 Independent investigation to be commissioned by NHS England and NHS Improvement. The Terms of Reference are currently being drafted for this investigation.

December QP Update: No change to last update.

January 2020: The final version of the Terms of Reference are currently being drafted for this investigation.


February 2020: The Terms of Reference for the investigation are going for consultation and data is being collected to support the investigation.

28/02/2020: CCG has inputted into TOR and review to commence in April 2020. Suggestion to revise scores at QP to be held in March 2020.

19/20/D Nov-19 CCG QP The Special Educational Needs and Disability (SEND) reforms came into effect in 2014 and were detailed within a Code of Practice which was published in 2015. A recent review of the CCG Compliance and Local system compliance with the reforms has indicated several areas for improvement. Whilst there is ongoing work across the system, a inspection is expected within the next few months and likely to be critical.

Quality/Patient Safety 2 4 8.00 SEND Operational and Strategic Group chaired by the Local Authority and

leading on majority of improvement work required.

There is an Inspection Planning Group also chaired by the Local Authority.

The Quality and Performance Committee will be receiving regular

updates in relation to the specific areas for improvement in the CCG.

The Health and Wellbeing Board will be receiving regular updates in relation to the system position in relation to the

reforms.

Time restrictions Minutes of SEND Operational and Strategic Group.

Minutes of Inspection Planning Group.

Minutes of Quality and Performance Committee.

Minutes of Health and Wellbeing Board.

Time restrictions. 2 4 8.00 LQ March 2020 QP

January 2020 QP 04/12/19 New risk added following QP held in November 2019. Suggested scoring as consequence 2 and likelihood 4, to be reviewed and agreed at QP to be held in December 2019.

December QP Update: Members agreed to proposed wording and risk scores.

January 2020: The position remains the same at present.


February 2020: The position remains the same at present - Next update due for March 20 QP.

28/02/20: Inspection awaited at present.

19/20/E Feb-20 CCG QP MSK failure to meet key performance indicators of the service.

Commissioning 3 5 15.00 A contract Performance notice has been issued.

Remedial action plan agreed and a number of actions with deadlines

agreed.

The Quality and Performance Committee will be receiving regular updates in relation to performance.

Awaiting redesign of the MSK pathway.

Minutes of the Contract meeting.

Performance dashboard.

Remedial action plan.

Reputational damage.


Prolonged waits for patients.

Cost to the system.

NH March 2020 QP

28/02/20: New risk agreed to be added following QP Meeting held on 25/02/2020. Suggested scores with consequence of 3 and likelihood of 5.Progress has been made against the Contract Performance Notice and performance is now being achieved for Physiotherapy. Ongoing action required against pain management and rheumatology and the pathway redesign work will capture this.

Impact Values

Negligible 1

Minor 2

Moderate 3

Major 4

Catastrophic 5

Probability Values

Rare 1

Unlikely 2

Possible 3

Likely 4

Almost Certain 5

Green/Yellow/Red Threshold Values

Green - maximum score 4

Yellow - minimum score 5

Yellow - maximum score 12

Red - minimum score 15

Page 2 of 2

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT

Risk Please indicate High Yes Medium Low

FINANCE REPORT MONTH 10 – January 2019/20

Agenda Item: 3.1 Reference GB19-20/0048 Public / Private Public Meeting Date 10th March 2020 Lead Officer/Author of paper

John Doyle – Interim Chief Finance Officer

Contributors Ken Jones – Deputy Chief Finance Officer Emma Edwards – Senior Reporting and Planning Accountant

To Approve To Inform Yes To Assure Yes To Endorse Executive Summary This report sets out the financial position for NHS Wirral Clinical

Commissioning Group (NHS Wirral CCG) as at the end of January (Month 10) 2019/20, the main headlines are:

• Year to date deficit position of £15.5m. • The year-end forecast outturn position is now formally reported

to NHS England/Improvement (NHSE/I) in line with the previous risk adjusted position of £13.975m deficit.

• The cumulative carried forward deficit of £11.8m

Recommendations The Governing Body is asked to note: • The financial position at month 10 being a £15.5m deficit. • This position is supported by the release of £2.7m of

contingency. • The formally reported forecast out turn position is £13.975m

deficit which is consistent with the latest recovery plan • The impact of further mitigations needed in 19/20 that may

worsen the 20/21 starting position. • The cumulative brought forward deficit of £11.8m.

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Detail of Risk Description

The key risks for the CCG in 2019/20 are consistent with those reported in previous years being the achievement of a substantial QIPP programme of £24.245m, and ensuring operational/contract expenditure is managed within the financial plan set at the start of 2019/20 and signed off by budget holders.

Clinical engagement taken place N Patient and public involvement taken place N

Equality Analysis/Impact Assessment completed N

Quality Impact Assessment N

Strategic Themes Working as One, Acting as One – we will work together with all partners for the benefit of the people of Wirral.

Y

Listening to the views of local people – we are committed to working with local people to shape the health and care in Wirral.

Y

Improving the health of local communities and people – Wirral has many diverse communities and needs. We recognise this diversity and will help people live healthier lives, wherever they live.

Y

Caring for local people in the longer term – we will focus on having high quality and safe services, with the best staff to support the future as well as the present.

Y

Getting the most out of what we have to spend – we will always seek to get the best value out of the money we receive.

Y

This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path i.e. other papers that are directly related to the current paper under discussion.

Governance route prior to Governing Body Meeting Date Objective/Outcome CCG Governing Body Quality and Performance Committee Finance Committee 25.2.2020 Audit Committee Remuneration Committee Health and Wellbeing Board Business Management Group

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GOVERNING BODY REPORT

Governing Body Paper - Finance Report M10 Page 1 of 10

1.0. INTRODUCTION

This report sets out the financial position for NHS Wirral Clinical Commissioning Group (NHS Wirral CCG) as at the end of January (Month 10) 2019/20. The main headlines are –

Year to date deficit position of £15.6m. The CCG’s control total was set by NHS England as break-even which means the CCG is £15.6m away from plan.

The CCG position comprises of an overspend of £1.1m across NHS Contracts, Non NHS contracts are overspending by £67k and prescribing is overspending by £2.5m, an adverse movement of £441k from Month 9. Out of hospital packages of care are also overspending by £3.2m, an adverse swing of £434k from month 9. The remainder of the pressure is due to unidentified Quality Innovation Productivity and Prevention (QIPP (offset by the full use of contingency)) £12.2m. There are also some small non-recurrent prior year fall outs supporting the Month 10 position. Further information on the variances is provided in Section 3 below.

At the end of January 2020, NHS Wirral CCG has formally reported a revised deficit outturn position of £13.975m to its regulators. This is consistent with the original financial plan signed off for 2019/20 in that the CCG always reported a risk adjusted deficit of circa £14m, predominately due to the extremely challenging level of QIPP required and the amount that remained unidentified. There are also further operational pressures within prescribing and commissioned out of hospital healthcare in year.

The accelerated non-recurrent support provided to Wirral University Teaching Hospitals NHS Foundation Trust (WUTH) in previous months has now been reversed in Month 10.

There are a number of mitigations needed to ensure the CCG reaches the revised deficit outturn position. Details of these risks and mitigations can be found in Section 2 – key risks, and Appendix 1 – board report extract.

The CCG’s QIPP target is £24.245m of which £17.941m remains unidentified, this pressure will continue to add to the deficit position each month going forward. Further information in relation to QIPP can be found in Section 4 below.

It should be noted that £2.7m of the CCG’s contingency (the full amount) has now

Report Title Finance Report for the period - 1st April to 31st January 2020

M10 – 2019/20 Financial Year Lead Officer John Doyle – Interim Chief Finance Officer

Recommendations 1. To note the financial position of the CCG at Month 10. 2. To note the high level budget/expenditure summary for

2019/20. 3. To note risks attached to achieving the 2019/20 planned

position.

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been utilised to support the year to date (YTD) financial position given the developing pressures outlined above.

The financial position across the Wirral system is reported through the Healthy Wirral Partners Board. At the time of writing the finalised Month 10 report is not yet available, as such the usual report will be distributed once available and a verbal update will be provided at the meeting.

There have now been a number of iterations of the system wide recovery plan shared with NHS England/Improvement (NHSE/I) and monthly recovery meetings are now in place with the last one being 7th January 2020. The directions from NHSE/I remain in place. All systems need to have well-defined and deliverable plans, with all system members being clear about the actions and deliverables for which they are accountable to ensure the net system financial risk of £20m is reduced as much as possible, to note this position is prior to the non-receipt of Q4 Provider Sustainability Fund (PSF) funding initially earmarked for WUTH. 2.0 . KEY ISSUES

For the YTD to Month 10, the CCG is reporting a deficit position of £15.6m which deviates significantly away from the planned break even position.

The deficit position is largely driven by10/12ths of unidentified QIPP £14.6m, less the full utilisation of the CCGs £2.7m contingency. In addition to the above, there are also continuing pressures within commissioned out of hospital healthcare and prescribing, causing a further £0.9m deterioration in the year to date (YTD) position during Month 10.

The table below shows the breakdown of this position by expenditure area.

As mentioned the formal forecast has now been amended from a breakeven position to a deficit of £13.975m.

The unidentified element of QIPP is sat against reserves which appear within the “other” section in the table below.

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RISKS AND MITIGATIONS

Despite the outturn of the CCG now moving to £13.975m deficit, there are some key mitigations required to ensure the CCG achieves this revised control total. This is primary due to the in-year pressures of prescribing and commissioned out of hospital healthcare.

Some of these mitigations have some uncertainty attached to them and additional mitigations are therefore being explored to ensure the revised control total is still achievable. It must also be understood that some of these mitigations will have an impact on 20/21 financial year.

Wirral CCG Financial Position as at 31st January 2020 (Month 10)

Expenditure Area M10 Annual budget £'000

M10 YTD

Budget £'000

M10 YTD actual

£'000

M10 YTD

variance £'000

M9 YTD

variance £'000

Movement £'000s

Month 10 Forecasted Year End Outturn

£'000

NHS 395,896 329,526 330,652 1,126 3,395 (2,269) 1,852Non NHS 16,827 13,906 13,973 67 256 (189) 155Prescribing 60,302 50,224 52,730 2,506 2,065 441 1,398Commissioned out of Hospital 49,595 41,385 44,622 3,237 2,803 434 3,545

Primary Care 9,658 8,053 8,084 31 17 14 55Better Care Fund 27,233 22,694 22,694 0 0 0 (100)Other (Incl Contingency/ reserves) (4,622) (5,057) 3,735 8,791 7,477 1,314 7,247Running costs 5,983 4,941 4,764 (176) (196) 20 (177)In Year Operational performance 560,872 465,672 481,255 15,582 15,817 (235) 13,975Deficit b/fwd. (11,810) (9,842) 0 9,842 8,857 984 11,810CCG YTD overall 549,062 455,831 481,255 25,424 24,675 749 25,785

Month 10 CCG Calculated FOT 22,122

Prescribing - change in prescribing practices (1,400)WUTH Contract under performance EL/ DC (350)HW Medicines Optimisation Programme (380)CHC reviews (500)BCF (400)Primary Care (280)Sepsis (1,200)Transformation Monies (100)TCP (600)MH Programme Slippage (340)Balance sheet provisions (900)Technicial mitigations/ additional balance sheet (1,697)

Revised FOT @ M10 13,975

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3.0 IMPLICATIONS – KEY MONTHLY REPORTING MESSAGES NHS Contracts NHS contracts are reporting an overspend of £1.1m year to date. This is a favourable movement of £2.3m from the month 9 position primarily due to the reversal of the accelerated non recurrent support provided to WUTH. WUTH is showing an underspend of £0.5m at month 10 mainly due to underspends in elective/daycase and Non PbR adjusted for the impact of the year-end agreement which is in place. (see Appendix 2 for more details) The remaining NHS Contracts are showing an over spend of £117k. The adverse movements to note this month are at the Countess of Chester Hospital, Christie Hospital (within NEL high cost) and Manchester Hospital (various areas). In addition there has been continued over performance at Royal Liverpool and Broadgreen Hospitals £501k (within NEL and Adult Critical Care), Wirral Community Health & Care Foundation Trust £212k (mainly Ophthalmology), Liverpool Heart and Chest (within NEL, NELXBD and OPFUP) and West Midlands Ambulance Service reports an overspend of £75k, incorporating the financial cap (mainly due to sitter 2’s and 1a's). Favourable movements and under performance continue to month 10 in contracts with Liverpool Women's, Alder Hey (mainly due to urology and drugs), Clatterbridge Cancer Centre (DC, OP and Drugs) and Walton Centre across various points of delivery. There is also a favourable movement of £52k at Aintree University Hospital NHSFT (within Adult Critical care and Electives). Non NHS Contracts Non NHS contracts are overspending by £67k largely due to over performance against plan of £320k at Spa Medica for cataracts activity. Other contract pressures to note are Peninsula £61k mainly in dermatology, Spire Liverpool £41k, Individual Funding Requests £35k and BPAS £31k. These are offset mainly by Locally Commissioned services £179k, Spire Murrayfield £176k and non-material underspends across other contracts. One to One (Northwest) Limited went into administration on 31st July 2019. Although there is nothing further to report regarding the administration process, there is still the risk of duplicate payments with local providers, primarily at WUTH, due to the nature of the maternity pathway payment mechanism. This pressure is included in the finance risk position, however discussions are in progress to formalise an agreement for 2019/20 with the Trust. Prescribing The reported prescribing position at the end of January is an over spend of £2.5m, +4.9% over planned budget, with an adverse movement of £441k from the month 9 position. The practice position is based on 8 months actual prescribing data and 2 months estimates. (Practice prescribing information is received 2 months in arrears). The breakdown is shown in the table below:

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November prescribing spend was 2.0% higher than November 2018, at £5.08m. The average monthly increase in spend to date is 5.1% above 2018 spend. The average prescribing spend per dispensing day for 2018/19 and 19/20 is shown below:

In a recent return to NHS England it is reported that the impact of No Cheaper Stock Obtainable (NCSO) and stock shortages is estimated for M10 at £1.5m. This equates to 60% of the reported overspend year to date.

Whilst the prescribing QIPP is showing delivery year to date there are still developing cost pressures. This is being monitored closely to understand the high spending drug areas by the Midlands and Lancashire Commissioning Support Unit (MLCSU) Medicine’s Management team, BI and finance and will also form part of the detailed prescribing reports discussed at the monthly medicines management meetings. The high focus areas in the last quarter of the year continue to be:

• Direct Oral Anticoagulants (DOACs) – Edoxaban first line formulary and appropriate switches – additional clinics set up with targeted practices,

• Self-care – Paracetamol and hay fever – GP communication and practice monitoring.

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• Sip Feeds – Community use of formulary, Care home usage and acute discharges.

• Dressings – in particular the use of expensive silver dressings.

A further update on the comparisons of cost and items for NHS Wirral CCG against its Right Care partners will be distributed prior to the Committee meeting.

Commissioned out of Hospital Care Commissioned out of Hospital Care has been reported based upon actual packages in place and is reporting a year to date over spend of £3.2million. This is an adverse swing of £434k from the previous month.

The forecast outturn remains at a £4m overspend being a slight increase of £21k against last month’s position.

In view of this forecast overspend a number of financial controls remain in place including:

• All packages over £700.00 per week now requiring Director approval. • All Fast Track requests for care homes require Director approval. • Any additional care requirements leading to a total in excess of £700 week

requiring Director approval.

In addition to this, we continue to work with Mersey Internal Audit Agency (MIAA) who have been commissioned to expedite the establishment of the Care Home Framework.

A desktop review of all Packages of Care has been undertaken to ensure costs are being recorded correctly against the appropriate area. This has resulted in the reclassification of a number of Joint Funded packages out of Continuing Health Care (CHC) and into Mental Health / Learning Disabilities.

The MIAA review of 67 fast tracks packages that have not had a 12 week review undertaken has now commenced.

Packages of Care (Broadcare): Month 10 Movements

Driver No. of packages Forecasted Costs (£000's)

New Packages Approved 221 1,566,343 Packages Closed (211) (1,389,482) Overall Movement of Packages in Broadcare

10 176,860

Backdated Packages added with start date prior to 1st January*

94 624,222 NB: patients may have more than one package in place.

• Of the 221 New Packages added to Broadcare in January, 94 of them had start dates prior to January. Some of these start dates went as far back as November

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2018 (but the packages have only just been added to Broadcare in Jan 20). The Full Year forecast cost of all the backdated packages is £624,222.

Domiciliary care packages being paid via the Local Authority’s Liquid Logic system are included in these figures.

A further 5 Elderly Mental Illness (EMI) Beds have been made available via the Better Care Fund which should reduce the demand on CHC to fund Discharge to Assess beds.

Overall there were 110 new patients awarded a package of care outside of hospital in Month 10.

Contracts Outside of Broadcare:

Cheshire and Wirral Partnership NHS Foundation Trust (CWP) Rosewood Rehabilitation costs have been received for April to December. There are currently 12 Beds occupied, increasing the forecast overspend by £16k in Month 10.

There were 9 Continuing Healthcare patients found to be newly eligible in January that are not yet on Broadcare (information provided by the CHC Clinical Team). These packages are estimated to cost £105k year to date and £199k for the full year. This is a decrease of £76k to the previous Month’s forecast. These figures have been included within the month end position and will continue to be monitored each month.

In January, a further £28k has been received back into the CCG as a result of writing out to all PHB recipients to request the return of any surplus of funds available.

Retrospective claims to be paid out in 2019/20 have been reduced as the audits will not be completed until next financial year.

Swings from Month 9 to Month 10

YTD Swing (£000's)

Forecasted Swing (£000's)

Reason for Movement in Forecast

Broadcare 364,978 176,860 Movement of Packages in Broadcare (Open/Ceased)

Contracts outside of Broadcare

-18,550 -155,802 £16k Rosewood -£76k Newly Eligible -£28k return of PHB surplus Fast Track -£67k Reduction of retrospective claims not due until 20/21

QIPP slippage 87,626 0 Based on QIPP Profile Total 434,054 21,058

Better Care Fund

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At the end of January, the Better Care Fund pooled budget is reported in line with plan. Any developing slippage or pressures will be managed via the Pooled fund executive Group and reported through each partners monthly performance figures. Other (Incl Reserves) The CCG’s contingency reserve of £2.7m has now been fully utilised. This means that all of the £2.7m contingency is now supporting the year to date financial position.

Further information in respect of reserves/‘other spend’ can be seen in the table below. (To note, not all budgets in this section are profiled in 12ths)

Running Costs Running costs are reporting an underspend of £176k year to date. This has largely been driven by a number of vacancies and prior year accrual fallouts offset by the QIPP target. 4.0 QUALITY INNOVATION PRODUCTIVITY AND PREVENTION (QIPP)

The 2019/20 QIPP plan was set at £24.245m. Of this, the CCG currently has a total of £6.304m of schemes identified meaning £17.941m remains unidentified. Performance against QIPP remains difficult to judge given prescribing data is based upon 2 months estimates, acute data is based upon Month 9 Service Level Agreement Monitoring (SLAM) information and CHC performance is based upon Month 9 reports.

Given the above position YTD QIPP performance has been largely estimated for Month 10, with YTD to month 9 based upon actuals (with the exception of prescribing). We are forecasting delivery of £6.2m of the total QIPP programme being 25% of the original £24.245m target.

Expenditure Category Annual Budget £

Budget to Date £

Spend to Date £

Variance £ Description

Programme Projects (Diabetes & Respiratory) 400,746 333,945 333,955 10CHC Admin Team 1,164,517 970,421 995,487 25,066CHC Admin Team - Other 212,395 176,990 176,979 (11)CSU MM Programme charges 863,801 719,830 739,270 19,440Winter Pressure 0 0 0 0Safeguarding 557,550 464,560 317,745 (146,815)Non recurrent programmes (STP) 883,000 784,606 784,608 2Contingency 2,732,000 2,732,000 0 (2,732,000) Util ised in full to support WUTH Q2 pressures

Unidentified QIPP (17,891,240) (14,951,039) 0 14,951,039MH5Y4V 482,785 0 0 0 Mental Health 5 Year Forward View 2018/19 Paybacks (brokerage) 5,100,000 4,834,000 3,500,000 (1,334,000) Util ising to support WUTH Q2 pressures

CEOV (140,000) 0 0 0 Shortfall funded from contract reserve below

Contracts 1,012,107 (1,121,830) (3,113,500) (1,991,670) Committed reserves. Plus prior year fall outs/ efficiencies

Total (4,622,339) (5,056,517) 3,734,543 8,791,060

Other Expenditure & Reserves Analysis as at Month 10 2019/20

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The year to date QIPP slippage is £0.111m against the identified target, a summary of programme areas is shown below – (the details are discussed at the Financial Recovery Group).

5.0 OTHER

Underlying Position

The CCGs QIPP requirement in 2019/20 of £24.245m has a significant impact on the underlying position going into 20/21. There is also the worsening of prescribing and commissioned out of hospital healthcare in year that adversely affects the CCG’s underlying position. It must also be noted that the CCG still has a cumulative deficit of £11.8m brought forward from 2018/19. The underlying deficit is therefore in excess of circa £35m. Cash Management The CCG’s cash book balance at the end of January was £6k. This is in line with current NHS England guidance that CCGs only hold cash balances up to 1.25% of the current month cash drawdown.

The Better Payment Practice Code (BPPC) monitors public sector organisations on the timeliness their financial payments both in terms of volume and value. Guidance recommends 95% of payments are made within 30 days, the CCG performance was

QIPP Programme Area SRO Programme Lead Programme - Planned Saving

Programme Plan - YTD

Programme Actual - YTD

Programme Variance - YTD

RAG movement between M9/10 YTD

Prescribing Mike Treharne Iain Stewart £2,400,000 £2,000,000 £2,536,652 £536,652

£6,304,000 £5,253,333 £5,364,389 £111,055

Unidentified £17,940,000 £14,950,000 £0 (£14,950,000)

£24,244,000 £20,203,333.33 £5,364,389 (£14,838,945)

Position improved

Position worsened

Position static

Total (Identified QIPP Plan)

Total QIPP Programme

(£13,212)

£1,290,000 £1,075,000 £740,119 (£334,881)

£1,053,454

Phil Forester

Planned Care Nesta Hawker Ian Williams

£0

£784,000 £653,333 (£77,503)£575,830

£458,333OtherMike Treharne /Paul Edwards

N/A

£1,280,000 £1,066,667

£550,000 £458,333

Commissioned Out of Hospital Packages of Care

Lorna Quigley Iain Stewart

Non Electives Nesta Hawker

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99.97% for January. The following table shows the number of invoices paid against target.

Expenditure incurred above £25k is collected monthly and published on the CCG’s website in line with the requirement set out by NHS England.

6.0. CONCLUSION

NHS Wirral CCG’s Governing Body is asked to note:

• The financial position at Month 10 being a £15.6m deficit. • The accelerated non-recurrent support provided to WUTH has now been

removed from the YTD position having reversed in Month 10. • This position is supported by the release of the full contingency £2.7m. • The formally reported forecast out turn position is now £13.975m deficit

which is consistent with the latest recovery plan. • Mitigations totalling £8.1m required to ensure the revised deficit of

£13.975m are delivered in full. • The Wirral system financial position at Month 10 will be shared at the

meeting via a verbal update. • Agreement has now been reached with WUTH in relation to the

underperformance on the Elective and Daycase programme, with the latest full year estimate remaining at around £1.8m.

• The cumulative brought forward deficit of £11.8m.

John Doyle

Interim Chief Financial Officer NHS Wirral Clinical Commissioning Group 17th February 2020

Month Period Number

Paid Year Total Number of Invoices Paid

Total Paid Within Target No.

%age Total Value of Invoices Paid £

Value paid w ithin Target £

%age

APRIL 01 19 875 871 99.54% 42,520,361.40 42,377,382.39 99.66%MAY 02 19 1014 1014 100.00% 39,014,359.66 39,014,369.66 100.00%JUNE 03 19 1164 1155 99.23% 43,981,014.86 43,957,399.02 99.95%JULY 04 19 923 920 99.67% 48,226,561.20 48,212,376.94 99.97%AUGUST 05 19 1091 1088 99.73% 46,935,656.06 46,654,948.56 99.40%SEPTEMBER 06 19 1076 1062 98.70% 39,222,326.94 39,212,834.29 99.98%OCTOBER 07 19 1193 1189 99.66% 40,874,364.85 40,848,630.19 99.94%NOVEMBER 08 19 1423 1422 99.93% 44,365,036.75 44,364,895.32 100.00%DECEMBER 09 19 1268 1263 99.61% 49,386,012.65 49,260,530.93 99.75%JANUARY 10 20 1317 1312 99.62% 39,665,178.85 39,653,213.65 99.97%

11344 11296 99.58% 434,190,873.22 433,556,580.95 99.85%

Performance Against Better Payment Practice Code (BPPC) ALL

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NHS Wirral CCG

APPENDIX 1 - Month 10 Board Report Extract

Cost Centre Annual Budget

Budget to Date

Spend to Date Variance Prior Mth YTD

Variance

Change In YTD Variance

Forecast Spend

Mitigations Outturn Variance

Wirral University Teaching Hospital NHS Foundation Trust 269,418,366 223,417,721 222,871,722 (545,999) 1,672,989 (2,218,989) 269,418,366 (350,000) (350,000)North West Ambulance Service 13,280,562 11,067,110 11,059,063 (8,047) (7,241) (806) 13,270,907 0 (9,655)West Midlands Ambulance Service 2,404,590 2,003,826 2,078,889 75,063 74,404 660 2,488,147 0 83,557Royal Liverpool & Broadgreen University Hospitals NHS Trust 5,771,337 4,809,440 5,310,191 500,751 496,488 4,263 6,369,632 0 598,295Aintree University Hospitals NHS Foundation Trust 3,180,920 2,650,760 2,634,686 (16,074) 35,522 (51,596) 3,164,390 0 (16,530)Countess of Chester NHS Foundation Trust 6,282,129 5,235,100 5,322,851 87,751 69,651 18,100 6,390,006 0 107,877Liverpool Womens NHS Foundation Trust 2,668,572 2,223,800 1,887,622 (336,178) (251,049) (85,129) 2,237,570 0 (431,002)Liverpool Heart & Chest NHS Foundation Trust 1,757,538 1,464,610 1,570,401 105,791 101,269 4,522 1,890,932 0 133,394Alder Hey Childrens NHS Foundation Trust 2,444,362 2,036,960 1,708,736 (328,224) (246,508) (81,716) 2,060,753 0 (383,609)St Helen's & Knowsley NHS Trust 1,121,371 934,460 944,659 10,199 18,811 (8,612) 1,138,063 0 16,692Clatterbridge Cancer Centre 7,993,954 7,413,610 7,259,152 (154,458) (115,304) (39,154) 7,797,779 0 (196,175)Manchester University Hospitals NHS Foundation Trust 416,356 346,950 352,047 5,097 (11,254) 16,352 413,749 0 (2,607)Warrington & Halton Hospitals NHS Foundation Trust 82,956 69,120 113,594 44,474 55,354 (10,879) 132,788 0 49,832Wrightington, Wigan and Leigh NHS Foundation Trust 207,824 173,170 182,528 9,358 10,060 (701) 217,319 0 9,495Walton Centre NHS FT 2,268,178 1,890,131 1,715,632 (174,499) (160,825) (13,674) 2,064,481 0 (203,697)Christies NHSFT 106,127 88,430 180,357 91,927 73,563 18,364 237,550 0 131,423Non Contracted Activity (Acute NHS) 2,908,455 2,423,691 2,404,765 (18,926) (4,071) (14,855) 2,889,530 0 (18,925)Non Contracted Activity (Acute Non NHS) 463,752 386,460 386,460 0 0 () 463,752 0 0Non Contracted Activity (Acute Other) 20,180 16,812 16,815 3 () 3 20,180 0 0Cheshire & Wirral Partnership NHS Foundation Trust 36,236,323 30,161,916 30,097,562 (64,354) (57,528) (6,827) 36,159,098 0 (77,225)Greater Manchester West MH NHSFT - Military Vets 30,714 25,590 25,711 121 204 (83) 30,714 0 0MH NCAs (Various Providers)/ Merseycare NHS Trust 90,600 75,500 97,350 21,850 24,787 (2,937) 119,455 0 28,855MH NCAs (Various Providers) Non NHS 0 0 47,063 47,063 39,915 7,148 47,063 0 47,063Mersey Care NHS Foundation Trust- IPS Wave 2 124,000 103,329 103,333 4 3 1 124,000 0Specialist Perinatal Mental Health Service 407,000 339,164 339,393 229 206 23 407,272 272Wirral Community NHS Foundation Trust 34,796,656 28,997,172 29,209,777 212,605 193,202 19,403 35,051,782 0 255,126Wirral Community NHS Foundation Trust - OOH 3,353,053 2,794,210 2,794,211 1 1 0 3,353,053 0 0Acute QIPP (2,074,000) (1,728,330) 0 1,728,330 1,555,497 172,833 0 0 2,074,000M12 Performance Prior Yr. fallouts for Acute 0 0 (172,833) (172,833) (172,833) () 0 0 0Collaborative Commissioning Acute 102,469 85,390 85,391 1 1 0 102,469 0 0Invest to Save - QIPP 32,000 20,117 25,354 5,237 () 5,237 37,237 0 5,237Total NHS Contracts 395,896,344 329,526,219 330,652,481 1,126,262 3,395,311 (2,269,049) 398,098,037 (350,000) 1,851,693Spire - Murrayfield 1,675,032 1,395,850 1,219,590 (176,260) (99,572) (76,688) 1,486,556 0 (188,476)Spa Medica 2,205,715 1,838,090 2,157,830 319,740 416,373 (96,633) 2,545,777 0 340,062One to One Midwifery 758,359 631,960 635,172 3,212 3,211 1 894,930 0 136,571Spire Liverpool 183,234 152,690 193,615 40,925 44,129 (3,204) 240,097 0 56,863Extended Choice Network 114,182 95,150 99,692 4,542 8,494 (3,952) 119,883 0 5,701Locally Commissioned Services - Minor Surgery (Wallasey&Bebington) 183,380 152,780 143,487 (9,293) (2,967) (6,326) 172,184 0 (11,196)Peninsula 756,514 630,420 691,709 61,289 60,871 418 816,510 0 59,996Locally Commissioned Services 2,406,329 2,005,270 1,826,303 (178,967) (178,967) 0 2,155,281 0 (251,048)Stroke Association 139,428 116,190 116,190 0 0 0 139,428 0 0Specialist Care / IFR Panel Approvals Non NHS 433,210 361,000 395,699 34,699 31,403 3,296 474,839 0 41,629Marie Curie 129,285 107,730 107,737 7 7 1 129,285 0 0End of Life 344,440 287,030 287,467 437 763 (326) 344,960 0 520St Johns Hospice (Wirral) 1,674,819 1,395,680 1,396,277 597 (3,096) 3,693 1,675,618 0 799British Pregnancy Advice Service 210,506 175,420 206,105 30,685 24,934 5,751 244,469 0 33,963Patient Transport 26,767 22,300 14,264 (8,036) (7,790) (247) 18,031 0 (8,736)Mental Health Services 141,177 110,546 104,868 (5,678) 258 (5,937) 141,177 0 0MH/LD Assessment & Support 15,000 12,496 12,500 4 3 1 15,000 0 0Primary Care Advice Link 307,950 256,620 249,346 (7,274) (5,958) (1,316) 300,000 0 (7,950)Improving Access to Psychological Therapies 4,668,546 3,925,250 3,925,259 9 7 2 4,668,546 0 0Social Prescribing 97,000 80,831 80,533 (298) 2 (300) 96,640 0 (360)Parenting & Prevention 53,340 44,450 37,885 (6,565) (5,277) (1,288) 44,991 0 (8,349)Homeopathy 0 0 0 0 0 0 0 0 0Looked After Children 74,472 62,060 24,639 (37,421) (32,424) (4,998) 29,567 0 (44,905)Palliative Care/ Hospice Reserve 173,000 0 0 0 0 0 173,000 0 0Prior Yr. fallouts for Non NHS 0 0 0 0 0 0 0 0 0Total Non Acute Contracts 16,826,685 13,905,646 13,973,127 67,481 256,320 (188,839) 16,981,994 0 155,309Primary Care Prescribing 57,882,545 48,207,183 50,667,901 2,460,718 2,033,450 427,268 61,036,516 (1,780,000) 1,373,971Central Drugs 1,855,818 1,546,510 1,640,169 93,659 71,507 22,152 1,960,879 0 105,061Air Liquide 564,101 470,080 421,742 (48,338) (39,570) (8,768) 483,266 0 (80,835)Total Prescribing 60,302,464 50,223,773 52,729,813 2,506,040 2,065,388 440,652 63,480,661 (1,780,000) 1,398,197Learning Disabilities (100% Funded NOT CHC) 417,958 349,583 382,633 33,050 31,858 1,192 453,323 0 35,365Section 117 - Learning Disabilities 1,494,804 1,247,008 1,781,170 534,162 476,572 57,590 2,133,814 0 639,010Mental Health Services - Adults Under 65 (100% Funded NOT CHC) NHS 1,478,995 1,236,486 1,297,875 61,389 47,852 13,538 1,461,163 0 (17,832)Mental Health Services - Adults Under 65 (100% Funded NOT CHC) Non NHS 3,738,701 3,120,412 3,924,067 803,655 729,885 73,770 4,775,551 0 1,036,850Mental Health Services - Adults Over 65 (100% Funded NOT CHC) 1,008,179 843,254 904,978 61,724 66,877 (5,153) 1,060,206 0 52,027Section 117 - Mental Health Adults 6,769,685 5,651,621 5,280,173 (371,448) (347,316) (24,132) 6,322,319 0 (447,366)Continuing Healthcare/ Fully Funded Packages of Care 18,503,924 15,436,553 15,714,272 277,719 241,446 36,273 18,894,082 (500,000) (109,842)Continuing Healthcare/ Fully Funded Packages of Care Personal Health 3,950,678 3,304,394 5,579,889 2,275,495 2,014,482 261,013 6,745,390 0 2,794,712Continuing Healthcare/ Joint Funded Packages of Care 4,011,608 3,352,312 2,828,193 (524,119) (521,592) (2,527) 3,377,932 0 (633,676)Continuing Healthcare/ Joint Funded Packages of Care Personal Health 522,790 437,264 774,267 337,003 311,401 25,602 904,240 0 381,450Children with Special /Safeguarding Needs 1,413,827 1,168,537 1,176,373 7,836 (3,781) 11,617 1,417,090 0 3,263CHC Childrens Personal Health Budgets 147,296 123,198 176,848 53,650 43,615 10,035 216,699 0 69,403Funded Registered Nursing Care 5,970,213 4,975,775 4,810,628 (165,147) (133,288) (31,858) 5,696,023 0 (274,190)Acute transition (step down) 166,292 139,086 140,772 1,686 (5,408) 7,094 181,711 0 15,419Prior Yr. fallouts for CHC 0 0 (150,000) (150,000) (150,000) 0 0 0 0Total Commissioned out of Hospital 49,594,950 41,385,483 44,622,137 3,236,654 2,802,600 434,054 53,639,543 (500,000) 3,544,593LES Budgets 3,426,265 2,855,158 2,855,186 28 20 8 3,426,265 0 0LES Budgets Practice Transformation 2,909,000 2,424,160 2,424,167 7 7 () 2,909,000 0 0Primary Care Development Other 340,000 283,330 283,330 0 0 0 340,000 0 0Think Pharmacy 22,089 18,400 13,744 (4,656) (4,173) (482) 16,494 0 (5,595)WCCG Service Development 625,659 521,360 544,061 22,701 6,394 16,308 663,157 0 37,498Interpreting Services 93,382 77,810 78,553 743 (295) 1,038 93,918 0 536Collaborative Fees 180,625 150,520 150,520 () () () 180,625 0 0Phlebotomy 804,558 670,460 687,965 17,505 15,754 1,751 825,558 0 21,000GP FORWARD VIEW 85,500 76,000 76,000 0 0 0 85,500 0 0Primary Care GPIT 1,170,828 975,682 1,010,521 34,839 31,354 3,485 1,212,630 0 41,802Total Primary Care 9,657,906 8,052,880 8,084,048 31,168 17,061 14,107 9,713,147 0 55,241CWP BCF 671,908 559,910 559,923 13 12 1 671,908 0 0Mental Health Services - Advocacy 53,415 44,510 44,513 3 2 0 53,415 0 0Dementia CWP 479,248 399,360 399,373 13 12 1 479,248 0 0Dementia LES 71,400 59,500 59,500 0 0 0 71,400 0 0Community Services 42,720 35,590 35,600 10 8 2 42,720 0 0Hospices 0 (1) 0 1 2 (1) 0 0 0Intermediate Care 669,542 557,940 557,951 11 9 2 669,542 0 0Intermediate Care Wiral CT 4,511,691 3,759,708 3,759,743 35 27 8 4,511,691 0 0Palliative Care 43,782 36,480 36,485 5 5 0 43,782 0 0Commissioning - Non Acute 16,888 14,070 14,073 3 3 0 16,888 0 0Reablement Wirral CT 1,046,808 872,320 872,341 21 0 20 946,569 0 (100,239)Reablement WUTH 465,000 387,490 387,500 10 9 1 465,000 0 0Children's and Young People Palliative Care 235,949 196,621 196,624 3 2 1 235,949 0 0Reablement 18,924,836 15,770,673 15,770,673 () 0 (1) 18,924,836 0 0Total BCF 27,233,187 22,694,171 22,694,299 128 91 37 27,132,948 0 (100,239)Programme Projects (Diabetes & Respiratory) 400,746 333,945 333,955 10 8 1 400,746 0 0CHC Admin Team 1,164,517 970,421 995,487 25,066 22,140 2,926 1,192,428 0 27,911CHC Admin Team - Other 212,395 176,990 176,979 (11) (10) (1) 212,375 0 (20)CSU MM Programme charges 863,801 719,830 739,270 19,440 17,496 1,944 887,123 0 23,322Safeguarding 557,550 464,560 317,745 (146,815) (131,076) (15,738) 443,718 0 (113,832)General Reserve - Programme 5,972,107 3,712,167 386,501 (3,325,666) (3,155,439) (170,227) 3,639,293 (5,476,940) (7,809,754)Contingency 2,732,000 2,731,996 0 (2,731,996) (2,731,996) 0 0 0 (2,732,000)Rec QIPP Target (17,891,240) (14,951,039) 0 14,951,039 13,455,935 1,495,104 0 600,000 18,491,240Non recurrent Programmes 883,000 784,606 784,608 2 0 1 883,000 (100,000) (100,000)Non recurrent Reserves 482,785 0 0 0 0 0 482,785 (540,000) (540,000)

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Cost Centre Annual Budget

Budget to Date

Spend to Date Variance Prior Mth YTD

Variance

Change In YTD Variance

Forecast Spend

Mitigations Outturn Variance

Total Other (4,622,339) (5,056,524) 3,734,544 8,791,068 7,477,058 1,314,010 8,141,467 (5,516,940) 7,246,866Total Programme Budgets 554,889,197 460,731,648 476,490,450 15,758,802 16,013,829 (255,027) 577,187,797 (8,146,940) 14,151,660Chair and Non Execs 166,487 138,602 135,230 (3,372) (2,039) (1,332) 162,611 0 (3,876)CEO/ Board Office 909,744 776,410 817,392 40,982 2,407 38,576 973,885 0 64,141Clinical Governance 333,968 278,238 243,736 (34,502) (31,965) (2,537) 287,776 0 (46,192)Corporate Costs 841,708 701,348 651,470 (49,878) (46,182) (3,696) 786,100 0 (55,608)CSU SLA 428,254 356,870 355,301 (1,569) (753) (816) 430,028 0 1,774Business Informatics 431,220 359,310 344,723 (14,587) (13,799) (787) 414,131 0 (17,089)Education and Training 72,503 60,418 1,814 (58,604) (52,967) (5,637) 10,875 0 (61,628)Finance 882,287 735,188 712,146 (23,042) (11,482) (11,560) 853,150 0 (29,137)Commissioning 1,634,644 1,362,119 1,288,257 (73,862) (76,818) 2,956 1,576,956 0 (57,688)PALS 32,832 27,359 28,333 974 877 97 34,000 0 1,168Reserves. 249,156 144,682 185,677 40,995 36,241 4,754 276,677 0 27,521Total Running Costs 5,982,803 4,940,544 4,764,079 (176,465) (196,483) 20,018 5,806,189 0 (176,614)

Total Wirral CCG Spend 560,872,000 465,672,192 481,254,529 15,582,337 15,817,346 (235,009) 582,993,986 (8,146,940) 13,975,046

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Wirral University Teaching Hospital NHS Foundation Trust - NHS Wirral CCG summary position - January 2020

Month 10 Board Report 2019/20 based on month 9 1st cut

Full Year Plan Plan YTD Actual YTD Variance Full Year Plan Plan YTD Actual YTD VariancePBR DC and Elective 38,611 32,044 31,417 (627) £30,644,810 £25,505,648 £24,051,360 (£1,454,289)

A&E 77,909 65,568 69,338 3,770 £13,461,950 £11,329,577 £11,471,464 £141,887Non Elective 42,973 35,880 34,840 (1,041) £99,226,799 £82,909,335 £79,801,400 (£3,107,935)Non Elective Non Emergency 4,758 3,940 3,964 24 £10,261,223 £8,505,991 £8,719,581 £213,590XBDs (EL, NEL & NELNE) 13,500 11,265 13,401 2,137 £3,657,734 £3,051,261 £3,591,628 £540,366Outpatients First 67,323 56,040 57,033 993 £11,661,226 £9,700,716 £9,452,616 (£248,100)Outpatients Follow up 139,334 115,719 108,124 (7,596) £11,588,565 £9,627,693 £8,985,523 (£642,171)Outpatients Procedures 28,342 23,633 25,570 1,937 £4,756,758 £3,969,721 £4,354,598 £384,877Unbundled Diagnostic Imaging 24,111 20,102 22,859 2,757 £1,780,626 £1,485,181 £1,682,273 £197,092Maternity 5,582 4,643 4,685 42 £5,118,511 £4,268,219 £4,043,945 (£224,274)

442,442 368,834 371,231 2,397 £192,158,203 £160,353,344 £156,154,387 (£4,198,957)

Non PbR 0 0 0 0 £53,437,007 £44,524,476 £44,106,805 (£417,671)Non Recurrent Support 0 0 0 0 £4,556,010 £3,796,675 £6,985,360 £3,188,685Accelerated Non-Recurrent support 0 0 0 0 £0 £0 £0 £0CQUIN 0 0 0 0 £2,913,786 £1,214,320 £1,214,320 £0

Contract Performance 442,442 368,834 371,231 2,397 £253,065,006 £209,888,815 £208,460,872 (£1,427,943)

Contractual Adjustments Readmissions 0 0 0 0 (£2,323,136) (£1,940,726) (£1,940,725) £1Outpatients F/UP Cap 0 0 0 0 (£625,811) (£518,124) (£209,822) £308,302NEL Threshold 0 0 0 0 (£6,282,000) (£5,235,000) (£5,235,000) £0AAU Adjustment 0 0 0 0 £0 £0 £0 £0GP Registration Queries 0 0 0 0 £0 £0 (£25,289) (£25,289)PLCP - Not Funded 0 0 0 0 £0 £0 (£25,782) (£25,782)PLCP - Code omitted 0 0 0 0 £0 £0 £0 £0

MRSA 0 0 0 0 £0 £0 £0 £0VTE 0 0 0 0 £0 £0 £0 £0Never Events 0 0 0 0 £0 £0 £0 £0Single Accommodation Breaches 0 0 0 0 £0 £0 (£85,000) (£85,000)Clostridium Difficile 0 0 0 0 £0 £0 £0 £0Cancelled Ops 0 0 0 0 £0 £0 £0 £0Diagnostic Waits < 6 weeks 0 0 0 0 £0 £0 (£7,478) (£7,478)RTT - 52 week waits £0 £0 £0 £0

RTT 0 0 0 0 £0 £0 (£596,820) (£596,820)A&E 4 Hour Wait 0 0 0 0 £0 £0 (£1,212,449) (£1,212,449)Ambulance Penalty 0 0 0 0 £0 £0 (£587,200) (£587,200)Cancer 2WW 0 0 0 0 £0 £0 £0 £0Reinvest STP Sanctions 0 0 0 0 £0 £0 £2,396,469 £2,396,469

Contractual Adjustments Subtotal 0 0 0 0 (£9,230,947) (£7,693,850) (£7,529,096) £164,754

MSK Contract 0 0 0 0 £24,999,307 £20,832,756 £20,832,756 £0MSK Total 0 0 0 0 £24,999,307 £20,832,756 £20,832,756 £0

Agreement DC/EL 0 0 0 0 £0 £0 £717,190 £717,190Non Recurrent Support Cap Total 0 0 0 0 £0 £0 £717,190 £717,190

LAT Passthrough Winter Monies 0 0 0 0 £585,000 £390,000 £390,000 £0

WUTH Board Report 442,442 368,834 371,231 2,397 £269,418,366 £223,417,721 £222,871,721 (£545,999)

Month 10 Board Report 2019/20 based on month 9 1st cut

S:\Gov-Body\Meetings\Finance Committee\2020 Meetings\2) 25th February\Copy of Appendix 2 - Month 10 WUTH Position Finance Committee Report Page 1

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1

Report Title Finance Committee Chair’s Report

Committee Chair Lesley Doherty, Chair, Finance Committee

Recommendations The Governing Body is requested to note the Chair Report of 25th February 2020

1. PURPOSE To scrutinise NHS Wirral Clinical Commissioning Group’s (CCG) financial and provider contractual performance and the financial recovery programme on available levels of assurance and/or escalate risks and issues requiring action.

2. KEY ISSUES Month 9 - the Governing Body had a verbal update of the Month 9 position at the informal GB meeting on 11th February 2020. Month 10 Summary The Month 10 financial position was discussed in depth, the main discussion points were:

• The CCG’s control total as set by NHS England/Improvement (NHSE/I) was break-even meaning the CCG is £15.6m away from plan at Month 10.

• NHSE/I has agreed to revise the control total for 2019/20 to £13.975m deficit which closer to the original CCG risk adjusted 2019/20 financial plan of circa £14.7m signed off by the Governing Body. The reported forecast is consistent with the latest recovery plan which gives an out turn position of £13.975m.

• Month 10 sees a worsening in-month position with the CCG reporting a year to date position of a £15.6m deficit which includes the full release of the £2.7 million contingency monies.

o The CCG deficit position mainly comprises of £1.1 m overspend across NHS Contracts and £67k on Non-NHS

contracts Prescribing is overspending by £2.5m, an adverse movement of £441k

from month 9. Out of hospital packages of care overspending by £3.2m, an adverse

movement of £434k from Month 9. The remainder of the pressure is due to the continued unidentified Quality

Innovation Productivity and Prevention (QIPP (offset by the full use of contingency)) £12.2m.

• The impact of the current in-month position and the further mitigations needed in 19/20 could impact upon the 2020/21 Financial plan and this is being reviewed by the interim Chief Finance Officer (CFO).

• There remains a cumulative brought forward deficit of £11.8m.

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2

Turnaround Director Update The on-going actions being taken to the end of Quarter 4 2019/20 were reported as follows:

• Continued working with the Healthy Wirral Finance lead, Chief Executives and Directors of Finance to stabilise the Wirral system financial forecast for 2019/20 working closely with NHSE/I.

• Support the CCG to manage the year end risk. • Supporting the CCG and the wider Wirral system to take forward the recommendations

of the independent review of the Healthy Wirral programmes, identifying and prioritising delivery of programmes for 2020/21.

• Note the developing infrastructure for system programme management and delivery. • Continue to work across the Wirral system, and across Cheshire and Mersey and the

wider NHS, to identify further savings and mitigations. • Continue to support colleagues across the system and to provide input and support in

managing NHSE/I expectations. Risks and Mitigations Key mitigations continue to be required to ensure the CCG achieves the revised control total of £13.975m. Some of these mitigations have uncertainty attached to them and additional mitigations are therefore being explored to ensure the revised control total is achieved. Revisions and additions are being actioned by the interim CFO for the next Finance Committee meeting along with the identification of those mitigations which will have an impact on 2020/21 financial year.

3. IMPLICATIONS The Governing Body is asked to note the current financial position reported at Month 10 and that continuing actions and mitigations are in place and under review. It is essential that the CCG delivers the revised control total of £13.975m as a minimum to ensure it plays its role in delivering the overall Wirral system control total. The other key risk for the CCG continues to lie with system delivery risk and the assurance required that a comprehensive and cohesive plan is in place. While there is some progress in the system recovery plan there remains further work on the implementation and project management infrastructure that is to be put in place before assurance can be gained.

4. CONCLUSION

Governing Body is asked to:

• Note the issues and risks of the deficit and continuing lack of quantified systems savings to meet them.

• Note the work and risks to date on the internal and system recovery plan. • The current gaps in assurance on the programme management infrastructure to

oversee and manage the delivery of the system recovery plans.

Lesley Doherty 25th February 2020

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Report Title Audit Committee 30th January 2020 Committee Chair Alan Whittle, Lay Member (Governance and Audit)

Recommendations The Governing Body is requested to note the Audit Committee

30th January 2020 Chair’s Report

1. INTRODUCTION / PURPOSE NHS Wirral Clinical Commissioning Group (CCG) Audit Committee is a statutory sub-committee of the Governing Body which provides assurance in relation to the operation of key financial, clinical and corporate control systems operated by and on behalf of the organisation. It regularly receives and scrutinises progress and compliance reports from the external and internal auditors, Anti-Fraud Specialist and Information Governance Manager. It also assesses the accuracy and comprehensiveness of the Annual Governance Statement, and oversees the CCG’s approach to the identification, assessment, mitigation and management of those key risks which might prevent the achievement of the organisation’s strategic objectives or the safe custody of its assets. The Audit Committee agrees an annual workplan, which drives the agenda for its meetings. The Audit Committee is free to invite any officer of the CCG to attend a meeting or to commission expert independent advice to assist in the discharge of its responsibilities

2. KEY ISSUES / MESSAGES

• The Audit Tracker report provided assurance that all actions recommended following Internal Audit review were either completed or on course for completion by the due date.

• The Chair of the Primary Care Co-Commissioning Committee attended the meeting to present a summary of the recent activities of the committee. This included focus on preparations for taking on fully delegated commissioning of Primary Care services from April 2020, and the management of conflicts of interest. Both areas have recently received positive assessment following independent review by the internal auditors. Revised terms of reference, to reflect the new responsibilities and status of the Committee have been prepared in readiness for April. The Committee will continue to be supported by membership from NHS England.

• The Committee noted the alignment of risks and mitigations to the strategic aims of Wirral Health and Care Commissioning reflected in the updated Governing Body Assurance Framework.

• The Committee approved minor changes to the Scheme of Reservation and Delegation (SORD) to reflect recent changes to the financial services team structure and updating of delegated limits for monthly healthcare contract payments.

• The Committee noted the timetable for preparation of the Annual Report and Accounts

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2019/20, and the application of IFRS16 accounting practice in relation to leases, which will have minimal financial impact for the CCG.

• The Director of Quality and Safety provided the committee with an annual update on clinical governance activities, including arrangements for the management of Individual Funding Requests, which are patient referrals for specialist treatments not provided within normal healthcare contracts, and the benefits of the CCG’s membership of the Pan Mersey Area Prescribing Committee.

• The Committee received a bi-monthly progress report on Information Governance compliance and was pleased to note that the CCG is confident that it will maintain full compliance with data security and information governance requirements by the end of the financial year.

• The Committee received progress reports from the Local Anti-Fraud Specialist, and the internal auditor, and approved in principle the draft Internal Audit Plan 2020/21.Summaries of recently completed audit reviews of Integrated Commissioning (Moderate Assurance), and Financial Systems (Substantial Assurance) were noted. The committee also received a detailed report on positive progress with implementation of the actions recommended following a review of Personal Health Budgets, considered at the previous meeting

• The Committee received a progress report from the External Auditor, and reviewed the latest guidance relating to completion of the Annual Report 2020/21.

• The Committee Chair provided a verbal update on recent activities of the Auditor Panel.

• The Committee noted the arrangements for transferring the hosting arrangements for the Transforming Care Programme (TCP) from NHS England, along with the background for how the TCP functions. They also noted the low levels of financial risk associated with this transfer of responsibility.

3. IMPLICATIONS

The Committee is satisfied that its annual workplan is being met, and welcomed the

independent assurance provided in relation to Information Governance compliance, Financial Systems’ reliability, Anti-Fraud activities and clinical governance arrangements within the CCG.

4. CONCLUSION

Governing Body is asked to: - • Note the report of the Audit Committee Chair

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY BOARD REPORT

Risk Please indicate Detail of Risk Description

High Yes Medium Low

Financial recovery and delivery of constitutional standards are statutory requirements of the CCG. The CCG remains in formal directions of CCG and delivery of the financial recovery plans and improvement in performance of the constitutional standards are a priority for the CCG. The current corporate risk register includes the performance against the A&E target, the ambulance performance and also the ambulance handover times.

Director of Commissioning and Transformation

Performance Report

Agenda Item: 4.1 Reference GB19-20/0049 Public / Private Public Meeting Date 10 March 2020 Lead Officer/Author of paper

Nesta Hawker Director of Commissioning and Transformation

Contributors Sue Borrington Senior Commissioning Manager Heather Harrington Senior Commissioning Manager Rainbow Langdale-Smith Commissioning Manager Siju George Senior Commissioning Manager

To Approve To Inform Yes To Assure Yes To Endorse Executive Summary This report shares an exception report on CCG performance together with

an outline of mitigating actions. Recommendations The Governing Body is asked to:

• Note the performance of constitutional standards and mitigation actions taken

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Clinical engagement taken place Y Patient and public involvement taken place Y

Equality Analysis/Impact Assessment completed Y

Quality Impact Assessment Y


Y


Y


Y


Y


Y


Governance route prior to Governing Body

Meeting Date Objective/Outcome

CCG Governing Body Quality and Performance Committee Finance Committee Audit Committee Remuneration Committee Health and Wellbeing Board Business Management Group

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Report Title Director of Commissioning and Transformation Report Lead Officer Nesta Hawker Director of Commissioning and Transformation Recommendations Note recent performance of constitutional standards and actions taken

1. INTRODUCTION

This paper provides Governing Body with a report on the key performance issues related to the delegated duties of the Director of Commissioning.

2. PERFORMANCE AGAINST THE NHS CONSTITUTIONAL STANDARDS (December 2019)

All constitutional performance standards are discussed and overseen at the Quality and Performance Committee. A full NHS Wirral Clinical Commissioning Group (WCCG) Performance Pack is prepared on a monthly basis and reviewed at each Committee along with deep dives into specific performance areas. A copy of the full WCCG performance pack is available on request. Contract review meetings are held at regular intervals with providers to review individual provider performance and ensure that necessary remedial action is taken in the event of provider underperformance in line with the WCCG’s Contract Management Policy. The Activity Management Group of WCCG also reviews performance and any over or under performance triggers a deep dive in order to identify if there is opportunity for mitigating actions. The following dashboard demonstrates the exceptions only in performance against the NHS constitutional standards in November and December 2019 and includes a trend analysis (January 2019 to December 2019).

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3. A&E

Accident & Emergency (A&E) standards are overseen through the A&E Delivery Board which holds the system to account for achieving the A&E 4hr standard. A Service Development and Improvement Plan (SDIP) for 2019/20 has now been agreed and signed by WCCG and Wirral University Teaching Hospital NHS Foundation Trust (WUTH) to achieve the standard, recently re-set nationally (2019/20) by NHS England/Improvement (NHSE/I).

In addition NHSE/I have re-calibrated the trajectory targets for the four hour standard, starting from April 2019 as below.

Agreed A&E SDIP Trajectories: Month Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Plan 80% 81% 82% 85% 87% 90% 91% 92% 92% 90.5% 90.5% 95% Actual 73.57% 81.11% 83.50% 81.9% 79.9% 85.82% 72.68% 70.79% 72.13

The agreed trajectory for A&E performance was not met in November 2019 (70.79%) or December 2019 (72.13%) with a deteriorating positon since the period May-September 2019.

The total number of A&E (only) attends equalled 7,665 (Nov) and 7,345 (Dec) and the combined APH Walk in Centre and A&E attends equalled 11,087 (Nov) and 10,930 (Dec).

Performance against the National standards for 4 hour have been impacted by a number of factors:

• Relatively high proportion of long length of stay (LLOS) patients leading to delays for patients awaiting admission

• Delays in discharging non-complex patients • Bed losses due to norovirus/ flu • Low weekend discharges • Underutilisation of capacity within UTC for patients to be streamed to reduce overcrowding in

ED • Staffing shortages within A&E department

Analysis of local data compared with National, demonstrates that Wirral have been successful in reducing A&E attendances and Non Elective Admissions against a trend of increased demand.

Emergency Department (ED) Attendances

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Non Elective Admissions

This pattern suggests that the attendance and admission avoidance schemes commissioned within Better Care Fund (BCF) are having the desired impact. Further analysis is underway to establish which services are having the greatest impact. It also highlights that the pressures felt by the system are linked more to acuity and length of stay rather than increased demand.

To support overall Urgent Care System performance the following progress is reported against the priority areas below.

A. Streaming / Interim Urgent Treatment Centre (UTC)

The Walk in Centre (WIC) at Arrowe Park Hospital (APH) was re-designated as an Urgent Treatment Centre from 19 December 2020. This resulted in the following changes/developments to enhance the level of service offered and increased the number of patients that can be appropriately streamed:

• Access to diagnostics such as x-ray • GPs with specialist knowledge and experience in acute medicine covering the streaming rotas

within the UTC • Point of care testing (POCT) to be available comparable to UMAC/AMU – WCT are working

with biochemist from WUTH to ensure quality assurance including sign off of staff competency. Full implementation has been delayed due to timeframe to fully train staff. This has been escalated to executive level with the aim of accelerating training and full implementation.

• Less complex minor injuries to be managed within UTC – staff competencies are being reviewed however there is a list of minor injuries that the UTC staff are already trained to deliver.

B. ED Primary Care Streaming This pathway aims to reduce clinically unnecessary demand on the ED by directing patients to primary and community services such as the Interim UTC. Streaming activity has increased over the last few months with January 2020 peaking at 800 patients streamed, an average of 26 per day.

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• Despite the progress made, performance remains significantly below target position of 20% of ED attendances to be streamed to primary care. This would equate to approximately 47 patients per day for January 2020. A further ask has been made by NHSE to increase this proportion to 26% making the challenge for Wirral even greater.

C. Long Length of Stay (LLOS)

NHSE set a 19/20 target of reducing LLOS (patients with a LOS ≥ 21 days) by 40%, this equates to a year end position of 107 patients. Performance against this target is demonstrated below, latest position 211 patients:

The Emergency Care Intensive Support Team (ECIST) have been supporting the system to

implement robust weekly LLOS reviews with the aim of unblocking some of the issues creating delayed discharge. Whilst this has provided further oversight into what these patients are waiting for, it has yet to make a material difference to the number of LLOS patients within the acute.

It is acknowledged that improvements to ward based care as a whole will result in

improvements for LLOS patient cohorts as well as facilitating more efficient and timely non-complex discharges. These include the following key actions being taken this month: • Roll out of perfect board rounds adopting SAFER principles – 100% compliance so far with

all wards to be embedded by end February. The system will then utilise ward level dashboards and spot checks to ensure sustainability.

• Rapid Improvement event held to make key changes to pathway/processes for fast track patients to eliminate delays currently experienced

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• Focussed efforts to embed criteria led discharge. Therapy led discharge is now in place with a Standard Operating Procedure (SOP) being developed for weekend discharges. Nurse led discharge is being implemented on a phased approach with criteria initially leading to independent nurse discharge.

• Out of area discussions to resolve delays discharges non-Wirral residents

4. AMBULANCE

In both November and December, North West Ambulance Service failed to achieve all performance standards with only Category 1 90th Percentile target being met.

Standard (National Target) Plan Nov-19 Dec-19 Wirral CCG Cat 1 (mean) <7mins 00:07:52 00:07.26 Wirral CCG Cat 1 (90th percentile) <15mins 00:13:43 00:12:28 Wirral CCG Cat 2 (mean) <18mins 00:26:24 00:28:50 Wirral CCG Cat 2 (90th percentile) < 40mins 00:59:35 01:08:19 Wirral CCG Cat 3 (90th percentile) < 120mins 02:50:30 03:56:19 Wirral CCG Cat 4 (90th percentile) < 180mins 03:06:51 03:23:15 An improvement trajectory has been agreed, which outlines achievement of all categories in Quarter 4 2019/20, with the exception of Category 1 mean, which will be achieved in Q2 2020/21. Full roster changes will be implemented in order to achieve the standards.

The performance improvement plan is monitored by Northwest Strategic Partnership Board (Blackpool CCG, lead commissioners, NHSE and NHSI). Additional paramedics have been recruited to support across West Cheshire and Wirral.

There is a correlation between ambulance performance and ED performance as when ED is under increased pressure, crews are at increased risk of delayed handover and turnaround times which consequently impact their ability to respond to calls in a timely manner. The actions referenced in the A&E section above will support an improved position for ambulance performance.

Ambulance Handover

Ambulance handover and turnaround times have deteriorated in November/December with the turnaround standard (arrival to clear) no longer being met. Again this correlates to deteriorating performance in A&E where crews are being held awaiting clinical handover.

Standard (National Target) Plan Nov-19 Dec-19 Avg Arrival to Notification Time (Arrowe Park) N/A 00:07:16 00:07:13 Avg Notification to Handover Time (Arrowe Park) <15m 00:21:57 00:25:09 Avg Handover to Clear Time (Arrowe Park) N/A 00:11:32 00:11:25 Avg Overall Arrival to Clear Time all Attends (Arrowe Park) N/A 00:40:24 00:44:48

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5. REFERRAL TO TREATMENT

WCCG’s referral to treatment (RTT) 18 week wait for incomplete pathways standard was not met in November (79.96%) and December (79.84). WCCG has not met the 92% standard since December 2015. WUTH also failed the national standard in both the months, performing at 78.16% and 78.77% respectively. RTT performance nationally at the end of December was 83.7%. There continues to be zero 52 week breaches for both Wirral CCG & WUTH, since Apr-19.

In November, there were 24,596 patients and December there were 23,372 patients on the WUTH incomplete waiting list which is within the agreed trajectory of 24,736. These figures also take into account the MSK pathway changes that were commissioned from July 2018 which added approximately 3,000 patients on to the waiting list at that time. Overall the number of RTT patients waiting to start treatment has significantly reduced since April 2019. This represents approximately a 10% reduction compared to same period last year, whereas nationally there was an increase of 6.6% during this time.

The jointly agreed Recovery Plan to consistently achieve RTT standards is being achieved since May this year despite the fact that WUTH narrowly slipped the RTT 18 weeks target of 80% in recent months achieving 78.16% and 78.77% respectively in November and December 2019. WUTH’s 0-18, 26-40 and 40-52 week waits have continued to improve since April 2019.

The RTT performance continues to be monitored closely by WCCG through the bi-monthly Strategic RTT Group and the monthly WUTH Contract Review meeting. The Strategic RTT Board is chaired by WUTH’s Chief Operating Officer and includes members from WUTH, WCCG, and NHSE/I.

6. DIAGNOSTICS

Wirral CCG performance for diagnostic testing completed over 6 weeks was 1.11% in November and 1.53% in December, narrowly failing the target of <1%. The total number of diagnostics breaches for Wirral patients in November was 73 and December it was 97 patients.

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WUTH being the main provider most breaches occurred there, 43 in November and 52 in December. Nevertheless they met the diagnostics standard in both the months, performing at 0.8% and 0.9% respectively. Their overall diagnostics position improved in the recent months and the specialities those were reporting breaches previously such as Urodynamics and CT are now much closer to clearing their remaining backlogs. These specialities will remain under review. In recent months there were few Wirral breaches reported from Liverpool University Hospitals NHS FT for Echocardiography and Gastroscopy. They provided assurance that they are undertaking additional sessions and are looking at capacity across the system to improve the position.

Liverpool Heart and Chest (LHCH) are continuing to experience challenges in radiology despite the fact that they commissioned new CT/MRI scanners recently and they are fully in operation now. It’s mainly due to the complexity of the radiological examinations requested and radiology consultant capacity issues. However though they are managing legacy issues well and the waiting list size is gradually improving. They are in the process of recruiting more consultants and Clinical fellows to manage their ongoing capacity issues. They also run additional sessions to manage current waiters and clearing off the backlog. Due to the national shortage of Radiology Consultants there is a risk that there could be delays to the recruitment process and therefore this could have an impact on performance.

Performance against the diagnostics standard is monitored through the Contract Performance Meetings, and individual breaches are queried with the specific divisional managers. With regards to issues at providers in other CCG areas, this is escalated to the respective CCGs for action and raised during individual Trust contract meetings. In addition, areas of concerns/performance issues are escalated to the CCG's Activity Management Group for discussion and action.

7. CANCER

Wirral CCG continues to perform well in respect of cancer – in Cheshire & Mersey, for example, WCCG are the only CCG to have achieved the 62 day target for 11 consecutive months.

98.88% 98.91% 99.03% 98.90%98.08% 98.11%

98.56% 98.89%98.47%

96.00%

97.00%

98.00%

99.00%

100.00%

Apr -19/20

May -19/20

Jun -19/20

Jul -19/20

Aug -19/20

Sep -19/20

Oct -19/20

Nov -19/20

Dec -19/20

Jan -19/20

Feb -19/20

Mar -19/20

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In November, Wirral CCG failed two standards due to 3 breaches. Two breaches were due to complex multi-trust pathways and one was due to robotic theatre capacity. In December all performance target were met. Robotic theatre capacity has remained an issue for some time and in order to address capacity an additional member of staff has been trained and additional slots allocated for urology patients where most breaches were occurring. Wirral CCG has sought further assurance from the main provider, WUTH, to ensure that a permanent solution is put in place. The table below summaries performance across all targets since April 2019.

8. INCREASING ACCESS TO PSYCHOLOGICAL THERAPIES (IAPT)

From the 1st April 2019, the IAPT contract has been led by Insight Healthcare, working with partners to provide a range of therapies under the Talking Together Living Well Wirral service.

Standard (national targets)

Trajectory Plan Nov 19 Actual Dec 19 Actual

Access to First Treatment – 6wk

>= 75% 92.40% 89.90%

Access to First Treatment – 18wk

>= 95% 99.70% 99.30%

Access Target >= 1.83% 1.20% 1.15%

Recovery Rate >= 50% 32.60% 36.60%

The November and December data shows that WCCG has consistently achieved 2 of the national standards for access to first treatment within 6 weeks and 18 weeks.

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Access From a promising gradual increase in Access leading up to October, Wirral has seen poor access rates in November and December, despite a number of activities to promote referral pathways and increase team capacity to perform assessments (such as Saturday overtime) . This decline is reflected in other areas of the country and likely due to a variety of seasonal and social reasons. The reduction in access for Wirral for November and December would have been worse if not for the activities to try and raise Access rates that helped to mitigate this. Due to this decline, it is not anticipated that National targets will be achieved in 2019/20. The year’s performance pattern and impacts of activities are being evaluated to establish what can be learned to help improve, including understanding other areas activities also. Additional activity is also being completed to map resources for appointments required for the actual numbers of clients that need to enter into service to meet this. It is possible that the impact of the previous service waiting times, (for example) may have had a more detrimental effect the wider opinion of IAPT services than and the time and effort it takes to rebuild relationships and trust may have been underestimated initially. WCCG are continuing to promote the IAPT service to Primary Care colleagues, secondary care teams and third sector organisations and via public channels such as social media in order to meet improve and meet access targets. Self-referrals into the service continue to be high which is positive but we will continue to challenge and review our communication plan in order to increase referrals into the service. Recovery The recovery rate is gradually increasing, despite also being subject to seasonal variation, and anticipated to continue on this trend as client recovery data is consistently recorded, and clients are well supported to recover. WCCG meets with the IAPT provider monthly to seek assurance that all actions being taken to focus on continued improvements and to maintain momentum for the additional work needed to push towards the national targets. Narrative around exceptions is provided each month to assure commissioners on this agreed improvement plan. It is anticipated that Recovery rates will increase into the last quarter and should reach the National target by end Q4 19/20. All activity and waiting times/numbers at all modalities is being monitored through a patient tracker, and an additional First-Second appointment tracker is in place to demonstrate that the legacy patients from the inherited waiting list (from previous provider) have entered treatment, and ensure that the drive to increase access rates does not cause a new backlog of clients (waiting for treatment following assessment) to build up. WCCG will continue to robustly monitor the provider performance against agreed trajectory and key national targets. Performance against agreed targets is monitored via the contract meetings and issues are escalated via WCCG’s Executive Operational Meetings and Governing Body.

9. CONCLUSION

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Governing Body is asked to:-

• Note the review of recent performance of constitutional standards and mitigation actions taken.

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Report Title Primary Care Commissioning Committee 7th January 2020

Committee Chair Sylvia Cheater MBE

Recommendations The Governing Body is requested to note the Primary Care Commissioning Committee Chair Report

1. INTRODUCTION / PURPOSE

The Primary Care Commissioning Committee (PCCC) is a joint committee of NHS Wirral Clinical Commissioning Group (CCG) and NHS England. Its role is to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act 2006, except for those relating to individual GP performance management, which have been reserved to NHS England. The report covers transformation developments, operational and ad-hoc matters requiring agreed direction and resolution between CCG and NHS England co-commissioners.


• The two current Risk Register scores (Staffing Recruitment and Retention, and

Membership Engagement) have been increased to 6 and 9 respectively. The workforce concerns are around Practice Nurse recruitment and the wider use of Multi-Disciplinary Teams (MDT) including Clinical Pharmacy and Physician Associates. A risk profiling session will take place within the committee, facilitated by Paul Edwards, Director of Corporate Affairs, following delegation approval.

• The Committee was pleased to note that assurance has been received on the progress of the Primary Care Transformational Plan 2016-2021 and on place-based care delivery.

• The Committee received an update on the effectiveness review action plan; this will be an annual process and added to the Primary Care Work Plan. The action plan will return in May 2020 for update and sign off.

• Good progress in the Delegation Preparation action plan was noted with the majority of actions in place by April 2020.

• The Committee was pleased to note that an application for Primary Care Digital First Funding, non-infrastructure was submitted on 20 December 2019. The bid, totalling £227,000 included public health input.

• The Committee discussed its terms of reference and clarity around quoracy for voting purposes. A review of Cheshire’s PCCC terms of reference will be undertaken for information and comparison.

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3. IMPLICATIONS

The Committee continues to make good progress in preparing for the anticipated transition to full delegation of Primary Care Commissioning. 4. CONCLUSION

The Governing Body is asked to note the key issues managed by the Primary Care Commissioning Committee.

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High Yes Medium Low Highlights the possible risk to patients if statutory functions and duties are not monitored.

Clinical engagement taken place N Patient and public involvement taken place N Equality Analysis/Impact Assessment completed Y Quality Impact Assessment Y

DIRECTOR OF QUALITY AND PATIENT SAFETY’S REPORT

Agenda Item: 5.1 Reference GB19-20/0050

Public / Private Public Meeting Date 10th March 2020 Lead Officer/Author of paper

Lorna Quigley, Director of Quality and Safety

Contributors Richard Crockford, Deputy Director of Quality and Safety Tracey Wood, Health Protection Programme Manager Hannah Cotgrave, Public Health & Commissioning Analyst

To Approve To Inform Yes To Assure Yes To Endorse Executive Summary This paper provides Governing Body with a report on the statutory functions

and duties that the Director of Quality and Patient Safety is responsible for.

Recommendations This paper provides Governing Body with a report on the statutory functions and duties that the Director of Quality and Patient Safety is responsible for. These reports also align to the areas within NHS England’s Improvement and Assessment Framework and the NHS Constitutional standards.

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Y


Y


Y


Y


Y

Working as One, Acting as One – we will work together with all partners for the benefit of the people of Wirral.

Y



CCG Governing Body Quality and Performance Committee 25th February 2020 Discussion and assurance Finance Committee Audit Committee Remuneration Committee Health and Wellbeing Board Clinical Senate Quality & Improvement Group

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Report Title Director of Quality and Patient Safety’s Report Lead Officer Lorna Quigley, Director of Quality and Patient Safety Recommendations For Governing Body to:

• Accept the quality report. • To be assured of the processes in place to promote

quality and patient safety.

1. INTRODUCTION

This paper provides Governing Body with a report on the statutory functions and duties that the Director of Quality and Patient Safety is responsible for. These reports also align to the external Clinical Commissioning Group (CCG) assurance.

Health Care Associated Infection (HCAI) An issue has been identified in relation to data entry onto the national system; this has been reported through the Quality and Performance Committee (Q&P). This issue is under currently under investigation, early indications have suggested under reporting of cases of E.coli, Klebsiella, Pseudomonas and Clostridium Difficile. In addition to the under reporting some cases had been reported in error and some incorrectly attributed to organisations. Further exploration of the incident has been reviewed in February’s Q&P, an amended system is now in place to ensure accurate reporting and further understanding and lessons learnt will follow within the investigation report. A special HCAI Surveillance Report will be available in May 2020 detailing changes in figures since 2016/17 and how this has affected the rates. Figure 1 shows that In Wirral, 116 HCAI cases were reported for Quarter 3 (2019/20). Over half of the reported cases were E.coli (61.2%, n=71), followed by C. Diff (21.6%, n=25) and MSSA (15.5%, n=18). There were two reported cases of MRSA in Wirral for the same period. Figure 1: Numbers of MRSA, C.diff, MSSA, E.coli HCAIs in Quarter 3

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Methicillin-resistant Staphylococcus aureus (MRSA) Following 2 reported cases in Q3 2019/20, Wirral has an MRSA bacteraemia rate of 2.5 per 100,000. National and regional rates have increased slightly; 1.4 to 1.7 and 1.5 to 1.7 per 100,000 in the last 2 quarters respectively. It should be noted that national and regional figures have changed since the Q2 figures were produced. Figure 2: Rate of MRSA bacteraemia by area Quarter 4 2018/19 to Quarter 3 2019/20

Clostridium difficile (C.diff) Rates of C Diff in Wirral saw a further decrease between Quarter 2 and Quarter 3 (2019/20); 37.2 vs 31.0 per 100,000. Despite PHE North West also seeing a decrease in CDIs, Wirral's rate is now lower (although remains higher than England). It should be noted that national and regional figures have changed since the Q2 figures were produced. Figure 3: Rate of C.difficile infection by area, Quarter 4 2018/19 to Quarter 3 2019/20

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Methicillin-sensitive Staphylococcus aureus (MSSA) For 2019/20, Quarter 3 rates of MSSA bacteraemia in Wirral have slightly increased (16.1 vs 22.3 per 100,000). Contrastingly, rates for PHE North West and PHE National have seen a small decrease over the same period. It should be noted that national and regional figures have changed since the Q2 figures were produced. Figure 4: Rate of MSSA bacteraemia by area, Quarter 4 2018/19 to Quarter 3 2019/20

Escherichia coli (E.coli) Rates of E.coli bacteraemia in Wirral have increased in Quarter 3 compared to Quarter 2 (2019/20); 69.4 compared to 88.0 per 100,000. National and regional rates, however, have

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decreased to be lower than that in Wirral; 75.8 and 79.9 compared to 88.8 per 100,000 respectively. It should be noted that national and regional figures have changed since the Q2 figures were produced. Figure 5: Rate of E.coli bacteraemia by area, Quarter 4 2018/19 to Quarter 3 2019/20

Mixed Sex Accommodation Breaches (MSA)

NHS organisations are expected to operate without having any mixed sex accommodation except in very specific circumstances. The national definition of “sleeping accommodation” includes areas where patients are admitted and cared for on beds and trolleys, even when they do not stay overnight. It includes all admissions assessment units (including decision making units) day surgery and endoscopy units. It does not include areas where patients have not been admitted such as Emergency Department cubicles. Further guidance about Mixed Sex Accommodation Breaches has been shared from the Chief Nursing Officer on 27th September 2019 and highlights some changes to reporting that will come into effect from January 2020:

• Critical care patient breaches are no longer counted from when a clinical decision is made for a patient to be stepped down from level 2 or 3 care but from when patients are ready to be transferred from level 2 and 3 care – this aligns with current advice in the Core Standards for Critical Care Units.

• Transfers from critical care units should not take place between the hours of 10.00pm and 7.00am for the comfort and safety of patients – this aligns with NICE guidance CG50.

• Patients receiving end-of-life care should not be moved solely to achieve same sex accommodation.

• Patients should be moved from an assessment / observation unit within four hours of a decision to admit or from when the patient arrives in the unit and a decision to admit has already been made, this replaces the previous requirement to count from the outset.

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• Where high observation bays are used for patients in the first stage of recovery or when they require a period of close observation they will not be classed as a breach.

• Care should be taken not to confuse national and local reporting of breaches. Providers must agree with their commissioners, every month, the number of justified and unjustified breaches using the revised national guidance.

There have been nine breaches for NHS Wirral CCG in December 2019 which is the lowest position year to date. The new guidance that will come into effect for the breaches reported during January 2020 may mitigate some of these breaches. The measure is specifically in relation to privacy and dignity of patients and the Clinical Quality and Performance Group continues to seek assurance that patient privacy and dignity is maintained during any breaches. Friends and Family (FFT) When reviewing FFT data there is no specific target to achieve; however, data provides a good source of information about the quality of services. Some of our providers have set their own tolerances to recommendation scores (such as 95% at WUTH). The recommendations scores also need to be viewed alongside response rate to ensure the scores are from a sufficient proportion of patients to be representative of the service. Wirral University Teaching Hospital NHS Foundation Trust (WUTH) The FFT data from WUTH cover a range of areas; A&E, Inpatient Services, Outpatient Services and Maternity Services. The A&E data indicated 84% recommendation rate in November 2019, down from 87% in October 2019. The response rate was 10% in November 2019 again down from 11.0% for October 2019. This is a continued drop in recommendation rate over the last few months with the recommendation rate in August at 92%. The recommendation rate has now fallen in line with the national average of 84%. Both the deterioration and the continued rate below internal tolerance will be discussed through CQPG. With regards to Inpatient Services the overall position for WUTH was a recommendation rate of 96% with a response rate of 29.5% alongside a national position of 96% with a response rate of 24.8%. This represents a consistently positive position at a Trust level; however there is variation at ward level. Whilst the recommendation rate variation is not consistently highlighting the same areas there are some areas highlighted more often than others and further assurance will be

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sought. With regards to response rate there is a consistent nil return from Neonatal Unit and some other areas are regularly seeing low response rates, similarly the CQPG will seek assurance through the planned patient experience reports. With regards to Outpatient Services the recommendation rate at 94% matches the national position and has remained relatively consistent throughout the year. Finally Maternity Services are considered from four periods; antenatal care, birth care, postnatal ward care and postnatal community care. During November 2019 WUTH received 91% recommendation rate for antenatal which has dropped again from October 2019 and is below the national average and at the lowest rate since April 2019. In relation to birth care WUTH received 100% recommendation rate again and this area remains consistently above national rate. Postnatal ward care received 95% recommendation rate which is an improvement and above the national average of 94%. Postnatal community care continues to have low response rates preventing reflective patient feedback. Overall this is a positive position but the responses in relation to antenatal care will need observation through CQPG meetings. Cheshire and Wirral Partnership NHS Foundation Trust (CWP) The FFT data for CWP for November 2019 has led to a recommendation rate of 79% against a national position of 89% for Mental Health Services, this is representing a significant variation from month to month. The variation is likely to be linked to to low response rate with only 49 responses from a eligible cohort of 11 569 patients (0.4%). At October 2019 there had been an increase in response rate to 1.9% but this has not been sustained. the national response rate for mental health services remains at just over 3%. Wirral Community Health and Care NHS Foundation Trust (WCHC) The FFT data for WCHC for November 2019 represents an overall recommendation rate of 95% against an England average of 96%. This recommendation rate is a slight drop from 96% in October 2019. The response rate for these community services remains lower than the national average presenting a risk that the feedback is not fully representative of all service users. When looking at the breakdown of services a previous paper had noted a drop in the recommendation rate for community nursing services, however this has since returned to 100% for both September, October and November. Primary Medical Services The GP FFT data for Wirral during October 2019 is relatively positive with 92% recommendation rate against a national average of 91%, however the data is based on submission by 31 practices rather than the entire CCG membership. Whilst it is recognised that not all practices will receive feedback every month, there are 11 practices that have not submitted any FFT data (or sufficient data for analysis) for in excess of 3 months and 6 of these have not submitted any or sufficient data for in excess of 6 months. A proposal to explore the use of patient feedback in Primary Care will be presented to the Primary Care Co-Commissioning Committee during Q4 2019/20. Further variation can be seen from practices that have submitted data for analysis with recommendation rates ranging from 67% to 100%.

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Serious Incidents (SI) Serious incident are events in healthcare where the potential for learning is so great, or the consequences to patient’s families and carers, staff or organisations are so significant that they warrant using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect patients directly and include incidents which may affect patient safety or an organisations ability to deliver ongoing health care. A Serious Incident requires a provider organisation to undertake a root cause analysis within 60 days of the incident occurring, develop a remedial action plan and provide ongoing evidence of Implementation of the action plan. This process is managed through the Wirral Serious Incident Review Group (SIRG).

There have not been any further Never Events reported during January 2020. The SIRG are continuing to monitor the trends in reporting and seeking assurances from providers on identification and reporting processes within contract compliance meetings. The new Serious Incident framework is yet to be introduced and has been delayed until April 2020. The framework has been out to consultation and NHS Wirral CCG responded to this in June 2018. In advance of the new framework the national patient safety strategy has been published providing a further insight into the expectations of the new framework. As part of the patient safety strategy there is a requirement for patient safety specialists. The detail around these roles is being clarified and a consultation process is currently in progress. NHS Wirral CCG will be reviewing and feeding into this consultation.

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The main themes from Serious Incidents are detailed below, however there is an increase in incidents being reported with a category of ‘Pending Review’. Providers have been advised that this is not to be routinely used and must be amended as soon as the correct category is identified:

Wirral University Teaching Hospital NHS Foundation Trust (WUTH) The Trust have just undertaken a further Care Quality Commission (CQC) unannounced inspection from 7th October 2019, this inspection reviewed the five core services (Urgent Care and Acute, Maternity and Surgery). The Well Led inspection was undertaken in November 2019 in addition to a further unannounced inspection. The draft report is yet to be issued, this was expected in January 2020. Due to the non-achievement against the four hour standard the focus for both providers and commissioners is on corridor waiting and Hospital Acquired Harm. Commissioners have been attending the Trust command Centre to ensure that all actions are in place to ensure that risks to harm are being mitigated against and that patients are receiving treatment in assessment areas. Age UK have been commissioned in supporting the Trust within the Emergency Department (ED) to offer drinks low level care to improve the patients experience. All patients who are waiting over 12 hours for a decision to admit (DTA) a review of their time in ED is undertaken within 48 hours of the breach occurring. This review is shared with the regulators and NHS Wirral CCG, who review the level of harm that has occurred, if care has been delivered including prescribed medications, and if an apology has been given to the patient and their relative for the delay (Duty of Candour). The risk descriptor the level of risk and the mitigating actions associated with this has been discussed in Quality and Performance Committee.

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CONCLUSION

Governing Body members are asked to note the contents of the report.

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Report Title Quality and Performance Committee 28th January 2020 Vice Chair’s Report

Lead Officer Alan Whittle, Lay Member (Governance and Audit)

Recommendations The Governing Body is asked to note the Quality and Performance Committee Vice-Chair’s Report, 28th January 2020

1. INTRODUCTION The Quality and Performance (Q&P) Committee is a sub-committee of the Governing Body of NHS Wirral Clinical Commissioning Group (WCCG). The purpose of the Committee is to provide assurance to the Governing Body in matters of the quality of services provided and the performance of the CCG itself and, by extension, the providers that are commissioned by the CCG. The committee receives reports from a number of Executive Directors which include contributions from a range of staff. The committee also receives annual quality reports from main provider organisations. Additionally, the committee examines minutes from the Serious Incident Group and a range of contract performance and monitoring minutes of meetings held with external providers


Risk Register

The Committee agreed that the risk relating to the safety of patients waiting in hospital corridors for emergency treatment should more accurately reflect issues across the range of hospital emergency care, as treatment is provided from several different locations. It was confirmed that the risk rating assessed by the CCG matches Wirral University Teaching Hospital NHS Foundation Trust’s score.

Performance against Access and Contract Standards

Performance against most access standards during November was at a similar level to earlier months, with only 70.8% of A&E attenders being discharged or admitted within the 4-hour waiting time standard, 5 of 6 ambulance and 4 of 5 NHS111 service standards not met. Cancer services standards were met or exceeded in 7 of the 8 areas measured, continuing the excellent performance maintained for most of the year. Waiting times for Improving Access to Psychological Therapies (IAPT) have also improved.

The Committee agreed to retain the Contract Performance Notice issued to Wirral University Teaching Hospital NHS Foundation Trust in relation to the provision of Musculoskeletal Services (MSK) until there was evidence of achievement of sustained key performance standards, particularly for waiting times in therapy services.

Cancer Services National Survey

A report on a national cancer experience survey, published in September 2019 and conducted

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in spring 2018 provided evidence of high levels of patient satisfaction with local cancer services, with an overall rating of 8.8 out of 10. Cancer dashboard scores for key areas mostly scored at or above the expected range, with none falling below.

Policies

The Committee approved 2 revised Human Resources Policies in relation to Shared Parental Leave and Lone Working.

3. IMPLICATIONS

The Governing Body can be assured that the Q&P Committee continues to be vigilant in monitoring the quality of care commissioned for local people, and the performance against contracted services of local providers.

4. CONCLUSION

Governing Body is asked to:

Note on the report of the Quality and Performance Committee meeting held on 28th January 2020.

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High Medium Low Yes The Risk Register is presented as a separate item on this agenda, but no key risks are identified within the report itself.

Clinical engagement taken place N Patient and public involvement taken place N Equality Analysis/Impact Assessment completed N Quality Impact Assessment N

Strategic Themes

DIRECTOR OF CORPORATE AFFAIRS’ REPORT


Paul Edwards, Director of Corporate Affairs

Contributors Michael Chantler, Assistant Director Communications and Engagement Laura Leadsom, Corporate Affairs Manager

To Approve To Inform Yes To Assure Yes To Endorse Executive Summary This paper provides the Governing Body with a report on the statutory

functions and duties that the Director of Corporate Affairs is responsible for. These areas also align to the external Clinical Commissioning Group (CCG) Improvement and Assessment Framework (IAF).

Recommendations The Governing Body is asked to: • Note the report • To note compliance against CCG statutory duties

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To empower the people of Wirral to improve their physical, mental health and general well being

Y

To reduce health inequalities across the Wirral Y

To adopt a health and well-being approach in the way services are both commissioned and provided

Y

To commission and contract for services that:

• Demonstrate improved person centred outcomes • Are high quality and seamless for the patient • Are safe and sustainable • Are evidenced based • Demonstrate value for money

Y

To be known as one of the leading organisations in the country Y

Provide systems leadership in shaping the Wirral health and social care system so as to be fit for purpose both now and in five years’ time

Y





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Report Title

Director of Corporate Affairs’ Report

Lead Officer Paul Edwards, Director of Corporate Affairs

Recommendations Note key messages in report

1. INTRODUCTION

This paper provides Governing Body with a report on the statutory functions and duties that the Director of Corporate Affairs is responsible for. These areas also align to the external Clinical Commissioning Group (CCG) Improvement and Assurance Framework (IAF).


3. Emergency Preparedness, Resilience and Response Feedback from groups Local Resilience Forum (LRF): • NHS England represents the NHS at the main LRF group. • No issues were raised for the CCG at the last meeting.

Local Health Resilience Partnership (LHRP) Meeting: • No issues were raised for the CCG at the last meeting.

Business Continuity No further activity regarding Business Continuity since the last formal Governing Body report.

4. Commissioning Support Unit

The CCG contracts for the following elements from Midlands and Lancashire Commissioning Support Unit (MLCSU): End to End services (including areas such as Human Resources and Communications and Information and Communications Technology (ICT) together with Medicines Management, Individual Exceptional Funding Requests, Retrospective Continuing Healthcare (CHC), Health and Safety and Local Security Management. All service lines are performing well and MLCSU are actively working with the CCG to deliver efficiencies in support of the Quality, Innovation, Productivity and Prevention (QIPP) targets. Commissioning Integration Since the last report, there have been two meetings of the Joint Strategic Commissioning Board.

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On 12th November 2019, the key agenda items were: • Healthy Wirral Strategy • Pooled Fund Finance Report • Public Health Annual Report 2019 • Integrated Contract Management and Procedures Across NHS Wirral CCG And Wirral Council • Urgent Care Update • Better Care Fund Update

On 14th January 2020, the key agenda items were: • Healthy Wirral 5 Year Strategy • Pooled Fund Finance Report • Wirral Health And Care Commissioning Business Plan Update • Wirral Older People Outcomes Baseline 2019

The full agenda and minutes for both meetings are available at: https://democracy.wirral.gov.uk/ieListMeetings.aspx?CommitteeId=849

5. Communications and Engagement Healthy Wirral Engagement (Staff, Stakeholder and Public)

The second Healthy Wirral roadshow was completed between 20th and 24th January following the first roadshow being completed in November 2019. The second roadshow concentrated on NHS locations including Victoria Central, Arrowe Park Hospital, Miriam Medical Centre and St Catherine’s Health Centre and focused on both staff and public. The roadshow was completed in partnership with Healthwatch Wirral and Community Connectors. The next phase of the engagement will align with the publication of the Healthy Wirral 5 Year Strategy and Cheshire & Merseyside Health and Care Partnership (HCP) 5 Year Strategy.

A secondary campaign is in development to support the medicines management team with encouraging more self-care with the public and the prescribing of over the counter medications.

Help Us Help You Winter communications continue with a system wide approach promoting the NHS England and Public Health England winter pressures ‘Help Us Help You’ campaign. The last phase of the campaign ‘Stay Well Pharmacy’ encourages the public to ‘take the drama out of minor illnesses’ and use their local pharmacy as the first place to go to for clinical advice on minor health concerns such as coughs, colds, tummy troubles and aches and pains.

Norovirus As an action from the newly formed ‘Norovirus system planning and response group’ local norovirus resources and key messages were produced and shared across the system. The

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https://democracy.wirral.gov.uk/ieListMeetings.aspx?CommitteeId=849


resources, aimed at HCP’s and members of the public, served to raise awareness of symptoms, prevention and control measures.

Dry January Wirral Health and Care Commissioning staff were encouraged to take part in Dry January to reduce their alcohol consumption, with a number signing up and successfully abstaining. Coronavirus

Wirral Health and Care Commissioning is working as part of a national and local framework to manage the locating of repatriated UK citizens from China to Arrowe Park Hospital for quarantine. Structured communications and media handling is being led by NHS England and Public Health England with the support local NHS organisations and Wirral Council.

6. Policies

There were no policies due for review at the Quality and Performance Committee held in December 2019. The following updated policies were approved the Quality and Performance Committee held in January 2020: • Lone Worker Policy • Shared Parental Leave Policy

7. Statutory and Mandatory Training

The training compliance as at the end of January 2020 is as follows:

Competency Match Equality, Diversity and Human Rights 91% Fire Safety 83% Health, Safety and Welfare 88% Infection Prevention and Control 90% Moving and Handling 90% Preventing Radicalisation - Basic Prevent Awareness 92% Safeguarding Adults - Level 1 88% Safeguarding Children - Level 1 89% Display Screen Equipment 78% Fraud Awareness 85% Information Governance 79% Grand Total 87%

The target compliance rate for all Statutory and Mandatory training is 90% and the overall CCG compliance rate as at the end of January 2020 is 87%.

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It has been agreed that Conflicts of Interests (level 1) training will be mandatory going forward for all CCG staff and this is currently being added to the online training system by the Learning and Development Team, prior to a message being sent to all staff to highlight the needs for this to be completed on an annual basis. The online training system continues to have the ability to provide reminder emails to staff once month prior to their courses expiring and reminder emails continue to be sent directly to staff members, from the Corporate Affairs Team, to continue to address non-compliance. A face-to-face Information Governance training session has been arranged for all Governing Body members to be held as part of the Informal Governing Body meeting to be held on 11th February 2020.

8. Complaints

Within the period of December 2019 and January 2020, 21 new complaints were received, all of which were acknowledged within 3 working days of receipt in line with national guidance.

Complaints continued to be received with regards to Continuing Healthcare (CHC) funding assessments and requests for retrospective reviews. All complaints that were investigated and reviewed by the CHC Team provided assurance that the original decisions made were sound and robust. There has also been a continuation in complaints and concerns regarding the processes involved in assessments, and these require a response based on individual cases.

5 complaints are currently are being investigated by the Parliamentary and Health Service Ombudsman (PHSO). The CCG is awaiting the final outcomes and reports with recommendations in relation to the remaining cases and further updates will be provided at a future meeting.

There were 19 complaints closed within this reporting period (some of which were received in the previous reporting period). Full details of each investigation, outcome and lessons learned, where applicable, were provided in all complaint responses, in line with the national standards for managing complaints and National Health Service Complaints (England) Regulations 2009.

9. Patient Advice and Liaison Service (PALS) The PALS is commissioned by NHS Wirral CCG and provided by Wired to provide ‘on the spot’ help whenever possible, with the power to negotiate immediate or speedy resolution (within 48 hours) of problems. Where appropriate, the PALS will refer patients to independent advice and advocacy support from local and national sources including HealthWatch. There were 43 PALS enquiries received within November and December 2019. The two dominant areas of these related to Wirral University Teaching Hospital NHS Foundation Trust (WUTH) and GP Practices. Of the 43 calls received, 18 were formally raised as complaints with the relevant organisation and the remaining 25 were resolved satisfactorily.

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(Source: Monthly PALS report provided from Wired. To note, the data for January 2020 was not available at the time of writing this report).

10. MP Enquiries

Within the reporting period of December 2019 and January 2020, 4 new MP enquiries were received, all of which were acknowledged within 3 working days. 1 of the MP enquiries related to the provision of orthotic care and services, 1 related to GP waiting times, 1 related to A&E targets and the final MP enquiry received related to the CCG’s policy for In Vitro Fertilisation (IVF). There were 8 MP enquiries responded to and closed within this period all of which were investigated and responded to within the CCG’s Key Performance Indicator of 20 working days and therefore the CCG was fully compliant in managing and responding to MP enquiries within this period.

11. Freedom of Information (FOI) requests Within the reporting period of December 2019 and January 2020 50 new FOI requests were received. The subjects of the FOI requests received are detailed below:

Subject Number Received Primary Care 8 Continuing Healthcare (CHC) 5 Medicines Management 3 Mental Health 5 ICT 3 Financial Expenditure 3 CCG Commissioning 10 Contracts and Procurement 2 CCG Structure 1 HR 2 Other 5 Total 50

All FOI requests received during December 2019 and January 2020 were responded to within 20 working days.

12. Subject Access Requests (SARs) There were 6 SAR’s received within this reporting period. 5 of these requests were in relation to records originally held by One to One Midwives. All care records relating to One to One Midwives,

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have now been transferred to Restore Management as a sub contract to Wirral University Teaching Hospital NHS Foundation Trust (WUTH), on behalf of NHS Wirral Clinical Commissioning Group (CCG), as the lead Commissioner for this previously commissioned service. One of the SAR’s received was in relation to a Continuing Healthcare (CHC) assessment and package of care.

13. IMPLICATIONS

The CCG will actively seek to ensure Statutory and Mandatory training targets are continued to be completed with by reiterating messages for new starters to early completion of all training modules.

14. CONCLUSION Governing Body is asked to note the contents of the report.

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High Medium Low Yes

Clinical engagement taken place Y Patient and public involvement taken place Y



Medical Director Report March 2020


Dr Simon Delaney

Contributors Dr Stokes, Dr Ariaraj, Dr Jalan, Iain Stewart, Sarah Boyd-Short To Approve To Inform Yes To Assure Yes To Endorse Executive Summary Update detailing the work of the Medical Director and clinical leads

Recommendations Note the contents of the report and the ongoing work of the clinical leads

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Y


Y


Y


Y


Y





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Report Title Medical Director Report Lead Officer Dr Simon Delaney

10th March 2020 Recommendations Governing Body is asked to note the progress of the activities of the

Medical Director and Clinical team

1. INTRODUCTION This report provides Governing Body with an update on the activities and delegated duties of the Medical Director and CCG clinical leads


Engagement with Local Medical Committee (LMC) and Federations The benefit of the continued monthly meetings with LMC officers is evident in the improved communication and sharing of pathways and processes at an earlier stage in development. These monthly meetings are continuing and are showing signs of increasing cohesion. The Chair and Medical Director have made a commitment to attend the monthly LMC meeting and this has been appreciated by the committee. The LMC annual dinner was well attended. Delegated Commissioning arrangements for Primary Medical Services from NHS England Delegation preparations are going well. All necessary documentation such as; Committee Terms of Reference, NHS Constitution, risk profile updated in preparation of moving to full delegated commissioning in April 2020. All transferring activities have been allocated amongst all functions of the CCG with teams meeting regularly to finalise preparations Engagement with Wirral University Teaching Hospitals NHS Foundation Trust (WUTH) Consultants : The next meeting is planned for March 2020 as a joint Protected Learning Time (PLT)/hospital audit meeting. Preparation for this is ongoing between the Medical Directors. Clinical Senate February’s Senate was cancelled due to the situation at WUTH regarding quarantine of UK citizens from China.

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Planned Care Committee The Planned Care Board for February was cancelled due to the situation at WUTH regarding quarantine of UK citizens from China.

Urgent Care Update:Dr S Jalan, Clinical Lead for Urgent Care and Medicine Management Work is ongoing in the areas of Streaming, Urgent Care Treatment Centre, Long Length of Stay, Referral Pathway for urgent Surgical patients. Streaming: Currently 20-25 patients are streamed daily from A&E to Primary Care. There are discussions ongoing to increase this number, and clinical criteria agreed for complex streaming to further increase these numbers. Emergency Department (ED) Primary Care Streaming Clinical Reference Group has been set up with clinician representation from CCG, ED and also Primary care to agree the streaming criteria and review them regularly. The group has recently agreed on paediatric stream criteria, and also complex streaming. There are ongoing discussions re Minor Injuries and group to meet again to discuss this further. A meeting took place on 4th February 2020 to look at increasing this number and agreement reached on how this can be achieved, by all stakeholders. Urgent Treatment Centre: The development of the interim Urgent Treatment Centre has been ongoing. Point of Care Testing (PoCT) is still awaiting commencement whilst staff training takes place. Referral Pathway for Urgent Surgical Patients: The pathway for referral of patients to surgical assessment unit is currently reviewed. There have been meetings with the Clinical Lead for Emergency Surgery Team, and ongoing discussions to improve pathways and reduce admissions. We are awaiting a response from the Clinical Lead for Emergency Surgery, prior to changing pathways. Single point of Access: We are currently looking at the functionality of the SPA and how it could improve care navigation and reduce the admissions to UMAC by utilising other services within the community and hospital. This is ongoing. Medicines Management

We are currently looking at the Near Patient Testing Local Enhanced Service (LES).

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Wirral has adopted 9 chapters of Pan Mersey and will be adopting the remaining 3 soon.

We are looking at the cost efficiencies with regards to Apixaban and considering a project to review patients with view to changing to more cost effective options

AMR still high in Priority and Dr Atherton will be leading on it.

Wirral Self Care, Over the Counter drugs and products of low clinical priority policy is currently being reviewed.

Medicines Management team is also working on the proposed prescribing component of the PCQS.

GP IT

Health and Social Care Network (HSCN (replacement broadband for N3)) is commencing rollout across practices with an estimated completion by end of year for all practices. Docman10 installations are progressing (26 practices completed so far) – some practices dependent upon improved broadband connectivity so scheduling is aligned with HSCN rollout. Preparation is underway for planning the switchover to GovRoam (public sector WiFi). BlueBay Vision installation completed at 10 practice sites (stratification tool for use with locally commissioned services). Primary Care Update Dermatology Primary Care Network (PCN) Locally Commissioned Service. The key points to this service are; a) Service live from November 2019 for 6 months. b) 4/5 PCNs submitted plans that were approved for the testing phase. c) Service primary involves triage of referrals, medical appointments and Minor Surgery. d) Aim to improve timeliness of care and patient outcomes. The Homeless Locally Commissioned Service (LCS pilot (end march 2020)) suggesting up to 39% reduction in Non Elective (NEL) Admissions since November 2018. This is ongoing work. General Practice Enhanced Proactive Care has over 2,400 patients identified within Primary Care across 3 areas with outcome data expected from Business Intelligence (BI) in the next quarter. Groups being more proactively managed include: (a) High Intensity Users (b) Proactive Discharge Reviews (c) Domiciliary Frailty Care

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Long Term Conditions update: Dr Sian Stokes, Clinical Lead Long Term Conditions Work is ongoing in the areas of Diabetes, Respiratory, Elderly Care, Neighbourhoods and End of Life Care. Respiratory: A pilot is underway in the emergency department at Wirral University Hospital NHS Foundation Trust. A respiratory nurse specialist is based in the unit and also seeing patients in the Urgent Medical Assessment Unit presenting with respiratory conditions. They are assessing these patients rapidly with the aim of arranging early supported discharge where appropriate to prevent unnecessary admissions/shorten length of stay. The Chronic Obstructive Pulmonary Disease (COPD) service and the Cardiology Service have submitted a joint bid to co-host pulmonary/cardiac rehab. This should increase capacity for both these services but also make greater use of existing facilities and be more efficient. The Respiratory Steering Group is reviewing the use of current Respiratory ‘hot slot’ appointments. There is a feeling that these are not being utilised as planned and may not be being utilised most effectively. A plan for how these slots can be used in the future will be drawn up based on the outcome of this review. There is now an advice line for patients to use for 72 hours after discharge from hospital following a respiratory admission. This is being utilised instead of early supported discharge for low risk patients. Gastroenterology: The pilot triaging referrals to gastroenterology continues. The outcomes of this pilot will be reviewed and will help inform next steps in terms of developing a Gastroenterology Referral Advice Service (RAS). Review of the Right Care data for Gastroenterology shows that many of the outlying areas for Gastroenterology are centred around Alcohol use. As such Wirral Health and Care Commissioning are working with both Public Health and the provider of the Alcohol Service on Wirral to consider how this can be addressed. Also, as part of a Cheshire and Merseyside pilot, a Fibroscan machine is available for the next 12 months within the alcohol service to help identify patients with liver fibrosis earlier so that appropriate interventions can be made.

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Elderly Care: Wirral Community Health and Care Foundation Trust are working with stakeholders across Wirral to develop a Target Operating Model for Frailty. This work incorporates many aspects including developing a consistent language and definition of severe frailty, improved data sharing, a greater understanding of all the services available for frail older patients across Wirral, a consistent approach to the delivery of care plans, and consideration of the development of a multidisciplinary ‘frailty team’ within each PCN. The Tele-triage service are leading a project to introduce NEWS2 assessment into care homes across Wirral. They will be delivering training into 8 care homes per month. The purpose of this is to ensure that care home staff are trained to recognise deteriorating patients and know when to seek medical advice regarding a patient and can clearly communicate what their concerns are and what the patients observations are. This work was presented at GP members meeting in February. Planned Care update: Dr Lax Ariaraj, Clincial Lead Planned Care

Alcohol Wirral suffers a high degree of alcohol related health issues. Dr Anwar, consultant in public health, is leading a team to try and address issues and improve pathways. The CCG will be a key partner in this process.

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MSK Wirral CCG looks for assurance from the MSK service in terms of monitoring referrals, accessibility, wait times, GP engagement and complaints. Table of referrals to the MSK service up to November 2019

There has been a change to the booking process to allow easier appointment booking. A guide to opioid management was sent out to GPs.

An invitation was sent out to all GPs requesting ideas of GP participation in the delivery of MSK treatments and assessments. Offers to assist in a working group were received and will be taken up.

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Dermatology

Ongoing discussions as to best model to improve Dermatology services. Current issues are with shortage of Consultant dermatologists regionally and therefore long wait times. 2 Value Stream Analysis (VSA) events held support triage model. Dermatology pilots are up and running via Primary Care Networks.

Advice and Guidance

No further specialities added to consultant connect. Funding secured to enhance the service offer by opening up to further specialities (haematology and gastroenterology recommended).

NHS funding has been found to set up advice and guidance website similar to that used by NHS Lothian. The CCG is comparing bids from potential site developers. The website will be populated with information from local specialists and services and will be kept up to date with support from the CCG.

Cancer

The cancer clinical lead has resigned. The CCG have advertised for a replacement. We thank Dr Modi for her work in this post.

Performance standards - Wirral continues to perform well against regional averages as

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demonstrated by the charts below. From April 2020 a new 28 day Faster Diagnoses standard will apply. Shadowing monitoring of this standard has been in place for some time, average performance April – Dec 2019 regional 80.66%, Wirral 28.30%. The performance threshold has yet to be set. 2week waits:

62 days:

National Cancer Patient Experience Survey: The Quality and Performance Committee recently received an update regarding the National Cancer Patient Experience Survey (NCPES). Wirral scored an overall 8.8, where 0 is very poor and 10 very good.

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Performance against key indicators are below. The committee reviewed the NCPES in detail along with the action plan for improvements.

81% of respondents said that they were definitely involved as much as they wanted to be in decisions about their care and treatment (Improvement from 2017 78%)

94% of respondents said that they were given the name of a Clinical Nurse

Specialist who would support them through their treatment (Improvement from 2017 93%)

85% of respondents said that it had been ‘quite easy’ or ‘very easy’ to contact

their Clinical Nurse Specialist (Decrease from 2017 87%)

90% of respondents said that, overall, they were always treated with dignity

and respect while they were in hospital (Improvement from 2017 88%)

97% of respondents said that hospital staff told them who to contact if they

were worried about their condition or treatment after they left hospital (Improvement from 2017 95%)

59% of respondents said that they thought the GPs and nurses at their

general practice definitely did everything they could to support them while they were having cancer treatment. (Improvement from 2017 56%) Work continues with the Cheshire & Mersey Cancer Alliance to implement new initiatives and improve pathways including Early Detection, Head & Neck pathway and oesophago-gastric pathway. Work in in place with PCW to embed cancer care into PCNs through social prescribers and also to continue the pre-hab/ post-hab pilot for Cancer patients that was successfully piloted as part of the recent Macmillan Holistic Needs Assessment in the Community.

Mental Health

Four key work streams as part of the Healthy Wirral mental health programme for 2019/20:

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1. Dementia 2. Crisis Care 3. Physical Health in Mental Health 4. Talking Together Living Well Wirral (IAPT)

Additionally, a new priority has been set for 2020/21 following on from the publication of the Community Mental Health Framework. This framework outlines the how the Long Term Plan’s vision for a place based community mental health model can be realised and how community mental health services should develop to offer a holistic approach aligned with Primary Care Networks. The implementation of this new community mental health model will replace IAPT as a Healthy Wirral Mental Health Programme priority from March 2020

Dementia

• Engagement exercise conducted in 2018/19 during which we spoke to over 200 people either living with dementia, carers or professionals.

• Wirral Dementia Strategy refreshed for 2019-2022 and structured around NHS England “Well Pathway for Dementia”

o Working groups established through the Dementia Strategy Board to work towards the strategy objectives.

• Dementia Redesign group established to review opportunities to improve current offer for people with dementia, including a redesign of the memory assessment service (WMAS). Chaired by Dr Peter Arthur.

o A new model is in the process of being developed focusing on reducing waits in WMAS by supporting and enabling GP’s to diagnose “obvious” dementia in primary care – only if they feel comfortable in doing so.

o In the process of designing a questionnaire for GP’s practices on this model to establish confidence, ability and training needs.

o The primary care Dementia LES will be reviewed as part of this redesign o Reviewing local data and finances to inform this proposed model. o Reviewing our post-diagnostic support provision with a workshop planned with both

local stat and non-stat organisations to establish what is available and gaps. Crisis Care

• Two crisis care projects currently in development o Springview – A home treatment assessment area for patients in mental health crisis

open to CWP to be assessed away from A&E where there are no physical health needs. o Spider Project – A “crisis café” based in Birkenhead staffed by crisis support and peer

support workers. o Both projects are for adults 18+ with non-organic problems only.

• Springview is due to open by March 2020. The building for Spider Project is in the process of being purchased, and will be open by March 2021.

• Pathways have been developed for both services and initially access will be via referral. • Wirral CCG successfully bid for NHSE crisis transformation funds to develop the Crisis

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Resolution Home Treatment Team. The team will be 24/7 by March 2020 and working to high fidelity by March 2021. Recruitment has taken place to achieve this.

Physical Health in Mental Health

• National target of 60% of people on primary care Severe Mental Illness (SMI) to have received 6 annual physical health checks including blood pressure, blood glucose, cholesterol, BMI, smoking and alcohol assessments.

• Wirral currently achieving 29%. • Project group formed with representation from CCG, Cheshire and Wirral Partnership NHS

Foundation Trust (CWP) and primary care to review the current processes and develop an new model to improve the number of health checks being completed including:

o Data cleansing of practice SMI registers o Development of a shared care protocol o Training for practice staff o Improve communications and discharge processes o Development of an SMI registry on the Wirral Care Record o We are looking at how to invest in this area for 2020/21.

Improving Access to Psychological Therapies (IAPT (Talking Together Living Well Wirral))

• New provider in place, Insight Healthcare, working in collaboration with CWP, GP Federations, Age UK, Involve Northwest, Cruse Bereavement and Open Door Centre since April 2019.

• Talking Together Living Well Wirral is now fully embedded within the Wirral system, with positive feedback and outcomes.

Community Mental Health Framework

• This framework outlines how systems will develop new models of integrated primary and community care for people with SMI that spans both core community provision and dedicated services including the voluntary sector.

• This area has been identified as a new Healthy Wirral mental health programme priority area for 2020/21

Next steps include establishing a project group, governance and reviewing provision across the system including workforce.

3. IMPLICATIONS:

• Planned Care Board to focus on key priorities as highlighted in the Operational Plan • Ongoing review MSK service • Support from Practices for Delegated Commissioning. • Ongoing work on engagement with LMC, Primary Care and Secondary Care.

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• Note the work of the Clinical Leads.

4. CONCLUSION

Governing Body is asked to:- • To note update on the ongoing work of the Medical Director and Clinical Team of the CCG

recovery schemes in progressing the objectives of NHS Wirral CCG.

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High Medium Yes Low

The Local Plan is the key spatial plan for Wirral and will drive economic development and regeneration in the borough. The NHS needs to engage with the process with regard to tackling health inequalities and impact on local health services. Mitigation measures would be full engagement in the consultation on the local plan specifically on

Mapping of Population demography and needs

• Land and asset opportunities • Emerging delivery models

This risk in not already included in the CCG’s Corporate Risk Register

WIRRAL COUNCIL LOCAL PLAN


Julie Webster, Director of Public Health Wirral Council

Contributors To Approve To Inform YES To Assure To Endorse Executive Summary The Wirral Council Local Plan is a statutory document that sets out the place

ambition for Wirral and guides decisions on planning applications for local developments. Wirral’s Local Plan is currently being updated to reflect the Council’s long-term vision, objectives and spatial strategy for the Borough. In recognition of the significant impact that the Local Plan has on the health and wellbeing of communities in Wirral this report provides an overview of the current status of the development of the Local Plan.

Recommendations The Governing Body is asked to: • To note the content of the report • Consider how NHS Wirral Clinical Commissioning Group (CCG) want

to engage and inform the ongoing development of the Local Plan

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Clinical engagement taken place N Patient and public involvement taken place N




Y


Y


Y


Y


N





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Report Title Wirral Council Local Plan Lead Officer Julie Webster, Director for Health and Wellbeing Recommendations 1. To note the content of the report

2. Consider how NHS Wirral Clinical Commissioning Group want to engage and inform the ongoing development of the Local Plan

1. INTRODUCTION Wirral’s structural and economic environment is key to improving the health and wellbeing of local residents and reducing health inequalities. Wirral Council’s Local Plan therefore represents one of the most significant policy drivers to intentionally improve economic, social and health outcomes in the Borough. The Wirral Local Plan will cover a period from 2020 through to 2035 and set out policies and proposals to guide the future development of the Borough over that time. It will detail where future development will take place, and allocate land for housing, employment, mixed-use and other development. It will also seek to protect the most important characteristics of the Borough, by preserving the unique natural and historical assets from development. Ensuring that the Local Plan enables opportunities to address inequalities arising from employment, affordable and quality housing and the wider lived environment where people can aspire, thrive and become more personally resilient is vital. As part of the preparation of Wirral’s Local Plan the Council has recently produced an Issues and Options document for public and partner consultation to seek views on the proposed contents of the Plan. Following this a draft Local Plan will be developed by July 2020, for further representations, prior to submission to the Secretary of State by November 2020.

This report provides an overview of the current status of the development of the Local Plan and asks colleagues to consider how Wirral Health and Care Commissioning may wish to engage, and inform, the ongoing development of the Local Plan.


Local Plans set out a long-term vision for how an area will develop in the future, with policies that will shape future development. They address a wide range of issues, from strategic planning matters that affect the whole local authority area right through to finer details on the design of development on individual sites. The Government requires each local planning authority to produce a Local Plan and then review it at least once every five years to ensure that it is up to date. The Council has been preparing proposals for inclusion within the Local Plan based upon evidence about the economic, social and environmental needs of the Borough and a number

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of evidence studies have been commissioned or updated to inform the production of the Issues and Options document. The Local Plan Issues and Options document sets out the Council’s proposals and must be published for consultation under Regulation 18 of the Town and Country Planning (Local Planning) (England) Regulations 2012. Included within the document is a series of Spatial Options as to how the housing and employment requirements could be met within the Borough. The Preferred Option is for Urban Intensification which will involve maximising the use of all available urban land, including suitable previously developed brownfield sites. However, to meet the evidential requirements for deliverability and developability of the Borough’s development needs over the Plan period it is also necessary to consult on a range of other options should the requirements not be met by Urban Intensification alone. Following approval at a special meeting of Cabinet in January 2020 and an extraordinary meeting of full Council, Wirral’ s Issues and Options Local Plan 2020 - 2035 was approved for public consultation. The period for consultation commenced on Monday 27 January 2020 and run for 8 weeks until Monday 23 March 2020. The consultation portal is available at https://wirral-consult.objective.co.uk where individuals and organisations who wish to can view and submit comments on the Local Plan Issues and Options document. As well as this document other background reports and evidence is also available for review on the website. Economic regeneration and good design enable healthy communities and deliver a range of positive outcomes. The development of the Local Plan therefore represents an important opportunity to influence how the built and lived environment contribute to positive health outcomes and enables people to live well. The regeneration programmes already in development, and those planned for the future, are focused in the east of the Borough providing a unique opportunities to tackle health inequalities through place shaping. To support the development of the Local Plan and the opportunities inherent within it, an independent Health Impact Assessment (HIA) of the emerging Local Plan was conducted in October 2019. The scope of this HIA was to:

• Review the emerging Local Plan, and the accompanying Sustainability Appraisal, to ensure that any health impacts have been fully considered.

• Identify opportunities for improving the health and wellbeing of Wirral residents by reviewing evidence of good practice and ways in which to embed prevention of ill health and improvements to health and wellbeing into the Local Plan.

• Assess the impact of the Local Plan on health and wellbeing providing proposals to address both positive and negative influences.

The production of the HIA was overseen by officers from Planning, Intelligence and Public Health. To assist in the completion of the HIA a workshop was also held in October 2019 with a range of officers from across the Council and CCG representatives. This provided an opportunity to sense check the initial findings and incorporate knowledge and expertise of key officers. This is the first time that HIA has been used in the development of the Local Plan in Wirral.

The product of this work is a series of recommendations to maximise opportunities for health improvement and mitigate potentially negative health impacts. A copy of the HIA is attached to

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https://wirral-consult.objective.co.uk/

https://wirral-consult.objective.co.uk/


this report (the specific recommendations are included on pages 68 - 75). In summary, the HIA was conducted across the 12 strategic objectives of the Local Plan and includes detailed appraisal of the following key areas:

• Neighbourhood design • Housing • Food environment • Natural and sustainable environments • Transport • Arts and Culture • Reducing alcohol related harm

In addition to the above assessment of specific themes the HIA reported the following generic recommendations:

• Undertake a further HIA once the detailed policy stage is completed and give consideration as to how the interim HIA is built into the planning process.

• There are a lot of complex strategic objectives, with some duplication, consideration should therefore be given to simplifying these and or connecting them.

• There are few references to the people of Wirral, and the needs of specific population groups, within the Plan. This could be enhanced as the Plan develops and is implemented.

• Be clearer on what the Local Plan is for, what it can and cannot do, the place of Policy documents and Supplementary Planning Guidance and how the Local Plan complements other plans that the Council and partners may have that help achieve an overall vision for Wirral.

• Ensure the needs of specific groups in the population are addressed especially the growing older population and children and young people.

The HIA is part of a suite of assessments and supporting documents to inform the Local Plan development. It is important to note that it was not the purpose of the HIA to justify or challenge the rationale behind the Plan. Furthermore, the stage of development of the Local Plan precludes the estimation of effect of specific actions as, at this stage, specific actions are not yet defined. Completing the HIA to inform the Issues and Options Document is a major milestone in developing the final Local Plan and to identify ways in which policy can improve health outcomes. However, to achieve its fullest potential implementing the findings of the HIA and embedding this as ongoing practice is a crucial next step. In order to do so the following actions are already underway:

• The Council have used the HIA to develop the Local Plan and the narrative within the draft Plan now recognises the influence on health.

• A supplementary planning guidance will be developed and included in the final Local Plan to reflect the recommendations within the HIA and to ensure that health impacts continue to be assessed and managed.

• Work is also underway to develop the approach to undertaking HIA on the final Local Plan and how this is embedded on an ongoing basis.

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• The HIA has been shared with key Heads of Service to support the development of work across the Council. This is particularly relevant where some of the mitigating actions connect to, but fall outside of, the remit of the Local Plan, for example licensing.

• The HIA is informing key pieces if work, for example the development of an Air Quality Strategy for Wirral. There is also scope to use this work to influence the work to address child obesity.

• The HIA has also been used to inform the Liverpool City Region Spatial Development Strategy and to support the New Development Corporation funding application.

A workshop focusing on the Local Plan with health system partners is scheduled to take place in March 2020. This workshop will provide health and care system partners with an overview of the Local Plan and explore the findings of the HIA. This is intended to support colleagues to consider the impact of changing population demographics and needs, land and asset opportunities and emerging delivery models within the context of the Local Plan. Following the Issues and Options consultation document, the final draft Local Plan will be brought to Council for approval in July 2020 and further public representations will then be invited (the Regulation 19 stage). The final draft Local Plan and all representations received will then be submitted for Examination by an independent Planning Inspector appointed by the Secretary of State. This is currently expected to take place in November 2020.

3. IMPLICATIONS

The Local Plan will contain policies to guide new housing, business development and infrastructure, and to inform decisions that impact on the environment for the next 30 years. The link between the environment and health is well established and the impact on health, both negative and positive, is widely acknowledged. Supporting the creation of healthy communities and environments through good design, active travel, physical activity and providing access to facilities and services and high-quality open spaces is key to improving the health of Wirral residents and reducing health inequalities. Conversely, living in poor housing in a deprived neighbourhood with a lack of access to open space impacts negatively on physical and mental health. Health inequalities are a significant issue for Wirral. A key challenge is to ensure that the Local Plan provides opportunities to address inequalities arising from employment, affordable and quality housing and the wider ‘lived’ environment where people can aspire, thrive and become more personally resilient. The influence of the Local Plan on the health of the population cannot be understated. Ensuring that opportunities for health improvement are maximised is an important part of the ongoing development of the Local Plan as well as pivotal to achieving the ambitions health partners share for population health.

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4. CONCLUSION The Governing Body is asked to note the content of the report and to consider how NHS Wirral Clinical Commissioning Group want to engage, and inform, the ongoing development of the Local Plan.

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Minutes of the WCCG Quality & Performance – Tuesday 17th December 2019 Page 1 of 8

NHS WIRRAL CLINICAL COMMISSIONING GROUP Quality and Performance Meeting

Minutes of Meeting

Tuesday 17th December 2019 2pm – 4pm

Room 539, Marriss House Present: Linda Roberts (LR) Chair Lay Member, WHCC Richard Crockford (RC) Deputy Director of Quality & Safety, WHCC Dr Simon Delaney (SD) Medical Director, WHCC Mike Treharne (MT ) Chief Finance Officer, WHCC Paul Edwards (PE) Director of Corporate Affairs WHCC Alan Whittle (AW) Lay Member, WHCC Steve Cocks (SC) Assistant Director for Contracts and Delivery, WHCC Lorna Quigley (LQ) Director of Quality & Safety, WHCC Dr Paula Cowan (PC) Chair, WHCC Nesta Hawker (NH) Director of Commissioning, WHCC In attendance: Gail Moore (GM) Corporate Officer, WHCC (minutes) Emma Jaeger (EJ) Medicines Optimisation Pharmacist, MLCSU (item 3.1 & 3.2)

Lorraine Foulkes (LF) Specialist Community Practitioner – District Nursing Student (observer)


QP19/20/0057

Preliminary Business 1.1 Apologies for absence

Apologies were received from Simon Banks. 1.2 Declarations of Interest Declarations declared by members of the QP committee are listed in the CCGs Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link: https://www.wirralccg.nhs.uk/media/3842/copy-of-conflicts-of-interest-staff-listing-august-2017.pdf There were no declarations if interest 1.3 Chairs Announcements/Opening Remarks Chair announced that this meeting would be her last as she is stepping down from the post as of 31st December 2019.

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1.4 Minutes & Action Points from previous meeting held on 26th November 2019 Minutes The minutes of the previous meeting held on the 26th November 2019 were discussed, and agreed as a true and accurate reflection of the meeting apart from the following: Page 3: change the following narrative from “The national average for achieving the 4-hour target in August was 97%” to “The North West average for beginning of October being 81.1%” The minutes have been amended accordingly. Action Points Members reviewed action points and updates were provided for members on progress of the outstanding actions to date. The action log was updated.

QP19/20/0058

2.0 Items for Assurance 2.1 Risk Register 14-15G Quality, Patient Safety - Members discussed in depth this risk in light of recent deteriorating performance against the 4-hour standard at WUTH. Members concluded that whilst there was evidence that some harm may have occurred, this was deemed to be not clinically significant. Therefore, it was agreed to raise the consequence level to 5 (recognising the potential for more significant harm) but to reduce the likelihood of this occurring to level 4, because robust mitigation is in place to safeguard against major patient safety issues. LQ agreed to contact the trust to understand how this risk has been identified within the Trust 16-17C Quality, Patient Safety – scoring to remain the same 16-17D Quality, Patient Safety & Commissioning – scoring to remain the same. To remain on the risk register as a 'watching brief'. 17/18F All – there have been no changes since the last update 17/18H Commissioning/ Quality – Members discussed in depth this risk in light of continued poor performance against the ambulance turnaround times. Members concluded that scores should remain the same as the risk of potential harm remains present, but at this stage there has been no significant risk to patient safety. 18/19C Commissioning – Members discussed in depth this risk in light of continued poor performance of the ambulance service. Members concluded that scores should remain the same as the risk of potential harm remains present, but at this stage there has been no significant risk to patient safety. 19/20D Quality, Patient Safety - Members agreed to proposed wording and risk scores.

2.2 Performance Pack SC presented the performance pack for October 2019:

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A&E and Non-Elective Admissions- WUTH Current Position: In October 2019 the combined A&E and Arrowe Park Walk in Centre (AP WIC) performance fell below the national standard (95%) to 72.68%, and didn’t meet the locally agreed Service Development Improvement Plan (SDIP) trajectory for October (91%). The national average for achieving the 4-hour target in October was 83.6%. 2019-20 A&E > 4 Hour Wait Trajectories – WUTH A&E (APH site combined) Performance against a 4-hour standard dropped below 95% target, this has been impacted by higher than average numbers of long length of stay patients impacting on flow across the bed base. MT asked if the 95% target for March 2020 for A&E attendances where the service user was admitted, transferred or discharged within 4 hours of their arrival at an A&E department would be met? NH advised that this would not be met due to the long length of stay of patients. The Urgent Treatment Centre (UTC) was due to open on 19th December but there has been a slight delay in this due to building work. Ambulance October’s position demonstrates continued performance with only Cat 1 90th centile target being met at 00:13:46, target being 15mins. Cat 1 response average which relates to life threatening cases has improved - compared to September 2019 at 00:08:11 with October 2019 being at 00:07:55. Performance has deteriorated for both Cat 3 and Cat 4. There is a performance improvement plan in place with NWAS which is monitored by Northwest Strategic Partnership Board, additional paramedics have been recruitment to support Wirral’s position. There is a correlation between ambulance performance and ED performance as when ED is under increased pressure, crews are at increased risk of delayed handover and turnaround times which consequently impact their ability to respond to calls in a timely manner. 111 Calls All indicators with exception of clinical intervention have deteriorated during October 2019. 111 service is provided by NWAS and the contract is managed by Blackpool CCG on behalf of North West CCG’s. performance is monitored, and progress against actions to improve performance, which is discussed at the fortnightly combined 999 and 111 performance improvement meetings with NWAS executives and NHSE/I. A revised Performance Improvement Plan (PIP) has been developed. Actions undertaken by NHS 111 to improve performance include ongoing continuous service development, focused recruitment and retainment of staffing drive, recruitment programme delivered to plan including additional recruitment to support the new Mersey site at Estuary Point in December 2019. Staff sickness continues to present significant issue for the service, sickness masterclasses have been rolled out to support managers to deal with sickness within their teams and ensure staff are supported to return Ambulance turnaround times have slightly improved in October, however remains very slightly above target at 0:30:56. Ambulance handover times continue to meet target of less than 15 minutes with October performance of 00:12:18 to work. Cancer

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In October, Cancer Performance is continuing to show a significant improvement from the position reported in previous months, Wirral CCG failed one performance standard (1/8) this month. WUTH has met all cancer standards for the last five consecutive months. Challenges to the overall CCG position continue to arise from various system pressures, mostly unavoidable. The CCG missed the following standard this month: 2-week breast: One patient breached this target due to patient choice delay relating to first outpatient appointment. Patients are actively tracked on pathways and tests expedited where possible however, for some complex pathways, such as robotics surgery, the performance targets present a challenge. Patient trackers are in place to progress patients through the pathway. Patients are asked from the point of referral and throughout their pathway to be available for appointments, to avoid patient choice related breaches. With regards to the Urology capacity issues, the CCG has raised this with the provider, WUTH, who are aware of the issue. The provision is constantly under review to ensure capacity meets demand. In addition to additional staff training, allocations are varied to meet demand. SC advised that Wirral CCG are currently the second-best CCG in the Northwest regarding Cancer targets. LQ requested the data be interrogated for info regarding breaches and asked were patients given reasonable time frames within patient choice. RC added that in from his previous experience, patients were unaware that they had been referred under the 2-week rule, as this wasn’t communicated to them at the point of referral. PC advised that communications were sent out to patients to advise of the 2-week pathway and that they would be required to attend an appointment within 2 weeks. Dr Nicola Stevenson had confirmed that since the communication had been sent out in May there had been a better response to attend appointments by patients. RTT (Referral to Treatment) October data not available. Improving Access to Psychological Therapies (IAPT) 40.8% of referrals recovered in October 2019, compared to 34.49% in October 2018. 93.7% waited less than 6 weeks and 99.9% waited less than 18 weeks in October 2019 compared to 83.63% and 99.3% respectively in October 2018. Diagnostics October data not available Mixed Sex Accommodation October data not available Transforming Care The Department of Health published ‘Transforming Care: A national response to Winterbourne View Hospital and the Concordat: Programme of Action’ in December 2012. The review of services received indicated that failings were widespread within the operating organisation but importantly also evident across the wider care system. The Concordat and 63 actions detailed within the review seek to address poor and

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inappropriate care and achieve the best outcomes for people with a learning disability, or autism, who may also have mental health needs or behaviour that challenges. In line with the Transforming Care Agenda and ‘Building the Right Support’, NHS Wirral CCG has continued to work with partners to support people in the community and develop further services to ensure the continued reduction of inpatient bed numbers. The target was achieved in October 2019 (all patients are adults). The target of 4 remains for 2019/20. Current position explanation and issues The reporting of the LD Inpatients has changed to reflect only LD Assessment and Treatment beds (previously all patients with a diagnosis of LD and/or Autistic Spectrum Disorder (ASD) were included, even those in an acute mental health bed. However, NHSE wishes Wirral CCG to report on all admissions. The Tier 4 beds are case managed by NHSE specialist commissioning and no targets are set by NHSE regarding Tier 4 inpatient numbers. The CCG recognises as an outlier regionally with these admissions. Work continues to be undertaken in examining reasons (clinical, social and demographic) with the support of public health. Actions and processes previously outlined in response to the reduction admissions include:

▪ Weekly teleconference with relevant stakeholders to gain pace with any issues ▪ Dynamic Support Database DSD for CYP & monthly tracker meetings supported

by commissioners ▪ Undertaking an in-depth analysis to understand why Wirral is an outlier ▪ CYP Intensive Support Function (of LD CAMHS) due for mobilisation in Dec

2019 ▪ Further worker on PID for Capital being developed with key partners out re. step

up and step-down provision/admission avoidance ▪ Engage with Local Authority colleagues to ensure all stakeholders are involved

at the appropriate all relevant stages of the pathway

Healthcare Acquired Infections (HAI) LQ advised that some care homes in addition to hospital wards had been closed due to Norovirus, it was brought to the committee’s attention, that with the increase in testing, this can lead to an increase in Cdificle. All cases of Cdif and MRSA have a Post Infection Review undertaken to ascertain if these were unavoidable or due to lapse in care. Action plans are developed for any cases due to lapse in care. A high-level trust Infection and Prevention Improvement Plan has been developed to address the key issues, including; Accountability Framework, Back to Basics, Simplification of Processes and Improving IT to Improve IPCT. A deep dive is to be undertaken into Healthcare Acquired Infections due to the significant increase in cases. HCAI is discussed at the monthly Quality meeting with the trust.

2.3 MSK update SC presented this interim update on progress following previous reports to this committee and the issuing of a Contract Performance Notice.

WUTH has submitted an updated Remedial Action Plan (RAP), which shows significant improvement in response to both the Deep Dive and CPN. WUTH also compiled a Concerns & Complaints Report, which again shows significant improvement.

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The WHCC Chair (Dr Paula Cowan) sent out communications to GP and Practice Manager Colleagues giving them an update on the MSK service and advising them that they will be an integral part of the redesign of this service going forward. Based on progress to date, the content of this and previous updates, WHCC proposes to withdraw the CPN once WUTH has confirmed that both the sub-contract they have with Wirral Community Health and Care NHS Foundation Trust has been signed and that the identified inappropriate Key Performance Indicators have been updated, agreed and varied into the contract as identified within the latest letter

SC advised a full report would be brought to January QP meeting.

2.4 Contract Register update SC presented the update to provide continued assurance around the management of Wirral Clinical Commissioning Group (WCCG) contracts covering renewals, extensions and procurement activity. Included within this update is a high-level summary of Public Health contracts which will be developed in the coming months, along with the inclusion of Department of Adult Social Services (DASS) contracts, as work continues with other Wirral Health and Care Commissioning (WHCC) partners. This development to include both DASS and Public Health contracts will be concluded upon full implementation of the new Contract Management portal, which is scheduled for completion by the end of 2019/20. WCCGs Contracts and Procurement team is working with WHCCs Programme Management Office (PMO) in the development of a timeline that clearly documents when key decisions are required to aid future work plans, this will be rolled out to include DASS and Public Health and form part of the new portal. There are 45 contracts due to expire on 31st March 2020 and 45 contracts due to expire on 30th September 2020, and the committee was advised of progress till the end of March 2020. Members thanked SC for the update. 2.5 Quality Impact Assessment (QIA) RC presented the report and asked that committee ratify the policy, approve the new QIA tool and endorse training sessions for all commissioning managers through January 2020 and consider any other staff groups that should access training. It is also requested to raise the consideration to the Joint Strategic Commissioning Board for this process to be adopted across all Wirral Health and Care Commissioning. RC advised he had met with several Assistant Directors who had recognised that this would be an important step moving forward. There is an existing process within the CCG for completion of QIA in line with business proposals, however the existing processes are not consistently complied with, often completed at the final stages of a project. The QIAs that are completed, are often completed incorrectly by commissioning managers and need significant support from the Quality and Safety Team to capture and consider potential quality impacts. There has been a QIA policy in draft, however this has not been ratified to support a shared

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understanding within the organisation. The draft policy is for Wirral CCG as opposed to WHCC and does not reflect the current structures within WHCC. A revised draft policy is available and applicable for CCG commissions, however there is a strong argument that a standard process should be in place for all CCG and LA business proposals through WHCC. There has not been any training delivered for commissioning managers to support a full and clear understanding of the QIA processes. The draft Quality Impact Assessment Policy has been updated to reflect how the QIA process would work in line with best practice. The QIA tool has been updated to simplify and include additional guidance tabs. Training session plans are in development for all commissioning managers. The Quality Impact Assessment Policy describes several assurance measures to monitor compliance with the policy. RC advised that committee will receive an annual assurance report to demonstrate levels of compliance with the policy. NH advised she was pleased to see that the Commissioning Policy was referred to within the policy and that she would like her team to be a part of the training. PE advised that EMT is not the correct way for this to be approved for alignment with LA processes. VERTO has a risk system built in which shows the correct direction for policies/process. Action: PE/RC to liaise regarding narrative to be included in the policy Members thanked RC for the work that has been undertaken and where happy to approve the policy notwithstanding the addition of the narrative to be included.

PE/RC

QP19/20/0059

3.0 Items for Approval 3.1 Area Prescribing Committee (APC) EJ presented the update, which was brought to QP for members to ratify the contents. This report gives a summary of the recommendations made in the November APC meeting. The recommendations in the report have been discussed at Wirral CCG Medicines Management Committee (MMC) and their recommendations will be given verbally.

MT enquired about the 90-day implementation period for the two new drugs Rivaroxaban tablets and Pentosan Polysulfate Sodium capsules, what implications will this have on GP’s?

EJ advised that Dr Saket Jalan has assisted with a Primary Care Communication advising GP’s

Members approved the recommendations.

3.2 Anticoagulant Guidelines EJ presented the report which contains the updated Oral Anticoagulant Guidelines and DOAC patient information leaflets which have been agreed to adopt instead of Pan

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Mersey due to the local differences in prescribing between Wirral and Pan Mersey for DOACs. All documents have been updated with no significant changes.

The documents have been discussed at Wirral CCG Medicines Management Committee (MMC) and their recommendations will be given verbally. Members ratified the guidelines.

QP19/20/0060

4.0 Items for Information 4.1 Other Committee Minutes Serious Incident Review Group (SIRG) Members noted the minutes from November’s SI meeting. Contracts Meetings Members noted the minutes. Work plan The work plan will be reviewed in January 2020.

QP19/20/0061

5.0 Current Risk Register

There was nothing further to add

QP19/20/0062

6.0 Any Other Business PC thanked LR for her work during her time as Chair of QP Committee and wished her a happy retirement

QP19/20/0063

7.0 Communications from this meeting

• Full MSK report for January meeting • Updated 2020 workplan for January meeting

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Minutes of the WCCG Quality & Performance – Tuesday 28th January 2020 Page 1 of 11

NHS WIRRAL CLINICAL COMMISSIONING GROUP Quality and Performance Meeting

Minutes of Meeting

Tuesday 28th January 2020 2pm – 4pm

Room 539, Marriss House Present: Alan Whittle (AW) CHAIR Lay Member, WHCC Richard Crockford (RC) Deputy Director of Quality & Safety, WHCC Dr Simon Delaney (SD) Medical Director, WHCC Mike Treharne (MT ) Chief Finance Officer, WHCC Paul Edwards (PE) Director of Corporate Affairs WHCC Steve Cocks (SC) Assistant Director for Performance and Delivery, WHCC Lorna Quigley (LQ) Director of Quality & Safety, WHCC Dr Paula Cowan (PC) Chair, WHCC Simon Banks (SB1) Chief Officer, WHCC In attendance: Karen Duckworth (KD) Acting Senior Corporate Officer, WHCC (minutes) Sue Borrington (SB2) Senior Commissioning Lead – Planned Care (item 2.3 & 2.4)

Jenn Galle (JG) Administrator (observer) Ian Huntley (IH) Lay Member for Quality & Outcomes (observer)


QP19/20/0064

Preliminary Business 1.1 Apologies for absence

Apologies were received from Nesta Hawker. 1.2 Declarations of Interest Declarations declared by members of the QP committee are listed in the CCGs Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link: https://www.wirralccg.nhs.uk/media/3842/copy-of-conflicts-of-interest-staff-listing-august-2017.pdf There were no declarations if interest

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1.3 Chairs Announcements/Opening Remarks Chair introduced IH as the new Chair of the Quality and Performance Committee, and was attending the meeting as an observer prior to commencement of role in February. 1.4 Minutes & Action Points from previous meeting held on 17th

December 2019

Minutes The minutes of the previous meeting held on the 17th December 2019 were discussed, and agreed as a true and accurate reflection of the meeting apart from the following: Page 5: to remove the section for mixed sex accommodation as this was already on page 4. Page 6: item 2.4, 3rd paragraph to include ‘and the committee was advised of progress till the end of March 2020’. The minutes have been amended accordingly. Action Points Members reviewed action points and updates were provided from members on progress of the outstanding actions to date. The action log was updated.

QP19/20/0065

2.0 Items for Assurance 2.1 Risk Register 14-15G Quality, Patient Safety – Members discussed the potential risk involving corridor waits, but are assured that the measures in place to reduce patient harm therefore the score can remain unless this changes. LQ also advised that w/c 6th January 2020, a quality review was undertaken with the Chief Nurse at WUTH and during this time it was observed the process for patient flow were managed well, at the time of the visit no corridor care was observed. LQ also flagged that focus should not just be on corridor waits but also how patients are cared for in assessment areas in order to have a truer reflection of the patients experience and to ascertain that patients are receiving care in the appropriate ward at the right time. It was also noted that the risk score is the same as the hospitals. 16-17D Quality, Patient Safety & Commissioning – there have been no changes since the last update

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17/18F All – there have been no changes since the last update 19/20C Financial – there have been no changes since the last update 19/20D Quality, Patient Safety – there have been no changes since the last update, however, it was noted that there is an inspection pending.

2.2 Performance Pack SC presented the performance pack for October 2019: A&E and Non-Elective Admissions- WUTH Current Position: In November 2019 the combined A&E and AP WIC (Arrowe Park Walk In Centre) performance fell below the national standard (95%) at 70.79%, and it also failed to meet the locally agreed Service Development Improvement Plan (SDIP) trajectory for November (92%). The national performance in November was 81.4%. It was highlighted that out of the 32 measures only 16 had been achieved, 4 just missed and the remaining 12 not showing any improvement. 2019-20 A&E > 4 Hour Wait Trajectories – WUTH A&E (APH site combined) Performance against 4 hour standard dropped below 95% target, agreed trajectory and National average for November 2019. This is impacted by higher than average numbers of long length of stay patients impacting on flow across the bed base. Ambulance November’s position demonstrates Ambulance performance measures have continued to fail the National target with slight fluctuation across each measure. 90th centile for Cat 1 calls is consistently met however the mean target is not. Additional paramedics have been recruited to support improvement however there are considerable knock on effects from the system’s failure to deliver 4 hour standard, corridor care and delayed discharges. The actions taken to improve A&E and discharge pathways will translate to improved performance against the ambulance metrics. However, it is important to note that even when handover and turnaround targets have been met earlier in the year, other performance measures were not indicating that the problem is multifaceted. There is a dedicated focus on improving see and treat pathways to enable more patients to remain at home with the support they need. The knock on effect of this is that paramedics are able to respond to additional calls in the time they would have conveyed and handed over at hospital. Hear and treat pathways are also being improved, supported by primary care and the urgent care GP to ensure paramedics are only dispatched to the most appropriate calls.

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111 Calls All indicators with the exception of clinical interventions have deteriorated during November 2019. 111 service is provided by NWAS and the contract is managed by Blackpool CCG on behalf of North West CCGs. Performance is monitored, and progress against actions to improve performance, which is discussed at the fortnightly combined 999 and 111 performance improvement meetings with NWAS executives and NHSE/I. A revised Performance Improvement Plan (PIP) has been developed. The recruitment and training programme is ongoing with an additional 28 health advisors commencing Monday 23rd December 2019. Sickness remains a concern and additional management training continues to ensure staff are supported upon their return. AW voiced concerns around the underperformance of 111 and what assurance was being given by Blackpool CCG that they are doing all that is possible? ACTION: SC to request the latest version of the recovery plan from Blackpool CCG. Also, to obtain the national NWAS data to understand how this compares for the next QP Meeting. RTT (Referral to Treatment) For 2019/20, Wirral CCG and WUTH have jointly agreed an RTT Recovery Plan with trajectories to achieve 80% RTT compliance and zero 52 week waits consistently until March 2020. Wirral CCG 18 week RTT performance in November was largely driven by WUTH. The CCG missed the aggregate level incomplete pathway target, performing at 80% against a 92% standard. WUTH also failed the national standard and narrowly missed the locally agreed trajectory of 80%, achieving 78.1%. There continues to be zero 52 week breaches for both Wirral CCG & WUTH, since Apr-19. In November, there were 24,596 patients on the WUTH incomplete waiting list which is within the agreed trajectory of 24,736. These figures also include approximately 2,500 MSK patients. LQ highlighted that for December there had been 0 breaches. Cancer In November, Cancer Performance is showing continuous improvement, NHS Wirral CCG failed two performance standard (2/8) this month due to 3 patient breaches. WUTH has met all cancer standards for the last seven consecutive months. Challenges to the overall CCG position continue to arise from various system pressures, mostly unavoidable. The CCG narrowly missed the following standards this month; Cancer 31 Days Subsequent Surgery: Two patients have breached this target, one at Aintree/ Royal Liverpool & Broadgreen Trust due to elective cancellation (for non-medical reason) and the second patient at WUTH due to

SC

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inadequate robotic theatre capacity issues in Urology. The CCG has raised capacity and demand issues with the providers, who are aware of these patient breaches. Provision is constantly under review and patient pathway tracking is in place to ensure capacity meets demand. Cancer 62 Days Screening: One patient breached this performance standard within a two provider pathway - Referral day 42 RLBUTH to WUTH - Treated in 72 days - Breach shared RLBUTH and WUTH - Delay for initial scope then patient needed further scope and biopsies before decision for surgery. Diagnostics Wirral CCG narrowly missed the 1% performance standard in Nov-19 performing at 1.1%. The total number of diagnostic breaches for Wirral patients in Nov-19 was 73. The lowest performing provider in Nov was Liverpool Heart and Chest (LHCH) with 19 Wirral patients breaching the 6 weeks performance standard. They are continuing to experience challenges in CT/MRI with increased demand and the complexity of the radiological examinations requested. 5 patients breached at Liverpool University Hospitals NHS FT for Gastroscopy. They are undertaking additional sessions and are looking at capacity across the system to improve the position. CCG's main provider WUTH met the target at 0.8%, their overall diagnostics position improved in the recent months, specialities those were reporting breaches previously, such as Urodynamics, are now much closer to clearing their remaining backlogs. However recently there were issues in Radiology, in Nov there were 20 breaches for CT. This will remain under review. Improving Access to Psychological Therapies (IAPT) 32.6% of referrals recovered in November 2019, compared to 28.62% in November 2018. 92.4% waited less than 6 weeks and 99.7% waited less than 18 weeks in November 2019 compared to 85.8% and 99.1% respectively in November 2018. Mixed Sex Accommodation There were 26 combined MSA breaches in November 2019 i.e. 14 critical care patients, 6 in UMAC and 6 in SEU. LQ advised that the 6 UMAC and 6 SEU breaches involved only 2 patients. Transforming Care The Department of Health published ‘Transforming Care: A national response to Winterbourne View Hospital and the Concordat: Programme of Action’ in December 2012. The review of services received indicated that failings were widespread within the operating organisation but importantly also evident across the wider care system. The Concordat and 63 actions detailed within the review seek to address poor and inappropriate care and achieve the best outcomes for people with a learning disability, or autism, who may also have mental health needs or behaviour that challenges.

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In line with the Transforming Care Agenda and ‘Building the Right Support’, Wirral CCG has continued to work with partners to support people in the community and develop further services to ensure the continued reduction of inpatient bed numbers. The target was achieved in November 2019 (all patients are adults). The target of 4 remains for 2019/20. Current position explanation and issues The reporting of the LD Inpatients has changed to reflect only LD Assessment and Treatment beds (previously all patients with a diagnosis of LD and/or Autistic Spectrum Disorder (ASD) were included, even those in an acute mental health bed. However, NHSE wishes Wirral CCG to report on all admissions. The Tier 4 beds are case managed by NHSE specialist commissioning and no targets are set by NHSE regarding Tier 4 inpatient numbers. The CCG recognises as an outlier regionally with these admissions. Work continues to be undertaken in examining reasons (clinical, social and demographic) with the support of public health. Actions and processes previously outlined in response to the reduction admissions include:

▪ Weekly teleconference with relevant stakeholders to gain pace with any issues, with face to face meetings currently being arranged to build on this work

▪ Dynamic Support Database DSD for CYP & monthly tracker meetings supported by commissioners

▪ Undertaking an in depth analysis to understand why Wirral is an outlier, with a paper being presented to TCP Operational Board towards the end of January 2020

▪ CYP Intensive Support Function (of LD CAMHS) commenced mobilisation in Dec 2019, with key clinicians now in post. Work has commenced with consultations with clinicians and identifying cohort of CYP to engage with.

▪ Further worker on PID for Capital being developed with key partners out re. step up and step down provision/admission avoidance

▪ Engage with Local Authority colleagues to ensure all stakeholders are involved at the appropriate all relevant stages of the pathway.

SB1 advised that he will be attending a regional and national meeting for MH and LD (North West) on 29th January 2020 and will share the outcomes with the team. PC confirmed that a communication was being sent to all GP Practices again around LD data on Cerner. Healthcare Acquired Infections (HAI) LQ informed the committee that she has been notified by the Chief Nurse of an incident identified in the Wirral Hospitals laboratory regarding the second of a

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two part test for C Diff is currently being investigated. IPC at WUTH and Countess of Chester Hospital have been alerted to the incident. Public Health England have also been notified. This has led to some patients who have had equivocal results to being positive. A review of all patients affected is underway to ensure that treatment administered has been appropriate, and no clinical harm has been caused as a result of this incident. In addition, it has been highlighted that there has been data capture errors on the national Health Care Acquired Infections (HCAI) reporting system. In view of this, there is a potential that the HCAI reports to the board may be incorrect. ACTION: LQ to arrange for a deep dive to be undertaken into the two Health Care Acquired Infection issues for Q&P to assure Governing Body. This will be undertaken and brought back to the February QP Meeting.

LQ

2.3 MSK update SB2 gave an update on the current position of the progress made within the MSK service following the issuing Contract Performance Notice (CPN) being served and discussions at contract management meetings and clinical meetings. Updates on the actions are provided which shows significant progress against actions but identifies a number of areas where slippage has occurred, with 2 actions suspended as they are linked to recruitment issues. Waiting times have improved significantly especially for Musclo-skeletal Clinical Assessment Service (MCAS) and Physiotherapy. A proposal re waiting times and an amended dashboard has been received by the MSK Clinical Group on 7th January 2020 and any recommendations will be considered at the next MSK Contract Review Meeting on 22nd January 2020. MCAS are currently seeing 88% of patients within 3 weeks and within Physiotherapy 82% patients are seen within 8 weeks. SB flagged that the pain management service currently has an 18 week wait of which 34% of patients are being seen in the contract 8 weeks. SB2 went on to advise that challenges still remain in secondary care and a review of waiting times had been discussed at the clinical meeting on 7th January 2020, this will inform a contract variation by 31st January 2020.

SB2 confirmed that engagement for MSK has been taking place as a newsletter has been distributed and also have met with the GP Federations. Also further GP engagement will be discussed at the next clinical leads meeting. SB2 advised that the contract with Wirral Community Health & Care NHS Foundation Trust has now been signed.

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PC reported that a subgroup from the Overview and Scrutiny Committee (OSC) had advised that primary care is still not happy and that further engagement with Primary Care Networks (PCNs) and GP Federations is needed. In addition, Novembers Governing Body reviewed 3 options, with a 4th option proposed with a caveat that there was GP engagement around the service. It is felt that messages are not getting out to the wider GP community. Dr Ariaraj will be visiting GP practices and obtaining further feedback. LQ fed back that progress seems to have been made since the CPN has been in place, however there is slippage on the actions. LQ flagged that cover sheet for the MSK paper reflects the risk as being low, although it is felt that this is incorrectly assessed as there is a reputational risk for the CCG. SD aired concerns that the Rheumatology has the potential for patient harm and the explanation given as to why things have not changed is not acceptable. SB1 advised that it was appropriate that the CPN remains in place as the service is still failing to deliver what was agreed. Members agreed with the recommendation of the team, that the CPN should remain in place until further improvements have been made. 2.4 National Cancer Experience Survey (NCPES) SB2 presented the report and informed that this survey has run over the last 9 years and the cancer programme is designed to monitor national progress on cancer care, to drive local quality improvements, to assist commissioners and providers of cancer care and to inform the work of the various charities and stakeholder groups supporting cancer patients. The results was published in September 2019 and Wirral had scored 8.8 out of 10 (previously had scored 8.9). It was noted that there had been positive changes for Lung Cancer results which had been driven by the changes in the pathway.

SB2 advised that herself and Dr Jennifer Modi (Clinical Lead) had reviewed the report and had no concerns on regarding tertiary services. WUTH will also get their own version for review with their cancer team. Primary care could do more as had been scored low, 59%, which is in line with the national average, however it was felt that there is room for improvement.

SB2 advised that nurse training is provided however, the last session was

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cancelled due to low take up.

It was discussed that this was an opportunity for PCN’s to be involved more with cancer care and be involved early with any pathways.

AW fed back that this was a positive report and was assured regarding the waiting times.

RC queried if patients are fully aware of the different parties involved during their patient journey? For example: how much should GP’s are involved, and what to expect from different services with waiting times?

PC/SD explained how cancer patients are cared for within their own GP Practices, who are reviewed to see if there is anything differently that can be done and that there is an open door should they need it.

Members noted the report and supported the actions in place.

2.5 Compliance Report PE updated Continuing Healthcare (CHC) continues to be a theme for complaints which mainly involves funding eligibility and the length of the CHC process. PE reminded committee regarding topics discussed privately in Governing Body that these could end up in the public domain and concerns raised to MP’s for example there has been a number of MP Enquiries received around orthotics, thus there is a need to be mindful of decisions made as this might be open to further discussion and scrutiny. RC presented the serious incidents, which are broken down by type. It was noted that there has been an increase in ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria incidents and the Serious Incident Review Group (SIRG) requested for a review but this did not raise any gaps in care. It was noted that there are also a wide range of incidents reported and there was no Never Events during this reporting period. AW acknowledged the on-going work and continued success of the FOI team in meeting response deadlines. 2.6 Special Education Needs and Disability (SEND) update RC advised that following on from the last update at the November meeting, 10 areas have been identified within the service specification review as showing progress and a couple of items have yet to start.

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RC confirmed that an inspection is pending but assured that things are moving in the right direction and are compliant. This also needs to remain on the risk register and a further update will be provided to the March meeting. SB1 fed back that the trust between the joint commissioning arrangements with the local authority for children’s services is positive. RC also flagged that in relation to 2.8, Healthwatch are regular members of the Health and Wellbeing Board (but have not attended a number of meetings) but are sighted on progress with SEND through the updates to this meeting. A further invite to the SEND Strategic Group meeting has been made to Healthwatch but has not been accepted to date. Members noted the report and supported the recommendations.

QP19/20/0066

3.0 Items for Approval 3.1 HR Policies PE updated that there are 2 HR polices for review: Lone Worker Policy: Although staff are more office based there are times when staff will be off site or even if they are working late in the office, it needs to be assured that people are aware individuals are. Shared Parental Responsibility: As the definitions changes we need to ensure that the policy complies and reflects the current parental definitions which have been obtained from ACAS and implemented. Members approved the recommendations.

3.2 Area Prescribing Committee As there was no December meeting there are no items to raise.

QP19/20/0067

4.0 Items for Information 4.1 Other Committee Minutes Serious Incident Review Group (SIRG) Members noted the minutes from December’s SI meeting. AW fed back that was assured by the level of challenge given to providers and the level of commitment of the attendees to this meeting.

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Contracts Meetings No contract minutes for December due to cancelled meetings. Performance Group Minutes Members noted the minutes from December’s meeting 2020 Work plan The work plan will be reviewed when new Chair starts in February 2020, to ensure still appropriate and happy with the approach.

QP19/20/0068

5.0 Current Risk Register

There was nothing further to add

QP19/20/0069

6.0 Any Other Business AW thanked MT for his work during his 4 years at Wirral CCG.

QP19/20/0070

7.0 Communications from this meeting

Communication for new HR policies to be advised via Comms Team and uploaded to staff intranet.

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Minutes of the WCCG –Finance Committee – 17th December 2019 Page 1 of 8

WIRRAL CLINICAL COMMISSIONING GROUP

Finance Committee

Tuesday 17th December 2019 10:15am

Room 539, Marriss House

Present: Lesley Doherty (LD) Registered Nurse (chair) Alan Whittle (AW) Lay Member Mike Treharne (MT) Chief Finance Officer Dr Paula Cowan (PMC) Clinical Chair Anna Coyle (AC) PMO Manager Lorna Quigley (LQ) Director of Quality and Patient Safety Paul Edwards (PE) Director of Corporate Affairs Ken Jones (KJ) Deputy CFO Simon Banks (SB) Accountable Officer Dr Simon Delaney (SD) Medical Director Steve Cocks (SC) AD for Contracts and Delivery Emma Edwards (EE) Senior Reporting Accountant In Attendance: Chelsea Worthington (CW) Acting Senior Corporate Officer Chris Harrop (CH) Turnaround Director

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Preliminary Business 1.1 Apologies for absence There were no apologies received.

1.2 Declarations of Interest Declarations made by members are listed in the CCG’s Register of Interests. The Register is available via the CCG website at the following link: https://www.wirralccg.nhs.uk/about-us/whos-who/registers-of-interest/

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There were no declarations of interest. 1.3 Minutes & Action Points from previous meeting held on 26th November 2019. Minutes The minutes of the previous meeting held on 26th November were agreed as a true and accurate record.

Action Points Members noted the action log, all actions have been closed. 1.4 Matters Arising The RAG rated Financial Recovery Plan mitigations were circulated to members yesterday for noting.

Month 8 Financial Position EE presented the Month 8 financial position and brought members’ attention to the key issues. For Month 8, the CCG is reporting a year to date deficit position of £14.6m which deviates significantly from the planned breakeven position. The deficit is largely driven by 8/12ths of unidentified QIPP at £11.9m, less the full utilisation of the CCG’s £2.7m general contingency, plus non recurrent support provided to WUTH at Q1 £1.3m and Q2 £2.7m (both are repayable). In addition, there are also continuing pressures within commissioned out of hospital care and primary care prescribing. Members noted the table which shows a breakdown of the position by expenditure area. LQ provided an update on commissioned out of hospital care. There have been 90 fast track patients:

• 68 have been reviewed • 7 have passed away • 46 are continuing to receive packages of care • 4 have been re-admitted to hospital

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There has also been a desk top review of all packages/Broadcare and some packages have been realigned to children’s services from Month 8, transferring costs of £297k. Members noted that a deep dive has been commissioned by FRG for prescribing expenditure and medicines optimisation as at September. Prescribing costs were 10% higher than this time last year. CHC and prescribing are the CCG’s 2 biggest financial risks for the rest of the financial year. AW raised the mitigating action at NHS St Helens CCG regarding the accounting treatment for the pricing of Pregabalin which he has mentioned to KJ and MT. NHS St Helens CCG discussed this issue at a recent Audit Committee meeting and the external auditors (Grant Thornton) are sympathetic with the CCG’s view that an accrual should be made to represent the refund due to over-pricing, amounting to over £5m. It was agreed that the position for Wirral would be reviewed AW asked whether elective activity at Spa Medica was being challenged, given the over-spending against the contract value. NH and MT have met and advised that Spa Medica will now hold off on taking referrals and use the capacity for the rest of the year for other commissioners, which should save £200k. The risks and mitigations are submitted to NHSE and the figure included has also been included in the latest submission of the Financial Recovery Plan. Members agreed to change the forecast outturn figures at month 9.

2.2 2019/20 QIPP plan delivery update – M8

AC provided a M8 update on the 2019/20 QIPP Plan and the Programmes within it.

The Prescribing Programme has continued to over deliver, resulting in the year to date position being £540k above plan. Plans are currently being worked up by the Healthy Wirral Medicines Optimisation Group on additional schemes which are expected to deliver £380k of additional savings.

Currently the Commissioned Out of Hospital Packages of Care Programme is under achieving by £69k. Confirmation is being sought from the Head of Service as to whether the position is likely to improve by the end of the year.

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Focussed work is being undertaken on a review of all Fast-track packages of care and 28 day reviews which is expected to deliver an additional £500k in 2019/20.

Overall the Non-Elective Programme is currently £400k away from plan, however this is an improvement of £106k from the previous month.

The savings from the Planned Care Programme continue to be significantly away from plan with a year to date adverse variance of £432k.

At M8 for the identified element of the QIPP Plan the CCG should have delivered £4,202,666 and has delivered £3,841,258 (91%). Overall, including the unidentified element of the Plan, the CCG has reported delivery of £3,841,258 savings against a year to date plan of £16,162,666 (24%). All the figures included in the monitoring report are in line with the figures submitted to NHSE.

AW commented that the CCG should celebrate the success of achieving QIPP savings on identified schemes so far this year.

SB advised that there needs to be more robust arrangements in place for next year’s contract management arrangements for pathway changes, as they were included for this year but there has not been much progress with delivery.

2.3 Turnaround Director Update

The main change which has been made to the Financial Recovery Plan is the QIPP savings for CHC. It is good we can note the success of achieving the £6m QIPP savings. Members also noted the further system-wide savings which have been identified, £1m from the mental health services trust and just short of £1m for WCFT, Both the CCG and the acute trust will have similar deficits of £14m at year end. MT advised members of a recent conversation he had with NHS Sunderland CCG regarding Medicines Optimisation. The main reason for the apparent lower prescribing expenditure is due to inconsistent classification of dressings costs compared to Wirral.

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CH advised members that meetings have been set up in January to look at spending for 2019/20 to help plan for next financial year. One significant area for review is BCF.

2.4 Orthotics Procurement NH presented the report on the procurement process for Orthotics services. NH apologised for the tabled report due to late receipt of legal advice. Members noted that this paper is disclosable. After a 12-month scoping exercise and review of the Community Appliances Service, including engagement with patients and health professionals, a redesigned service model was produced with the intent to deliver a more integrated pathway and improved patient care. It was agreed to rename the service ‘Children and Adults Community Orthotics and Wigs Service’ and to complete a full procurement exercise to source a provider for this new model. In March 2019, a paper was submitted to the Governing Body outlining two options: to proceed to procurement for the new service or give a direct award to Wirral University Teaching Hospital NHS Foundation Trust (WUTH), incorporating the service into the existing MSK contract. In line with the recommendation in the paper, Governing Body approved the decision to procure. The procurement exercise began in March 2019 with the aim of service commencement from 1st April 2020. The procurement process was underpinned by a robust project implementation plan and overseen by the Orthotics Project Steering Group. All activities outlined in respect of pre-tender, tender and evaluation process were completed in line with the timeframes. There were three bids submitted for the contract, two of which came from the incumbent providers who provided the strongest bids. Evaluation of the tender documentation and presentations resulted in Bidder 2 ranking first in the quality element, although only one point above Bidder 1; however, the Bidder 1 financial offer was eight points above that of Bidder 2. Hence, combining the overall Quality and Cost award criteria when ranked, Bidder 1 came first overall. The tender process therefore concluded by recommending Bidder 1 as the winning bidder and a paper to this effect was put to Governing Body, with the bidders being anonymised as per established practice. Upon receiving approval for this paper, an intention to award letter was issued to Bidder 1. The contract award was subject to the completion of the standstill period, which allowed unsuccessful bidders to raise their concerns.

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During this standstill period, Bidder 2 advised that they would not work collaboratively with any external provider to deliver the procured integrated model, thus frustrating the procurement process and causing Wirral Health and Care Commissioning to reconsider its ability to award the contract as specified in the published tender. During the extended standstill period an informal discussion took place with both providers in respect of a collaborative service model and concluded with Bidder 2 confirming their unwillingness to work with a third party Prime Provider and Bidder 1 confirming their unwillingness to work with Bidder 2 under any other arrangement than that which was outlined in their tender submission. During the standstill period, on 23rd October, a letter was received from the Acting Director of Finance at Bidder 2, objecting to the outcome of the procurement, and requesting an extension to the standstill period to allow for their objections to be considered. The letter included questions around the technical process undertaken, serious concerns around the likely effect of the award on the hospital’s service, and stated that Wirral Health and Care Commissioning had acted contrary to ‘the commitment to the Healthy Wirral Programme principles of ‘Acting as One’ and the CEP-Lite approach to contracting’. A further extension of the standstill period was agreed until 14th November to review the issues raised by Bidder 2, and all bidders were informed of the extension. SB advised that bidder 2 had a meeting with himself and PC to advise that they were not happy with the decision which had been made and explained the costs which would be incurred by them through stopping the service. As highlighted above this meeting was after the letter was sent out to the bidders on the 23rd October. The current plan is to write to the existing providers seeking to extend the contract for a further 12 months whilst the CCG reviews the current service model. It was confirmed that Finance Committee are not a decision-making body and the conversation will need to be had at Governing Body with members. AC asked of the risk of Bidder 1 not extending service provision past March 2020. Where will all those patients be seen that were with that provider?

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PC suggested completing a “lessons learnt” review when a final decision has been made on this. LQ asked about the financial risk to the CCG? NH explained that if awarded to bidder 1 there would have been some savings. Having both providers extend for a further 12 months will bring no savings to the CCG during that period. Finance Committee noted that the procurement will not be going ahead, and that Governing Body had previously noted the procurement process which was taking place. The Finance Committee can advise the Governing Body that it notes the financial impact and members are aware that discussions at this committee can not help influence the Governing Body’s decision. For any contract extension then GB must make the decision. SB and PE will work together on how this will be taken forward to Governing Body. AW advised that GB members may seek assurance that service continuity will be provided beyond March 2020. A QIA will be completed first so that members can look at the options available. Members questioned whether the bidders can object to an extension of the contract? There was a clause in the bidders’ current contracts to advise that an extension of up to a year can be added on but this has already taken place and if extended again it is the providers’ decision whether they wish to extend or not.

2.5 Communication requirements from this meeting There were no communication requirements from this meeting.

3.1 Finance Committee Risk Register Members discussed the current risk register for the Finance Committee. The change in Forecast outturn position will need to be updated within the Finance Committee risk register, this will be altered once it has been approved by NHSE, members agreed to review the risk in January. Once the Orthotics Procurement Process has been to GB this may need to be added to the risk register.

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LQ advised members that the Terms of Reference are still waiting to be agreed by NHSE/I for risk 19/20C.

Any Other Business There was no other business discussed.

Date and Time of Next Meeting

Tuesday 28th January 2020, 10.15-11.45am, Room 539, Marriss House

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Minutes of the WCCG –Finance Committee – 28th January 2020 Page 1 of 12

WIRRAL CLINICAL COMMISSIONING GROUP

Finance Committee

Tuesday 28th January 2020 10:15am

Room 539, Marriss House

Present: Lesley Doherty (LD) Registered Nurse (chair) Alan Whittle (AW) Lay Member Mike Treharne (MT) Chief Finance Officer Dr Paula Cowan (PMC) Clinical Chair Anna Coyle (AC) PMO Manager Lorna Quigley (LQ) Director of Quality and Patient Safety (left the meeting after 2.9) Paul Edwards (PE) Director of Corporate Affairs Ken Jones (KJ) Deputy CFO Simon Banks (SB) Accountable Officer Dr Simon Delaney (SD) Medical Director Steve Cocks (SC) AD for Contracts and Delivery Emma Edwards (EE) Senior Reporting Accountant In Attendance: Chelsea Worthington (CW) Acting Senior Corporate Officer Chris Harrop (CH) Turnaround Director Sam Kirby (SK) Lead Divisional Pharmacist WUTH Norma Currie (NC) Senior Lead Commissioning Manager for LD and or

Autism (Transforming Care)

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ance Committee

28.1.20

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Action

Preliminary Business 1.1 Apologies for absence Apologies were received for Nesta Hawker. LQ was in attendance for items up till 2.9.

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1.2 Declarations of Interest Declarations made by members are listed in the CCG’s Register of Interests. The Register is available via the CCG website at the following link: https://www.wirralccg.nhs.uk/about-us/whos-who/registers-of-interest/ There were no declarations of interest. 1.3 Minutes & Action Points from previous meeting held on 17th December 2019. Minutes The minutes of the previous meeting held on 17th December were agreed as a true and accurate record.

Action Points Members noted that all actions have been closed. 1.4 Matters Arising SB advised members that the Wirral System received a letter from Jonathan Stephens with regards to the system distance from trajectory for 2020/21 plans which equates to £19m. The CCG will be challenged on this and is being asked to deliver an improved trajectory. Of the Cheshire and Merseyside patch, Wirral and Cumbria fall into the top 10 highest risk systems. SB and Claire Wilson are going to London for a recovery support regime conference on 5/2/20. There is a meeting scheduled Thursday afternoon for the DoFs and Chief Execs to discuss Financial Recovery and to work on the system plan which was also discussed in the Financial Recovery Group meeting. MT advised that there is a table which breaks down the £19m distance from target for 2020/21, although it is more than likely to be £26m for the system. This table is to be circulated and discussed before the conference on the 5th February. The conference will also confirm what system recovery help the CCG will get. Prescribing Accrual

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The CCG has looked for some time at trying to include a prescribing accrual adjustment in relation to year-end prescribing into its figures in order to help mitigate financial pressures for the year end. Members noted the two letters which have been included. The first is from St Helens CCG who have implemented these changes and the second from Sefton CCG who are about to implement the changes. There is the potential to reduce expenditure by approx. £727k by implementing a change in accounting practices in relation to over 28 day prescribing at the year end. Previously there has been reluctance from GPs to change clinical practice, but clearly other CCGs have implemented the change. It was suggested that this discussion should be had at the Finance Committee prior to the Audit Committee in order to ensure that everyone is clear on the implications. For our auditors to accept this change an audit trail is required, with communication and discussion with GPs. SD advised that himself and MT have had this discussion but no wider discussion with GPs has taken place. It is noted that there is support for this change to take place but there is a feeling that letters to GPs should not be sent out. CH asked if there was an option for a technical adjustment from April which MT advised he was happy to endorse this approach. AW mentioned that the size of the one-off financial benefit from this proposal was broadly equivalent to recent in-month overspendings against the prescribing budget. He suggested that the CCG should be trying to get a grip on the prescribing spending trends. LD asked what the risks are with this? MT advised that it is below the External Audit defined £9m threshold for materiality and the CCG may receive an additional letter when signing off this year’s accounts. Members agree to action the Prescribing accruals adjustment but not to send a letter to the GPs. The final discussion will have to be had at the Audit Committee.

2.1 Month 9 Financial Position The Month 9 report sets out the financial position for NHS Wirral Clinical Commissioning Group (NHS Wirral CCG) as at the end of December. The main headlines are –

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• Year to date position of £15.8m. The CCG’s control total was set by NHS England as break-even which means the CCG is significantly off target.

• The CCG position compromises of an overspend of £3.4m across NHS Contracts. Non-NHS contracts are overspending by £256k and prescribing is overspending by £2.1m an adverse movement of £651k from Month 8. The remainder of the pressure is due to unidentified QIPP (partly offset using contingency) £10.7m. there are also some small non-recurrent prior year fall outs supporting the month 9 position.

• At the end of December, the CCG had reported a year end forecast outturn of breakeven to NHS England in accordance with its control total, despite the extremely challenging level of QIPP required and the amount that remains unidentified.

• There are also further operational pressures within prescribing and commissioning out of hospital healthcare in addition to the net risk reported to NHS England of £13.975m which is now in line with the latest Financial Recovery Plan submitted in December. It is further anticipated that this risk adjusted forecast will be formalised with NHSE/I as a revised control total in Month 10.

• The CCG’s QIPP target is £24.245m of which £17.941m remains unidentified, this pressure will continue to add to the deficit position each month going forward.

It should be noted that £2.7m of the CCG’s contingency (the full amount) has been utilised to support the year to date financial position given the developing pressures outlined as well as the additional non-recurrent support to WUTH. The financial position for the Wirral system is reported through the Healthy Wirral Partners board. Formal directions from NHS England remain in place and all systems need to have a well-defined and deliverable plan with all system members being clear on the actions. KJ advised that normally if providers have a surplus, then this is put towards the bottom line for the system which is not the case this year and conversations regarding brokerage may need to take place.

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Members asked why electives are under performing? PC advised that this may be due to reluctance from consultants to undertake additional sessions due to the adverse pension implications. SB brought members’ attention to the 52-week waiter reported and advised that this will need to be picked up at the Quality and Performance meeting. LQ advised that she is attending an RTT meeting at the Trust after this meeting where this will be discussed and LQ will feedback to members.

2.2 Update on WUTH year end elective outturn dispute The main purpose of this paper is to explain the context of the current dispute between WHCC and WUTH in respect of the forecast underperformance of elective inpatients/day cases, and how they should be treated in both organisations’ year end forecast. MT discussed the key issues and proposed options from the paper. Any further under-performance in year will be discussed at the contract meetings to provide an audit trail. KJ advised that when contracts were signed for this year, electives were always included in PbR, so why is WHCC subsidising the Trust’s under performance? For the next contract round the CCG will be moving away from PbR and this is where there needs to be more realistic conversations regarding elective activity capacity. SB advised that option 3 is the best option but does agree with KJ’s challenge as to why is the CCG paying for this? Members asked if a separate paper could be included on the next agenda regarding the change in WUTH’s under performance. CW to include agenda item for the February meeting. Members agreed to support the preferred option 3.

2.3 Impact on 2020/21 of mitigating actions KJ advised that the report sets out the impact of pressures emerging in 2019/20 and the carry forward effect into the 2020/21 planning round and financial year. The current financial recovery plan reports a revised forecast outturn for the CCG of a £13.975m deficit for 2019/20 financial year. In order to reach £13.975m deficit, there are a number of mitigations needed, some of which

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are non-recurrent and will impact on the planning assumptions for 2020/21 financial year. This was also discussed in the FRG meeting earlier this morning. The £4.5m existing mitigations will already have an impact on next year. KJ suspects that when the operational plan goes to Governing Body members will be looking for assurance from the Finance Committee, this paper will also be included on the February Governing Body private agenda.

2.4 2019/20 QIPP plan delivery update – M9

AC presented the M9 QIPP monitoring report. For identified schemes, good delivery of savings has been maintained.

2.5 Turnaround Director Update

CH provided members with an update regarding:

• current financial position, progress towards the Financial Recovery Plan and the current issues across the Wirral system.

• the work being undertaken by the Turnaround Director and associates and the impact this is having on the CCG Financial Position and the wider Healthy Wirral Programme.

• the next steps and the proposed approach for Q4 and beyond.

2.6 Update on Transfer of the Continuing Healthcare and Complex Care Team Following the approval from private Governing Body in September 2019 to explore an alternative provider for the Continuing Health Care and Complex Care teams a project team has been established to manage this programme of work for the transition by 31st March 2020. This paper is to give Finance Committee an update on the progress made to date and to identify the key risks to delivery.

LQ advised that a provider for delivering this service has been identified and they are in the process of discussing with their Governing Body, once this has been agreed LQ will provide members with a further update. Staff will then start to transfer over and will be in place by 1st April 2020.

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2.7 Commissioned out of Hospital Care update on Operational Budget (Month 9) Commissioned out of Hospital Care includes all care that is commissioned on an individual basis for people who have continuing Health Care or Complex Care needs. The total budget for this service is £49.5m, as described in the budget report forecast outturn is now a £4m overspend which has increased by £758k against last month’s forecast out turn position. It is expected that this trend will continue in month 10. Members will note the issues relating to the overspend and the measures in place. QIPP

The 2019/20 QIPP plan for Commissioned out of Hospital Care is £1.3m. To date this has delivered £846,662 in savings with the expectation that this will fully deliver by March 2020.

Operational Budget

In addition to the actions that are described within the finance report there are a number of additional actions that are being undertaken to manage the operational budget

Broadcare: This is a procured clinical system which is used by Commissioners for recording care packages and the payment of care packages. There is a delay between the procurement of the package of care and the uploading of the information onto the Broadcare system. This delay can lead to inaccurate financial forecasting. A review is being undertaken looking at an index case to understand the issues and put remedial actions in place.

Fastrack: Work has commenced at pace in relation to fast track referrals, MDTs are commencing w/c 4th February. The initial review has identified a number of issues including the identification of the rapidly deteriorating patient and reviews post discharge. A four-day rapid improvement event is being

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undertaken from 2nd February to address these issues. There are 91 reviews to take place and 70 have already been undertaken.

ADAM/DPS. Notice has been given on this contract which has been seen as problematic from a quality and finance perspective. In the interim a “soft ceiling” has been applied which is a cost envelope of £800 to prevent more expensive homes from bidding. This trial commenced 13th January 2020.

Mental Health: Monthly Mental health panels have been re-established as a way of reviewing proposed packages of care. These are chaired by the CCG and the Finance team will attend to observe. This will add more “challenge” to the decision-making process and ensure that timely reviews are being undertaken.

Action- LQ to bring the best estimated figure for the year end to the next meeting.

2.8 Referral Assessment Proposals Referral Assessment Service (RAS) provides clinicians with the ability to triage referrals before booking an appointment, both to support complex clinical pathways and to help manage demand for elective care services. RAS allows clinicians to review the Clinical Referral Information (CRI) without the need for an appointment to have been booked. RAS enables clinicians to assess the CRI from the GP/referrer and make an informed decision on the most appropriate onward clinical pathway. Clinicians can either; accept the referral, return the triage request to the original referrer with advice or redirect the referral to another speciality. Members agreed that whilst this is supported, it’s a small step taken within the last 15 months when discussions have taken place on larger scale transformation of outpatient services. PC advised that she is supportive of this to happen but expressed her disappointment that a WUTH clinician has not been included in the development of this. Although the pilot will be in Nephrology, it’s been identified that this needs to take place in a number of different areas and these will need to also be presented at Finance Committee to keep them up to date and provide assurance. It would be useful to know what conversations that took place with LMC and what cost is being taken out of the system.

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Finance Committee approved this pilot.

2.9 Reduction of Assessment Treatment Beds across Cheshire and Wirral NC presented the proposal to reduce the number of assessment treatment beds across Cheshire and Wirral. Building the Right Support (BRS 2015), for people with Learning Disabilities and or Autism is a national plan to develop community services and close inpatient facilities for people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition.

In accordance with this, Cheshire & Wirral CCGs have agreed with Cheshire & Wirral Partnership Trust (CWP) to reduce the current Assessment and Treatment (A&T) bed numbers from 16 to 12. This is in line with the national targets set. Wirral is currently an outlier for children with Learning Disabilities and Autism who are admitted into CAMHS specialised commissioning beds. The majority of Wirral CYP admissions have autism and therefore we plan to work with CWP to look at developing the right community support for this particular cohort of CYP along with the Intensive support function of LD CAMHS. The request is therefore for CWP to retain the funding for the reduced beds in order to invest in these services. Current funding sources NHSE bid money for CYP ISF - £348,489, non-recurrent has been agreed to be used for supporting children and young people by reducing the bed numbers and those using community services. If Wirral does require further beds then it has been agreed that we can use one of the Cheshire beds and vice versa. Although the bed numbers we commission will reduce the beds are still there. SB supports this given the rise in demand for children and young people. Noting that CWP have agreed that they can manage the enhanced service within the set budget, members agreed the paper and all recommendations.

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2.10 Individual Patient DOAC reviews SK was in attendance to present the DOAC review paper. There is a significant expenditure on Direct Oral Anticoagulants (DOACs) in the Wirral health economy with numbers continuing to rise. National guidance indicates that Edoxaban offers clinical equivalence to other DOACs for stroke prevention in Nonvalvular Atrial Fibrillation (NVAF). The Pan Mersey Area Prescribing Committee recommends in the absence of a specific clinical reason to select a particular DOAC, that the least expensive DOAC for patients with NVAF should be used, currently Edoxaban. The majority share in DOAC prescribing across Wirral is Apixaban with 61% (~4000 patients) of prescribing compared to Edoxaban at 5%. Currently the cost difference between Apixaban and Edoxaban is £182.50/per patient year. This proposed scheme detailed in the report attempts to provide individual patient reviews for those on DOACs and to switch those appropriate onto the most cost effective and clinically appropriate option. Education for prescribing colleagues in primary care will also be essential to ensure the most appropriate option is prescribed in the first instance. SK explained that the first target for the DOAC review would be to get the GPs to discuss the change with their patients. We are asking WUTH staff to look at 10 patient reviews per clinic at the GP surgeries or community pharmacies which are local to patients. There are 360 reviews, but the scheme is for 6000 patients and we are considering how we get this in place from April 2020. Currently this is just for practices with a pharmacist, to make sure it works and then it will be rolled out Wirral wide. It was noted that SD and Saket Jalan are supportive of this as GPs on Wirral. We are wanting to make every contact count within the service and what other services/interventions are available. Members also noted that this is something which has already been done in Chester. The work which is being done in the pilot by GPs is just the switching and letters have gone out to all practices, we still start to see financial savings from 2020/21. Action AC to check with Caroline Crouch regarding the letters to GP practices.

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This paper has also been discussed at BMG and ask from them was that clinical pharmacist would be charged next financial year which SK confirmed the Trust is happy to do. Members noted that if prices change or become off licensed then this may need to be reviewed again but this will be 6 years or more into the future. Members agreed this paper.

2.11 Finance Committee Terms of Reference PE presented the current version of the Terms of Reference for Finance Committee. PE discussed with members the new constitution standards from NHS England, the only change would be to remove ‘Lay Member’ from LD’s title.

2.12 Financial Recovery Group (FRG) Terms of Reference AC presented the FRG terms of reference and discussed the main changes to be:

• SB is now chair and will hold members to account • The BMG group will have final sign off of papers

Members agreed both of these changes. PC raised the current set up of FRG being held immediately before the Finance Committee. There is some unavoidable duplication as not all members of Finance Committee attend FRG. PE advised that both meetings were established following the Capability review and they were moved inline so that there was better attendance at the meetings. SB now chairs FRG as the SRO for delivery and to hold people to account. It was agreed for this to be picked up outside of the meeting and discussed in April when the new CFO starts, to confirm what FRG’s role will be going forward. The revised version will be included on the April agenda.

2.13 Summary of proposed changes to the 2020/21 NHS Standard contract SC highlighted the in-year changes and advised that he will keep committee members up to date with any progress. Members noted the paper.

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2.14 Communication requirements from this meeting To make sure that staff are following processes and that the right papers are going to the right meetings.

3.1 Finance Committee Risk Register There are no changes to the Finance Committee risk register at this stage This will be reviewed again at the next meeting.

3.2 PFEG Finance report Members noted the PFEG Finance report from the January PFEG meeting. KJ provided a further update on the discussions which took place at the meeting regarding the potential pressures from both the Council and CCG for year end. The February meeting has been cancelled, CW will speak with Nicky Peel to see if we can get a date in the diary.

Any Other Business As this is MT’s last week, LD thanked MT for all his time and contribution to the meeting over the past 4 years.

Date and Time of Next Meeting

Tuesday 25th February 2020, 10.15-11.45am, Room 539, Marriss House

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S i g n e d – C h a i r P a g e 1 of 9

Audit Committee Meeting

Thursday 21st November 2019

2pm - 5pm, Room 514, Marriss House

Present: Alan Whittle (AW) Lay Member (Audit & Governance) Chair David Murray (DM) Audit Lay Member Dilys Quinlan (DQ) Audit Lay Member Bernard Halley (BH) Audit Lay Member In Attendance: Chelsea Worthington (CW) Acting Senior Corporate Officer (minute taker) Laura Leadsom (LL) Corporate Affairs Manager Paul Edwards (PE) Director of Corporate Affairs Mike Treharne (MT) Chief Finance Officer Clare Shelley (CJ) Head of Financial Services Ann Ellis (AE) MIAA Robin Baker (RB) Grant Thornton Helen Stevenson (HS) Grant Thornton Ken Jones (KJ) Deputy Chief Finance Officer Pippa Joyce (PJ) IG MLCSU Linda Roberts (LR) Lay Member for Audit and Governance

Item No. Agenda Items

Action

AC19-20/3

PRELIMINARY BUSINESS

1.1

Apologies: There were no apologies. AW welcome members to the meeting, in particular PJ who was in attendance for the first time and LR in her role as chair of the Quality and Performance Committee.

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AW congratulated DQ on her recent appointment as a Lay Member at Warrington CCG.

1.2

Declarations of Interest: AW reminded members of their requirements to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of NHS Wirral Clinical Commissioning Group. This will be addressed at each meeting and a declaration must be made by anyone who has an ‘individual’ conflict of interest with an agenda item in the meeting. The chair will then make a ruling as to the action to take considering the significance of that conflict.

Declarations by members are listed in the CCG’s Register of Interests. The Register is available via the CCG website at the following link: https://www.wirralccg.nhs.uk/about-us/whos-who/registers-of-interest/ Relating to item 2.2, AE declared that she works for MIAA, the company which the CCG’s Turnaround Director works for. It was noted that the renewal of the Grant Thornton contract is also on the agenda for information, this has already been to the CCG’s Governing Body and is on today’s agenda for information. AW proposed that Grant Thornton representatives should remain in the room for this item, and this was agreed by the committee.

1.3

Minutes /Action points of previous meeting held on Thursday 19th September 2019 The minutes of the previous meeting held on 19th September 2019 were reviewed and members agreed them to be a true and accurate record of the meeting, subject to the amendment that Financial Services are being transferred in house to the CCG from 1stDecember 2019. Members noted that CS was recently appointed as the Financial Services Accountant who will manage the new service, including overseeing the transfer of staff from NHS West Cheshire CCG. The SORD will be updated to reflect the financial services changes and an updated version will be included on the January agenda. CS was congratulated on this appointment. Actions The actions agreed at the meeting held on 19th September were discussed. AP43: MT is assured that this action has been completed, MT to find the original email and send documents to members for their assurance. AP45: This action has been closed.

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AP46: LL is working with the CHC team to arrange a day when all staff are in the office for UPrint to come in and set up the PIN numbers on the printers for everyone. It is hopeful that this task will be completed on 11th December when all staff will attend a team meeting, a further update will be provided at the January meeting. DM queried if this would be something that could be rolled out to all CCG staff, which LL and MT agreed to investigate.

1.4 Matters Arising AW advised members that the Finance Committee has received assurance that the QIPP savings associated with the management of CHC assessments and reviews has not been double counted and that the expected savings will be delivered for this financial year. Feedback on the Grip and Control checklist completed by the CCG has been received from NHS England, and a letter including a number of actions was provided to the CCG, which is being worked through. Action MT to share with members and the response letter.

1.5 Audit Tracker LL presented the Audit Tracker. Audit Tracker action 5 - Managing Conflicts of Interest: a section has been added to the Tender Waiver form and this will now be the standard form rolled out to staff. A copy of the updated form was provided to committee members. Members agreed for this action to be closed. Audit Tracker action 2 - Risk Management Review: training has been arranged; PE will send to BH who is happy to observe the session. Members agreed for this action to be closed. Audit Tracker actions 1 & 2 - PMO review: Anna Coyle has now provided updates and changed the completion date to January 2020 which has also been agreed with AE from MIAA. Audit Tracker action 3 - PMO review: members agreed for this action to be closed.

AC19-20/3

ITEMS FOR DISCUSSION

CCG Agenda Items

2.1 Quality and Performance Committee LR attended to present the update on the committee’s effectiveness. LR explained that the QP Committee has completed the action plan which was issued by MIAA following the last committee effectiveness review and

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the committee is now reviewing agenda the papers and how often things are reviewed at the committee. Key areas are picked up on and deep dives are completed where members feel necessary. The committee is getting better assurance from the monitoring of NHS contracts which had been an area of frustration in the past. There is a broad business remit which the committee covers in reviewing risk management arrangements, narrative within the risk register has been significantly improved to help assure members, and the committee also receives committee minutes from contract meetings and the Serious Incidents Group for scruitiny. DM queried if the CCG is assured that the contracts manager has the skills for these meetings and how do we monitor any gaps. LR advised that it is hard to monitor any gaps as QP only receives the minutes. It may be worth LR attending a contract meeting for assurance as previously with the Serious Incident group. MT confirmed that he has confidence in the team members. DQ raised the Area Prescribing Committee quoracy issues. This is yet to be resolved, as the GPs members can never attend the scheduled date, but a temporary solution has been put into place. If there are any contentious items to be considered they require to be signed off at another meeting. If all members present agree with a recommendation, then it is approved or signed off at the committee even though it is not quorate. It has also been suggested that the Terms of Reference of the committee be reviewed to avoid quoracy problems. AW thanked LR for her report and assurance provided. 2.2 Review Tenders Waived and Losses and Special Payments There have been no losses written off or special payments made for the period 20th September 2019 to the 21st November 2019.. As such, there was no register of losses and special payments included within the report. There has been one tender waiver approved since the last meeting of the Committee in respect of a further extension of the Turnaround Package provided by MIAA since the CCG was placed under directions in August 2019.

NHS Wirral CCG was notified in August 2018 that NHS England (NHSE) has reapplied its power to enforce Directions in order to ensure the financial position is addressed. As MIAA had already been commissioned by NHS Wirral CCG on behalf of the Wirral system as a whole, the Chief Officer approached MIAA to enhance the support to the Wirral system in the form of a formalised Turnaround Director package to fulfil the requirements set out by NHS England in the directions letter At the last Audit Committee meeting members suggested that if the Turnaround package was to be extended, this should be done for a period of 6 months till the end of the financial year. A further extension was agreed for the period October 2019 to March 2020 at a cost of £75,000. Members noted

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a copy of the completed tender waiver form included within the paper. The directions letter states that a Turnaround function is required for the whole Wirral system and not just the CCG, actions included within the letter also state that they are to be completed by the Wirral System. RB queried why VAT is not applicable to this? KJ to check and feedback to the committee. Members noted the tender waiver. Action: KJ to report back to the committee on the VAT issue. 2.3 Review Information Governance report PR presented the IG report. The key achievements/progress for the past 2 months:

• Met with SIRO to discuss a new way of working for reporting on risks within the CCG

• Started U Assure project within the CCG

• Created timelines which have been accepted by SIRO

• Increased site visits to once a fortnight to build relationship between the CSU and CCG

• Improvement in relationship between the CSU and CCG will have an impact of information being shared.

• Increasing the visibility of the CSU team within the CCG will mean that CCG staff will be able to rely on CSU to provide updates and advice more readily.

• Baseline submission of the toolkit was completed on the 31st October

Key objectives for November and December:

• Complete all face to face IG Refreshe training

• Complete IAA and IAO training • Continue to work to the IG Delivery

Plan • Commence U Assure update • Work towards implementation of

quarterly Risk Visual • Create more visibility of the Toolkit

assertions for the CCG

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• Include percentage of DSPT complete in next Bi-Monthly report

Issues that have been identified:

• Lack of quality information in Bi-Monthly reports – Due to there being disjointed information being communicated between CSU and CCG, the information held in Bi-Monthly reports is lacking full descriptions. This means reporting on dates, delays, lessons learned are not thorough.

• Breach reporting is too vague • SAR information is too vague • Update on toolkit completion is too vague

BH welcomed the more focused approach towards the toolkit as the missing dates and amber RAG rating can be worrying. Appendix A within the pack has been provided as it needs members to agree, this will then go live on the website. Members discussed some amends for PR to make before this goes live. MT advised that he is more assured with the work and presence of PJ as our IG lead compared to this time last year when we were working with IG interim consultants. 2.4 Review Internal Audit Progress report AE explained that since the previous meeting of the Audit Committee, the following reviews have been finalised:

• Personal Health Budgets (PHBs) – ‘Limited Assurance’. • Finance Shared Service – 3rd Party Assurance – ‘Substantial

Assurance’. The Integrated Commissioning (Section 75) review and the Financial Systems, Reporting and Integrity review are in fieldwork stage. The Personal Health Budgets audit was given’ limited assurance’ and there were 2 high and 4 medium risks identified, this audit was also completed as a joint review with the Anti-Fraud service (NHSCFA). MIAA has reviewed Personal Health Budgets previously, when numerous control system weaknesses were identified. KJ raised his concerns regarding the Personal Health Budget overpayment recovery arrangements, which the guidance highlights should be completed by the finance department. KJ advised that he has spoken to the CHC team regarding this, but it is not yet resolved.

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It was agreed that an action plan will be prepared for the next meeting, which will allow the CCG to monitor the recommendations via the Action Tracker report. MT agreed that he will discuss the report with Nesta Hawker to identify who will pick this up in Iain Stewart’s absence. Committee members requested that either Iain Stewart or Lorna Quigley attend the next meeting to present and report progress on implementation of the action plan. BH raised concerns that there is a contractual issue related to the performance of the Broadcare system that should be addressed. Internal Audit follow up report Members noted the MIAA follow up report. MIAA Insight The MIAA insight was provided for information. 2.5 Review External Audit progress report RB presented the External Audit progress report. 2018/19 Grant Thornton’s audit of the 2018/19 financial statements is complete and the findings report was discussed with members at the meeting in May and then with the CCG’s Governing Body. Members will note that the Audit opinion was signed off on the 28th May. 2019/20 Formal work will begin later in the year but in the meantime, members will note that Grant Thornton will:

• Continue to have regular discussions with management to inform risk assessment for 2019/20 financial and value for money audits

• Review board papers and latest financial and operational performance reports

• Consider any reports from the regulators regarding operational effectiveness.

Members noted that RB, HS and MT had a pre meet ahead of Audit Committee and discussed the issue of the current Wirral System financial performance, and members noted the likelihood that a section 30 report would be issued. Consultation – New Code of Audit Practice from 2020 Schedule 6 of the Act requires that the Code be reviewed, and revisions considered at least every five years. The current Code came into force on 1 April 2015, and the maximum five year lifespan of the Code means it now

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needs to be reviewed and a new Code laid in Parliament in time for it to come in to force no later than 1 April 2020. The most significant changes are in relation to the Value for Money arrangements. Rather than require auditors to focus on delivering an overall, binary, conclusion about whether proper arrangements were in place during the previous financial year, the draft Code requires auditors to issue a commentary on each of the criteria. This will allow auditors to tailor their commentaries to local circumstances. Report on Mental Health Investment Standard (MHIS) HS provided members with an update on the Mental Health Investment Standard compliance statement and explained the purpose of the report and the approach to materiality. The CCG’s draft Compliance Statement recorded: NHS Wirral CCG considers that it has complied with the requirements of the Mental Health Investment Standard for 2018/19. Our work on your MHIS Compliance Statement is substantially complete although we are finalising our procedures in respect of: • obtaining a letter of representation from management Subject to this, we are proposing to issue an unmodified opinion on your MHIS Compliance Statement.

AC19-20/3 ITEMS FOR INFORMATION

3.1 Conflicts of Interest Indicator Members noted the quarterly return to NHS England and that the CCG is compliant in relation to Conflicts of Interest indicator. 3.2 Report of extension of the current External Audit contract AW advised that each of the 6 Governing Bodies which form the Joint Auditor Panel will receive a copy of the report recommending a 2 year extension of the contract with Grant Thornton. Audit Committee noted the assessment of the External Auditor’s performance and noted the approval of the Governing Body at its last meeting for the 2 year extension of the contract. 3.3 Financial Control self-assessment report to NHS England Members noted the financial self-assessment report which has been submitted to NHS England for quarter 2. DM advised that it would have been appreciated to have a one page covering sheet to advise of the RAG rating and numbers included. Members noted that the Q1 column defaulted to red as the CCG was not required to submit a return in Q1. 3.4 WHCC Contracting Procurement schedule

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Members noted the WHCC contracting procurement schedule and agree this provides assurance of the grip on the contracting process. 3.5 Audit Committee – Workplan Members noted the workplan. KJ asked if the reporting and accounting item can be deferred to the January meeting and AG asked if the fraud name could be changed to Anti-Fraud. These changes were agreed. 3.6 2020 Audit Committee meeting dates Members noted the confirmed 2020 dates.

AC19-20/3 ANY OTHER BUSINESS

4.1

Any other business There were no other items discussed.

AC19-20/3 DATE AND TIME OF NEXT MEETING

The next meeting will be held on: Thursday 30th January 2019, 10.00am in room 539 Please forward apologies / agenda papers to [email protected]

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Cheshire and Merseyside Collaborative Commissioning Forum Notes

13th November 2019, 9.30am – 12.30pm

Room 514 – Wirral CCG,

Marriss House, Hamilton Street, Birkenhead, Wirral CH41 5AL Attendees:

Dr Andrew Wilson (AW) Chair – NHS Eastern and South Cheshire CCGs (CHAIR) Simon Banks (SB) Chief Officer – NHS Wirral CCG and Wirral Health and Care

Commissioning Dr Paula Cowan (PC) Chair – NHS Wirral CCG and Wirral Health and Care

Commissioning Clare Watson (CW) Accountable Officer – Cheshire CCG’s Leigh Thompson (LT) Chief Commissioner – NHS Halton CCG Jan Ledward (JL) Chief Officer – NHS Liverpool CCG Dr Fiona Lemmens (FL) Chair – NHS Liverpool CCG Martin McDowell (MMc) CFO – NHS South Sefton & Southport & Formby CCG Tony Woods (TW) Director of Strategy & Performance – NHS Knowsley CCG Eileen O’Meara (EOM) DPH – CM Population Health Board & CHAMPS Dr Ian Watson (IW) Chair – Warrington CCG

In attendance:

Karen Duckworth (KD) NHS Wirral CCG and Wirral Health and Care Commissioning Senior Corporate Officer (meeting support)

Paula Wells (PW) Project Manager – C&M CCF


1.0 Preliminary Business

Welcome and Apologies The Chair welcomed everyone to the meeting and introductions made. Apologies were received for the following: Fiona Taylor Rob Caudwell Iain Stoddart Craig Gillespie Andy Davies Andrew Bibby Geoffrey Appleton David Merrill

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Tracey Cole

Minutes & Action Points from previous meeting held on the 23rd July 2019 Minutes The minutes of the previous meeting held on 23rd July 2019 were agreed as a true account of the meeting. Action Points The group reviewed the outstanding actions recorded and noted the updates provided on the progress to date. Matters Arising

It was confirmed that Alan Yates, is the new Chair of the Cheshire and Merseyside Health and Care Partnership.

2.0 Business Items

C&M Directors of Commissioning Update: • Directors of Commissioning (DoC) Terms of Reference (ToR):

The DoC have now met and every CCG is represented with the right representation from each. Good feedback has been received for this group and also an informal network set up to support each other (peer support for each other).

• Social Value Compact – paper from H&CP (DoCs recommend all CCF Orgs and partner orgs sign up to this): There has been request from the DoC Group that each CCG should adopt this compact within their commissioning intentions from 2021. This is to be taken back to each CCG in order to sign up to it. CW also highlighted that for the Cheshire CCGs the new leaders within the local authority have declared a climate emergency and this is also to be factored in their commissioning intentions from January 2020.

• CCF Project Manager Appointment:

The appointment of Paula Wells is for a 2 year fixed term and it was discussed the funding split for each CCG. It was also noted the risk that at the end of the 2 year term, if the role was not to continue the implications of this for both the CCF and the post holder. ACTION: CW to follow up in writing with each CCG, to formally confirm the cost share arrangements for the CCF Project Manager.

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Draft Funding Paper for SMB JL updated that this was first presented at the Cheshire and Mersey (C&M) HCP Management Board but the meeting was not quorate this could not be approved as CCG representatives could not be present. The paper was also discussed at the Accountable Officers (AOs) meeting on 8th November 2019. At the AOs meeting there was discussion around the breakdown of funding from CCGs to the HCP: 0.2% to support programme delivery – these needs greater clarity on what the expected outcomes are from those programmes. 0.1% recurrent C&M Partnership structure 0.2% for place – which needs to have accountability but less bureaucracy. Discussion followed. It was agreed JL and CW would raise this issue with the new Chair of the HCP. This would provide clarity from CCGs in regard to the use of these resources and would help with the commissioning requirements. There is an opportunity to influence in order for there to be synergy between the programmes and the plan. ACTION: All to feedback to JL & CW regarding the SMB paper, who will then summarise and share a narrative that CCG’s can forward to the new Chair of HCP. HCP Population Health EOM presented the progress being made on the C&M Strategy for Population Health. The presentation was noted by the Forum and discussions took place around what GP engagement there had been in the development of the approach, with the need to improve the communication links between the public health team and clinical leads. It was noted that this should be feedback to the Directors of Public Health (DPHs) in each place in order to link in with the GP Practices, as DPHs have a responsibility to feedback information to practices. Discussions also took place around the need to link in at a local level in order to drive things more effectively as the local knowledge is key to feedback what will work in what areas. The Forum also fed back that Making Every Contact Count (MECC) should have more of a secondary care focus and there may be the need for a cultural change. It was also questioned on what is the take up or how is this evaluated/monitored. MMc flagged that work has been done with their medicines management team on Anti-Microbial Resistance (AMR) for NHS South Sefton CCG and NHS Southport & Formby CCG as they were an outlier. The outcomes gave some interesting results and would be happy to share this information.

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ACTION: MMc to share outcomes for AMR with EOM Mental Health Programme Board Update SB updated that there has been a check and challenge on World Mental Health Day. A Mental Health review has been submitted however, no feedback has been received. It is clear in the Long Term Plan (LTP) about what is needed to be delivered, and it is understood that there will be a financial pressure in delivery. The Improving Access to Psychological Therapies (IAPT) briefing has been shared with AOs and there has been at teleconference on 8th November 2019, to discuss outcomes. This is a robust model which needs consideration on how this can be done. ACTION: IAPT outcomes are to be considered by the DoC Group, with a C&M Approach and the DoC group to provide some suggestions on how this can be delivered. Transforming Care Update SB stated that all AOs should be regular briefings from Maddy Lowry on progress in regard to Transforming Care. AOs have been asked to keep an eye on Care Education and Treatment Reviews (CETR) and delivery of annual health checks. It is anticipated that Children and Young People with learning disability and/or autism will be a key area for systems to focus upon. Community Midwifery Update SB confirmed that the community midwifery activity previously provided by One to One has been vired into the contracts of local NHS providers with a common specification that will deliver the requirements of Better Births and the NHS Long Term Plan. MMc highlighted that the collapse of One to One had raised issues about the requirements for insurance of independent providers. ACTION: MMc to share a copy of the South Sefton & Southport & Formby CCG insurance letter with the Forum for information. Palliative Care Funding SB highlighted that Wirral Health and Care Commissioning had received a query regarding the support given to local hospices and issues with pathways. The Forum was asked if this has been an issue across the patch and if a collective approach was needed. It was agreed that this is an issue best dealt with in place at a local level.

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3.0 System wide commissioning & leadership

Cheshire & Merseyside Health and Care Partnership System Management Board Update CW/JL gave feedback on the main discussions from the Cheshire & Merseyside Health and Care Partnership System Management Board was around the appointment of the new Chair and also the SMB papers. AW fed back to the Forum following being on the interview panel for the new HCP Chair that there would be a bottom up approach, being more inclusive and had a strong background of engagement with people in innovative ways. There was positivity that a new approach will be taken to drive forward programmes. 5 Year Plan & Operational Planning 2020/21 SB fed back that currently there is a hold due to Purdah on any key decisions being made. However, going forward this will link in with the DoC as this develops.

4.0 Development

The future of commissioning – proposed development session AW updated the Forum of a potential date in January for the Toby Lowe development session, which will be facilitated by AQUA in Haydock, which will be opened up as a North West event. There was a request from the Forum if this could be pushed back to March due to operational planning focus before year end. JL also shared that there is a good development video available called Ted Talk which, was created by Hilary Cottam and it would be good to link in with her for this development session. Please see below link to take you through to Ella’s story: https://youtu.be/Mr8nvXvl-y8 ACTION: AW to liaise with AQUA regarding new date for development session and the if possible to include Hilary Cottam.

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https://youtu.be/Mr8nvXvl-y8

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5.0

Any Other Business

There was no other business.

6.0 Date and Time of Next Meeting

Date: 24th January 2020 Time: 9.30am - 12.30pm Location: MIAA Offices, Regatta Meetings Rooms 1 & 2 – Ground Floor, Regatta Place, Brunswick Business Park, Summers Road, Liverpool, L3 4BL Apologies to be sent to: [email protected] Deadline for papers: 13th January 2020. Agenda circulation: 17th January 2020

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