TAMESIDE AND GLOSSOP CCG GOVERNING BODY PUBLIC MEETING TO BE HELD ON WEDNESDAY JULY 2 ND AT 1.00PM BOARD ROOM, NEW CENTURY HOUSE, DENTON A G E N D A

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1 TAMESIDE AND GLOSSOP CCG GOVERNING BODY PUBLIC MEETING TO BE HELD ON WEDNESDAY JULY 2 ND AT 1.00PM BOARD ROOM, NEW CENTURY HOUSE, DENTON A G E N D A 1. Welcomes and Apologies to the Public Meeting 2. Initial Declarations of Interest 3. Consideration of Any Other Business 4. Chair s Introduction (Annual Report, Chair s Action update) 5. Minutes of the Meeting Held on June 4 th 2014 & Action List (3-22) 6. Public and Patient Impact Minutes of the PPIC held on May 14 th Celia Poole (23-30) Draft Minutes of PPIC held on June 11 th Celia Poole (31-39) 7. Quality Publication of hospital safety indicator data Gill Gibson (40-46) on NHS Choices, including safe staffing Minutes of the Quality Committee Meeting held Celia Poole (47-53) On May 28th Draft Minutes of the Quality Committee Meeting held on June 25 th Verbal Update Celia Poole

2 8. Planning and Implementation and Quality NHS Tameside and Glossop CCG 5 Year Commissioning Strategy Clare Watson (54-75) 5 year strategy refresh and KLOE Clare Watson (76-101) Draft Minutes of PIQ Committee held on Graham Curtis ( ) June 18th 2014 Health and Social Care Integration Care together Kathy Roe ( ) Bi Monthly Transition Directorate update Clare Watson ( ) 9. Integration Governance Audit and Risk Draft Minutes of IGAR held on June 4 th 2014 Graham Curtis ( ) 10. Performance Clare Watson/ ( ) Elaine Richardson 11. Finance Report Kathy Roe ( ) 12. Locality Leads Update Locality Leads Minutes held on 24 th June 2014 Dr Richard Bircher ( ) 13. Tameside Health and Wellbeing Board Minutes Minutes of the Meeting Held on 13 th March 2014 Steve Allinson ( ) 14. Greater Manchester Meetings Association of GM CCGs Governing Group Steve Allinson/Dr Tina Greenhough ( ) 15. Healthier Together Committee in Common Minutes Dr Alan Dow ( ) 16. Any Other Business 17. Date and Time of Next Meeting August 6 th at 1.pm

3 MINUTES OF TAMESIDE AND GLOSSOP CCG GOVERNING BODY PUBLIC MEETING HELD ON JUNE 7 th 2014 Present: Steve Allinson Chief Operating Officer Dr. J. S. Bamrah Secondary Care Doctor Member Dr. R. Bircher GP Member (Urgent Care) Graham Curtis Deputy Chair/Lay Member Dr. Jamie Douglas GP Member (PC Quality and HT) Dr. T. Greenhough Dr. Amir Hannan Angela Hardman Dr. Ram Jha Nikki Leach Celia Poole Yvonne Pritchard Kathy Roe Clare Symons Dr. G. Wilkinson (In Chair) GP Clinical Vice Chair (Mental Health Families and Partners and Integration) GP Member (Long Term Conditions, IMT) Public Health Advisor GP Member (Planned Care/Cancer) Director of Nursing and Quality Lay Member Lay Advisor Chief Finance Officer Nurse Member (Caldicott Guardian) GP Member (Planned Care) 1. Welcome and Apologies to the Public Meeting Welcomes: Lesley Surman Glossop PPG, Sharon Battersby Smith PPG, David Parker Sanofi, Paul Broadhurst Member of the Public. Ali Lewin, Elaine Richardson, Julie Bell Tracey Simpson, David Walsh, Mark Simon (in attendance for the Annual Accounts and Annual Report sign-off) Apologies: Dr. Alan Dow, Clare Watson 2. Initial Declarations of Interest (Item 9. PIQ Meeting outlined in the minutes) 1 3

4 3. Consideration of Any Other Business There were no AOB s put forward. 4. Chair s Introduction Royal Garden Party Tina Greenhough and her Practice Manager had attended the Queen s Garden Party on June 1 st. Tina stated how grateful she was to have been nominated and both had experienced a most memorable day. Commissioning in Healthcare Conference Alan Dow had left information on the above Conference, taking place in September. If a Governing Body was interested they were advised to contact Alan Dow. Patient Stories Richard Bircher gave two anecdotal patient stories, both of which outlined how well they are supported by their neighbours and as a consequence, able to live at home. Richard stated that such experiences could inform how we work with the Local Authority in our Care Together Programme, to think more innovatively with community teams for more joined up delivery of care. Dr. Jha stated that Patient Participation Groups were a good vehicle to engage society in helping others within the community indeed his own PPG was currently proactive in this respect. Angela Hardman stated that Pam Watts is undertaking a key piece of work around community resilience, an enabler to help people to self care. Pam would be linking into the CCG, to embed this into the joint integration work. A discussion took place around how the CCG could recognise unsung heroes. Steve Allinson stated that he would work with Celia Poole and through the Care Together Programme, would put forward some suggestions on this particular issue and how best to engage the wider volunteer groups. 2 4

5 Lesley Surman (PPG representative) stated that this was Volunteer Appreciation Week and Glossop was holding a drop-in at Bradbury House on Thursday June 5 th at 1.30pm and all volunteers were eager to work with the CCG. 5. Ratification of External Audit and Annual Accounts The Governing Body ratified the External Audit and Annual Accounts. In terms of the Annual Report, this was not complete and would require further amendments. It was agreed that Alan Dow would take Chair s Action and report back to the next Governing Body meeting. 6. Minutes of the Meeting Held on May 7 th 2014 The Minutes were agreed as a correct record of the meeting, with one clarification:- Children and Families Transitional Arrangements: Angela Hardman clarified that she was the Lead for the Local Authority and the NHS the lead organisation for the transition. Action Log Update:- Merseybank Nursing Home Amir Hannan stated that the issue was that GPs had not been informed of its closure and this was causing an impact on general practice. Amir and Alan Dow had now met and agreed that in future GPs would be informed about any nursing home closures. Locality Leads Update It was noted that Locality Leads terms of office had been rolled over for a further 12 months period. RADAR In view of the fact that the meeting between Clare Watson and Tina Greenhough had not been able to take place, it was agreed that Tina would liaise with Clare Watson to pen a formal letter outlining the CCGs concerns. 3 5

6 Health and Social Care Integration It was noted that the narrative, to reflect that the CCG would be looking for expert opinion to other GM applicants of outstanding calibre, would be addressed once the CCG had firmed up all the governance arrangements. It was noted that the Risk Sharing Register, ought to have read, Risk Register, as the Governing Body had discussed specific risks around the implementation and capacity. Graham Curtis stated that the risks had been reviewed at IGAR and IGAR made recommendations to extend various risks to meet certain requirements. In terms of finance, Steve Allinson clarified that in the Integration Programme a Finance Risk Share would be developed, with any risks captured in the Risk Register also. It was noted that the Patient Representation element which was missing from the May report which Graham Curtis raised, would be reflected appropriately in the next version. Lorenzo Discharge Letters It was noted that Amir Hannan had not yet met with Jamie Douglas and Jo Bircher to look at how best to set the CCGs own standards and to scrutinise a random set of Discharge Letters. Graham Curtis reported back from IGAR stating that one practice had received 80 discharge letters recently, in error. Clare Symons stated that in terms of potential breaches, the CCG had asked John Fletcher to assure us that they have investigated this appropriately and had evidence to support this. Nikki Leach stated that a conversation had taken place at the Quality Committee about what is being captured through the IM & T Committee. Amir Hannan and Nikki Leach would discuss this further outside the meeting. Nikki stated that clarity would also be required in terms of whether indeed discharge summaries were in connection with Lorenzo or an underlying issue greater than Lorenzo. In terms of 18 weeks compliance, Steve Allinson stated that the Trust was developing a specific 18 weeks Recovery Plan and would be 4 6

7 asking the CCG for clinical input, possibly via Guy Wilkinson and Ram Jha route. Improvement Plan Quarterly Report It was noted that there was now a formal process in place for general practice to contact the Trust with any further concerns. This was via a telephone call or contact at the Trust. Nikki Leach stated that a meeting was being arranged with Naomi on her return from leave around exploring options for an electronic system for referrals. Safeguarding Level 3 Training It was noted that the CCG had sent out further details to General Practice Safeguarding leads outlining all the regulations. Finance Strategy Better Care Fund Kathy Roe stated that a communication had been sent out to General Practice regarding accessing the 5 per head monies. The Governing Body felt that the information was buried in paragraph 5 and did not go out to all GPs. Ali Lewin agreed to re-issue the information. Locality Leads - Engagement in the ICO It was noted that this piece of work would take place after the formal consultation process. 7. Draft Public and Patient Impact Committee Minutes Held on May 14th Celia Poole gave a verbal update to the Governing Body on key issues and decisions made at the meeting:- Patient Participation Group Event May 15 th Celia Poole stated that the CCGs Patient Engagement Manager had not been integral to the managing of this Event. There had also only been four members of the public who had registered and as a consequence the Event had been cancelled. Three PPG members raised their concerns that the CCG did not appear to be taking seriously, the views of the public. 5 7

8 Celia stated that she believed that the CCG was not at a point in the planning of its overall corporate patient and public engagement strategy to adequately ensure that appropriate and timely communications and engagement for the Care Together programme could be carried out effectively and this would require future discussions and action. CAP/PPIC future arrangements Karen Sykes updated that the Terms of Reference for the Consumer Advisory Panel ( CAP ) had now been revised. It is agreed that Julia Allen will remain as an advisory member of the CAP and it was further agreed that there would be a refresh on the days the group will meet and the name of the group. Plans for future complaints reporting It was noted that Nikki Leach and Gill Gibson had recently met with the Greater Manchester Commissioning Support Unit ( GM CSU ) Quality team to devise a template for providers to provide a regular quality report. This had also been agreed at Quality Committee. Consultation on restructure off community mental health services Members discussed some of the negative impacts detailed within the paper particularly around the significant gaps in the service with the discontinuation of weekend working. Members felt that this required external scrutiny. It was also highlighted that there seemed to have been no patient engagement detailed within the paper. Following the meeting, Celia Poole had been assured that appropriate engagement had taken place and therefore she took Chair s Action at PIQ and gave approval on behalf of PPIC members. At this juncture Celia Poole stated that there was probably a need to re-assess the governance and timings of the Committee meetings in terms of integrating, for example, what the PPIC is trying to achieve in its commissioning intentions. Amir Hannan felt that the organisation is going through a maturing process, looking at new commissioned pathways, learning as Committees and will get better, and, if we are doing things right, especially in terms of patient engagement, we should be confident from the start that it will go through the relevant internal governance process. 6 8

9 With regard to patient engagement, Ali Lewin stated that high level patient focus is a major part of service redesign and the commissioning team includes the public at high level decision making, but perhaps this is not necessarily communicated or documented as well as could be. Steve Allinson stated that he would be discussing the public and patient agenda in further detail with Graham Curtis and Celia Poole to ensure the engagement work supports the new challenging integration agenda. A proposal would go through PPIC. The Governing Body noted the verbal update. 8. Minutes of the Quality Committee Meeting Held on April 23 rd It was noted that Celia Poole gave a verbal update on key issues and decisions made at the May Governing Body meeting. The Governing Body received the minutes. Draft Minutes of the Quality Committee Meeting Held on May 28 th 2014 Celia Poole verbally updated on the following key issues arising from the meeting:- Safeguarding update An update was provided on The Supreme Court Ruling on the extension of The Deprivation of Liberty Safeguards to a much wider section of people who use the services which detailed the implications and consequences for the CCG and partners in terms of capacity issues. Local Improvement GP Update Celia Poole updated on the links with TFT; Primary care Quality Improvement work; New Areas for Quality Improvement and the work of LIG, which was currently on hold pending decisions relating to ongoing managerial, data analysis and administrative support. It was noted that the May meeting had been cancelled. Lorenzo Implementation Nikki Leach updated on three main issues with the pharmacy model. 7 9

10 After a lengthy discussion members still felt that assurance was required on the validity of information and requested that further detail is provided. Clare Symons was concerned that John Goodenough s response letter did not assure the CCG that there had been no risk to patient identifiable information being shared as the FT are in breach of more than 50 records of personal sensitive information being shared, as per the Data Protection Act. It was proposed that information fed through from IM&T to PIQ be shared with Quality Committee members and Graham Curtis and Celia Poole agreed to explore that suggestion. Nikki Leach updated that a formal notice had been issued to TFT and the CCG is currently awaiting a response from the Trust. Improvement Board Update Naomi Ledwith from Tameside FT updated that there were three remaining Ambers on the plan and gave a brief update on each of those. It was noted that a recent interface meeting had taken place between TFT and the CCG where discussions took place on assurance, with an agreement to map out the assurance process. Provider Visits Training Pack Peter Denton (Healthwatch) tabled a proposal on the training given to carry out provider visits. Members agreed that there were areas where the CCG could carry out in-house visits. Peter Denton agreed to amend the current proposal accordingly and provide a revised costing. Junior Doctors Advisory Team Members received an update on the unannounced visit from the Deanery. It was noted that the key action related to GP Trainees. Nikki Leach would be seeking assurance from Tameside FT that actions were actively being addressed. The Governing Body received the verbal update on key issues from the meeting held on May 28 th

11 9. Draft Minutes of the PIQ Committee Held on 21 st May 2014 Graham Curtis updated on the key issues arising from the meeting:- EUR Policies PIQ recommended approval of the Cataract Surgery, Hyperhidrosis, Body Contouring and Pelvic Vein Embolisation Policies. PIQ asked the EUR lead to feedback concerns from Tameside & Glossop CCG relating to the Persistent Non Specific Lower Back Pain. PIQ recommended for final approval, EUR policies for Tonsillectomy, Aesthetic Breast Surgery, Lycra Body Suit and Hyaluronic Acid. The Governing Body discussed Policies in general, noting that the CCG would need to ensure that all GPs understand the Policies that have been agreed or a change in protocol of a Policy. Ali Lewin agreed to take this forward with Clare Watson. Consultation of Restructure of Community Mental Health Services PIQ noted the consultation paper for information. Graham Curtis reiterated his disquiet about mobile working and how the proposed business case would contribute to the efficiency of the proposed model of transforming CMHTs. The Governing Body agreed to ask Senior Team to raise this issue at the next CCG and Pennine Care Interface meeting. QOF QP Evaluation PIQ Noted the end of year reviews. Clinical Engagement: Reimbursement of Practice Manager Representation on the Local improvement Group 9 11

12 PIQ recommended approval of remuneration for the Practice Manager Representative on the Local Improvement Group. Sessional Funding for Radio Show PIQ recommended that current arrangements (i.e. no funding) continue whilst the issue is captured as part of a wider discussion around the Communication Strategy. Primary Care Development/GP Provider Model Steve Allinson stated that further guidance would be received on Friday June 6 th and he would share this with the Governing Body. A conversation took place around keeping the public purse in order, being cautious about how much is promised, and how much can be delivered. 9i. 5 Year Strategy Everyone Counts Elaine Richardson stated that the Five Year Plan had been developed with Tameside Metropolitan Borough Council, Derbyshire County Council and Tameside NHS Foundation Trust. Elaine stated that the Strategy will draw together the majority of health and social care resources (people, money, buildings) some 350 million a year and provide care together. The papers presented to the Governing Body (Everyone Counts submission required for June 20 th ) consisted of:- Strategic Plan on a Page Strategic Key Lines of Enquiry Narrative Five Year Strategy It was noted that the KloE and Narrative would be subject to further revision as information is awaited on Co-commissioning, the South Sector developments and the future arrangements at THFT. In view of this, it was agreed that the narrative might need to be undertaken virtually, to meet the June 20 th deadline. The Governing Body made the following observations from the Key Lines of Enquiry document:

13 J S Bamrah felt that the CCG ought to be more explicit about the Healthier Together work which is now hitting the headlines. Elaine stated that this would be made more explicit following conversations Steve Allinson was having with his COO colleagues across GM. Celia Poole stated that the Technical Appendix (Key Lines of Enquiry) outlined that the Patient Engagement Strategy would be strengthened further, however, it was agreed that this ought to be amended to read Patient and Public Engagement Framework. The financial assumptions on page 16 would be clarified further as there were some minor inaccuracies. Angela Hardman would work with Elaine to strengthen the Health Inequalities section to reflect the wider role of working in partnership. Elaine would work with Celia Poole to develop a more patient friendly short Strategy which would talk about our Care Together ambitions, and to include patient stories. The Governing Body approved the Strategic Plan on a Page; gave initial approval to the Strategic Key Lines of Enquiry noting that certain areas required further strengthening and would feed back on the Narrative by June 13 th 2014 in time for final submission. 9ii. Health and Social Care Integration Update Kathy Roe stated that the report provided an update on the programme including the revised timeline with Monitor and progress on the ongoing discussions with partners and our planning for public consultation. Kathy stated that the meeting with Monitor on May 9 th unfortunately had to be postponed due to illness of Monitor s Regional Director. Since then telephone conferences have taken place, the CCG had provided additional information and replied to several queries that will inform a decision of the Monitor Board in respect of what regulatory action they will take on Tameside Hospital Foundation Trust (THFT) in light of our Care Together proposals

14 The meeting is expected to take place on 18 th June 2014 (Monitor s internal Provider Regulatory meeting). It was noted that Monitor had concerns around the risks to this particular proposition but were willing to explore these further with the CCG. It was noted that the South Sector work (Challenged Health Economy) will be completed by the end of June, and Monitor may wait to see the outcome of this, before making their final decision. The Governing Body noted that whilst this is a significant event and the CCG have undertaken considerable work to get to this point it was important to bear in mind this is still the beginning of the integration journey. The three feasibility studies provide a compelling case and clearly identify the scale of the challenge for Tameside & Glossop. Steve Allinson stated that, linked to the service reviews, the first round of Outline Business Cases will be ready by the end of June and will then be submitted via the appropriate governance structures in July for approval to continue. This will provide tangible evidence of the Care Together Programme moving to the next phase. A second set of Market Days have been agreed and will take place on 24 th, 26 th & 30 th June. In addition the CCG, in conjunction with NHSE GM LAT are co-hosting an event with providers on 13 th June to inform and support the development of 5 year plans that providers have to submit on 20 th June The Risk Register was discussed again and it was noted that hard decisions would need to be made going forwards however the concern would be around any fragmented service delivery and these were the types of conversations the CCG were having with Monitor. In summary the Governing Body:- Noted the key date with Monitor Noted the co-hosted event with NHSE Gt. Manchester LAT and the dates for the next set of Market Days; Would receive, once complete, the business case that will underpin the proposals for public consultation; Would receive a further update at the July meeting

15 10. Verbal Update from IGAR Committee Held on June 4 th Graham Curtis updated on the following key issues from the meeting held earlier in the day:- The main item was the Annual Accounts and Annual Report There were 3 Red Risks on the Risk Register with one new risk Safety and Resilience. The Committee received a internal Progress report from Internal Audit The Committee received an update on Information Governance The Committee discussed the Register of Interest and Graham made a plea that the Governing Body keep their information up to date. Further correspondence would be sent out to Locality Leads for their declarations and it was agreed to extend this to other GPs who are employed by the CCG. The Governing Body agreed to this proposal. The Governing Body would receive the draft minutes at the July Governing Body meeting. 11. Performance Elaine Richardson updated on the overall CCG Assurance Position; Quality Premium; Provider Performance; Clinical Challenge Performance and the Dashboard Summaries. Elaine stated that the main focus was the preparation for the Quarter Four Checkpoint meeting which would take place the following day. Elaine stated that there should be no shocks and the CCG had positive stories to share. On a general note Celia Poole mentioned an issue which came to light at the Consumer Advice Panel, in that a patient from Spring Hill had presented at A & E and was then registered as a new patient. Guy Wilkinson updated from his Ophthalmology re-assignment work earlier in the day, stating that two independent providers were eating activity from other Trusts with rapid high quality and a level of innovative work styles which were revolutionary. The Governing Body received the performance update

16 12. Draft Minutes of the Finance Meeting Held on May 7 th 2014 Yvonne Pritchard took the Governing Body through the key issues and decisions from the meeting held on May 7 th. The Governing Body received the minutes. 13. Locality Leads Minutes Held on May 27 th 2014 The following key issue arising from the meeting held on May 27 th 2014 were noted:- Elaine Richardson provided an update on the Tameside & Glossop Care Together Programme to Locality Leads and requested their support in wider member practice engagement. The Locality Leads discussed how best to engage member practices in the service redesign work stream considering their capacity and agreed that high level discussions would take place at the June localities to give an overview to update all practices. The current role and remit of Locality Leads and their relationship with member practices were discussed. The Leads felt that their role had become more corporate and therefore left little capacity to engage with their respective member practices. It was agreed that a revised paper/job description would be presented to PIQ in June. Joanna Bircher advised of the Outcome of Care Home/GP Practice Communication workshop held at Hyde Town Hall to explore how the CCG can improve communication between our local Care homes and GP practices. Joanna Bircher gave feedback on the CSU s Prescribing Indicators. She advised that the benchmarking data was welcomed as it can form a useful basis for Quality Improvement work, and in future the CCG would like the CSU to ask us what quality markers we would like to be included in this exercise The Governing Body discussed having a stronger link between the Governing Body and the Localities and it was noted that this would be part of the work which Steve Allinson and Graham Curtis were taking forward through PIQ. The Governing Body received the Locality Minutes

17 14. Health and Wellbeing Board Minutes The Governing Body noted the key decisions and discussions held at the meeting on February 6 th Greater Manchester Meetings Association of GM CCGs Governing Group The Governing Body received the minutes of the meeting held on May 6 th Guy Wilkinson asked about ISCATs exit costs. Kathy Roe stated that she believed these were Contract Management Exit Costs. She would be meeting with CFO s shortly and this would be high on the agenda. JS Bamrah asked about Specialised Commissioning being under threat and whether this would need to be placed on the Risk Register. Kathy Roe stated that this was a 3.6M risk for Greater Manchester. Healthier Together Committee in Common Minutes The Governing Body received the minutes of the meeting held on 16 th April. Amir Hannan asked if there had been any further clarity on funding for Derbyshire in terms of Care Together. It was noted that Derbyshire were willing to work with the CCG to try to apply a consistent approach, however this CCG had less influence on their decisions, because it was only a small part of their conglomerate. In terms of the AGG description of the Consultation, Guy Wilkinson had read that this would not be a traditional consultation. The Governing Body raised concerns and agreed to ask Alan Dow to clarify what this meant. Steve Allinson stated that the Healthier Together Consultation Team would be talking to each CCG about their bespoke issues, and the consultation would be managed collectively. He stated that our context remains Care Together and the key was that Healthier Together was a component of Care Together. Steve Allinson stated that he had asked Leila Williams to work with the CCG to ensure that as we develop our proposition through Care Together, we are absolutely clear we have the Healthier Together component inside it

18 16. Any Other Business There was no further business to discuss. 17. Date and Time of Next Meeting July 2 nd at 1.pm

19 GOVERNING BODY MEETING HELD ON JUNE 4TH 2014 ACTION LOG TITLE Actions B/FWD from May GB Meeting:- RESPONSIBLITY FOR ACTION AND OUTLINE OF ACTION ACTIONED OR REFERRED TO FOLLOWING GB ACTION LIST Children and Families Health and Social Care Integration (page 6) Clare Watson Clare Watson had spoken with Elaine Michel about arrangements in Derbyshire for Children s services and she would be taking a paper to PIQ in June around Children s commissioning. Kathy Roe/Doreen Hounslea Re: 5 Expert Roles To ensure the narrative is changed to reflect that the CCG would look for expert opinion; would be open to GM applicants of outstanding calibre, being mindful of any micro politics. PAPER TO BE PRESENTED TO PIQ IN JULY THIS WOULD BE ADDRESSED ONCE THE CCG HAD FIRMED UP ALL THE GOVERNANCE ARRANGEMENTS Lorenzo Amir Hannan Re: Quality of Discharge Letters 1 19

20 Amir Hannan questioned if the CCG could set its own standards, then scrutinise a random set and start to monitor that particular set, for example. AMIR HANNAN TO MEET WITH JAMIE DOUGLAS AND JO BIRCHER Improvement Plan Quarterly Report Steve Allinson agreed with Amir, stating that the recommendations should therefore be presented to the Quality Committee, worked up by Amir Hannan, Jamie Douglas and Jo Bircher (with her approval), based on Amir s proposals, taking the issue of Discharge Summaries, totally separate from the Lorenzo discussions. Naomi Ledwith To develop a Protocol to assist general practice in contacting the Trust with any further concerns. To discuss with the Trust an electronic system for referrals and report back Naomi Ledwith/Clare Watson ACTIONED NIKKI LEACH/NAOMI LEDWITH TO DISCUSS ONCE NAOMI BACK FROM ANNUAL LEAVE To meet to discuss how best to take GP engagement forward, using appropriate established groups/forums CLARE WATSON TO DISCUSS WITH NAOMI LEDWITH 2 20

21 RADAR ACTIONS FROM JUNE MEETING Clare Watson/Tina Greenhough It was agreed that Tina and Clare Watson would send a formal letter outlining the CCGs concerns. TINA AND CLARE TO SEND A FORMAL LETTER OUTLINING THE CCGS CONCERNS LORENZO Amir Hannan/Nikki Leach to meet Nikki Leach stated that a conversation had taken place at the Quality Committee about what is being captured through the IM & T Committee. Amir Hannan and Nikki Leach would discuss this further outside the meeting AMIR HANNAN AND NIKKI LEACH TO DISCUSS THIS FURTHER OUTSIDE THE MEETING Finance Strategy Better Care Fund Kathy Roe stated that a communication had been sent out to General Practice regarding accessing the 5 per head monies. Ali Lewin The Governing Body felt that the information was buried in paragraph 5 and did not go out to all GPs. ACTIONED ALI LEWIN TO RE- ISSUE Steve Allinson/Graham Curtis/Celia Poole Steve Allinson stated that he would be discussing the public and patient agenda in further detail with Graham STEVE ALLINSON/GRAHAM CURTIS/CELIA POOLE TO MEET TO DISCUSS ENGAGEMENT 3 21

22 Curtis and Celia Poole to ensure the engagement work supports the new challenging integration agenda. A proposal would go through PPIC. WORK EUR Policies ALI Lewin/Clare Watson Consultation of Restructure of Community Mental Health Services The Governing Body discussed the CCG Policies in general, noting that the CCG would need to ensure that all GPs understand the Policies that have been agreed or the ones which have a change to the protocol. CMT Graham Curtis reiterated his disquiet about mobile working and how the proposed business case would contribute to the efficiency of the proposed model of transforming CMHTs. The Governing Body asked senior management team to raise this issue at the next CCG and Pennine Care Interface meeting. ALI LEWIN TO DISCUSS A WAY FORWARD WITH CLARE WATSON CMT TO RAISE THIS ISSUE AT THE NEXT INTERFACE MEETING WITH PENNINE CARE (September), AND OTHER RESPECTIVE PROVIDER TO COMMISSIONER MEETINGS IN THE INTERIM. HT Consultation Alan Dow In terms of the AGG description of the Consultation, Guy Wilkinson had read that this would not be a traditional consultation. The Governing Body raised concerns and agreed to ask Alan Dow to clarify what this meant ALAN TO BE ASKED TO CLARIFY THIS POSITION 4 22

23 GOVERNING BODY MEETING Title of Subject: May Public and Patient Involvement Committee minutes Date of paper: 14 th May 2014 Prepared By: Celia Poole History of paper: Public and Patient Impact Committee held a meeting on 14 th May 2014 and will meet regularly, promoting and providing assurances to the Governing Board that the CCG is providing strategic leadership for the development of Public and Patient Engagement. Executive Summary: Key Issues discussed: Communications/Media Members were presented with an update on recent communications/media activity: Annual report Guidance has since been received and content is being finalised and AS will circulate content in between meetings for PPIC member feedback due to timings. Dying Matters week entitled You Only Die Once YODO AS explained that this is a Public Health campaign and due to purdah the Local Authority could not be involved in promoting the event. PPG update TT presented members with an options appraisal paper following on from a previous paper presented to PPIC which provided an overview of the levels of engagement with and activity in Tameside & Glossop s PPGs. The options appraisal outlined three options by which the CCG could step-up engagement with and involvement of PPGs in the CCG s business and commissioning decision-making. Members felt that option 2 was the best option from 23

24 the paper. CAP/PPIC future arrangements (update) KS updated that the Terms of Reference for the Consumer Advisory Panel ( CAP ) have now been revised. Plans for future complaints reporting The Greater Manchester Commissioning Support Unit ( GM CSU ) Quality team have been asked to devise a template for providers to provide a regular quality report. This was agreed by Quality Committee members. Transforming Participation in Health and Care North West Field Force Programme Update The Field Force Programme has been set up by NHS England to provide dedicated funding to CSUs so that they can provide bespoke support to Clinical Commissioning Groups to improve performance around involving patients and their carers and empowering them to manage and make decisions about their healthcare. An update report will be presented in July. Consultation on restructure off community mental health services Members were presented with a paper detailing the consultation on restructure of communication mental health services. Members requested sight of evidence of patient engagement. Update on TFT Engagement Members were presented with an update on TFT Engagement with patients, staff and the local community using existing methods such as Patient Opinion Survey, staff forums, ward forums and the PALS and Complaints routes. Recommendations required of the Governing Body (for Discussion and Decision) QIPP principles addressed by proposal: Direct questions to: To discuss and note the key issues discussed and agreed at the meeting on 14 th May To receive the report Celia Poole 24

25 Final Present:- Celia Poole (CP) Yvonne Pritchard (YP) Peter Denton (PD) Alison Lewin (AL) Karen Sykes (KS) Tracy Turley (TT) MINUTES Public and patient Impact Committee (PPIC) Wednesday 14 th May am-11.30am Boardroom, NCH Denton GB Lay Member, CCG (Chair) GB Lay Advisor, CCG Healthwatch Manager, Healthwatch Tameside Deputy Director of Transformation, CCG Head of Safeguarding, Quality and Patient Safety, CCG Patient Experience Manager, CCG In attendance:- Adam Shepphard (AS) Paul Wilson (PW) Jane Ankrett (JA) Doreen Hounslea (DH) Clare Bromley (CB) Head of Communications, GM CSU Interim Communications Manager, THFT (Part) Business Manager and Lead Nurse, Community Healthcare, SFT Care Together Programme lead (Part) PA, Corporate Office (note taker) 1. Chairs Welcome, Introductions and Apologies CP conducted round the table introductions and welcomed Jane Ankrett, SFT to the meeting and PD confirmed that his attendance was to include representation for Anna Hynes, Health and Social Care Network, CVATs. In the absence of a GP being in attendance, it was noted that Karen Sykes was providing clinical representation to ensure quoracy was maintained. Apologies were received from:- Clare Symons Nikki Leach Dr Amir Hannan Anna Hynes Julia Allen Jo Baines Nigel Caldwell Governing Body Nurse, CCG Director of Nursing and Quality, CCG Governing Body GP Member, CCG Co-ordinator for the Health and Social Care Network, CVATs Equality and Diversity Consultant, GM CSU Chief Officer, Volunteer Centre, Glossop High Peak CVS 2. Declarations of interest There were no declarations of interest to note. 3. Minutes of Previous meeting: 9 th April 2014 The minutes of the previous meeting were agreed as an accurate record. 1 25

26 Final 4. Matters arising not otherwise on the agenda The following actions were discussed:- Arriva Services PD updated that the report is still being written by the research company and once received PD will share at Quality Committee. Action: PD Joint Learning Disability Commissioning Strategy Clare Symons is still to circulate details of the Learning Disabilities event taking place at Medlock Vale on 8 th July. Action: Clare Symons Care Together Programme AL agreed to share guidance notes that have been developed to support the application of the patient engagement framework with PPIC members. Action: AL 5. Communications/Media (update) Adam Shepphard updated members on recent communications/media activity to include: - Annual report Guidance has since been received and content is being finalised and AS will circulate content in between meetings for PPIC member feedback due to timings. Action: AS AS explained that there is also an AGM booklet produced which is reading friendly for the public. IPOP Murray 360 degree feedback results have now been received and AS agreed to share these with members at the next PPIC meeting. Action: AS - Tameside PPG event This has now been cancelled on Thursday 15 th May due to the small numbers signed up to attend. Alison Whelan has already engaged with Glossop PPG cluster and Doreen Hounslea had also attended PPGs shortly before Easter. There is a communications workshop to take place on the morning of Thursday 15 th May to discuss plans for public consultation document to go out to the public. Alan Dow is to write up findings and this will then be shared. It is expected that consultation will take place next month in June. - Dying Matters week entitled You Only Die Once YODO AS explained that this is a Public Health campaign and due to purdah the Local Authority could not be involved in promoting the event. Adam briefly outlined a national campaign - YODO which is aimed at obtaining engagement with the younger population to encourage younger generations to start to think about end of life care. 2 26

27 Final PD confirmed that Anna Hynes has been a partner in the promotion of this with the CCG. PD is also doing a piece of engagement work through CVAT and Healthwatch. 6. Update on TFT Engagement deferred to await attendance by Paul Wilson later in meeting 7. PPG update overview of Patient and Participation Groups TT presented members with an options appraisal paper following on from a previous paper presented to PPIC which provided an overview of the levels of engagement with and activity in Tameside & Glossop s PPGs. The options appraisal outlined three options by which the CCG could step-up engagement with and involvement of PPGs in the CCG s business and commissioning decision-making. Members discussed the 3 options. Members felt that option 2 was the best option from the paper. They commented that with option 3 there was lots of overlap with other work streams. There was suggestion to adopt part of option 3 and one way would be to invite a PPG a member to a PPIC meeting. CP noted that the PPG event which had been due to be held the day after PPIC before being cancelled highlighted the greater need to engage with the public. Members were concerned that general practices were not supporting PPGs. CP proposed that we build on the 26 PPGs in Tameside & Glossop and ensure the best use of a PPG Network. All members voted for Option 2. 8 CAP/PPIC future arrangements (update) KS updated that the Terms of Reference for the Consumer Advisory Panel ( CAP ) have now been revised. It is agreed that Julia Allen will remain as an advisory member of the CAP and it is further agreed that there will be a refresh on the days the group will meet and the name of the group. CP requested that there is dedicated activity to encourage members onto CAP. 9. Plans for future complaints reporting KS updated that Nikki Leach and Gill Gibson has recently met with the Greater Manchester Commissioning Support Unit ( GM CSU ) Quality team to devise a template for providers to provide a regular quality report. This has been agreed at Quality Committee. KS noted that discussions have already taken place with SFT. It is agreed that GM CSU quality team will lead on this to ensure more robust reporting. PD noted that interviews are taking place for a complaint advocacy lead for Healthwatch and once appointed PD will ensure they link in to this reporting process. 3 27

28 Final 10. Transforming Participation in Health and Care North West Field Force Programme Update KS presented the Transforming Participation Field Force Programme report. The Field Force Programme has been set up by NHS England to provide dedicated funding to CSUs so that they can provide bespoke support to Clinical Commissioning Groups to improve performance around involving patients and their carers and empowering them to manage and make decisions about their healthcare. There was some concern around how the funding would work and what impact it would have on resources. PD highlighted that there was no mention of Heathwatch England in the Field Force Programme and no representation at the introductory event NHS England held at which KS attended. KS agreed to provide members with guidance and information about what our statutory duties are as a CCG and a statement from the Annual report that lists what our statutory duties are which includes engagement and consultation. KS agreed to include this in an updated report in July. Action: TT 11. Consultation on restructure off community mental health services AL presented a paper in Clare Symons absence on the consultation on restructure of communication mental health services. AL explained that although this is a Pennine Care internal issue, we as a CCG need oversight as commissioners. Members discussed some of the negative impacts detailed within the paper particularly around the significant gaps in the service with the discontinuation of weekend working. Members felt that this required external scrutiny. It was highlighted that there seems to have been no patient engagement detailed within the paper. Members agreed that as the patient engagement evidence is not included with the paper, together with evidence on information of usage of the service on weekends and the visibility on impact, CP will ask Clare Symons to provide evidence of patient engagement and consultation before the PIQ meeting due to take place on May 21. If CP thought it necessary she would circulate this evidence to members for feedback in advance of PIQ. If she felt assured that appropriate engagement had taken place, she would take Chair s action at PIQ and approve it on behalf of PPIC members retrospectively. Action: CP 12. Care Together Programmes (update) Doreen updated on activity and work streams as part of the Care Together Programme. Doreen explained that a full business case is being written up which allows discussions with NHS England. There will be community required services as part of the Care Together Programme and the business case will illustrate all aspects of public engagement which will include Tameside and Glossop, Healthier Together and Challenged South Sector. Doreen highlighted the importance of discussions with public needing to be very clear and consistent. 4 28

29 Final Doreen explained that there will be 4 stages/gateways of communications of which Nikki Leach will have oversight as Lead Director for Engagement work streams. They will include a clinical reference group, yet to be developed, PPIC and CAP. There is to be greater engagement with primary care and AL confirmed that there is already engagement with practices in the localities. There is a Healthier Together plan to carry out formal engagement by the end of June. TT confirmed that she will be joining a challenged health economies south sector conference call on Friday 16 th May on public engagement and to invite those early conversations. CP requested that an update paper be presented at the next PPIC meeting in June. Action: DH AL agreed to share an update on areas of engagement on service re-design work streams with Doreen and PPIC members. Action: AL 13. Any other business - Patient Opinion update TT updated that the CCG have now signed up to Patient Opinion. TT is attending a speak easy session at Target and Practice Managers Forum to raise awareness on this. - Pre engagement Pro forma Gill Gibson had requested that the pre engagement pro forma toolkit that TT had drafted presented to PPIC members for review for comment/feedback. This pro forma was adapted from the one Stockport CCG currently use and Gill requested that members review this to scale out what is required as a PPIC committee, particularly as the original framework put in place at the start of this committee required some governance around it. TT agreed to circulate the draft pro forma to members for review. Action: TT DH pointed out that the first section of the pro forma is included on the outline business case however AS noted that communications did not receive the outline business case. TT therefore agreed to liaise with AS further to discuss the PR implications around the pro forma and DH agreed to send all outline business cases to AS in future from the PMO office. Action: TT/DH 6. Update on TFT Engagement Paul Wilson arrived at the meeting at after being held up in traffic. He presented members with an update on TFT Engagement with patients, staff and the local community using existing methods such as Patient Opinion Survey, staff forums, ward forums and the PALS and Complaints routes. Paul presented the key areas of engagement as follows: 5 29

30 Final Ask Karen set up for all staff to Karen via communications team with any questions/queries they may have and Karen aims to respond within 48 hours. Paul explained that that two way dialogue is now used to inform the team brief. There will also be a weekly blog by from Karen. First Friday ward visits are still taking place for inspection and face to face discussion. The Everyone Matters posters Paul had previously shared with members are now displayed throughout the hospital and in addition there has been a values launch. There is You Tube clip promoting hand wash day with a family day to take place in July at the hospital which will receive local newspaper coverage. There is a new intranet site featuring patient engagement examples and the aim is for more engagement between the staff and the community to be included. CP requested that the FT demonstrate they have listened to feedback You said we did. It was suggested that Helen Howard be invited along to the next PPIC meeting to update on how TFT uses patient opinion and any plans that TFT may have to develop its use. CP to formally invite Helen to the next meeting. Action: CP NB: PD and Jane Ankrett not present for this item. 14. Date and Time of next meeting Wednesday 11 th June 2014, 9.30am-11.30am, Boardroom, New Century House Meeting closed: 12.05pm 6 30

31 GOVERNING BODY MEETING Title of Subject: Draft June Public and Patient Involvement Committee minutes Date of paper: 11 th June 2014 Prepared By: Celia Poole History of paper: Public and Patient Impact Committee held a meeting on 11 th June 2014 and will meet regularly, promoting and providing assurances to the Governing Board that the CCG is providing strategic leadership for the development of Public and Patient Engagement. Executive Summary: Key Issues discussed: Communications/Media Members were presented with an update on recent communications/media activity to include: Annual Report - As discussed at the last PPIC meeting; we will be producing a document for the event that is far more patient friendly than the annual report to really highlight the work we have done over the last year. A draft of this will be coming to July s PPIC meeting. Press Coverage There have been two stories in the MEN regarding THFT finance. We featured in the second story. Local Campaigns We will be supporting TMBC s campaign against domestic violence. Healthwatch Hour Radio Show A couple of live shows have taken place recently inviting patients to phone and in health related 31

32 questions. Healthier Together Close to finalising plans for the public consultation (likely to start early July) This should be happening today. A lot of big public events in Manchester to promote the consultation. PPG update Members discussed the proposals to move forward with the previously agreed recommendations to establish and implement a PPG Network made up of PPG Chairs within all localities of Tameside and Glossop. Transformation of CMHT update Members were presented a paper following a previous report on the Transformation of Community Mental Health Trust. Members raised queries in relation to patient/carer engagement, weekend working and depot clinics. Members accepted the additional information and evidence provided within the paper and to chair s action for approval at PIQ and the subsequent discussion Governing Body on 4 th June. PPIC where we are so far/review of our work CP opened discussions regarding the future of PPIC and review of where we are so far and welcomed a review of PPIC work in terms of the agenda structure and areas of focus and the purpose defined by the Committee s Terms of Reference. Members discussed the interdependency between PPIC and PIQ and both committees although agreed for a more joined up approach in terms of assurance on all commissioning intentions although a clearer process on this is needed and PPIC focus given to all work streams not just business cases going to PIQ. Members agreed that this is what the framework was intended for and that plans for commissioning in the planning stages before a business case is prepared. Members agreed to receive a list of work streams in relation to Care Together and then identify where the possible gaps may be in terms of patient engagement together with offering recommendations and advice on engagement with public. 32

33 Recommendations required of the Governing Body (for Discussion and Decision) QIPP principles addressed by proposal: Direct questions to: To discuss and note the key issues discussed and agreed at the meeting on 11 th June To receive the report Celia Poole 33

34 V3 Present:- Celia Poole (CP) Dr Amir Hannan (AH) Nikki Leach (NL) Clare Symons (CS) Yvonne Pritchard (YP) Peter Denton (PD) Alison Lewin (AL) Lynn Jackson (LJ) Tracy Turley (TT) Nigel Caldwell (NC) In attendance:- Clare Bromley DRAFT MINUTES Public and patient Impact Committee (PPIC) Wednesday 11 th June am-11.30am Boardroom, NCH Denton GB Lay Member, CCG (Chair) Governing Body GP Member, CCG Director of Nursing and Quality, CCG Governing Body Nurse, CCG GB Lay Advisor, CCG Healthwatch Manager, Healthwatch Tameside Deputy Director of Transformation, CCG Quality Improvement Officer, CCG Patient Experience Manager, CCG High Peak CVS PA, Corporate Office (note taker) 1. Chairs Welcome, Introductions and Apologies CP conducted round the table introductions. PD confirmed that his attendance was to include representation for Anna Hynes, Health and Social Care Network, CVATs. Apologies were received from:- Adam Shepphard Anna Hynes Julia Allen Jo Baines Jane Ankrett Doreen Hounslea Dr Naveed Riyaz Helen Howard Head of Communications, GM CSU Co-ordinator for the Health and Social Care Network, CVATs Equality and Diversity Consultant, GM CSU Chief Officer, Volunteer Centre, Glossop Business Manager and Lead Nurse, Community Healthcare, SFT Care Together Programme Lead Locality GP Head of Patient Experience/Supervisor of Midwives, THFT CP agreed to send a further invite to Helen Howard to attend the next PPIC meeting. Action: CP 2. Declarations of interest CS declared an interest for item 7 Transformation of CMHT update, in her role as Mental Health Commissioner. 1 34

35 V3 3. Minutes of Previous meeting: 14 th May 2014 The minutes of the previous meeting were agreed as an accurate record subject to a change to organisation name for Nigel Caldwell to be amended to High Peak CVS and to note the action for CS under item 11 to provide evidence on patient engagement. 4. Matters arising not otherwise on the agenda The following actions were discussed:- Joint Learning Disability Commissioning Strategy CS noted that there are posters around New Century House regarding the Learning Disabilities event taking place at Medlock Vale on 8 th July. NL noted that details of this have also been forwarded to Adam Shepphard to note on the list of events that the communications team produce. Transforming Participation in Health and Care North West Field Force Programme Update KS to provide an update deferred until July. Action: KS Arriva report PD updated that the survey report will be presented at the next Quality Committee meeting. PD explained that this is a GM survey and assured members that feedback has been received that since the survey was carried out the number of patients arriving at their appointment on time as improved. PD further noted that there is to be a future survey carried out. For the purpose of this committee, PD noted that part of the feedback from the survey highlighted that Tameside and Glossop scored high in terms of communication and awareness of the service to its public and patients. Care Together update NL met with Doreen Hounslea, Adam Shepphard and Gill Gibson to map out two main areas of engagement within Care Together as follows: - Review of existing strategy around patient engagement and communications. - Business case/documents turned into something more meaningful for public/patients. Suggested areas of support can be tied in from AQUA as a CCG we are already a member alternatively external may be brought in via IMAS (an NHS organisation which assists in sourcing short term specialist support. NL has discussed support from CSU to tie in Equality Impact Assessment. CP agreed to share a paper regarding her thinking in this area Action: CP AL noted concern from GPs regarding an event taking place on 1 st July at Phoenix City and noted discussions regarding patient representatives with Ben Gilchrist regarding CVAT involvement about particular work streams. PD noted that the voluntary sector had not had clarity in the planning of some events and would request to be clearer on their input and involvement to promote such events. NC echoed that from a Glossop and High Peak perspective. NL agreed to feedback to Steve Allinson regarding this. Action: NL 2 35

36 V Dr Amir Hannan joined the meeting. Pre engagement pro forma TT to chase Karen Sykes around pre engagement pro forma and liaise with AS regarding a comments and engagement joint toolkit. Action: TT 5. Communications/Media (update) including an update on engagement and consultation plans for Healthier Together Adam Shepphard had provided CP with an update on recent communications/media activity as follows: Annual Report We have a version with NHS England at the moment / The public facing one will be uploaded by Friday Work is on-going on the initial plans for the AGM this is likely to be in the second week of September As discussed at the last PPIC meeting; we will be producing a document for the event that is far more patient friendly than the annual report to really highlight the work we have done over the last year. A draft of this will be coming to July s PPIC meeting (Press Coverage There have been two stories in the MEN regarding THFT finance. We featured in the second story. (See links below) Local Campaigns We will be supporting TMBC s campaign against domestic violence this is running throughout the world cup. We are waiting to receiver their online campaign strategy but we expect to do a lot of promotion via the website and social media Healthwatch Hour Radio Show A couple of live shows have taken place recently inviting patients to phone and in health related questions Healthier Together We are close to finalising plans for the public consultation (likely to start early July) This should be happening today A lot of big public events in Manchester to promote the consultation Expect a lot of coverage from Key 103 and the MEN 3 36

37 V3 Locally nothing is finalised yet but HT should be sending a street team to Tameside and to Glossop to engage with local populations Dr Alan Dow (and possibly Steve Allinson) are also likely to be speaking at some events. CP will ask AS to share an update via CB on Healthier Together before the next meeting. 4 Action: CP/CB 6. PPG update TT presented a follow up paper to one previously presented in March 2014 to give an overview and provide an update on the Patient Participation Group Directed Enhanced Service (PPG/DES). Members were asked to review all recommendations contained within the report and make a decision as to the best option for us as CCG. Members agreed to option 2 of that paper for the CCG to establish and implement a PPG Network made up of PPG Chairs within all localities of Tameside and Glossop. TT asked members to consider and agree the proposals detailed within the report and make a decision as to the most appropriate way to drive the Network forward within the CCG. Members made the following comments: CS noted that although the paper identifies the risks it would be useful to include within the report a proposal on how to address those risks. It was suggested that this could be a first piece of work for the PPG Network to work in a collaborative way to encompass/include a wider spectrum for membership and to help drive/encourage varied groups such as mental health, learning disabilities, children and young people. AH noted that PPGs do find it difficult to reach out to wider public groups and noted that the format and styles for communication out to encourage this should be carefully considered for example young people the use of Facebook and Twitter would be best. AH requested that we can draw on leads of groups and experience of Healthwatch to strengthen the types of engagement. AH further noted the different funding options which might be available for each PPGs to make application to. PD suggested that this would be a good piece of work for the PPG Network and that links could be made with CAP who are also currently reviewing their membership. PD and NC further noted that there is a route to explore drawing funding from CVAT both Tameside and Glossop and High Peak CVS. NL noted that a meeting is due to take place with Kathy Roe to include CP, NL and Alison Whelan regarding funding for engagement. There is also to be a review of admin carried out which will map out future needs of the CCG across all functions/work streams. Members noted the update and agreed for proposals to be taken forward and to provide regular updates to members. Action: TT 7. Transformation of CMHT update CS presented a paper following a previous report on the Transformation of Community Mental Health Trust. At the last PPIC meeting members raised queries in relation to patient/carer engagement, weekend working and depot clinics. The paper provides Pennine Care responses to each of the areas including some additional evidence. 37

38 V3 As a result of the queries raised at the last meeting, CP attended PIQ and gave chair s approval on behalf of members to accept the report for approval in relation to the evidence produced. Members accepted the additional information and evidence provided within the paper and to chair s action for approval at PIQ and the subsequent discussion Governing Body on 4 th June. 8. PPIC where we are /review of our work CP opened discussions regarding the future of PPIC and review of where we are so far and welcomed a review of PPIC work in terms of the agenda structure and areas of focus and the purpose defined by the Committee s Terms of Reference. Members agreed it would useful to have an overview of change in service of each main provider in terms of patient engagement. Members discussed the interdependency between PPIC and PIQ. It was felt works programmes and areas of redesign should be discussed at PPIC earlier in the process. This would provide the opportunity to advise on, and inform the engagement process prior to it commencing. AL agreed to provide members with a list of work streams via CB in relation to Care Together. Members could then have the opportunity to identify where the possible gaps may be in terms of patient engagement together with offering recommendations and advice on engagement with public. Action: AL/CB 9. Any other business - Patient opinion TT queried whether members requested to receive a regular update report or whether a report should be submitted to Quality Committee. Members agreed that a different report would be required at both committees, PPIC to receive an overview on the type of patient engagement and Quality Committee for an overview on feedback regarding the quality of a service. PD and TT agreed to liaise regarding review of the same data on patient opinion by both the CCG and Heathwatch. Action: PD/TT - Health needs assessment Glossop and High Peak NC highlighted a recent piece of work on health needs engagement detailing what Public Health are doing. CP agreed to review the Bruce McKenzie report on environmental factors and NC agreed to share the report with members in September. NC noted that he and Jo Baines are a member on that steering group. Action: NC/CP - Pharmacy needs assessment - Tameside PD highlighted that there is currently a pharmacy needs assessment taking place for Tameside and that a joint strategy needs assessment framework is being reviewed. 5 38

39 V3 Healthwatch are on the steering group who will shortly be asking for a local community representative to become involved PD therefore requested if members know of anyone they should get in touch with PD. NHS England and the Local Authority are leading on this and Glossop is being covered. PD noted that the first draft for consultation will be available in September. - AGM and Expo Tameside PD noted Healthwatch involvement in the Tameside AGM and EXPO taking place on 30 th June at St John s Church, Dukinfield and invited members to attend. - Lorenzo AH highlighted the recent IT problem with abnormal test results not being sent. PD flagged up PPIC receiving a periodic update on the patient engagement element of issues with Lorenzo and CP confirmed that she and Graham Curtis have taken an action from Quality Committee on the governance of the 3 different committees discussing Lorenzo including IM&T, Quality Committee and PIQ and agreed to factor this into that action. Action: CP Members agreed for Quality Committee members to receive updates on Lorenzo and lead on discussions relating to that. TT noted that herself and Lynn Jackson have held discussions after the Nursing and Quality Directorate away day regarding pulling together information on patient experience to include complaints, PALS, Arriva and PTS and are meeting with John Winter to develop a piece of work bringing together information onto an IT system/database. TT agreed to update members further on that work stream. Action: TT 10. Date and Time of next meeting Wednesday 9 th July 2014, 9.30am-11.30am, Boardroom, New Century House Meeting closed: 11.22pm 6 39

40 GOVERNING BODY MEETING Title of Subject: Publication of hospital safety indicator data on NHS Choices: Including information on safe staffing. Date of paper: 24 th June 2014 Prepared By: History of paper: Executive Summary: Recommendations required of the Governing Body (for Discussion and Decision) QIPP principles addressed by proposal: Direct questions to: Lynn Jackson / Karen Sykes Presented to Quality Committee 25 th June This paper provides; A brief background as to why these indicators have been developed. The areas covered within the dataset; Ward staffing data Infection and cleanliness information Open and honest reporting information VTE risk assessment Responding to patient safety alerts Staff recommendation NHS safety thermometer CQC ratings An overview of performance for the month of May Confirmation of future assurance and monitoring arrangements. For discussion Nikki Leach, Gill Gibson 40

41 Publication of hospital safety indicator data on NHS Choices: including safe staffing. Background The national and local health economies have been challenged over the last 12 months in terms of the quality and transparency of patient care. This can be seen in the finding of the Francis Report, Berwick Review and locally in the Keogh Review of our local hospital. As a response to this, NHS England has requested that providers make public more information on patient safety and quality. As of 24 th June 2014, the publication of new data and the bringing together of existing data on safety will be published in one place on NHS choices on a monthly basis. The CCG will ensure that all information and data on hospital safety indicators is scrutinised by the Quality Team and assurance will be sought from providers through the monthly Tameside Hospital FT (THFT) Performance & Quality and Quality meetings. Overview Overview of the data published on NHS choices including new and existing data. Additional data on Friends and Family Test and patient score for cleanliness is also published on the safety section of NHS choices. Data Ward staffing data Infection and cleanliness information Open and honest reporting information VTE risk assessment Responding to patient safety alerts Staff recommendation NHS safety thermometer CQC ratings On NHS Choices NEW NEW composite indicator using a range of existing data on NHS Choices NEW composite indicator using a range of existing data from various sources EXISTING EXISTING EXISTING but newly added as a safety indicator NEW to NHS Choices using existing data EXISTING Page 1 of 6 C:\Documents And Settings\Clare_Bromley\Local Settings\Temporary Internet Files\Content.Outlook\B8VAUQXI\Publication Of Hospital Safety Indicator Data On NHS Choices1.Doc 41

42 Ward staffing data As of 24 th June acute trusts, mental health and community sectors with publish nurse, midwife and care staffing level data for inpatient wards. The data will be published monthly and show the average nurse, midwife and care staffing level by hospital and ward over the month compared with the planned staffing level. It will be broken down by hours over each day and night. The planned level is the level agreed by the Board, based on what evidence shows is the typical staffing level requirements for each ward. Providers are expected to use an accredited acuity tool for their calculation of safe staffing. The expectation would be that the actual level is close to the planned level. However, if a ward is below 100%, it doesn t mean it is understaffed or unsafe. Likewise, if award is above the planned level, it doesn t mean a ward is overstaffed. For the month of May, THFT reported 100%. It is important that providers understand the context and nuances of their data and are able to provide a supporting narrative as to the quality of safe staffing. Infection and cleanliness This is a new composite indicator constructed from the following existing data on NHS choices: MRSA and C.difficile infections over the previous 3 months NHS patient survey data on cleanliness of wards The most recent results of each Trust s Patient-led Assessment of the Care Environment (PLACE), introduced in April This data will be combined to give an overall rating good (green), Ok (blue), or poor (red). The data is rated as follows; Components of the composite indicator RED (Poor) BLUE (OK) GREEN (Good) Number of MRSA cases in last 3 months (as currently displayed on NHS Choices Trusts with one or more MRSA Cases in the last 3 months Not used (Zero intolerance means trusts are either good zero months or bad 1 or more) Trusts with no MRSA cases in the last 3 months Page 2 of 6 C:\Documents And Settings\Clare_Bromley\Local Settings\Temporary Internet Files\Content.Outlook\B8VAUQXI\Publication Of Hospital Safety Indicator Data On NHS Choices1.Doc 42

43 C.difficile infections (CDIs) in last 3 months (as currently displayed on NHS Choices) Patient survey score for cleanliness of wards (as currently displayed on NHS Choices) PLACE assessment score for cleanliness (new data for NHS Choices) Trusts who are statistical outliers in the top (quartile/quintile) for CDI in the last 3 months Trusts who are worse than expected (Zscore methodology) Lower quartile for cleanliness All other trusts Trusts who are statistical outliers in the bottom (quartile/quintile) for CDIs in the last 3 months Trusts who are as expected (z score methodology) All other trusts Trusts who are better than expected (z score methodology) Upper quartile for cleanliness Any organisation with two or more red indicators will be given overall red rating. Any organisation with a single red indicator will be given an overall blue rating regardless of the other ratings (even if all others are green). Any organisation with two or more green indicators and no red indicators will be given a green rating. All other organisations will be given an overall blue rating (OK). For the month of May THFT were rated red for infection control and blue (OK) for their patient score on cleanliness. The reporting for this indicator is for the previous quarter and reflects a period of increased incidence at the Trust; any improvement in performance will not be viewed until the next quarter reporting. Open and honest reporting This is a new composite indicator using patient safety incident reporting and response indicators used by the CQC as part of their intelligent monitoring. This data is based on spotting those organisations that are statistically significantly worse at reporting than their peers. Components of the composite indicator RED (Poor) BLUE (OK) GREEN (Good) Potential under-reporting of patient safety incidents to the NRLS Trusts who are statistical outliers at risk or at elevated risk All other trusts Not used (underreporting a concern, but elevated reporting ambiguous) Page 3 of 6 C:\Documents And Settings\Clare_Bromley\Local Settings\Temporary Internet Files\Content.Outlook\B8VAUQXI\Publication Of Hospital Safety Indicator Data On NHS Choices1.Doc 43

44 Potential under-reporting of death and severe harm patient safety incidents to the NRLS Trusts who are statistical outliers at risk or at elevated risk All other trusts Not used (underreporting a concern, but elevated reporting ambiguous) Patient survey score for cleanliness of wards (as currently displayed on NHS Choices) Trusts who are statistical outliers at risk or at elevated risk All other trusts Not used (underreporting a concern, but elevated reporting ambiguous) Organisation commitment to at least monthly reporting to the NRLS Reported in only three or less out of past six months Reported in only four or five out of the past six months Reported at least monthly for past six months NHS Staff survey KF15 Fairness and effectiveness of incidents reporting procedures Trusts who are statistical outliers at risk or at elevated risk Trusts in neither the red nor green category Top 20% Any organisation with any red indicator will be given an overall red rating. Any organisation with at least two green indicators and no red indicators will be given an overall green rating. All other organisations will be given an overall blue rating (OK). For the month of May, THFT scored blue (OK) for their open and honest reporting arrangements. Responding to patient safety alerts Alerts are a key way to help trusts improve the quality of care they provide, and give them an opportunity to demonstrate their accountability for the safety of patients. NHS trusts in England are required to respond to alerts and to indicate, using the Central Alerting System, when they have completed the actions required in the alert, or to confirm that no action is required. The poor (red) category shows that the organisations has not signed off as complete one or more NHS England Patient Safety Alerts for which the deadline has passed, the good (green) category shows that the organisation has signed off all NHS England Patient Safety Alerts for which the deadline has passed. For the month of May, THFT were rated as green. Page 4 of 6 C:\Documents And Settings\Clare_Bromley\Local Settings\Temporary Internet Files\Content.Outlook\B8VAUQXI\Publication Of Hospital Safety Indicator Data On NHS Choices1.Doc 44

45 Staff recommendation This is the percentage of staff who agreed that if a friend or relative needed treatment they would be happy with the standard of care provided by the trust, as measured by the NHS Staff Survey. For acute trusts the indicator will show if the organisation is performing as expected on this indicator as compared to other trusts:- 75% and above = compares with highest 25% of acute trusts 25% and below = compares to lowest 25% of acute trusts Between 25% and 75% = compares to middle 50% of acute trusts For the month of May, THFT scored 54% which places them in the middle 50% of trusts (rated red); NB currently this is an annual survey and therefore, no improvement will be seen until the next survey is undertaken later in NHS Safety Thermometer The NHS Safety Thermometer is a data collection that is used once a month in hospitals and other organisations to do a spot check survey on how many patients that are currently being cared for have suffered one or more of a defined list of patient safety associated harms ; pressure ulcers (bed sore), falls resulting in harm, urinary tract infections in patients with catheters and venous thromboembolism. It provides a quick temperature check of how many of their current patients have a pressure ulcer (bed sore). The survey does not distinguish if the harm was avoidable or not, nor does it determine whether the harm was caused by the organisation that is currently care for the patient. However, it is very useful for allowing hospitals to measure how they are doing internally and to help the whole local healthcare community to track whether they are reducing the risk of patients developing pressure ulcers in the community and in hospital. It cannot be used to compare one organisation to another. Venous thromboembolism (VTE) risk assessment The indicator shows the percentage of all adult inpatients assessed for blood clots risk on their admission to hospital using the national risk assessment tool. All hospitals should risk assess at least 95% of patients when they are admitted, so 95% or more is good (green) and fewer than this is poor (red). For the month of May, THFT were rated red for VTE risk assessments (81%); historically the hospital has consistently met its target for this area of patient safety; the reduction in performance is felt to be as a result of difficulties with the Lorenzo electronic recording system as opposed to clinical practice however this will be picked up via the THFT Quality meeting. Page 5 of 6 C:\Documents And Settings\Clare_Bromley\Local Settings\Temporary Internet Files\Content.Outlook\B8VAUQXI\Publication Of Hospital Safety Indicator Data On NHS Choices1.Doc 45

46 NB: Falls and pressure ulcers have not rag rated for the month of May due to a difficulty with data however the trust have reported 1.75% for pressure ulcers and 0% for falls. CQC ratings As the independent regulator for health and adult social care in England, the Care Quality Commission (CQC) check whether services are meeting their national standards of quality and safety. The data presented summaries CQC s assessment of whether the hospital is meeting standards as expected. Organisations are rated as either meeting the required standards or not. This is the most authoritative view of the safety of a hospital and is the most meaningful source of data that is available on patient safety. THFT are currently rated red for CQC assessment, the outcome of the recent hospital inspection undertaken by the CQC is not yet known and is not therefore reflected in the current data. Future monitoring Data in isolation cannot reflect the context or complexities of patient care and should therefore be reviewed alongside other quality assurance processes. All elements of the Hospital safety indicator dataset will be monitored by the CCG Quality Team via THFT Quality and Performance & Quality meetings as part of the contractual arrangements, and reported into Quality Committee by exception. Recommendation of Governing Body Governing Body members are requested to note the contents of this paper. Page 6 of 6 C:\Documents And Settings\Clare_Bromley\Local Settings\Temporary Internet Files\Content.Outlook\B8VAUQXI\Publication Of Hospital Safety Indicator Data On NHS Choices1.Doc 46

47 GOVERNING BODY MEETING Title of Subject: May Quality Committee minutes Date of paper: 28 th May 2014 Prepared By: Celia Poole History of paper: Quality Committee meets regularly, promoting and providing assurances to the Governing Board, on all matters relating to the vision and strategy for continuous quality improvement. Executive Summary: Key issues discussed: Safeguarding update Members received an update on The Supreme Court Ruling on the extension of The Deprivation of Liberty safeguards DoLs to a much wider section of people who use services. The report details the implications and consequences for the CCG and partners. Local Improvement GP update Members received an update on current work streams undertaken by JB as Quality Improvement Clinical Lead to include the following key highlights: Links with TFT/ Primary care Quality Improvement work / New Areas for Quality Improvement/ Primary Care (or Directly Commissioned) Quality Surveillance Group at Area Team. Performance dashboards Members received a data pack which is produced by NHS England Greater Manchester Area Team and circulated to CCG prior to the Greater Manchester Quality Surveillance Group meeting. It was noted that although TFT appear to have high levels of clinical assessment incidents reported via National Patient Safety Authority (NPSA) this has been reviewed by National Patient Safety Alert NPSA and the FT have been found to report incidents appropriately whilst other organisations do not all record such incidents. Members also received an update report on T&G CCG s submission to the Area Team outlining the key 47

48 areas of current quality concerns for the CCG and discussed the following highlights of the report: Community Provider (SFT) SUI: The low number of incidents reported via STEIS and SFT interpretation of national reporting guidance has been raised directly with the provider. Lorenzo Implementation NL updated on the 3 main issues to include: Discharge Summaries, implementation of the pharmacy module, system rebuild to support outpatient clinics. Improvement Board update There was a recent interface meeting between TFT and CCG where discussions took place on assurance and there was agreement to map out the assurance process. It was also noted that the ethos of the star chambers was positive as a good face to face discussion forum and a good deep dive opportunity. Junior Doctors Advisory Team NL updated members on the recent unannounced visit that took place on 23 rd April. Overall the feedback was positive, there were 5 recommendations the majority relating to the review of rotas however one relates to the review of FY2 GP placements. NL to seek clarification as to what action has been taken to address this area. Recommendations required of the Governing Body (for Discussion and Decision) QIPP principles addressed by proposal: To discuss and note the key issues discussed and agreed at the meeting on 28 th May Quality Direct questions to: Celia Poole 48

49 Final Present:- NHS Tameside & Glossop Quality Committee Minutes Wednesday 28 th May am-12.30pm Celia Poole (CP) Clare Symons (CS) Nikki Leach (NL) Graham Curtis (GC) Dr Joanna Bircher (JB) Dr Jamie Douglas (JD) Lynn Jackson (LJ) Peter Denton (PD) Dr Saif Ahmed (SA) Governing Body Lay Member (Chair) Governing Body Nurse, CCG Director of Nursing and Quality, CCG Governing Body Lay Member, CCG GP/Clinical Quality Improvement Lead, CCG Governing Body GP Member, CCG Quality Improvement Officer, CCG Healthwatch Manager GP Locality Lead, Stalybridge Locality In Attendance:- Naomi Ledwith Gideon Smith Clare Bromley (CB) Programme Director for Improvement, TFT (Part) Public Health Consultant, TMBC PA, Executive Secretariat, CCG (note taker) 1. Chair s Welcome, Introduction and Apologies The Chair introduced and welcomed everyone to the meeting. Apologies were received from:- Gill Gibson Deputy Director of Nursing and Quality, CCG Clare Watson Director of Transformation, CCG Gideon Smith Public Health Consultant, TMBC Alison Lewin Deputy Director of Transformation, CCG Yvonne Pritchard Governing Body Lay Advisor, CCG 2. Declarations of Interest Peter Denton declared an interest under item 9, Provider Visits Training Pack, as this is possible income for Healthwatch. 3. Minutes of previous meeting: 23 rd April 2014 The notes of the previous meeting were agreed as an accurate record except for a correction on page 3, last paragraph of item 6 to be changed to NL to write formally (not informally) to TFT. 4. Matters arising not otherwise on the agenda All matters arising are covered on the agenda. 5. Standing items - Safeguarding update 1 49

50 Final Members received an update on The Supreme Court Ruling on the extension of The Deprivation of Liberty safeguards DoLs to a much wider section of people who use services. The report details the implications and consequences for the CCG and partners. LJ gave a brief overview of the report to members and discussed the implications of the judgment for Tameside and Glossop CCG and its partners detailed within the report. There is a potential lack of resource to support DoLs assessment which will lead to assessments exceeding required timescales under the act and it is recognized that each Local Authority will experience the same issues with capacity and therefore additional best interest assessors will need to be trained. CS noted that the Deprivation of Liberty puts a review process in place. Members passed on their thanks to Gill Gibson for the report as an easy read report and requested that Gill provide members with any necessary updates in the future. Action: LJ - Local Improvement GP update Members received an update on current work streams undertaken by JB as Quality Improvement Clinical Lead to include the following key highlights: Links with TFT JB continues to attend the Trust Mortality Steering group which oversees the Dr Foster data alongside other specific areas of work on Trust mortality including the every death review process. The meeting is not yet receiving robust feedback from the divisions following the death reviews and this situation is being closely monitored. JB is scheduled to deliver training to Foundation year 1 and 2 doctors on how to produce useful, safe discharge summaries on 5/6/14 and 10/6/14 in partnership with Lorraine Wood (TFT Patient Safety Officer). It is unclear whether this training is mandatory, although JD thought it unlikely as night shifts and annual leave could be reason not to attend. Suggestion was made to tie the training into induction or the Clinical Reference Group. JB noted that it is important for the CCG to look at outcomes and not necessarily to be responsible for providing that training. JB agreed to clarify whether this training is mandatory. Action: JB JB has been invited to work in partnership with Dr Mike Tapley (Willow wood) Dr Bashir El Mahmoudi (TFT MAU), Anne Marie Daniels, Ursula Humphries(Public Health)and Psychiatrist Dr Sadia Ahmed to audit MAU admissions from Care Homes of people with dementia, using a Standard tool developed by the Kings Fund. Her role will include providing feedback to practices where concerns are raised. Primary care Quality Improvement work The work of the LIG is currently on hold pending discussions/decisions related to on-going Managerial, data analysis/display and administrative support. The May meeting was cancelled. JB explained that the work of the LIG is expanding offering support to practices especially in terms of co commissioning of Primary Care quality. JB feels that the supportive role would re- 2 50

51 Final quire at least one day per week as an analytical role as well as an admin role setting up visits to practices. JD suggested that the cost saving elements in self finding is important and GC agreed that a business case to PIQ could demonstrate the savings of this if continued. JB has discussed this previously with Dr Alan Dow who is very supportive of the continuation of the LIG. Members agreed that as the LIG is set up to review quality and efficiencies and to support communication and links with our member practices, it may be difficult to capture the cost saving elements. However CP would support a business case being presented at PIQ with full approval from members of Quality Committee should this be required. NL agreed to raise the question of the replacement of the primary care Quality Manger post at CMT and provide feedback to Quality Committee Members would like CMT to agree an interim measure put in place to support the next scheduled LIG meeting in order that this is not cancelled. Action: NL New Areas for Quality Improvement The LIG has approved a number of new areas for Quality Improvement as follows: a. Variations in coverage with flu immunisations between practices. A workshop targeted on practices with the lowest coverage rate being planned for this Summer. b. Early diagnosis of cancer (use of 2 week waits and conversion rates by practice). Working with Elaine Richardson and Ricky Hind. Comparative data by practice being gathered. Some information already received just awaiting the Public Health information. c. Improving communication between care homes and GP practices. Workshop went ahead on 1/5/14 with 30 participants representing GP practices, Care homes, TMBC, Healthwatch and the CCG. 5 Key themes emerged: Theme 1 Responsiveness and Respect Theme 1 Clear transmission of information Theme 3 Pro-active Care Theme 4 Relationship building Theme 5 Links Primary Care (or Directly Commissioned) Quality Surveillance Group at Area Team The April meeting was cancelled by the Area team. Next meeting 25/6/14 although JB noted that she is unable to attend. 6. Performance dashboards - Greater Manchester Quality Surveillance Group report Members received a data pack which is produced by NHS England Greater Manchester Area Team and circulated to CCG prior to the Greater Manchester Quality Surveillance Group meeting. It was noted that although TFT appear to have high levels of clinical assessment incidents reported via National Patient Safety Authority (NPSA) this has been reviewed by National 3 51

52 Final Patient Safety Alert NPSA and the FT have been found to report incidents appropriately whilst other organisations do not all record such incidents Members also received an update report on T&G CCG s submission to the Area Team outlining the key areas of current quality concerns for the CCG and discussed the following highlights of the report: Community Provider (SFT) SUI: The low number of incidents reported via STEIS and SFT interpretation of national reporting guidance has been raised directly with the provider. 3 x governance breaches were added to the StEIS this month and outcomes of investigations and remedial actions plans are awaited. 7. Lorenzo Implementation NL updated on the 3 main issues Discharge Summaries, implementation of the pharmacy module, system rebuild to support outpatient clinics Pharmacy module A fix was put in place to address the underlying issue, however 2 further issues were then identified. A final fix is due to be put in place at the end of May and regular checks would be made on the fix that was put into place. Addition pharmacists are working within A&E to mitigate any clinical risk. Outpatients The re-build of clinics and templates has commenced with the aim to finish this by the end of July. Discharge summaries Overall members still felt that assurance is needed on the validity of information and request that further detail is provided. NL updated that she has formally written to John Goodenough and Brendan Ryan seeking clarification as to the internal assurance processes in place in this area. In addition improvement in Trust performance in this area is being perused contractually CS was concerned that John Goodenough s response letter does not assure us that there has been no risk to patient identifiable information being shared as the FT are in breach of as it is believed that more than 50 records of personal sensitive information have been shared, as per the Data Protection Act. It was proposed that information fed through from IM&T to PIQ be shared with Quality Committee members and GC and CP agreed to discuss and explore that suggestion. Action: GC/CP 8. Improvement Board update Naomi Ledwith updated members on the action plan from the most recent Improvement Board meeting. 4 52

53 Final Naomi updated that there are 3 remaining amber on the plan and gave an overall brief update on each of those. There was a recent interface meeting between TFT and CCG where discussions took place on assurance and there was agreement to map out the assurance process. It was also noted that the ethos of the star chambers was positive as a good face to face discussion forum and a good deep dive opportunity. Members accepted and noted the report and agreed that we are in a unique position with TFT as provider after Keogh in receiving this report and suggestion was made to request all other provider s minutes of quality meetings. NL agreed to speak to the Nursing and Quality team to establish the quality meetings taking place within providers and to liaise with the GM CSU quality team to explore how the information is obtained from all providers and to confirm dates for a meeting with Pete Weller, Naomi Ledwith and the CSU quality team at TFT. Action: NL 9. Provider Visits training pack Peter Denton tabled a proposal on the training given to carry out provider visits. Members agreed that there are areas of the proposal in terms of gathering data which the CCG could provide in-house via the GM CSU Quality team although agreed that the proposal draws on the knowledge and expertise of Healthwatch in carrying out provider visits. Peter agreed to amend the current proposal accordingly and provide a revised costing. Action: PD 10. Junior Doctors Advisory Team NL updated members on the recent unannounced visit that took place on 23 rd April. Overall the feedback was positive, there were 5 recommendations the majority relating to the review of rotas however one relates to the review of FY2 GP placements. NL to seek clarification as to what action has been taken to address this area. Action NL No feedback has been received from the visit undertaken by North West Deanery 11. Any other business - Arriva Survey PD updated members on the feedback report received from the recent Arriva Survey report which will be published on 6 th June. PD agreed to circulate this to members once received. Action: PD 12. Date and time of next meeting:- Wednesday 25 th June 2014, 9.30am-12.30pm, Boardroom, New Century House Meeting closed: 11.30am 5 53

54 NHS Tameside & Glossop Clinical Commissioning Group Commissioning Strategy

55 Contents Foreword 3 Introduction 6 Chapter 1 Improving Health in Tameside and Glossop 7 Chapter 2 Our Care Together Programme 9 Building up the strength of individuals and communities 11 Integrated Teams based in Localities 12 Specialist Pathways 13 Hospital Based Care 14 Chapter 4 How we will Make the Changes 15 Chapter 5 Achieving Excellence 18 Chapter 6 Conclusion 21 Chapter 7 Other Useful Documents 22 [2] 55

56 FOREWORD In 2012 we wrote our first Tameside and Glossop Clinical Commissioning Group (CCG) five year plan. This year our updated plan is not just ours, it has been developed jointly with our local Councils (Tameside Metropolitan Borough, Derbyshire County and High Peak Borough) through discussions with local service providers. Last year we took a critical look at the way services are arranged to keep people in good health and how they work when someone becomes unwell. We found that three particular groups of people, the elderly with multiple medical conditions, families who cared for a child with complex needs and people with long standing mental health problems received the most care from both the NHS and Local Authorities. We found a lot of the time staff from both organisations were doing the same work as each other. For example, Edna is 80 years old, has dementia, poor circulation and disabling arthritis. She sees her care workers (Local Authority) several times a day. Her district nurse (NHS) visits daily to check her leg ulcer. She sees her GP about twice a year and the practice nurse does her health checks (NHS). She goes to a day care centre once a week (Local Authority) and every 2 months visits a clinic for people with dementia (NHS). Edna may be getting lots of care but it may not be co-ordinated, and it is difficult for one set of carers to know what the others are doing. So when her dementia gets worse, and she doesn't eat well, or gets confused and her sleep gets worse her family don't know who best to contact for help. At times neither do the professionals around her. This can mean services are slow to come to someone s aid, crises happen more often and people like Edna end up in hospital, when earlier intervention would have prevented an admission. Too often we hear carers and patients say they feel passed from pillar to post when they want help. They desperately want someone to co-ordinate their care. In our 2012 plan we said we were looking at how to link together health and social care services together so we could; make care less complex, cut out duplication, respond quicker, provide care closer to home and help people change their unhealthy lifestyles. In this re-fresh of our five year plan, we give more detail on how we will bring our community health, mental health, hospital, social care and voluntary teams together in one organisation and give more care in the community. Many things traditionally delivered in hospital will be provided in the community by staff with the right skills to provide the care needed. Our plans are bold and far-reaching, and have never before been implemented to such a large scale anywhere else in the country. We have shared them with Government Officials and influential bodies in the NHS, and they agree they are inspiring and possible. We think other parts of the country will, in the future, want to copy what we are doing. We call our plans Care Together. Through three Tameside and Glossop residents we explain in this document how services for local people will be different in the future. We call them our Patient Guides. They and their [3] 56

57 families cope with unpredictable stressful situations every day and, like hundreds of others in similar circumstances, need the highest quality support in order to help them have lives free from exhaustion and crisis. We hope you become as excited as we are about the future for health and social care locally and will join us as a partner in making Tameside and Glossop a healthier place to live. Dr Richard Bircher, GP Governing Body Member and Lead for Strategic Commissioning Dr Alan Dow, Chair, NHS Tameside and Glossop Clinical Commissioning Group Steve Allinson, Chief Operating Officer, NHS Tameside and Glossop Clinical Commissioning Group [4] 57

58 INTRODUCING OUR PATIENT GUIDES Edna is aged 80 and has dementia, diabetes and has developed poor circulation. She worked all her life in a local mill and over time developed disabling arthritis in her knees and hips. She can only just make it to the bathroom in her house, and needs help preparing meals. She weighs only seven and a half stone and doesn't eat too well, and is often anxious. Her son, David, lives next door. He is 58, and works as a joiner for a building company. He is often working away. Faisal is 12 and has cerebral palsy. He lives with his family in Ashton. He was born premature and struggled to breath for the first few weeks of his life. He developed brain damage and was unable to feed. He was fed by a tube for the first year of his life until he learned to swallow. He cannot walk, and goes to a special school in a wheel chair. He becomes scared very easily and cries out unexpectedly. His sleep is erratic and needs help with his toileting. He lives with his mum and dad, who are both in poorly paid jobs and his grandma who doesn t speak good English. He has two sisters, both younger than him. Robert is 30 lives in Hyde but struggles to leave his house due to severe depression. His parents were both heavy drinkers. He left school with barely any qualifications and has not managed to hold down a job for any length of time. He is low in mood, very anxious and drinks and smokes too much himself. He gets panic attacks when he tries to go out, the supermarket is terrifying for him. He feels ill most of the time, and has been in hospital many times after taking an overdose. His sister is his next of kin, and she has two children, at primary school. [5] 58

59 INTRODUCTION In our five year plan published in 2012 we set out the CCG aim of inspiring all NHS colleagues, working closely with partners, ensuring the development of excellent, compassionate, cost effective care and local people leading longer healthier lives. That aim continues and our work moves on. We can now describe in more detail how health and social care will come together and change over the next five years. You will read the stories of our patient guides Edna, Faisal and Robert and see how you, like they, will be supported to keep yourself healthy and out of hospital. You will see why we cannot stay as we are, if we want to improve the health of local people. As you read our plans you will see how we are reducing duplication and streamlining all services so we improve your health and make sure we can afford the care that will be needed locally even with expected reductions in the funding. You will know how we are addressing the challenges our local hospitals face to provide excellent quality for you at whatever time you need it 24 hours a day 7 days a week. You will read how we are working with local people and voluntary groups (the third sector) to develop communities where people look out for each other and where carers don't become exhausted and frustrated. These plans come at a time of marked change in health and social care across England. From next year the money we get from the government will reduce and we and the local authorities will have less money to spend on care for local people. If we carry on doing what we are doing we will have a funding gap that grows from 47.25m in 2015/16 to 74.1m in 2018/19. We don't want to cut services, as we know it will be people like Edna, Faisal and Robert who will be hit hardest. We believe we need the fundamental change we describe in this plan. [6] 59

60 CHAPTER 1 IMPROVING HEALTH IN TAMESIDE AND GLOSSOP A job for all of us Tameside and Glossop are good places to live. We are surrounded by hills; we have parks, local football teams, good rail and road connections, vibrant well used town centres and lower levels of crime than neighbouring areas. But we are blighted by more than our fair share of ill health and experience too many life-threatening, life-changing events that devastate families and friends. We do not carry more illness genes than other populations but local people have a Healthy Life Expectancy more than 3.5 years below the England average, and there is a 13 year difference in life expectancy between Old Glossop and Hadfield North? Such Health Inequality is unacceptable. T&G 59.6 years England 63.5 years Male Healthy Life Expectancy The key reason for these differences is people of Tameside and Glossop have lives which are peppered with unhealthy behaviours. We see people smoking despite their breathlessness, drinking too much despite the arguments, debt and violence, and eating too much poor food when already overweight and vitamin T&G 61.2 years England 64.8 years Female Healthy Life Expectancy deficient. It all leads to people suffering ill health and dying young. Families and friends pass these damaging behaviours onto others by making them normal and acceptable. It is easy to see why local people are disabled and killed by heart disease, respiratory conditions and cancer more often than in most other parts of the country. The behaviours that cause this ill health start from birth. A fifth of our local babies are born to mothers who have smoked during their pregnancy and only 34% get the benefits of breast feeding for more than a month. 33% of our Year 6 children are overweight, and are already developing the risk of heart disease and diabetes for their adult life. Too many local people are overwhelmed by stresses to the point of not being able to cope with the basics of life. GPs will tell you that half the time people book medical appointment because they have an illness, and half the time because they are overwhelmed by stress related to debt, violence, loneliness, poor self esteem and lack of opportunity. Babies brought up in homes with parents who are overwhelmed by life events find it difficult to grow up with confidence, and many develop troubling behaviours as they hit school age. Too many of our children are not school ready at the time they start school. Within our population we have around 80 per 100,000 looked after children and at any one time about 200 are the subject of a child protection plan. 27% of adults are overweight, 25% smoke, 26% are high risk drinkers, and at any one time around 2,500 adults are under the care of mental health services. [7] 60

61 There are a growing number of people under pressure caring for their frail and elderly relatives. We expect to see the number of over 65 year olds increase by 19% and the number of 85 year olds to have doubled by It s no wonder last year, in Tameside and Glossop we saw 379 heart attacks, 725 strokes and 1169 new cases of diabetes, around 631 overdoses and 18 suicides. We can change this if we change the way we live our lives and look after ourselves and each other better. We believe improving health is not about having more hospital beds or more high tech equipment. It is not about having an A&E which sees more patients quicker. It cannot be done from the consulting room or by taking pills. It is about sowing the seeds of improved lifestyle, encouraging people to change through plenty of opportunities and providing a safe place for healthy living to grow. By joining health and social care we can learn from each other. Doctors and Nurses are excellent at doing things for patients. Social Care reminds us of the importance of helping people to help themselves and their loved ones by providing the right environment and support. For example, in order to support Edna (our frail and elderly lady with dementia), or Faisal (with autism) or Robert (with depression) it may be more appropriate to help their relatives, with respite and training, in preference to increasing the number of carers who may visit. Health, Public Health and Social care have a responsibility to look after people from conception to death, supporting local people to have the best start in life, to live healthy and fulfilled lives and to die in comfort with dignity. But creating a much healthier future is a job they share with education, housing and the police and most of all it is a job they share with local people. The combined resourcefulness of our local residents to create a better Tameside and Glossop is paramount. Every time we choose to drink less, or stop smoking, or take the children to the park, or eat smaller portions, or foster a child or pick up some shopping for an elderly neighbour, or help an exhausted young mother, or join a club, socialise, laugh, confide and hug, drive carefully or treat each other with understanding and respect we are part of a better, healthier Tameside and Glossop. That is why we make sure we involve local people at every step of our planned changes, and listen to their comments and ideas. Most of us will know someone like Edna, Robert or Faisal. Their particular opinion is something we must foster and be guided by. [8] 61

62 CHAPTER 2 OUR CARE TOGETHER PROGRAMME Our Care Together programme brings local health and social care together under the management of one organisation (an Integrated Care Organisation) and designs new ways for its teams to work. At present the NHS and our Local Authorities commission services from a lot of different organisations. The main ones are: Hospital care from Tameside Hospital NHS Foundation Trust (but also to a lesser degree every other hospital in Greater Manchester) Community nursing and therapy services from Stockport NHS Foundation Trust Mental Health care from Pennine Care NHS Foundation Trust Intermediate care from Stockport NHS Foundation Trust and Meridian Healthcare Social care, home care workers and rehabilitation services from local authorities and independent providers General Practice from 42 separate GP surgeries Private Nursing and Care homes Healthy living and healthy lifestyle support from charity and volunteer organisations We will bring as many of these as possible together into one organisation that will be able to care and support a person wherever they are in Tameside and Glossop. If Edna, Faisal or Robert becomes unwell this organisation will be able to look after them, at all times. The Care Together programme is arranged into four 'levels' of service. Level one is a universal service and brings together all the healthy lifestyle and community support initiatives. For Faisal, Edna and Robert, it provides care for them and their carers, helps them keep healthy, offers volunteer support and provides activities which foster friendship and fend off loneliness. Building up the strength of communities Integrated teams based in localities Specialist pathways Hospital based care Level two is a more responsive (faster acting) community team, with an extended range of skills that care for people at home. Most of the time they will be looking after people who have complex disabilities or people who are recovering from a recent illness. This team will [9] 62

63 provide the backbone of care in the community and know, understand and coordinate services for people like Edna, Faisal and Robert. Level three is a new way of providing specialist care across the area. This will see specialists in cardiac medicine, respiratory illnesses, diabetes, cancer, disabled children and many others working both inside and outside the hospital as a co-ordinated team. This specialist care will make sure expert advice is given to patients, their carers and the community team rapidly and effectively. Faisal, Robert and Edna may all require specialist help at times, and they will not need to travel so far to receive it. Level four is hospital services for serious conditions, where super specialist care, such as emergency surgery, stroke and heart attack care is needed. This involves working with other local hospitals to develop the most up to date, best equipped and fast acting departments. Everyone may need this from time to time, and a speedy recovery is essential for all of us, especially those who have to care for others. Over the next five years we will develop the services that you will receive from each of these four levels. Some changes have already started to happen like our Diabetes Service which provides support to people with diabetes in the community rather than in a hospital and equips them to manage all aspects their own health both physical and mental. In its first year 577 people including Edna no longer had to go to the hospital for their check -ups and a lot less people have ended up in hospital because their diabetes was out of control. [10] 63

64 Level 1 Building up the strength of individuals and communities Building up the strength of individuals and communities We are responsible for our own lives and most of us want to be able to do the things we want to and be with the people who are important to us. Keeping ourselves well is part of being able to do that. As described earlier our behaviours have a big impact on our lives so we will help you understand the risks you are taking and how you can change harmful behaviours like smoking and drinking too much. We will develop the advice and support available to you and bring together our Wellness services so it is easier for you to help yourself. We have a good spirit of community in Tameside and Glossop based around our townships and villages. There are many voluntary groups and many more informal groups that help and support local people. We will work with these groups to increase the opportunities for them and help build local communities and local support. We will develop the support to our local families with young children and our carers who do so much. We will equip them to cope with the stresses and strains of doing the best for our most vulnerable citizens. By building up the strength of individuals and communities we hope to help you to help yourself and those close to you. Robert used to go days without seeing anyone because he would not go out and when he needed food or cigarettes he would take over an hour to get to the local shop and back and often return in a dreadful state of anxiety. His sister heard about a local group for people who struggle with panic attacks and asked them for help. John, a member of the group, came to talk to Robert and after several months of regular visits encouraged him to join them on a local gardening project. John now goes to help every week and has learnt a lot about growing fruit and veg. He has taken over part of his sister s garden and is helping his nephew and niece grow a sunflower for the school competition. Robert s sister, in turn has been encouraged to stop smoking herself. [11] 64

65 eams based alities Integrated teams based In localities Level 2 Integrated teams based in localities We have five localities each of which will have teams of multi skilled professionals who will be the first line of support for people in need. The teams will include nurses, doctors, therapists and social care workers who can help local people to manage their own conditions and offer expert treatments at home. This will prevent you having unnecessary admissions to hospital. If you do become so ill you have to go to hospital the team will help you to be discharged as early as possible. The teams will identify who is most vulnerable, At Risk, and put in place plans that describe the health and social care needs of a client and what to do should they become unwell or fail to cope. By using Telehealth and Telecare services the teams will be able to see when people may be starting to become ill and be able to put things in place quickly to prevent an illness, or difficult social situation getting worse. Care Coordinators will reduce the need for people to tell their story over and over again and make sure that others work together to support people when they need more help. Our Adult and Children s teams will make sure we have the right people working with vulnerable or frail people on a regular basis and so they can really understand their needs. They will be available for more hours of the day and at weekends. Our teams will mean local people do not have to find everything out for themselves and will make sure they get help before they become too ill. Faisal chokes one day on his dinner, and next morning has a cough, which becomes worse. A day later he has a high temperature and is being sick. His mum is really worried as last time this happened she had to take time off work and go to the GP, get antibiotics from the chemist and, because that did not help, Faisal ended up in hospital for 5 days and she had to stay with him which was difficult for the family. This time his dad calls Rachel, his care co-ordinator, who belongs to a specialist community paediatric team. She arranges for a nurse, Sue, to visit that morning. When Sue sees Faisal she rings the GP and together they decide to start antibiotics. Sue contacts the family every day and realises they need extra help with clearing Faisal s phlegm and feeding him as he is starting to feel sick. She arranges for a physiotherapist to visit and asks the opinion from a paediatrician. A home monitoring machine is set up, to check Faisal s oxygen levels. Over the next week he starts to recover slowly. His grandmother and sisters are really pleased Faisal was able to stay at home and his youngest sister now wants to be a nurse. [12] 65

66 Level 3 Specialist pathways There will be times when the locality based teams need advice from specialists to be sure you get the care you need. Sometimes you will also have to be seen by a specialist either for a diagnosis, test or for treatment. Specialist Pathways Our specialist pathways will work across the whole of Tameside and Glossop and provide short term support and advice and/or long term care depending on an individual s needs. We will be developing over twenty specialist pathways. Some of these will be for specific diseases such as Respiratory and Cancer, others will support specific people such as All Age Learning Disabilities and End of Life and some cover types of services such as Admissions Avoidance and Intermediate Care. All of them will make sure that as much care as possible is provided out of hospital with the most appropriate professional assessing what somebody needs and making sure they get treatment as conveniently as possible. Specialists teams will, where it is safe, provide hospital type care at home or in the community. When someone needs to attend a clinic or see a specialist we will reduce the number of times they have to attend appointments by making sure all the necessary tests are done during one visit. Where possible we will ensure people have their tests done before they see the specialist so they can discuss treatments at that first appointment. We already have some routine services that run outside 9 to 5 Monday to Friday and we expect this to increase to make it easier for people to organise things around their work and family. Our specialist pathways will make sure people get the care they need promptly and get them back on their feet as quickly as possible. Edna needs to go to the toilet before her carers arrive for breakfast. She is not quite awake stumbles and bangs her head. Her son David hears her fall. Before when Edna fell David rang 999 and Edna ended up in hospital for several days. She was confused and scared and did not eat well. By the time she came home she and David were exhausted. This time David rings her care co-ordinator, Jane, who sends a nurse specialist, Bushra, to see Edna within an hour. Bushra stitches her head, and checks her out. Jane also arranges for Michael, a physio, to visit and he looks for ways to make her safer. The next day Paula, a sitter arrives and stays with Edna all day so that David can get to work. During this time Paula makes careful note of Edna s needs and feeds it back to the Jane. Services are changed to make Edna safer. [13] 66

67 Level 4 Hospital Based Care Even with excellent care in the previous three levels some people will Hospital Based Care need to go into hospital. We want to make sure that when in hospital you will be treated by the best doctors and nurses and have the best outcomes regardless of the time of day or day of the week. This means having senior staff, high tech laboratory and x-ray backup and intensive care facilities available at all times. There are not enough specialist staff to provide everything in every hospital across Greater Manchester and even if there were we do not have enough money to do this. This is why we are working with the eleven other local CCGs and all the hospitals in Greater Manchester on a programme called Healthier Together. Healthier Together is looking at the care that is so specialised it needs to be provided in hospitals. It is identifying where we need to concentrate expertise in teams delivering the once-in-a-lifetime specialist care at a particular hospital e.g. Stroke Care. This will build a hospital network of high quality care that meets best practice standards and provides the best outcomes and experience for patients. These plans are consistent with the messages coming from the Department of Health and the body that oversees hospitals like ours (Monitor) that smaller hospitals need to work within new models of care and share staff and facilities. Locally we have been talking to neighbouring hospitals about what needs to be done together. There has been a great deal of focus on how Tameside Hospital will work with partners in a 'southern sector' but we know our patients also use other hospitals and so we continue to discuss how hospital care should be organised. This will mean that for some specialist treatments either routine or emergency you may have to travel outside Tameside and Glossop. You will, however, get the best care and so be able to get back on your feet quicker. Treatment that is less specialised will be available more locally and we expect to have a greater range of outpatients and day surgery services (e.g. cataract operations) available at our local hospital site. We know that for some people travelling to hospital is difficult and we will be developing patient transport services with both the NHS services and community transport groups. Faisal s mother is involved in a car accident and is critically injured. She is taken by emergency ambulance to South Manchester Hospital where she is treated by specialist teams able to respond quickly even during the night. She undergoes emergency surgery, performed by two consultants, and thankfully begins to make a good recovery. Once she is stable and out of danger, she is transferred to Tameside Hospital for the remainder of her treatment. This is much easier for Faisal and his family to visit. After she goes home Faisal s mother has several other operations but these are done as day cases. They are performed at Tameside Hospital, by the same expert team who looked after her the night she almost died. [14] 67

68 CHAPTER 4 HOW WE WILL MAKE THE CHANGES We know our programme is ambitious but we are confident we can deliver it over the next five years. We have the backing of senior health officials to make sure you are among the first in England to benefit from this new way of caring for people. We also have their backing to look at changing the way your services are run. This may not sound important but the Chief Executive of the NHS in England and the body that oversees hospitals like ours (Monitor) both feel that unless small hospitals are willing to change they will not be able to make ends meet financially. They say that the main things for us to focus on are: To identify new models of care for patients, such as redesigning services to improve the integration of care and move it closer to home. Our Care Together Programme is about doing exactly this. To develop ways to share staff with nearby hospitals, use new technology or build networks between smaller hospitals and major centres. Care Together and Healthier Together both involve taking expert clinical advice and talking with nearby hospitals about when we need to do this and what options are open to us. To make sure that the right balance is struck between redesigning services and making sure patients are treated near to where they live. This is at the heart of our Care Together Programme. As well as the backing of senior health officials we want the backing of local people and the people who need to make the changes to the services. We have already discussed some our plans and ideas through our Listening2Patients events in 2013 and Market Days in early Throughout the summer of 2014 we will be asking local people to comment on what we are calling a 'single service model'. Through this model we will ensure most care services will continue to be provided in Tameside and Glossop, through increasingly sharing staff or building clinical networks with nearby hospitals. We will ask what you think about some early changes for very specialised emergency hospital services. However, we feel it will be necessary to make further changes beyond that in the next five years, and we will work with you to share and discuss what we mean by this. We have already started the work on redesigning services and will continue this work over the next couple of years. We are bringing together patients, community groups and the people able to provide services to help design our new services. We know that only by working together can we be sure we get the right services in the right place that deliver the highest standards of care. We know as well as redesigning services we need to make sure that the information needed to make decisions about the care you need is available to the right people at the right time. A key feature of our vision is how we share information amongst care professionals so that the people caring for you can be sure they take everything into account when they discuss with you the care you need. Keeping your information safe is essential and we will be asking [15] 68

69 your opinion and views on this as we develop our plans so that you are assured your interests are at the heart of every decision. We will also make sure over the next five years you have access to your full medical and social care records. We are looking at how we develop the workforce that will provide the care you need. The staff will be multi skilled health and social care professionals who work with you to agree the care you need to get the best possible outcomes. To deliver our ambition of person centred care health and social care professionals will change their roles from care givers to partners in care. You will have an equal say in how you want your care arranged so it meets your needs. We want all our services to be delivered from high quality locations that are easy to get to and provide safe access. Over the next five years there are likely to be changes in where you go for your care as we bring services together and make sure we use our more modern buildings as much as possible. We expect to use the Tameside General Hospital site as a hub with satellite centres in our townships. When we locate our services we will consider the needs of the people living in those areas to ensure those who need services the most can access them easily. We are planning patient transport alongside our estates and service redesign work so we can be sure that you will be able to attend your appointments on time and get home again promptly. Care Together is about keeping people well and independent and delivering high quality care within the money available to us. The NHS is coming to the end of a five year efficiency programme that has seen almost 20 billion reduced from budgets for patient care. Unfortunately this is only the tip of the iceberg. Forecasters are telling us that a further 30 billion reduction across England will be needed by There have also been significant reductions in central Government funding to local councils which means local economies are facing critical financial challenges. Tameside and Glossop health and social care economy are facing a gap of 74.1m over the next five years m m m m m CCG Local Authority TOTAL COMMISSIONING Tameside FT TOTAL ECONOMY GAP [16] 69

70 Care Together will see an increase in the amount of money we spend on services in primary and community care which will decrease the amount we have to spend on hospital services. Increased primary and community services Decreased hospital based services This will allow us to bridge the gap 74m gap in our funding and ensure we continue to have high quality services that are clinically effective and safe now and in the future. The diagram below shows how we will have reduced our funding gap by 2018/19. We have based our plans on what we know and expect to happen which includes getting 9.8m back from NHS England as this will enble us to invest in our new plans over the next two years. We also know we have to change quickly as if we delay we will run out of money and this could affect local services including our local hospital. [17] 70

71 CHAPTER 5 ACHIEVING EXCELLENCE We believe everyone in Tameside and Glossop should be able to access high quality care wherever they live. When we asked local people what was important to them they ranked this as their top priority. We were also told that we were getting many things right and people liked most of the services they get. End of Life care was particularly mentioned. However, they also told us red tape got in the way in urgent situations and they did not think they were always listened to by the people treating them. We know our services could achieve better outcomes and are not happy that some of you are dissatisfied with services. We believe the current complexity of services hinders quality improvement. Our plans to simplify things through Care Together will make it easier for people to get the right care, quickly and appropriately. Sharing of patient records and joining workers together into one team are key ways of improving the quality of care. Simplifying care is a cornerstone of our quality strategy. Simplification of care will also free up resources to use on things which matter to local people. In a future where budgets are going to be smaller, it is essential we stop doing things that do not add any value to you. By involving you in the redesign of services we can be sure they are set up to deliver the care that works for you. By involving you in our ongoing quality improvement work we can be sure that you continually get that care that works for you. Our quality team s job is to do four things: Monitor the quality of services, by measuring what they do and by inviting comment from users and use this information to guide all quality improvements Coordinate remedial action should things fall below an acceptable level. Protect the most vulnerable in our society Encourage continuous quality improvement at all levels in the organisation 1. Monitoring and Listening All our local health and social care services have their performance measured against expected standards. There are many NHS and Social care dashboards (a series of important indicators) which show our local area to be performing about average across Greater Manchester. Many of these indicators measure processes, such as staffing levels in A&E, or number of staff trained in child protection procedures. Though these are important to the management of care, they may not be as important to you. What you say you want is responsive, compassionate care delivered respectfully by well trained staff. You want to know that you are being given the best chance at recovery. Care Together will place greater value on these outcome measures. In our 2012 five year plan we promised we will listen, and then go take a look. We have done this many times and as a result have challenged poor practice and supported [18] 71

72 improvements. This has happened more than anywhere in our local hospital. We have played a very important role in facilitating a change in leadership and worked in partnership to make services better. These improvements have been measurable and sustained, and accompanied by a refreshing challenge against complacency. We are getting better at listening to our public, but have a way to go before we are excellent. Some of the best ways we gather opinion are through NHS Choices, PALS, Patient Opinion (on line service) and HealthWatch. All our services have ways for users to give feedback and Care Together will make it easier to learn from this and look at your whole experience. We are also developing a Professionals portal so that workers (who are often also residents) can feedback on the services they work in and with. We will increase the involvement of patients and carers in our work, so you can give constant feedback and direction to the professionals who support you. 2. Remedial action Taking remedial action to put things right involves never ignoring concerns and being bold enough to challenge any part of the system. We have worked very closely with the Keogh Enquiry over concerns with our local hospital and been partners in delivering a level of change which was long overdue. If our monitoring systems are working well we should know when things are going wrong before anyone comes to significant harm. However, health and social care is complex, and extra-ordinary events can happen at any time. We have systems which capture the most serious risks but we are weak at making sure prompt action is taken to resolve them. We will develop systems which investigate serious risks the same day, and make sure all the relevant people know who must resolve the issue and that they take the right action quickly. When risks are resolved we will feedback to the people who brought the problems to our attention, and encourage them to be equally vigilant in the future. We take our Duty of Candor seriously, and do not shy away from informing our Regulatory bodies when we have concerns about the performance of an individual or organisation. They will always be informed about any remedial action plan. 3. Protecting the Vulnerable We work every day with people who are fragile and vulnerable to exploitation by others or could be damaged by the services we provide. Much of the time, these people are out of sight and out of mind to the general public, and can become marginalized, despite them having most need for our help. We are developing ways of asking their opinions, as often they are not good at sharing them. This way we can make sure we have the care they need. Our safeguarding teams help make sure that everything we do will look after vulnerable people, like our patient guides, in a safe and compassionate way by checking it is easy for them to get the same level of care as other people. [19] 72

73 4. Encourage continuous quality improvement at all levels in the organisation Improving quality is a job for everyone working in the NHS and Social Care. This is where our aim of inspiring all NHS colleagues, working closely with partners, ensuring the development of excellent, compassionate, cost effective care and local people leading longer healthier lives takes on meaning. There are many things which can help individuals, teams and organisations improve. An essential ingredient is to have a culture where everyone, who comes across something which could be better, recognises it and works with others to make it right. Care Together will encourage this and make complacency and a make do culture a thing of the past. This is devolved leadership; the ability of people of any level to take stock and say things are not good enough, and for their seniors to facilitate and respect these views. We will foster this attitude and couple this to the best quality improvement methods available. We will encourage openness when things do not go well and make no blame analysis standard practice. We want nurses, doctors, cleaners, porters, chief executives, and volunteers to be involved in making our care systems safe, effective, caring, responsive and well led. These are the values of the Care Quality Commission, which we share wholeheartedly. It is not right, that any part of our health and social care system relies on external agencies to give judgments on the quality of our service. Judgment should come from within, constantly and be welcomed. [20] 73

74 CHAPTER 6 CONCLUSION In the last year the health and social care organisations in Tameside and Glossop have moved from knowing we had to work closely together to improve the health and wellbeing of our population to designing a plan which has attracted considerable local support and national interest. We have a level of agreement, from local agencies, never seen before, that this is the way forward and we are willing to work jointly to achieve the huge changes we propose. Together with local people we are already changing care services piece by piece. We believe we have a way of turning around some of the most in-ground health issues which blight our local residents lives. We are confident our plans also address the worrying quality issues of our local hospital, by facilitating them to change from being a 'struggling' district general hospital into something new and innovative, better serving local people s needs. We believe our plans will make better use of the money we are given to provide care. We have challenging times ahead, and we will be measured on our ability to do the same and more with less money. The most important measurement, however, is the feedback we receive from Edna, Faisal and Robert, and the people who care for them. There is no higher compliment than someone saying they feel better cared for. [21] 74

75 CHAPTER 7 OTHER USEFUL DOCUMENTS We have several other documents that explain in more detail what will be doing over the next five years. You will find the documents below on our website Glossopccg.org NHS Tameside and Glossop 2014/15 to 2015/16 Operational Plan NHS Tameside and Glossop Finance Strategy NHS Tameside and Glossop Five Year Strategy Key Lines of Enquiry NHS Tameside and Glossop Quality Strategy NHS Tameside and Glossop Organisational Development Strategy Tameside Joint Strategic Needs assessment If you would like to receive this document in another language or format - such as audio, large print or Braille please contact our Communications Department on or use the Text Relay Service (for Deaf and hearing impaired patients). Contacting us If you have any questions or comments about Tameside and Glossop CCG or you would like to get directly involved in our plans please contact us via: TGCCG.Communications@nhs.net or TGCCG.listening2patients@nhs.net You can find out more about the CCG via Our website; Following us on Liking us on Facebook; facebook.com/tgccg [22] 75

76 GOVERNING BODY MEETING Title of Subject: NHS Tameside and Glossop 2014/ /19 Five Year Strategic Plan & Key Lines of Enquiry Technical Appendix Date of paper: July 2014 Prepared By: History of paper: Executive Summary: Clare Watson/Richard Bircher/Elaine Richardson Previous Drafts to GB and relevant committees. Submitted to NHS England Friday 20 th June NHS Tameside and Glossop, Tameside Metropolitan Borough Council, Derbyshire County Council and NHS England are all committed to reducing demand on more intensive health and social care services by focussing on community based prevention and early intervention initiatives. As local commissioners we have come together to fundamentally address the health and social care challenges faced by our population. We have created a Care Together Programme to redesign and realign health and care services to provide joined up care to Tameside and Glossop citizens. This will ensure that people get the right care in the right place from the most appropriate professional and within the resources available. Recommendations required of the Governing Body (for Information, Discussion or Decision) Governing Body are asked to note and ratify our 2014/ /19 Five Year Strategic Plan & Key Lines of Enquiry Technical Appendix QIPP principles addressed by proposal: Direct questions to: All Clare Watson/Richard Bircher 76

77 NHS Tameside and Glossop 2014/ /19 Five Year Strategic Plan Key Lines of Enquiry Technical Appendix 1. Submission details 1.1. Which organisation(s) are completing this submission? NHS Tameside andglossop Clinical Commissioning Group 1.2. Contact name and contact details Richard Bircher, GP Governing Body Member, Clare Watson, Director of Transformation, Elaine Richardson, Head of Delivery and Assurance, NHS Tameside and Glossop Clinical Commissioning Group New Century House Progress Way Windmill Lane Denton Manchester M34 2GP Switchboard: System vision 2.1. What is the vision for the system in five years time? NHS Tameside and Glossop, Tameside Metropolitan Borough Council, Derbyshire County Council and NHS England are all committed to reducing demand on more intensive health and social care services by focussing on community based prevention and early intervention initiatives. As local commissioners we have come together to fundamentally address the health and social care challenges faced by our population. We have created a Care Together Programme to redesign and realign health and care services to provide joined up care to Tameside and Glossop citizens. This will ensure that people get the right care in the right place from the most appropriate professional and within the resources available. Whilst commissioner led, this vision is partnership driven as only by working together can we ensure a sustainable care sector. Care Together aims to introduce a new form of provision into the care services market namely a fully Integrated Care Organisation spanning primary, community, mental health, social and local hospital based care. This will ensure Tameside and Glossop people receive holistic high quality health and social care that lines up to the principles of the 6 Cs (Care, Compassion, Competence, Communication, Courage and Commitment) and delivers the best possible health outcomes. S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 1 77

78 The care will be organised around four levels as shown in the diagram below and aims to promote self care whilst ensuring support is available when required coordinated by people who are able to consider the wider needs of the individual and plan their care accordingly. Building up the strength of communities Integrated teams based in localities Specialist pathways Hospital based care Level 1 Building up the strength of individuals and communities Understanding the things already available to support people and ensuring people know about them Using technology and other equipment to help people be more independent Investing in community groups and the 3rd sector to provide low level support to others Level 2 Integrated teams based in localities: Teams of multi skilled professionals based in the 5 geographical localities Identifying and proactively supporting "at risk" people Using integrated case management and care coordination Access to appropriate specialist resources and services when required Focused on better condition management, preventing admissions, and facilitating discharge Level 3 Specialist pathways: Seamless continuity of care across specialist, community and primary care Recognising the need for specialist support in certain pathways and providing more flexible access Using the broader hospital network and thinking differently to deliver specialist care A consistent, high quality approach to discharge by proactive planning, involving the right people, when someone is admitted Level 4 Hospital Based Care: The best health outcomes delivered 24 hours a day, 7 days a week Concentrated expertise in teams delivering the once in a lifetime specialist care at a particular hospital S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 2 78

79 We, along with our Local Authorities, are committed to driving up healthy life expectancy and supporting people and communities to flourish through self care and independent living and right service right place and time. We will work with our public, patients and professionals to redesign the way services are organised and delivered shifting the locus of care away from hospital settings and eliminating the fragmentation they experience today How does the vision include: Ensuring that citizens will be fully included in all aspects of service design and change, and that patients will be fully empowered in their own care The work on developing the integrated care vision started in 2012 with discussions with the public, members and partners about the need to focus on preventing ill health and organising care around the needs of the individual. People are aware of the financial pressures local authorities and health services are under and our recent consultations have shown local people expect us to work together to reduce waste and provide high quality care. Our Care Together programme includes a Communications and Engagement workstream that aims to ensure plans are shaped by our local population. Our Service Redesign workstream enables patient experience to feed into the design of individual services. We also use complaints and compliments to identify poor and good practice and to inform future commissioning. We will strengthen this further through our revised Patient Engagement Strategy to ensure the patient perspective is fundamental to our commissioning decisions. We are developing the use of technology to make it easier for patient opinions to be gathered. In particular we are using software to analyse patient feedback that is fed into both local and national systems so we can use the learning to inform service development. We encourage feedback from our most vulnerable patients and have developed easy to read questionnaires to make sure we gain their views on the care they have received. This along with developing our understanding of the needs of people who are seldom heard will enable us to make sure that our services are accessible to all those that need them. We see the role of the lay representative in our governance structures as key and expect them to ensure patients have been consulted and involved in all our plans. Our Patient and Public Impact Committee has representation from Tameside, Derbyshire and High Peak Overview and Scrutiny Committees, Healthwatch (Tameside and Derbyshire), Community Voluntary Action Tameside (CVAT), High Peak CVS, Tameside and Derbyshire s Health and Wellbeing Boards, Public and Patient Engagement/Customer Service Representation from Arriva, Tameside Foundation Trust, Stockport Foundation Trust and Pennine Care. It makes sure that public and patient involvement in Tameside and Glossop CCG: identifies the needs and aspirations of local people is being used to develop priorities, strategies and plans S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 3 79

80 has influenced service delivery has helped to procure services is effectively monitoring services for key public and patient engagement quality outcomes and standards The needs of our Protected Groups are discussed in our Consumer Advisory Panel which is a service user advisory group representing the needs of vulnerable and protected groups to ensure fair access to healthcare services in Tameside and Glossop. Our Care Together model starts with building the strengths of individuals and communities enabling individuals to take responsibility for their care. We have identified programmes for delivery in 2014/16 that will support this aim, including the development of our "Wellness Offer", redesign of services and support for carers, ensuring the engagement and development of our Third Sector providers, and the development of "advice and support" services. The Integrated Locality Teams are the first line of support for patients who need more help. They will become partners with patients and carers in planning the care needed to keep people as well and independent as possible. Through effective risk stratification, integrated case management and care co ordination they will prevent admissions to hospital and if someone does have to go to hospital they will enable them to be discharged as early as possible. The CCG and Local Authority commissioning partners will develop and implement plans for integrated locality teams for adults and for children during 2014/ Wider primary care, provided at scale Part of our strategic reform of the local system is a changing Primary Care. Our Care Together vision is for a fully joined up, high quality, sustainable, modern and accessible health and care system. Primary Care have a lead role in delivering this vision as providers of essential, additional and enhanced care, and of taking on increasing responsibility for an extended range of services. We will look to practices to co deliver, working together more closely in larger units for some services, particularly in support of the frail elderly and urgent care services; and to offer improved access when needed. We know that all providers of care need to change the way they deliver care for our changing population, and Primary Care will need to respond to the needs of its patients in today s society. It may need to change the way and time it delivers some of its services. IT and IM&T solutions are key enablers to ensuring primary care can contribute to the integration of care, and the promotion of patient centred care. We are keen to explore solutions for integrated care records and patient focused creative technology. We see Primary Care as a provider within the Care Together Programme, yet recognise that general practice needs investment and support to deliver its core GMS/PMS/APMS contractual rquriements. We will therefore be developing our own local Primary Care plan, which complements the Greater Manchester strategy, and ensures that our practices have the right S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 4 80

81 capacity and capability to meet the demands within their existing contracts and to take on the additional responsibilities that our Care Together programme asks of them. We will work with GM Local Area Team to ensure our practices are well placed and appropriately resourced to provide the best care, access and quality for our patients. Primary Care, and general practice in particular, is at the heart of our new system wide transformation of care for Tameside & Glossop as part of our integration work. We know the importance of primary care as the cornerstone of plans to reform local health services and improve health and outcomes for local people Our service redesign new models of care are focused on delivering as much care as is safe and appropriate in primary and community care. NHS Tameside and Glossop is working with Tameside Metropolitan Borough Council, Derbyshire County Council and NHS GM to reduce demand on more intensive health and social care services by focussing on community based prevention and early intervention initiatives. We are working together to address the health and social care challenges faced by our population. We know that if all other services fail, one does not general practice. Primary Care is the safety net for our patients, and we need to ensure that we work with and develop our practices to ensure they can meet the needs of patients when demand rises, but also support them to sign post elsewhere, when their level of input is not appropriate or needed. We have created our Care Together Programme to redesign and realign health and care services to provide joined up care to Tameside and Glossop citizens. This will ensure that people get the right care in the right place from the most appropriate professional and within the resources available. We want more care out of hospital, integrated pathways and services in an extended primary care. Having the ability to plan and commission primary care services alongside the social care, hospital, community and mental health services will allow the local health economy to make faster progress on these plans and design services and contract mechanisms which work across the whole system of care. We are working with our partners to ensure a sustainable care sector to ensure the people of Tameside and Glossop receive holistic high quality health and social care that lies up to the principles of the 6 Cs (Care, Compassion, Competence, Communication, Courage and Commitment) and delivers the best possible health outcomes. Primary Care can lead the way in the implementation of these principles, and we will look to build these into our general practice quality work through the LIG, and our local performance framework/balanced scorecard. Our Care Together model of delivery is organised around four levels and aims to promote self care whilst ensuring support is available when required coordinated by people who are able to consider the wider needs of the individual and plan their care accordingly. General practice is the focal point for these levels of care because the general practice primary health care teams already provide care and wellbeing services on a list based/micro basis, which we are looking to develop for a wider population based approach to care; putting patients first and wrapping care around them. S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 5 81

82 A modern model of integrated care The interrelationship of health and social care requires that we commission as one. Integrated commissioning provides the only strong viable option to the pressures within Tameside and Glossop and it must be matched by integrated provision. Our vision is an integrated provider that offers clinical viability and more importantly a safe and sustainable service that has patients and the wider population at its heart. The artificial barriers of primary, secondary and social care will be consigned to history as we develop a continuum of prevention, treatment and care that has the right person in the right place delivering the most appropriate interventions, service and care for the patients in their own home or very close to it. As we move services into the community and wrap care around the patients, we will need staff to move with the patient and work in a new environment. There will be a need for training and support to enable this to happen. Staff will need to work together in an integrated way, crossing multi professional boundaries to deliver care for the patient. Through the integrated delivery vehicle organisational boundaries will be blurred and removed, and therefore staff will work within one governance and delivery framework. Our principles for integrated care are: Improve health and wellbeing outcomes Reduce health inequalities and improve healthy life expectancy Better experiences of using services Designing needs led, evidence based services Focusing on wellness, maintaining good health and preventing illness including longer term health improvement High quality, safe, local treatment and support in planned and urgent situations Clear accountability for quality and safety across the whole system Getting good value for money for our taxpayers Managing our finances within the reducing available funding Making sure people don t have to give the same information lots of times Better access to care when and where people need it Making each contact count by identifying other things that are available and pointing people towards them Consistency of service quality across the localities Ensure delivery of statutory obligations Ensure delivery of services which meet safeguarding requirements Delivery of patient centred care plans and patient held records We want a strong hospital based sector in our community that has outcomes that are amongst the best in the country. But it has to be safe, sustainable and affordable and that cannot be achieved by horizontal integration across GM hospitals alone. We must have vertical integration to enable only those conditions that require intensive support to take place in a hospital environment with the majority of care delivered within a patient s own community. S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 6 82

83 In 2014/15 we have developed joint commissioning intentions with Tameside Metropolitan Borough Council. These aligned our intentions for our commissioned spend relating to all health and social care services. During 2014/15 the two organisations will align their commissioning and look, over the next 2 years, to bring together the commissioning functions. Whilst we do not have any agreement with Derbyshire County Council to align any budgets we will be working in partnership to ensure the proportionate share of commissioning resources support this population. This supports the Better Care Fund approach to joint working. During 2014/16 we will test and extend this way of working for the good of our population. Where providers feel unable to change and work with a newly integrated model, we will look to recommission the care from an alternative provider Access to the highest quality urgent and emergency care All levels of our Care Together programme support urgent care needs. We will ensure that when people need health or social care in an emergency they get prompt and effective support that gets them well again quickly. Our integrated teams ensure that our most vulnerable patients are risk assessed and have comprehensive care plans in place that will reduce the risk of deterioration to the point when a need becomes very urgent or an emergency. Our use of technology will support early intervention and enable rapid responses to avoid emergency intervention. However, when such a need arises we will have the ability to mobilise an appropriate response through a single point of access. The aim will always to be support the person in their own home but where this is not possible community step up or acute facilities will provide the appropriate level of assessment and care. Admissions Avoidance is a key programme in our 2014/16 plans. The initial focus is on the frail elderly with future work planned on Long Term conditions, Ambulatory Care and Minor illness/injury. Our All Age Mental Health, All Age Learning Disabilities and Children programmes will ensure access to specialist support in an urgent or emergency situation. Our work with North West Ambulance Service (NWAS) on our Paramedic Emergency Service (PES) will continue as they develop their changed role within an enhanced system of urgent care. Working together we will build on the development and implementation of initiatives such as the Urgent Care Desk, Paramedic Pathfinder, Referral Schemes into Primary Care, Targeting Frequent Callers, and increasing the percentages of patients that are treated by See and Treat and Hear and Treat. To develop the role of mobile urgent treatment centres so conveyance to hospital will be only one of a range of clinical options open to ambulance service. PES will be key part of delivering safe care closer to home in Tameside and Glossop. Our plans include developing our A&E and the Walk in Centre services so that people can be seen in the best place and by the most appropriate person. S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 7 83

84 The horizontal integration across GM hospitals through Healthier Together will support access to once in a lifetime specialist care at a particular hospital e.g. Stroke Care. This will give patients the best possible health outcomes 24 hours a day, 7 days a week. Our integrated case management and care co ordination approach and intermediate care services will ensure that patients are discharged promptly and enabled to return home wherever possible A step change in the productivity of elective care Through our specialist pathways and in hospital care programmes we will deliver high quality elective care that is more convenient for our patients and reduces the length of time spent in a hospital bed. We have a number of specialist pathway redesign programmes identified for 2014/16, nine of which will have a significant impact on the effectiveness of elective care Cancer Diagnostics Musculoskeletal Ophthalmology Sexual Health Specialist Long Term Conditions Respiratory Specialist Long Term Conditions Cardiovascular Stroke and Neurological Rehabilitation General Surgical Our integrated services will enable a multidisciplinary approach that ensures the right person supports the patient in the right place through the most appropriate intervention. Through seamless continuity of care across acute, specialist community and primary provision we will reduce duplication and waste and improve patient experience. Our increased access to direct access diagnostics and Straight to Test pathways will reduce delays and avoid unnecessary appointments freeing up both patient and clinician time. We will reshape provision at Tameside Hospital to that of predominately daycase and outpatient activity with diagnostic support. Retaining 64% of patient care locally and providing a clinically safe and viable platform from which to build a new model of health and social care provision. We will support all our providers to build capacity and capability. We will also support the development of new providers. We want a vibrant, flourishing and competitive provider market place to meet the challenges of the new integrated service models. We will reward innovation in delivery, particularly focused on quality, safeguarding and social values Specialised services concentrated in centres of excellence (as relevant to the locality) Working with partners in the South Sector of Greater Manchester and wider through Healthier Together we will build a model of specialist services that deliver excellent health outcomes. We will have centres of excellence where the very best doctors, nurses and therapist are available 24 hours a day, 7 days a week. S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 8 84

85 Our plans are congruent with the Healthier Together proposition but for us, that is an enabling staging post not our end state. The reforms proposed in healthier together are about saving lives not money. Although there are some predicted savings to reinvest in care out of hospital they do not go far enough for us in addressing the gap of 74m. There is a clear direction though, consistent with findings from the foundation trust regulator (Monitor) that smaller hospitals need not only to work within new models of care (Care Together and Healthier Together) but share staffing etc. (what is called a single service model). Locally we have been talking to neighbouring hospitals about what needs to be done together across a partnership of hospitals. There has been a great deal of focus on how TGH would work with partners in a 'southern sector' but we know our patients also use other hospitals and so we continue to discuss how best hospital care should he organised How does the five year vision address the following aims: Delivering a sustainable NHS for future generations Our Care Together vision of an Integrated Care Organisation will address the clinical and financial pressures that have been subject to local and national scrutiny. We are planning a viable and sustainable local economy but those plans are predicated on support from the relevant regulatory bodies for: The development of a new and innovative service delivery vehicle (the ICO); and Flexibility in the design of new procurement, payment and funding mechanisms. This support is essential to the success of our approach to integrated care. Our analysis clearly demonstrates that, if we do nothing, we will have an economy wide deficit of 74m by 2018/19. If we fail to address the issues at Tameside NHS Foundation Trust we will be paying an annual premium of c 20m over and above tariff for services locally, which is not sustainable or good stewardship of public finances. If we fail to tackle the larger issue of Tameside Metropolitan Borough Council s 44m deficit, this will impact massively on NHS services. Integrated commissioning provides the only strong and viable option to the pressures within Tameside and Glossop, and it must be matched by integrated provision. Our Care Together programme makes this explicit and we look to Monitor, the Care Quality Commission and NHS England to be our partners in making this vision a reality. The significant financial challenges facing the three principle public sector organisations within Tameside and Glossop have been labelled locally as the perfect storm : S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\8.1a NHS Tameside and Glossop KLOE_Technical_Appendix_14_19 final.docx 9 85

86 The above scenario provides a compelling case for change. This is a journey we commenced some 18 months ago and there have been severall detailed pieces of work completed to help identify and quantify the scale of the problem facingg the whole community. The mostt detailed pieces of work have been provided by Ernst and Young plus two further pieces of workk led by McKinsey and Company. With a projected deficit of 74m we know we must be imaginativee in addressing the needs of our community. Through joint working and jointly commissioning an integrated service thatt puts the needs of the patients first we can provide the highest quality of care by the right professional closer to the patients home, and support a hospital based system for those conditions that can only be and should only be provided in a high performing hospital. We know our proposals are extremely ambitious but our situationn is extremely challenging. When faced with the scale and impact of these competing pressures, tinkering at the margins of health and social care will not suffice. The scope of our Care Together programme is a minimum of 293m, providing us with the opportunity too make changes at a scale that can bridge the financial gap across the economy in a sustainable way. The CCG has ensured the financial plans aree congruent with the major m national and regional service configurations and reforms taking place over this period. The T CCG is working collaboratively with all partners, namely local authorities, Tameside FT with other providers and primary care to realisee genuine savings s from hospital based services in order to support the move to primary and community based services inn an integrated model and therefore bridge the t economic gap. Our vision for reconfiguration is based on the following six operational levers: Shift to out of hospital services Efficiency in out of hospital Decommission services Prevention and integrated care Estates consolidation Acute services reconfiguration S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\ \July\GB\8.1a NHS Tameside and Glossop KLOE Technical_Appendix_14_19 final.docx 10 86

87 Clinical commissioning groups - Planning Template for Version 6 87

88 Planning Round 2014/15 Every clinical commissioning group (CCG) will need to complete and upload to Unify2 this planning template, as part of their formal planning submission to NHS England. To complete this template: Read the detailed information given in Everyone Counts: Planning for Patients 2014/ /19 and Everyone Counts: Planning For Patients 2014/ /19: Technical definitions for Clinical Commissioning Groups and Area Teams found at Select your organisation from the dropdown box below Answer all sections on pages Self Certification, AmbitionsForImprovingOutcomes, QualityPremiumMeasures, Other Measures and A&E Activity (you may need to scroll down to see all sections) Complete drop-down boxes and yellow boxes Green boxes contain automated calculations, you will not be able to fill these in For the QualityPremiumLocalPriorities tab, please select either a measure from one of the domain dropdowns or enter your own measure into the texbox provided. The Data Validation Tests table further down this page tells you if the data you have entered into the yellow boxes are valid. If they are, boxes will be green and Unify2 will accept your template. If not, boxes will turn red. If any boxes are red Unify2 will not accept your template You will then need to submit your completed template to the Unify2 system To do this you will need a Unify2 account for your CCG/CSU Please see instructions at the bottom of this page on how to get a Unify2 account Please see box below How to Upload this Template for instructions on how to submit this template to Unify2 For queries related to this Planning Template and its submission to Unify2 please PAT@dh.gsi.gov.uk or telephone Please note CCGs are also required to fill out the ProvCom Planning Template How to upload this template: Once you have completed this workbook and saved it on your hard drive, please upload your data into Unify 2. To do this, login to Unify2 (see hyperlink in the 'guidance' section, at the bottom of this page) [If you are a CSU acting on behalf of a CCG, and have logged in using a CSU account you will now need to follow an extra step before continuing, see end of this section. If logged in as a CCG, continue to step below] Once logged in, click on Data collection & management..then NON DCT Home Page...and select the Upload option for the return Plan_CCG Then click Browse and point to the location of this workbook S:\CCG\Finance Information & Governance\Gvnce\Corp\Executive Secretariat\MEETINGS\CCG Governing Body\2014\July\GB\[8.1b CCG_Com_Planning_Template_(Functional)_V6.0v1 (Submitted ).xls] 88

89 ...before ticking Auto Sign Off and then clicking Upload. You will then be able to view your data through the Extraction Viewer menu, but please be aware that it can take a few hours for your data to filter through. Extra step for CSUs: If you are a CSU acting on behalf of a CCG, and have logged in using a CSU account you will first need to impersonate the CCG for whom you are uploading the template before you can continue. To do this: In the top right corner of the screen, click where is reads You are signed in as xxx as XXX COMMISSIONING SUPPORT UNIT Select the correct CCG from the organisation dropdown list Click Impersonate Follow remaining steps above, from 'Click on Data collection and management' Please choose your organisation: Selected organisation details: Code: Name: 01Y NHS TAMESIDE AND GLOSSOP CCG Template questions menu: Data Validation Tests Complete data entered Is format correct? Text/Number Within character limit? Required Commentary submitted 1.i Self-certification: NHS Constitution ii Self-certification: Provider CIP's iii Self-certification: MRSA i Ambitions for Improving Outcomes: PYLL ii 2.iii 2.iv Ambitions for Improving Outcomes: Quality of life for people with long term conditions Ambitions for Improving Outcomes: Avoidable Emergency Admissisions (5 years) Ambitions for Improving Outcomes: Inpatient Experience

90 2.v Ambitions for Improving Outcomes: GP/ GP out of Hours Experience ii Quality Premium Measures: Avoidable Emergency Admissions (Quarterly 2014/15) iii Quality Premium Measures: IAPT Access iv Quality Premium Measures: Friends and Family Test v Quality Premium Measures: Medication Errors vi 4.i Quality Premium Measures: Agreement with Health and Wellbeing boards 0 0 Quality Premium Local Priorities: CCG OIS/Locally defined measure i Quality Premium Local Priorities: Local Priority Measure i Other Measures: C.Difficile ii Other Measures: Dementia diagnosis rate iii Other Measures: IAPT Recovery i A&E Activity: A & E attendances - All Guidance: In order to upload a template for a CCG, colleagues will need a Unify2 account for their CCG/CSU To request a new account - please go to the Unify2 homepage - under System Links click Request a Unify account, - select domain Knowledge and Intelligence, and - select Organisation Type CLINICAL COMMISSIONING GROUP' or 'COMMISSIONING SUPPORT UNIT' as required 90

91 01Y Name: NHS TAMESIDE AND GLOSSOP CCG Read the definitions in the Everyone Counts: Planning for Patients 2014/ /19 Technical Definitions for CCGs and Area Teams before completing the template 1. Self Certification i) Do your plans ensure that the performance standards in the NHS Constitution will be delivered throughout 2014/15 and 2015/16? Yes/No Yes/No If No, please provide commentary (max 4000 characters) ii) Have you assured provider CIPs are deliverable without impacting on the quality and safety of patient care from till ? Yes/No Yes/No If No, please provide commentary (max 4000 characters) E.A.S.4 iii) Do you plan to manage HCAIs so that your local Yes/No If No, please provide commentary (max 4000 characters) population have no cases of MRSA in and ? Yes/No 91

92 01Y Name: NHS TAMESIDE AND GLOSSOP CCG Read the definitions in the Everyone Counts: Planning for Patients 2014/ /19 Technical Definitions for CCGs and Area Teams before completing the template Read 'Setting 5-year ambitions for improving outcomes A how-to guide for commissioners' before completing the template 2. Ambitions for Improving Outcomes Outcome Ambition 1 E.A.1 i) What is your ambition for securing additional years of life from conditions considered amenable to healthcare? E.A.1 PYLL (Rate per 100,000 population) Baseline Please insert baseline - these are provided in the Levels of Ambition Atlas 2014/ / / / / Note: PYLL forms part of the 2014/15 Quality Premium. Outcome Ambition 2 E.A.2 ii) What is your ambition for improving the health-related quality of life for people with long-term conditions? E.A.2 Average EQ-5D score for people reporting having one or more long-term condition Baseline 68.3 Please insert baseline - these are provided in the Levels of Ambition Atlas 2014/ / / / / Outcome Ambition 3 E.A.4 iii) What is your ambition for reducing emergency admissions? 92

93 E.A.4 Emergency admissions composite indicator Baseline Please insert baseline - these are provided in the Levels of Ambition Atlas 2014/ / / / / Note: the composite avoidable emergency admissions indicator forms part of the 2014/15 Quality Premium and is a measure in the Better Care Fund. Outcome Ambition 5 E.A.5 iv) What is your ambition for increasing the proportion of people having a positive experience of hospital care? E.A.5 The proportion of people reporting poor patient experience of inpatient care Baseline Please insert baseline - these are provided in the Levels of Ambition Atlas 2014/ / / / / Outcome Ambition 6 E.A.7 v) What is your ambition for increasing the proportion of people having a positive experience of care outside hospital, in general practice and the community? E.A.7 The proportion of people reporting poor experience of General Practice and Out-of- Ours Services Baseline 5.5 Please insert baseline - these are provided in the Levels of Ambition Atlas 2014/ /

94 2016/ / /

95 01Y Name: NHS TAMESIDE AND GLOSSOP CCG Read the definitions in the Everyone Counts: Planning for Patients 2014/ /19 Technical Definitions for CCGs and Area Teams before completing the template Read the Quality Premium Guidance before completing the template 3. Quality Premium Measures E.A.1 i) Potential years life lost (PYLL) from ammenable causes in 2014/15 E.A.4 E.A / PYLL (Rate per 100,000 population) ii) What trajectory are you aiming for in the composite avoidable emergency admissions indicator in 2014/15? E.A.4 Emergency admissions composite indicator Q1 2014/ Q2 2014/ Q3 2014/ Q4 2014/ E.A.3 iii) For IAPT, what proportion of people that enter treatment against the level of need in the general population are planned in 2014/15 and 2015/16? E.A.3 The number of people who receive psychological therapies The number of people who have depression and/or anxiety disorders (local estimate based on National Adult Psychiatric Morbidity Survey 2000) Proportion Q1 2014/ % Q2 2014/ % Q3 2014/ % Q4 2014/ % 2015/ % E.A.6 iv) Which Friends and Family patient improvement indicator have you selected for an improved average score to be achieved between 2013/14 and 2014/15. Please Select an indicator E.A.6 Do you plan to meet all other criteria of the Quality Premium Friends and Family measure? Please set out further details below. Yes. THFT have developed a plan to improve the implementation and embedding of the FFT in Maternity which will drive improvements in this area. FFT will roll out across Community, GP s and Mental Health Services in 2014/15 including the introduction of a staff FFT test. We will continue to work with our providers to ensure improvement plans are in place. 95

96 E.A.9 v) Have you agreed (in conjunction with your Health and Wellbeing Board and NHS England area team) a specified increased level of reporting of medication errors from specified local providers between Q4,2013/14 and Q4, 2014/15? Yes/No Yes/No Please provide commentary, explaining the specified level of increase and if you do not plan to meet this, why? (max 4000 characters) The trajectory for increased reporting will be agreed by the Joint Medicines Management Committee. They will also monitor the impact of any improvement plans identified. The Medicines Safety Thermometer CQUIN still applies, and will be monitored through Total provider. vi) Where there are requirements for Quality Premium measures and/or planned levels of improvement to be agreed with the relevant Health and Wellbeing Board and NHS England area team, do you have their agreement to each of these? Yes/No Yes/No If No, please provide commentary (max 4000 characters) 96

97 Indicator Definition (please specify the local measures chosen) max 4000 characters 2014/15 Numerator Denominator Measure Local Priority 1 Increase in newly diagnosed patients on primary care dementia registers from the 31st March 2013 baseline 1418 ######## 97

98 01Y Name: NHS TAMESIDE AND GLOSSOP CCG Read the definitions in the Everyone Counts: Planning for Patients 2014/ /19 Technical Definitions for CCGs and Area Teams before completing the template 5. Other Measures E.A.S.5 i) Number of C.Difficile infections in 2014/15 E.A.S /15 Total April May June July August September October November December January February March Total Number of C. Difficile infections E.A.S.1 ii) What dementia diagnosis rate are you aiming for in 2014/15 and 2015/16: E.A.S.1 Number of people diagnosed Prevalence of dementia % diagnosis rate 2014/ % 2015/ % E.A.S.2 iii) What level of IAPT recovery are you aiming for in 2014/15 and 2015/16? E.A.S.2 (The number of The number of people who have people who have completed treatment completed treatment within the reporting having attended at quarter, having least two treatment attended at least two contacts and are treatment contacts) moving to recovery minus (The number (those who at initial of people who have assessment achieved completed treatment "caseness and at not at clinical final session did not) caseness at initial assessment) % recovery rate 2014/ % 2015/ % 98

99 01Y Name: NHS TAMESIDE AND GLOSSOP CCG Read the definitions in the Everyone Counts: Planning for Patients 2014/ /19 Technical Definitions for CCGs and Please be aware CCGs are expected to provide further activity figures in the ProvCom planning template E.C Activity Measures i) A&E Attendances - All E.C.7-8 Activity Trajectories types 2014/15 Total /14 Forecast Outturn Forecast growth in 2014/15 0.6% 2015/16 Total Forecast growth in 2015/16 0.7% 2016/17 Total Forecast growth in 2016/17 0.7% 2017/18 Total Forecast growth in 2017/18 0.7% 2018/19 Total Forecast growth in 2018/19 0.7% 99

100 You do not need to complete 100

101 Tameside and Glossop health economy is a system comprised of partners from NHS Tameside and Glossop, Tameside Metropolitan Borough Council, Derbyshire County Council, Greater Manchester Healthier Together, Tameside Hospital Foundation Trust, Stockport Foundation Trust, Pennine Care and the voluntary sector who have come together to ensure that the people of Tameside and Glossop have: Access to Excellent, Compassionate and Cost Effective Care and Lead long and healthy lives. Strategic Aims Our population will be fully involved in developing and agreeing the services that will be available to them Our patients and carers will be involved in all decisions about their care Local primary care will be at the heart of our integrated services Care will be built around the patient Our patients will be able to access high quality emergency and urgent care Our elective care will be high quality, efficient and productive Our patients will receive specialist services in centres of excellence Delivered through Care Together An Integrated Care organisation clinically led and patient centric delivering holistic health and social care to the whole population of Tameside and Glossop through four levels. Building up the strength of communities Integrated teams based in localities Specialist pathways Hospital based care Patients and communities empowered to care for themselves and to work together to support local health and wellbeing Technology enabled access to information, advice & care Locality based integrated teams of multi skilled health and social care professionals using integrated case management and care coordination Identification and support of "at risk" people High Quality Primary Care working through new models Fewer overnight stays in hospital more community based urgent care, ambulatory care, surgery being carried out in daycase facilities or in clinics Services shared across hospitals concentrating the expertise in teams delivering the once-in-a-lifetime specialist care All the above will be developed jointly by commissioners, Health and Social Care providers, the voluntary sector and patients System values and principles The needs of the community come before any one organisation s sovereignty People will be supported in the right place with the right health and social care provided by the right professional Care designed around people s needs enabling them to lead an independent life within own homes and local community Focusing on wellness and preventing illness including longer term health improvement High quality, safe, local treatment and support in planned and urgent situations We will maximise value by seeking the best outcomes for every pound invested We work cohesively as commissioners, providers and voluntary sector Measured using the following success criteria Increased Healthy Life Expectancy Reduced health inequalities Delivery of the Everyone Counts ambitions Achieving the NHS Constitution commitments All providers assessed as safe and providing quality outcomes All organisations within the health economy report a financial surplus in 18/19 Overseen through the following NHS Tameside and Glossop Governing Body NHS T&G Public & Patient Impact Committee NHS T&G Quality Committee Partner organisations Boards Tameside and Derbyshire Health and Wellbeing Boards Tameside and Glossop Commissioning Executive Tameside and Glossop Integration Board 101

102 Title of Subject: GOVERNING BODY MEETING Draft June PIQ Minutes Date of paper: 18 th June 2014 Prepared By: History of paper: Executive Summary: Graham Curtis n/a Items discussed included:- 5 per head for over 75s scheme PIQ recommended that a revised recommendation is made to suggest both locality and practice based bids will be acceptable for the 5 per head funding for over 75s scheme. Primary Care Update CW presented the draft framework for the development of cocommissioning of primary care services across Greater Manchester. Expressions of interest for our CCG should be developed by June 20 th 2014 which would outline what elements of responsibility we may want to take on. GC took a vote on whether PIQ should proceed with the expression of interest with the final count at 5 GPs in favour to 2 not in favour. An expression of interest to the Local Area Team will be accompanied by a letter explicitly stating the powerful concern from our membership and that it will still remain a very live conversation for now. Health Foundation Scaling Up Bid This looks at an integrated treatment plan for patients. It would look to empower patients and their families by assigning an elder care facilitator when they reach the age of 75. Recommendations required of the Governing Body (for Information, Discussion or Decision) CCG are asked to note and consider any recommendations within the minutes for approval. QIPP principles addressed by proposal: Direct questions to: All Graham Curtis/Clare Watson 102

103 Draft Minutes of the PIQ Committee Wednesday 21 st May 2014, 12.30pm, Boardroom Attending: Graham Curtis (Chair) Clare Watson Director of Transformation Kathy Roe Steve Allinson Dr Jamie Douglas CCG Governing Body Member Dr Guy Wilkinson CCG Governing Body Member Dr Amir Hannan CCG Governing Body Member Dr Ram Jha - CCG Governing Body Member Dr Naveed Riyaz Ashton Locality Lead Dr Andy Hershon Hyde Locality Lead Dr Syed Asad Ali Denton Locality Lead Dr Tim Dowling Target Lead Alison Lewin Michelle Rothwell Head of Individual Commissioning, Quality & Patient Safety Celia Poole Lay Member Clare Symons Mental Health and Learning Disability Commissioning Mgr Peter Howarth Head of Medicines Management Rob Mitchell Local Pharmaceutical Committee Sarah Hadfield Minute Taker 1. Apologies for Absence Dr Alan Dow/Dr Saif Ahmed/Elaine/Gideon Smith 2. Triathlon Challenge GC advised members of his forthcoming triathlon challenge which will be raising money for the Alex Hulme Foundation. PIQ wished GC luck and success in his venture. 3. Declarations of Interest All GPs Items 9,10,11,12 Any other declarations would be stated against each relevant item. 4. Register of Interests GC noted that very few registers of interests had been received from locality leads and urged them to note these before the next meeting. Action: Locality Leads to contact SH/JK with any registers of interests for

104 5. Minutes of the Previous Meeting The minutes were agreed as a true record. 6. Matters Arising Carried forward Action: TG/SH to circulate LMC summary by Peter Wright. Specialist Practitioner for Vulnerable Year Olds SH confirmed that this post had been included within the risk register. It was noted that the PIQ summary devised by A Hershon was a helpful document and should be rolled out further. Action: AH to circulate the locality summary to all GPs. EUR A discussion was held around concern with responsibilities, GPs inability to track policies and dangers of conflicting information. RJ felt that a leaflet which outlined any change of policies may be helpful for patients. Action: SH to ensure that link is circulated to members which highlights any EUR policies within consultation. 7. Locality Issues Hyde A Hershon reported that discussion had taken place around expectation of GP involvement with regard to Care Together. CW explained that a decision had been made where GPs would be reimbursed to attend any related events. The amount for this remuneration will be confirmed in due course. Ashton NR advised that debate had been had around the 5 per head funding for over 75s scheme and whether they should look towards building a more reactive or proactive system. CW added that the monies for the scheme are recurrent as part of the Better Care Fund. The scheme must be supported in line with Care Together programme and ensure that it is signed off by the Local Authority. Any business case for the scheme would have to be received as soon as possible to ensure it is processed through the appropriate governance. CW noted that GPs must ensure that business cases are clear that the scheme is separate from the Admission Avoidance DES to ensure no duplication of payment

105 CW urged practices to utilise their CCG lead commissioning managers and finance leads in preparation of their bid. It was felt that utilisation of third sector groups and patient participation groups would be useful for the bid. Practices must also be careful to avoid any conflicts of interest. GPs felt that locality based proposals may not be as effective as practice based ones and that this could result in a time constraint. NR agreed adding that combining a few practices may result a more innovative result. CW took these comments on board and agreed that these comments be relayed back. Denton/Droylsden SAA fedback that suggestions had been discussed around increasing capacity which would allow a proactive approach to patients over 75 within primary care. There was frustration however with the bid process and drafting of business case. SAA also reported discussions around the locality lead roles and what their roles entailed. This has also sparked discussion on what CCG roles consisted of for example A Governing Body role. Glossop GW reported three schemes that had been explored for the 5 per head funding for over 75s scheme. These included a Practice based Pharmacy, Practice based nurse and a mobile application. It was concluded that the first two suggestions would be possibilities to develop further. Stalybridge PH reported that a similar scheme to Denton for the 5 per head funding for over 75s scheme had been discussed where it would look to allow a proactive approach to patients over 75 within primary care. S Allinson noted the great working which was apparent at the CCG between member practices and management staff and felt that this should be fedback through localities. PIQ recommended that a revised recommendation is made to suggest both locality and practice based bids will be acceptable for the 5 per head funding for over 75s scheme. Action: CW to circulate a revised business case to all GP member practices. Action: CW to re-stress the importance of Local Authority support for bids relating to the 5 per head funding for over 75s being in line with Care Together. Action: CW to urge practices to utilise their CCG lead commissioning managers and finance leads in preparation of any bid relating to the 5 per head funding for over 75s. Action: CW to circulate Better Care Fund metrics on what we will be judged by for the 5 per head funding for over 75s scheme

106 Action: Governing Body Clinical Leads to list outline of roles to then be circulated throughout localities. Action: CW to ensure communications are sent out around GP remuneration for attendance at Care Together events. 8. Finance Update KR presented the update and focused on the 2 main reserves held by the CCG: the Commissioning Development Fund and the Risk Reserve. KR gave a breakdown of the Commissioning Development Fund and highlighted commitments already agreed against the available pot of 5.1m which had been approved by the PIQ committee. The 5 per head for over 75s scheme has been added to the costs which would leave a balance of 3.3m if it went ahead. KR noted however that this balance was likely to decrease significantly in line with the 1 st and 2 nd phase Care Together business cases which will be considered at the next meeting. KR also noted pressures against the Risk Reserve which left a current balance of just over 1m. This will need careful management as anything committed over the available risk reserve would be taken from the Commissioning Development fund and reduce the funds available for pump priming integration schemes. A Hershon asked for further clarity on what the funding earmarked for the Mckinsey work had given us. KR explained that an extraordinary Governing Body meeting had been put into place before this work was commissioned which detailed what this was for. S Allinson agreed to write a brief to detail this request. KR reported that the month 1 position was showing a provisional slight underspend against secondary care. This was due to an underspend against non-elective admissions. CW added that A&E was performing much better and currently one of only three trusts within GM with green status. RB urged GPs to ensure all efforts are focused on patients being discharged from the Trust when appropriate to allow maintenance of our current performance. CW agreed adding that this approach could be considered as part of any bid for the 5 per head for over 75s scheme and would assist as part of the metrics for the Better Care Fund. CW noted that 1.6m resilience monies had been awarded nationally for our economy with respect to ensuring the RTT target is achieved along with preparing for winter and system sustainability. These funds will be managed through the Emergency Care Network which RB offered an open invitation for those interested to attend. Action: S Allinson to produce a brief which details a summary of work undertaken by Mckinsey

107 9. Care Together/Service Redesign Update AL updated that five outline business case would be coming to July PIQ. AL added that we had so far only had six responses to the Care Together event to be held on the 1 st July. AL urged members to encourage attendance of the event. CW added that remuneration would not be available for attendance of this event. RB noted the excellent work being carried out within the service redesign meetings. Action: SH to ensure communications for the Care Together event on the 1 st July are resent. Action: Locality leads to ensure encouragement of attendance for the Care Together Event and for the event to be advertised at the Target meeting. 10. Primary Care Update Declarations of Interest: All GPs CW presented the draft framework for the development of co-commissioning of primary care services across Greater Manchester. The framework sets out the elements of the commissioning cycle alongside a number of principles that it is based on. Expressions of interest for our CCG should be developed by June 20 th 2014 which would outline what elements of responsibility we may want to take on. After discussion at the CCG Management Team the view was that we adopt a level one strategic overview. CMT felt that the right approach would be to declare interest in those listed in box 3 and parts of boxes 2 and 4. This will allow a responsibility we influence the alignment of Care Together. CW added that at this stage we are unsure what the next steps are likely to be but we would not be held to account if we expressed any interest at this stage. Expressing an interest however will enable us to assess what are options are should we wish to explore further. At this stage the expression of interest is thought to be aimed at Primary Care specifically as opposed to any other contracted groups. General feeling from GP members was reluctance to move away from the national contract and that any expression of interest should be approached with great caution. A notion of risk must also be considered with regard to no transfer of managerial resource within the contract. GC feedback that Alan Dow felt that it was important to ensure an interest is expressed and to ensure that any conversations remain live at LMC and member practice forums. CS reported that views from the Stalybridge locality were that they were in favour but pros and cons would need to be clear. KR felt that in line with our plans to invest further within Primary Care we must take the option to express an interest as no future investment will be received from NHS England. GC took a vote on whether PIQ should proceed with the expression of interest with the final count at 5 GPs in favour to 2 not in favour

108 SA suggested that any expression of interest to the Local Area Team will be accompanied by a letter explicitly stating the powerful concern from our membership and that it will still remain a very live conversation for now. GC noted concern with the governance of this decision and felt a conversation would need to be held with S Allinson For Discussion and Recommendation 11. Health Foundation Scaling Up Bid Declarations of Interest: - All GPs TD explained that a previous bid for the PM Challenge Fund had been used which looks at an integrated treatment plan for patients. It would look to empower patients and their families by assigning an elder care facilitator when they reach the age of 75. The bid is based on an existing model in Mid Staffordshire which has received critical acclaim. It has been proven to decrease A&E attendances by 20% and would align with the Care Together program. CW explained that the CCG have been asked to formally sponsor the bid which would be awarded 500k if successful and that it had been discussed with enthusiasm at a recent management team meeting. PH, RB and GW all felt very supportive with the concept. GC felt that the bid may not show equality within the localities as only Hyde and the practices of GPs who knew about it were involved. TD informed that the Local Area Team had suggested that a smaller bid may be preferred but that an attempt had been made to roll out across the patch. TD also added that ultimately the patients interests were the key factor in any decision made so far. RB also felt that the nature of any pilot in its first phase would be inequitable. S Allinson gave thanks to TD and A Hannan for their work on the bid and though he agreed with the criticism of response from member practices the work put in had been excellent and it would be wrong to dismiss because it is not universal across the patch. 12. Investment Criteria AL presented the investment criteria, which have been amended to reflect comments at and since the May PIQ meeting. Following some debate, it was agreed that the investment criteria do need to be succinct, but that they should be re-worded to include a reference to increased productivity and cost benefit in the Cost section, and a criteria relating to whether the proposal supports selfmanagement. There was also a discussion relating to the absence of criteria specifically assessing the qualitative impact of proposals, and the impact on health inequalities, but it was agreed that the Care Together Project, Safety and Effectiveness cover these areas. Action: AL to make the further amendments as recommended 6 108

109 13. 5 Year Strategy Refresh RB explained that we had been given the opportunity to refresh our strategy which would enable us to ensure Care Together has a platform within the new draft. The resubmission has been clinically led and will be submitted on Friday the 20 th June. The draft will ensure that it is in an easy read format and include elements such as Key Lines of Enquiry and Health Social Care spend. The strategy also features character stories which details a journey of various services used. GC commended the use of the personal stories and how powerful it enabled the system to be personalised. 14. Approval of EUR Policy Hyaluronic Acid Injections for Osteoarthritis This item was removed from the agenda as it had already been approved. 15. Clinical Research & CCG Commissioned Community Based Services AL and PH presented a number of issues relating to the recruitment of Tameside and Glossop registered patients to clinical trial projects. This has come to light as an issue due to current activities within the diabetes service. Margaret Cooper from UHSM (TFT) was also in attendance to provide supporting information on the clinical trial processes currently in operation at Tameside FT. There were two main issues for discussion and decision the issue of clinical sessions commissioned by the CCG which are subsequently used to deliver clinical research trial activities, and the need for the CCG to consider how we have oversight of clinical research activity in the local area. Following extensive debate, PIQ members confirmed that patients should definitely not be seen within the diabetes clinic sessions if the contact relates to a clinical trial. PH noted concern about patients care once a trial ends and patients are referred back to their GP or local services pre-trial governance needs to be clear what any impact may be on the ongoing care provided. AL and PH will feed this back to Stockport FT as the provider of our diabetes service. MC agreed to feed this back via the appropriate routes within TFT. PIQ members recognised the value of and need for clinical research and trials, and the need to ensure that clinical research continues even if we are changing the way we commission and deliver services, and therefore asked that AL and PH work with the nursing and quality directorate to determine an internal process for the monitoring and development of clinical research, particularly in light of the Care Together plans. For Information 16. Emergency Care Network Minutes RB presented the minutes which highlighted the following issues:- Admission rates were down with an upward trend being seen within IRIS and ambulatory care

110 A full evaluation of IRIS is expected to be presented at the next PIQ. A review had been carried out in relation to the medically fit list as this is thought to be major factor of when A&E collapses. 17. IM&T Sub Committee Minutes A Hannan presented the minutes which highlighted the following issues:- A data sharing agreement was now in place with letters expected to be forwarded to member practices shortly. With regard to the funding gap within GP IT this figure has been confirmed as 557k. KR confirmed that this has not yet been added to the list as yet but would not be included within the risk reserve. Discussions were still ongoing around Lorenzo which were being addressed. 18. Any other business PH gave an update from the recent Medicines Management meeting which included details around antibiotic guidelines which required formal acknowledgement. RJ wanted to feedback from the recent Practice Managers forum issues around the Patient Opinion system. It had been reported that extra work was being created as the NHS Choices feedback system was widely used and could create duplication. A Hannan agreed that several papers had suggested that the patient opinion was the preferred platform for feedback and that there was a benefit to Healthwatch for using it as it provides reports for use at committees. CP added that PPIC had asked for an update around these three months after its launch so highlights of this could be shared with the Governing Body. Date & Time of Next Meeting Wednesday 16 th July 2014, 12.30pm, BR, NCH 8 110

111 GOVERNING BODY MEETING Title of Subject: Health & Social Care Integration Report Care Together Programme Date of paper: 2 nd July 2014 Prepared By: History of paper: Executive Summary: Doreen Hounslea, Programme Director for Integration This report updates the Governing Body on the discussions, developments and decisions that have taken place relating to the Care Together Programme since the last report in June. The report provides an update on the programme including the date for the decision from Monitor; the revised timing for Public Consultation and the ongoing discussions with THFT in respect of the base case for inpatient provision within the proposed ICO, which differs from the commissioner s model but must meet the three key tests: safe, sustainable and integrated. Recommendations required of the Governing Body (for Discussion and Decision) The Governing Body is asked to: i. note the decision from Monitor should be known w/c 30/6/14; ii. the ongoing work with THFT in agreeing the base case for change and in particular the future level of inpatient provision as part of the proposed ICO; iii. to receive, once complete, the organisation s engagement strategy including the revised timetable for the Care Together public consultation process; iv. to receive a further update at the next Board meeting. QIPP principles addressed by proposal: Direct questions to: All Doreen Hounslea / Kathy Roe / Clare Watson 111

112 Tameside & Glossop CCG Governing Body Meeting Health & Social Care Integration Update Report 2 nd July 2014 Agenda Item: Introduction 1. This paper should be the last in reporting that we are awaiting the outcome of Monitor s view of the Care Together proposals. Having been given additional time to stress test our assumptions and to present a proof of concept that we can address the three fundamental issues at stake for this economy: I. Safe services II. Sustainable services within the financial envelope available III. We have delivered an integrated care model that benefits patients 2. We are now awaiting the outcome of a special meeting that takes place week commencing 30 th June. By the time the Board meeting takes place we should know the outcome of Monitor s response to our request for a local economy wide solution for Tameside and Glossop. 3. However, we have not been idle waiting for this decision. Whilst the outcome is important the engagement of providers and the further refinement of our model is taking place. This has been via a co-hosted event with NHS England GM LAT and local providers (13/6/14); one to one meetings with senior managers from a number of Trusts and ongoing dialog with Tameside NHS Foundation Trust (THFT). 4. Whilst THFT support the overall direction of travel they do feel they can increase the baseline assumptions relating to the volume of work carried out at the site and its complexity. They have prepared a plan as part of their governance arrangements and we await sight of this. In discussion we have acknowledged that we have areas of commonality and we have made it clear that as commissioners any plan must deliver the three issues stated above. If this can been achieved then we would amend our plan accordingly as we have always wanted to retain services locally but only if they pass the three tests. Current Position 5. As stated above the work is ongoing to understand the patient flows and the clinical networks required to deliver the Care Together Programme across a range of providers. Meetings are taking place, including a meeting planned on the (1/7/14) with Primary Care clinicians and members of the wider primary care team to brief them on progress and to consider their role in the whole integration agenda. 6. It is important to recognise the influence of Primary Care in the development of our proposals as it is crucial to the success of the overall programme. We have indicated to NHE England (GMLAT) that we would be interested to bid for co-commissioning status and await the outcome. 7. There has been a review of the timetable for the implementation programme and in particular the timing for public consultation. It has been agreed by commissioners that formal consultation will be delayed until much later in the financial year. This is for several reasons including the imminent launch of the consultation for Healthier Together. We will be using this as a platform from which to build the next stage of the 1 112

113 integration model discussion as we must unsure transparency that for our economy Healthier Together will not address all our issues - but, it is an important first step. 8. We must also ensure that we have fully completed the pre-consultation phases that will be essential to the success of our engagement and involvement ambitions. To this end the CCG has appointed, in the short term, a specialist to write its engagement strategy, which includes the consultation process for Care Together. This document will be shared with Governing Body in due course. 9. It is import that we recognise the timing of our plans in light of the forth coming general election. We have to contend with parliamentary recess, purdah and of course the election itself. Given the bold and imaginative nature of our plans it would be short sighted not to consider the political aspects of the proposals, which has also had a bearing on the timing of the Care Together consultation progress. It must be stressed that we will continue to engage with the public via our redesign work streams and to work with the third and voluntary sector to ensure our proposals span the full patient pathway. We will be able to provide a clear timetable once the organisation s engagement strategy is complete and formally signed off by the Board. We are not taking this decision in isolation but in conjunction with TMBC and THFT as this must be handled on whole system basis one joined up consultation with the public on a model that is owned by all concerned. 10. At the end of June the first outline Business Cases (OBCs) from the Service Redesigned workstreams will have been completed and we begin the journey through the governance process of the CCG and Care Together Integration Board. Considerable work has taken place to review existing pathways, fully supported by providers and jointly led by CCG and TMBC staff. These OBCs will enable the other workstreams of estates, transport etc. to begin the review of infrastructure. As stated in previous reports the vision and ambition of the Care Together Programme has been set we must now harness our collective knowledge and skills to make this a reality. Conclusion: 11. The Governing Body is asked to: i. note the decision from Monitor should be known w/c 30/6/14; ii. the ongoing work with THFT in agreeing the base case for change and in particular the future level of inpatient provision as part of the proposed ICO; iii. to receive, once complete, the organisation s engagement strategy including the revised timetable for the Care Together public consultation process; iv. to receive a further update at the next Board meeting. Doreen Hounslea Programme Director of Integration 2 113

114 GOVERNING BODY MEETING Title of Subject: Transformation Report Date of paper: July 2014 Prepared By: History of paper: Executive Summary: Alison Lewin n/a The Report provides the Governing Body with an overview of the transformation work which is on-going supporting the GB clinical leads. Recommendations required of the Governing Body (for Information, Discussion or Decision) The Governing Body is asked to note the content of the Report and provide feedback on the content and the projects described. QIPP principles addressed by proposal: Direct questions to: All Clare Watson 114

115 Transformation Directorate Report July 2014 The aim of this report is to provide Governing Body with an overview of the transformation work which is ongoing, supporting the GB Clinical Leads. The report does not include information on ALL projects, but aims to ensure the report is concise and informative, identifying areas which are our priorities and which demonstrate both success and the challenges we face, and not duplicating information presented to GB on other projects. The Transformation Directorate covers a wide range of commissioning areas, and works through 4 teams. We work closely with colleagues in other directorates and are represented on all CCG Committees, ensuring the work we produce receives appropriate discussion, input and ultimately sign off prior to implementation. Directorate Wide Projects / Work Programmes Greater Manchester working: The Directorate continue to work with colleagues across Greater Manchester, in neighbouring CCGs, the Local Area Team and the Strategic Clinical Network teams on a number of areas, including Primary Care Commissioning, Cardiac & Stroke Commissioning, Mental Health, Integration, Heads of Commissioning, and Urgent Care Leads Integration: The Directorate has the lead for the CCG in taking forward the service redesign element of the integration agenda, working with colleagues in social care and our provider organisations to develop models of care and business case proposals for integrated services. The Directorate are represented on the Care Together PMO, and are currently developing a number of business cases for presentation to PIQ in July and September Contracts: The Directorate are working with colleagues in the finance team, nursing and quality directorate and the Commissioning Support Unit on the monitoring of our main contracts for This includes CQUINS (including GM CQUINS), service specifications and KPIs. Local CQUINs for are focused on 4 main areas Clinical Leadership: Adults and Transition, Clinical Leadership: Children, Frail Elderly and Medicines Management Strategic Programmes / Planned Care & Cancer CCG Performance: The Q4 Assurance checkpoint meeting was held on 4 th June 2014; along with a case study for diabetes; we expect to be assured for most of the domains. 2014/15 Planning: The following were submitted: Two year plan along with the Tameside and Derbyshire Better Care Funds; plan on a page and Key Lines of Enquiry documentation for the Five Year Strategy. Urgent Care: The majority of services opted to continue with daily reporting. Services self manage when in escalation. Weekly conference calls are held with all services to ensure all services are prepared for the next 7 days and can flex to meet demand. The review of winter 13/14 highlighted the benefits of closer communications and shared ownership of the system performance. We continue to be only one of the Urgent Care systems achieving the 95%, 4 hour A&E target Q1 to date. We are reviewing the patient transport with NWAS and Arriva. Use of ISCATs: The existing contract will end in February 2016; we are developing close down plans. Analysis of the feedback from GPs has shown that replacing like for like is not an option. The future need for services will be included in Care Together programmes going forward. Resilience planning 2014/15 In 2014/15 expectations have been circulated and link Urgent Care to elective RTT standards. We are currently developing plans for both. 115

116 Increasing Direct Access/Straight to Test Care Together: MSK and Ophthalmology are two Diagnostics: Work is continuing on promoting the of the phase one programmes. These will build on Cancer Straight to Test pathway for Colonoscopy previous work and look to develop out of hospital and evaluating the pilot. THFT are looking to services where safe and practical. Following extend the scope of eligible patients (e.g. non successful stakeholder events with our cancer). Direct access pathway for OGD that went stakeholders (including Providers and patients) the live in April outline Business, developed case will provide additional details. Mental Health & Learning Disability / Children & Families Dementia: Two additional GP clinical leads have been appointed to the MH and LD portfolio. A 360 review of the Dementia Specialist Nurse pilot at Willow Wood has been completed with positive feedback and this has been incorporated into the overall evaluation of the service. A paper to support the continuation of the Dementia Specialist Nurse role will be presented to PIQ in July The outline business case for dementia is underway and will be completed by the end of June To support the OBC, a stakeholder event was held on 23 May 2014, which provided valuable feedback from carers and the public to support the integration agenda. The outline business case will also include the training plan and support required for GP practices to take on the shared care (follow up) of dementia patients. The work plan for the Dementia Strategy Local Implementation Group is in progress, with a focus on one of the six priority areas at each meeting the focus for the next meeting (24 June 2014) is on end of life care (priority 4); working groups will then be assigned to support the local strategy refresh. Tameside Hospital Foundation Trust made considerable progress with the 13/14 national dementia CQUIN but did not achieve all elements of the local CQUIN. We are confident that for 14/15 THFT will continue to improve the national dementia CQUIN (there is no local CQUIN for 14/15). Their Specialist Nurse, Frail, Elderly and Dementia is now in post. Mental Health: We are still awaiting the IAPT intensive support team report to be shared with us. The number of older people accessing primary care mental health/iapt has increased to 11.8% for the first quarter of 14/15. A significant increase and is closer to the national expectation of 12%. The Primary Care mental health team have just recruited a member of staff who is Bengali to do some work on increasing the access to services from BME. The Community Mental health teams are undergoing a restructure and transformation and papers relating to this were presented at PIQ/PPIC Children & Families Commissioning: A workshop was held with key stakeholders to start the redesign of CAMHS (children and adolescent mental health service) with the additional investment of 200k non recurrently for 2 years. The aim is to get the new model of working up and running by 1/1/2015. The Care Together workstream for children s locality teams will be arranging the workshops to develop the outline business case Learning Disabilities: The first workshop for the All Age disability pathway was held on 12 th June and was well attended. The follow up workshop has been arranged for 26 th June, following which the outline business case will be developed. Clare Symons and Mark Whitehead (TMBC) attended the SAF validation meeting and this was a positive meeting overall, however the main point that was picked up, indicated that Tameside & Glossop are one of the worst performing areas in the country for GP s carrying out the LD annual health checks. This is an area we need to develop further to ensure that people with a learning disability are able to access the health checks on a yearly basis to improve their health outcomes. 116

117 Long Term Conditions / Admission Avoidance / End of Life Care / Primary Care QP End of Year Review: The 9 Quality and Productivity indicators (QP) remained within QOF for 2013/14. The aim of the indicators is to secure more effective use of NHS resources through improvements in the quality of primary care by reducing emergency attendances, reducing emergency admissions by providing care to patients through the use of alternative care pathways and reducing hospital outpatient referrals. The choices for the QP pathways were suggested by the CCG Governing Body Urgent Care/Planned Care Leads and approved by PIQ. During 2013/14 the intention was to make the CCG choices as clear as possible, to support the practices and build upon the successes of the previous year. 41 practices participated in the QP schemes as follows: Outpatients Review 2 reviews on outpatient follow ups were carried out ENT and gastro. Practices reviewed whether these patients who currently have routine follow up appointments could be brought back into primary care for their continued treatment. For ENT out of the 846 patients, 205 were discharged back into primary care (24%). For gastro out of the 857 patients, 254 were discharged back into primary care (29%). Telephone Review of Over 75s Re Admissions Practices reviewed by phone, all patients aged over 75, within 7 days of receipt of notification of discharge after an acute admission. The total number of patients >75 years who had been discharged during the month of November 2013 was 330 of which 238 (72%) had had a review by the practice within 7 days of receipt of discharge notification. 41 of those discharged 12% the practice felt had inadequate social support. 27 patients of those reviewed (9%) had been re admitted. Only 6 of the discharged patients were unsure about the follow up arrangements, and 28 (11%) of those reviewed were not recovering well. Straight to Test Colonoscopy This offered patients who are suitable, to receive their colonoscopy more rapidly without any first outpatient appointment. 563 patients were referred for suspected LOWER GI cancer; the total no. of patients eligible and referred for Straight to Test Colonoscopy was 226. This scheme is continuing. Telehealth Is the remote monitoring of a patient's vital signs, health and well being through monitoring equipment located in the patient's home. Practices were asked to undertake the clinical triage of up to maximum of 4 of their telehealth patients rather than the Long Term Conditions Team. 115 patients were clinically triaged within primary care as part of the QP process. Feedback from the patients was that they felt empowered to manage their own care, however some practices had concerns that it is increasing anxiety and feeding demand. IRIS: In response to the escalating pressures across health and social care, T&G CCG and TMBC developed an integrated rapid response service IRIS. The aim of this service was to prevent emergency admissions to secondary care and emergency residential care placements by managing people in their own homes or usual place residence. The scheme commenced in September 2013 and the no. of patients the practices referred through the IRIS team was 184; with 123 patients avoided hospital admission. A+E Access/Improvement Plans: Practices were provided with data on individual practice s A+E attendances during August 2013 and mapped these against their practice telephone availability to see if there was any correlation. In the majority of cases, there did not appear to be any correlation between A&E and phone access, 8am to 6pm, and that patients had chosen to go straight to A&E rather than their own surgery. The outcome of the above schemes is being fed into the Care Together Integration projects. End of Life Care: The Dying Matters event was a Stroke: The TIA ambulatory care pathway is open successful day with over 90 attendees. Staff felt at the Hospital and the new referral forms are the networking was beneficial to them and 97% currently being updated and rebranded, to be reported to be more informed and aware of communicated to the GPs. If a TIA is suspected the services available to them. With information taken patient should attend the urgent care pathway on 117

118 from the event and in collaboration with the direction from the local strategy groups we will build on work to address the aims of Priority 6 of the Health and Well Being Strategy aligned with the Care Together agenda, a main one being communication across all sectors. Conversations for Life training was commissioned by the Strategic Clinical Network and delivered to a mixture of 15 staff including hospital MAU nurses, community nurses and therapy teams. People found the course interesting, thought provoking and said that it would benefit the way they talk to patients and their carers in future about difficult decisions. the same day. If all patients are seen via this route then we should hit the 60% target of high risk patients seen within 24 hours. Currently referrals can be delayed either by the GP sending a letter to a consultant which could take 2 weeks or by the GP not writing a time of presentation down and sending the referral the next day via CBO. A TIA is a mini stroke and the chance of a stroke occurring after TIA is more than one in 12. A TIA is a medical emergency. Care Together: The team are the CCG leads for the development of outline business cases and service models for specialist respiratory services, end of life care, stroke and neuro rehab, and intermediate care / admission avoidance as part of the phase 1 and 2 Care Together projects. Medicines Management Pharmacy Repeat Ordering Local Improvement Scheme (LIS): The Pharmacy Repeat Ordering LIS supports QIPP in terms of cost efficiencies & improving quality by ensuring best practice & thus & improving patient safety. The LIS is now well underway & MMT has subsequently become aware of many incidents of poor practice, with pharmacies continuing to order on behalf of patients without making any contact with them first or signing to say they have contacted patients but clearly haven t (e.g. checks found one patient was on holiday in Spain & had not been contacted & did not require any medication, patients who had died for whom medication had been ordered, one patient had been requested to attend the surgery for urgent review due to the amount of Tramadol she was requesting on prescription but after investigation it turns out the pharmacy had been requesting without patient knowing & there was 3 months worth of prescriptions sat on the shelf in the pharmacy; there are many, many, many more examples but too many to list here!). The MMT are also working with GP practices to ensure best practice in processing & managing repeat medications (e.g. visits have highlighted practices issuing prescriptions for medications that have not been requested by either the patient or the pharmacy, visits have also highlighted the need to streamline & consolidate medications quantities so medication for individual patients only need to be re ordered at one time in the month). MMT continue to work with both pharmacies & surgeries to resolve concerns & improve processes. Local Authority Partnership Working: Working with Local Authority colleagues to launch the new Drug Misuse Pharmacy Enhanced Service, increasing the number of community pharmacies providing equitable access to drug misuse enhanced services across T&G to 35 pharmacies. MMT are representing CCG on the Joint Strategic Needs Assessment (JSNA) Steering Group & Pharmacy Needs Assessment (PNA) Steering Group. Health Care Acquired Infections: Within the context of organisational restructurings, challenging trajectories & a rise in c.diff numbers, the MMT are working to try & ensure that the root cause analysis process provides data sufficient to promptly learn & disseminate messages from cases such that we come back within trajectory. The Health Protection Group & Root Cause Analysis Group have both been re organised & re focused to support closer working with Local Authority. 118

119 Training In support of medicines and patient safety the Medicines Management Technicians are continuing to provide training in Safe Handling of Medicines to care home staff working within Tameside and Glossop and for RGNs (as part of the PINK programme). Prescribing Support Medicines Management Technicians continue to work in GP practices to support the achievement of Prescribing Local Improvement Scheme targets and identifying additional areas for consideration and work, all to support the delivery of 2014/15 QIPP agenda. Prescribing data are sent out to each practice on a monthly basis. Non Medical Prescribing: Continuing to support Non Medical Prescribers (NMPs) to maintain appropriate governance within their practice, by leading training, providing epact prescribing information, supporting production of P Lists etc. Also, facilitating clinicians to undertake Non Medical Prescribing qualifications & supporting them during their training, currently there are nine nurses & one pharmacist exploring & three nurses with confirmed places to start training in the autumn, with a further two nurses just qualified as NMPs. Their details will be added to the T&G register which currently includes 47 nurse & one pharmacist NMP). Also, working with colleagues across Greater Manchester & the North West region to ensure sharing of good practice & effective networks for NMP Leads. Greater Manchester: Members of the Medicines Management Team attend the GMMMG Board & Formulary sub group ensuring that suitable strategic guidance is in place at GM level which is of benefit to ourselves & other GM CCGs, for example the recently produced neuropathic pain guideline. The MMT represent the CCG s interests in working with colleagues from other GM CCGs to agree the CSU medicines management service specification & KPIs to cover the next three years of service offering from the CSU. Recommendations Governing Body are asked to note the content of the report and provide feedback on the content and the projects described. Ali Lewin Deputy Director of Transformation 119

120 GOVERNING BODY MEETING Title of Subject: Integrated Governance Audit and Risk Committee Minutes 4 June 2014 Date of paper: June 2014 Prepared By: Graham Curtis History of paper: Executive Summary: Key issues discussed Corporate Risk Register The new format was presented and discussed. There was one new entry noted and accepted and further discussion to have had around the Lorenzo entry with regards associated issues such as discharge letters Information Governance Verbal update given by Paul Hague GMCSU Assurance Their Internal Audit report was discussed and noted by the Committee. Improvements had been made on the previous version. GMCSU representative explained their view of the report which were again noted. Scheme of Delegation Further changes to the SoD were agreed to reflect the restrictions on the SBS system and the hierarchy of limits. 120

121 CCG Reports Losses & Special Payments Chair s action required and taken regarding an AVC payment Waivers new entry noted. A paper will be produced for the next meeting. Register of Interest - noted Internal Audit Report noted - no issues External Audit Following presentation and discussion it was agreed that the IGAR would recommend the Governing Body approve the Annual Accounts for 2013/14. Recommendations required of the Governing Body (for Information, Discussion or Decision) To note contents. QIPP principles addressed by proposal: Direct questions to: Yes Graham Curtis Chair of IGAR Kathy Roe Chief Finance Officer 121

122 DRAFT NHS TAMESIDE & GLOSSOP CCG INTEGRATED GOVERNANCE AUDIT & RISK COMMITTEE 4 June 2014 PRESENT Graham Curtis Chair Dr Richard Bircher Governing Body GP (part) Yvonne Pritchard Lay Advisor Celia Poole Lay Member Clare Symons Governing Body Nurse / Caldicott Guardian Mark Heap External Audit (from agenda item no 6 onwards) Gareth Mills External Audit (from agenda item no 6 onwards) Ann Watchorn External Audit (from agenda item no 6 onwards) Lisa Warner Internal Audit IN ATTENDANCE Steve Allinson Chief Operating Officer Kathy Roe Acting Chief Operating Officer Tracey Simpson Deputy CFO David Walsh Financial Consultant Mark Simon Head of Governance, Risk & Complaints Ian Fawthrop GMCSU Financial Accounts Ali Lewin Deputy Director of Transformation (from agenda item no 13 onwards) Paul Hague Information Governance (for item No 5) Joanne Keast Admin Support Governing Body Member who attended for agenda item no 17 Dr Alan Dow Dr Ram Jha Dr Guy Wilkinson Dr Jamie Douglas Dr Tina Greenough Nikki Leach Angela Hardman GC welcomed everyone and explained the format of the meeting with regards agenda item no 17 Annual Accounts. This part of the meeting will commence at 12 noon noting all the Governing Body have been invited. RISK 1. Declarations of Interest No declarations were made. 2. Minutes of Previous meeting held on 2 April 2014 Risk section of the minutes approved as a correct record

123 Actions MS confirmed all actions had been completed and updated with the exception of the never event issue, agenda item no 2 SIRI Monitoring Group which he agreed to follow up. Action: MS GC raised an issue with regards a fraud items raised at the last Medicines Management meeting. Peter Howarth had contacted Beric Dawson and is waiting for a response. LW was asked to chase Beric for the response. Action: LW 3. Corporate Risk Register MS presented the new format risk register. He highlighted the following entries: 1 new entry 5001 Risks relating to the safety and resilience of certain provider services This covers the issue with regards the Breast Service and the changes around it. It also covers wider issues and is under development. It was agreed that the score should remain at 12 but will be reviewed. 3 high level risks 2002 Healthcare associated infections - It was noted that the description for this risk has been amended following previous discussions but remains a high level risk - noted Keogh - amended to reflect not just Keogh issues but all providers and guidance issues - agreed to be kept as high level risk noted Lorenzo - The score for this risk relating to Lorenzo has been reduced to 16 from 20 as issues have started to be addressed but still remains a high level risk. There had been an issue raised at Quality Committee regarding discharge letters which the Committee felt should be reflected in this score. Following further discussion it was agreed that the score should remain as the discharge letters issue was not directly a result of Lorenzo but the risk as a whole should be re-worded to now include Lorenzo and associated issues of which the discharge letter is. It was therefore agreed that GC would have a discussion outside of this meeting with Nikki Leach, Director of Nursing and Quality and take Chair s action where appropriate to amend the entry. Action: GC 1002 Financial duties the wording for this entry has been amended to reflect issues such as mental health choice, commissioning of specialised services, slippage on savings schemes, financial risk associated with Care Together, Legacy balances and GP IT noted Fraud Risk. MS reported that Beric Dawson has been asked to make a presentation at a future staff coffee briefing. It was noted that Governing Body members should also be invited Information Governance Issue work ongoing 3002 FOI a formal training programme is being put in place for staff RB asked if a new risk should be entered relating to sharing patient records. It was agreed that RB and MS would discuss outside of the meeting. Action: RB/MS 2 123

124 4. SIRI Monitoring Group Deferred no meeting had taken place since IGAR last met. 5. Information Governance Paul Hague attended and gave a verbal update. He explained that a couple of investigations are being dealt with, the 1 st relates to a GMCSU service complaints process. The process is being broken down in order to progress work ongoing. The second relates to privacy documentation and work is also ongoing with regards this. Other issues raised: Training remains above 95% compliant as all new starters are being encouraged to complete the training. A new version of the Information Toolkit is due to be issued next month, no details have yet been received but will be progressed once it arrives. A work plan is currently being drafted and will be shared in the near future. AUDIT - External Audit joined the meeting. 6. Apologies Clare Watson Director of Transformation Beric Dawson Counter Fraud 7. Declarations of Interest Nothing declared. 8. Minutes of Previous Meeting held on 2 February 2014 Approved as a correct record, subject to the following change Present list - Steve Connor title should read Deputy Director of MIAA. Agenda item No 11 internal Audit It was reported that the plan and fee were approved twice within the item. JK agreed to amend accordingly. Agenda Item No 13 External Audit GM presented the 14/15, should have read 13/14. Action: JK to amend 9. Matters Arising / actions All actions were completed except the Register of Interest being raised at PIQ. GC agreed to follow this up. Action: GC 10. Training Reports from Committee Members No training under taken since last meeting

125 11. Internal Audit LW presented the last progress report from Audit North West. All future reports with be from MIAA. She explained the 2 reports which were given limited assurance, Information Governance and Payroll, have now been accepted and recommendations noted for action. She reported that they are due to start the 14/15 plan very soon starting with the review of quality commissioned services and quality responsibilities. DW asked about timing of the Care Together programme audit. LW confirmed it is within the plan and would liaise separately about timing. Action: LW / DW 12. GMCSU Assurance Ian Fawthorp attended the meeting to present this item. General Assurance - He explained the restructure has now been completed and we will have seen the changes with more GMCSU staff based in localities which is proving positive from both GMCSU and CCGs. With regards to the merger, there has not yet been any communication indicating any change but some changes are expected to occur. Finance Assurance IF reported that the year end had gone well and the new year is starting well. Deloittes Internal Audit Report IF explained that the report has been accepted and acknowledged that had been a learning curve. The report was time pressured towards the end and they were disappointed with some of the points raised within the reports. The Committee reviewed the type I document GC raised an issue with regards to the exceptions noted. There was only 1 raised within the type I document and this related to payroll. IF agreed to get further details and report back to GC. Action: IF The exceptions raised in type II were: Sales invoices IF explained that an agreement had been reached with a particular CCG who generates a high volume of low value invoices to have a summarised spreadsheet of all the items to serve as an authorised working paper to support all the monthly invoices being raised. As the GMCSU explicit procedure not did not fully reflect this pragmatic approach, Deloittes did not recognise it. Similarly for the Sales credit memo duplicated and corrected. As Deloittes do not recognise any deviations from procedure notes, this was also raised as an issue. Due to time constraints no re-testing was carried out and GMCSU were not given the opportunity to challenge the findings and correct them. Lessons learnt for next year include a review of procedure notes and the commitment to build in time within next year s plan for re-testing

126 From GMCSU point of view they have worked well with Grant Thornton for the T&G Audit. This was supported by Grant Thornton colleagues. Scheme of Delegation TS explained that although the Scheme of Delegation has been agreed at the last Finance Committee meeting to reflect the changes required, the SBS system required to implement the limits is not so flexible to accommodate our levels. The highest limit entered would cover all areas. IF explained that an internal system at GMCSU has to be created in order to work with the CCGs limits. This was noted by the Committee. 13. CCG Reports 13.1 Losses & Special Payment Register Finance committee have previously signed off the AVC As the formal sheet was not ready for this meeting it was agreed that Chair s action would be taken to IGAR sign off. Action: GC / JK 13.2 Register of Waivers The new register was presented for 14/15 detailing one entry. It was noted that a report will be presented to the next meeting explaining the waiver process and the CCGs position on volume. It was highlighted that we will probably have more than most due to our fast moving position on the integration agenda. KR suggested a benchmarking exercise against other CCGs. External Audit agreed to look at this and report back. Action: External Audit 13.3 Register of Interests noted. It was noted a few clinical leads / other clinicians were missing from the list. GC agreed to raise at PIQ in order to rectify. Action: GC 13.4 Gifts and Hospitality no updates. 14. Counter Fraud deferred. 15. Any Other Business No other business was raised. 16. Date and Time of Next Meeting Wednesday 6 August 2014, 9.30 am Boardroom, NCH. 17. External Audit MH presented the ISA 260 report. He explained what he is required to do and give an opinion on. He reported that the audit is now complete and he gives an unqualified opinion to the 2013/14 Final Accounts for Tameside & Glossop CCG. GC explained to those who were not familiar with the process that an unqualified opinion is what we require. MH continued to explain the executive summary of the report and noted the following; 5 126

127 Key Sections Opinion on the financial statements the draft accounts were provided in the timeframe indicated and can report on the positive working with GMCSU. Completed in line with guidance and thanks were expressed to IF and his colleagues at GMCSU as well as colleagues at the CCG. No issues other than presentational have been raised. Regulatory opinion issued an unqualified opinion VFM conclusion unqualified standard VFM opinion Agreement of balances no major issues to report Short action plan agreed noted Section 2 Audit Findings Risk based audit MH gave a safe audit opinion. We have addressed all risks and mitigated them Accounting policies, Estimates and judgements received green ratings Section 3 - VFM BCF work with TMBC. Reviewed the arrangements and gave positive comments Highlighted the actual form of words for the audit opinion which MH will sign following formal sign off from the Governing Body Letter of representation there is standard wording for this which will be signed by both the CCG Chair and Chief Operating Officer The Committee and additional attendees were invited to ask questions; GC asked if VAT is reclaimable on the 7k reimbursement of the audit fee. This was confirmed as not being reclaimable because of the way in which the values had been calculated. Dr Jha asked how the fee is set, thinking about value for money. MH explained the process noting the fee is set nationally and published along with other organisations. The only exceptions at this stage are Foundation Trusts who can go out to tender for their External Audit service. YP asked about addressing the Letter of Representation letter. Dr Wilkinson asked about 7k against clinical negligence. Mark Simon explained that, following the NHS reorganisation in April 2013, CCGs nationally had each been required to pay a contribution to the NHS Litigation Authority to cover any legacy clinical negligence claims that would previously have fallen to commissioning organisations such as Primary Care Trusts. SA thanked everyone for their input and noted the good report on the back of a challenging year. GC referred to the Deloittes report and was heartened by the progress made of GMCSU over the year. Annual Report Changes to the annual report will continue until Friday morning, should anyone have any issues / comments, they should be raised direct to MS. Alan Dow will then take Chair s action on approving the final document. Dr Jha asked about sickness reporting and if we separate stress against other illness. KR reported that CMT receive a report bi-monthly to review that type of information

128 Following the presentation and subsequent questions, it was agreed that IGAR should formally make a recommendation to the Governing Body that the 2013/14 Annual Accounts be approved at its next meeting. Action: GC to present to GB GC finished by thanking everyone for attending and all the hard work put into getting this CCG to this stage. He expressed special thanks to Grant Thornton for their work on the audit and their comments given. TS also added her thanks on behalf of the team to Grant Thornton and particularly Ann Watchorn and Mark Heap who have offered continuity from the PCT to CCG

129 GOVERNING BODY MEETING Title of Subject: Delivering Excellence, Compassionate, Cost Effective Care Governing Body Performance Update. Date of paper: 25/06/14 Prepared By: Louise Roberts / Elaine Richardson History of paper: Executive Summary: Regular Updates are presented on a monthly basis to Quality and CCG. This paper summarises the key performance challenges for 2014/15. It includes the dashboard summaries showing the current performance for our Clinical Challenges and Nursing and Quality along with dashboard summaries for our three main providers. It provides an update on the Q4 Assurance checkpoint meeting. Recommendations required of the Governing Body (for Information, Discussion or Decision) QIPP principles addressed by proposal: Direct questions to: Governing Body are asked to note the performance and identify any areas they would like to scrutinise further. Delivery of NHS Tameside and Glossop s Operating Framework commitments for 2014/15. Elaine Richardson/Clare Watson 129

130 Delivering Excellence, Compassionate, Cost Effective Care Governing Body Performance Development Update July Introduction 1.1 This paper provides an update on the quarter four CCG assurance checkpoint meeting. 1.2 It includes the dashboard summaries showing the current and expected end of year performance for our Clinical Challenges and Nursing and Quality along with dashboard summaries for our three main providers. 2 Overall CCG Assurance Position 2.1 The Quarter Four checkpoint took place on June 4th We submitted the case study on Diabetes in appendix 1 as an example of how we have improved health related quality of life, supported people to manage their own conditions and reduce unplanned admissions. 2.2 It was a positive checkpoint and we do not anticipate a change in our Q3 assurance levels. Overall Assurance Level Are patients receiving clinically commissioned, high quality services? Are patients and the public actively engaged and involved? Are CCG plans delivering better outcomes for patients? Does the CCG have robust governance arrangements? Are CCGs working in partnership with others? Does the CCG have strong and robust leadership Assured Assured with support Assured Assured Assured Assured Assured 3 Quality Premium 3.1 We are anticipating the final position for the Quality Premium performance will be available in September We anticipate receiving 436K. 4 Provider Performance 4.1 The three main providers are all facing performance challenges as seen on the performance dashboards. Please note the timing of the GB 130

131 meeting has meant thet THFT report related to March whereas Pennine Care and Stockport FT are April. 4.2 Performance issues are being raised through contract quality and performance meetings. 5 Clinical Challenge Performance 5.1 The overall performance is shown below and the dashboards can be found further in the report. 5.2 Our Urgent Care System performance remains challenged with attendances higher than expected (above the Upper Control Limit) on 23 rd June. However, we remain one of three GM trusts on track to achieve the Quarter One 4hr A&E standard even though we could fail June as a month. 5.3 We expect a detoriation in Completed Referral to Treat Performance in July, August and September as to support Operational resilience and capacity planning for 2014/15 every CCG and Acute provider has been asked to undertake additional activity to reduce the numbers of patients waiting 16+ weeks to sustainable levels by the end of September There is additional money available to: reduce backlog by focusing additional activity on patients that are waiting more than 16 weeks for treatment; and reduce the total number of patients waiting over 16 weeks by 115,000 nationally, to bring the system back to the level of over 18 week waiters seen in January NHS GM have been advised of a notional allocation in the order of circa 11m to support this additional activity. 5.6 We do not yet know the amount that will be made availble to us as a CCG and the lack of accurate incomplete data at THFT has severly hampered our ability to assess the level of activity we will need to fund. 131

132 5.7 Whilst not performance managed on the monthly figures we have failed the cancer 31 days and 62 days targets for the month of April with five people failing to be treated within within one month (31 days) of a decision to treat and nine people failing to be treated in 62 days in total. 5.8 There has been a considerable increase in the number of 2 week wait referrals which has caused increased breaches through capacity isssues. Patient cancellations also continue to be a problem. However, the standards are still been achieved. 5.9 An external review into the safety of the Symptomatic Breast Cancer services at Tameside NHS Hospital Foundation Trust took place 20 th and 23 rd June and the report is expected in July Care Together embraces all the Clinical Challenges and it is expected that as the year progresses and service changes are made improvements will be seen in performance against our indicators. 6 Recommendation 6.1 Governing Body are asked to note the performance and identify any areas they would like to scrutinise further. 132

133 NHS Tameside and Glossop CCG assurance framework health outcomes case study Ali Lewin, Deputy Director of Transformation, SUMMARY Our patients with diabetes have a higher than average mortality rate, a significant number of patients managed in secondary care and low levels of reported prevalence across primary care. We have committed to reducing deaths in people under 75 from diabetes to at least the national average by 2017 and have embarked on a number of initiatives to enhance the diagnosis and management of diabetic patients. Testimonial: The new integrated service has only been in operation since February. We are working with our providers to gather patient views. Patients were key to the development and implementation of the service and were involved at all stages. ISSUE Variance in reported versus expected prevalence of diabetes across the CCG, identified through the Quality & Outcomes Framework 2012/13. Significant number of patients being managed in an hospital outpatient setting who could be managed in a primary /community care setting. The issue was identified through SUS / SLAM baseline data 2013/14. Enhancing the management of patients with diabetes to improve morbidity/mortality. ACTIONS Implemented quality improvement across primary care and commissioned an external organisation, Insight Solutions to work with GP practices to identify new patients. Commissioned a review of out-patient activity by General Practice 98% of practices participated and reviewed a total of 1340 diabetic patients who were under secondary care. Redesigned diabetes services locally to deliver a community based integrated approach to the management of diabetes, providing a holistic service whilst reducing secondary care admissions/readmissions. OUTCOME Increased reported diabetes prevalence by 5% against baseline, which equated to 1069 patients being identified in 2013/14. A total of 577 patients (43% of total reviewed) are now being managed in primary care and subsequently discharged from hospital. This resulted in anticipated savings of 120k p/a based on the tariff of a diabetic medicine follow up appointment. We have seen a reduction of per 100,000 population in unplanned hospitalisation for chronic ambulatory care sensitive conditions between Qtr 1 and Qtr 3 in 2013/14. NEXT STEPS: The next step is to take the learning from this project forward through our integration work with the Local Authorities. We will be working in on the redesign of specialist services for patients with respiratory and cardiovascular disease, as well as the development of locality based long term conditions management team these teams will be designed to support patients with multiple long term conditions and provide a case management approach to their care. We will also be working with other CCGs on the 133 implementation of integrated stroke services hospital and community based

134 NHS Tameside & Glossop CCG Performance Summary Report April 2014 National, Regional and Local KPIs, CQUINs and Specification KPIs Tameside Hospital NHS Foundation Trust 134

135 Contents Introduction... 3 Performance dashboard

136 Introduction The purpose of this report is to provide an overview of the contractual performance of Tameside Hospital NHS Foundation Trust (THFT), specifically in relation to the performance against operational and quality standards. Finance and activity data is contained in a separate report, as requested by Tameside & Glossop CCG. The summary and performance dashboard below has been produced to give an overview of the key performance related issues. Further detail on what is being done to resolve any outstanding issues can be found in the exception reports for each area that is underperforming, to aid discussions in the monthly performance and quality meeting between the Trust and CCG. This report has been produced by the Contract Management and Performance Team at the Greater Manchester Commissioning Support Unit, working on behalf of Tameside & Glossop CCG and associates to the THFT contract, using various sources of data from the Trust. Summary Narrative 1. RTT April data for admitted and non-admitted service users was submitted, however there is still a gap in the reporting of Incompletes. This had an impact upon the ability to complete the NHSE RTT return regarding capacity issues, but this was completed and submitted late on agreement with NHSE. 2. A&E The Trust achieved the 95% target at 96.4% although there was a slight increase in the number of re-attenders, so an audit has taken place. The purpose of this audit is to see how many of the unplanned re-attenders return with a condition/injury/illness unrelated to their initial attendance. CM&P are awaiting the results of this audit to share with the CCG and ECN. 3. Cancelled elective ops - There were 2 recorded cancelled operations for this month; however CM&P are still awaiting confirmation of the final YTD figure for 13/ HCAI There has been no MRSA cases in April, but 3 cases of CDIFF against a full year threshold of 41 cases (For 2013/14, the final YTD actual was 51 cases of CDIFF against the target of 31). During April the hospital conducted a full inspection of their mattresses and any which were found to be contaminated were replaced immediately. The Trust has shared with the CCG their updated HCAI Improvement plan, which includes the development of a new diarrhoea assessment tool, additional training sessions for qualified, support, student an volunteers and audit plans in relation to compliance to infection prevention standards. 5. Ambulance A&E Handover data for April (39 patients waiting over 30 mins, 3 patients waiting over 60 mins) is subject to validation due to Lorenzo implementation. For 2013/14 the full year total was 395 over 30 minutes and 65 over 60. The HAS compliance achieved 74.78% which is still below the threshold (95%), new indicators in the 2014/15 contract have been created to support the continued improvement on these targets. These will be monitored in line with the contractual agreements. 6. Stroke April performance for all three stroke indicators was poor, with TIA still well below the 60% threshold at 35.7%, but the Trust and CCG are working together to support the new APC which was implemented from the start of April. A newsletter has been forwarded from the Trust to all CCG GP practices and this will also be highlighted at the CCGs locality meetings with a reminder regarding the correct referral processes from Primary Care. 7. Dementia training The Trust has not submitted any information regarding the 3 indicators, however one of the thresholds still needs to be agreed, using 13/14 baseline data, this is due to be agreed by the end of June. 8. Clinical communications The A&E letters indicator has been achieved for the first time in 12 months, however inpatients and outpatients communications both failed to reach the 95% threshold. The CCG and CMP are working together to review the timeliness and quality of the data being sent to the GP practices. 9. Complaints The reported achievement for complaints responded within timescales has significantly decreased from 86.11% in March to 68% in April, which falls far short of the 95% threshold. The Q4 Governance and Complaints report was sent to the last THFT Board meeting (May 2014) and CM&P are working closely with the newly established CSU Clinical Quality team to investigate and understand the reason for the underperformance. 136

137 10. Sickness/absence of nursing & midwifery staff The trust failed to meet the 3% target achieving 4.4%, this target was also not achieved throughout 2013/14. The Trust has reported there is an increased focus on any Hot Spots for sickness absence and training on the new attendance management policy is currently being rolled out. There are also on going recruitment campaigns to ensure that nursing establishments (and medical staff) are filled, which is the focus of the Local Improvement CQUIN Workforce. 11. CQUINs All CQUINs for 2014/15 have been agreed and the Trust has adopted a different internal reporting framework with named CQUIN clinical/managerial leads. 12. Friends & Family Test There has been a slight increase in the Response rate for Maternity and the Trust has reviewed the actions of a high performing Trust (Liverpool Women s Hospital) to understand how their interventions have impacted positively on their scores. A&E is still below trajectory, but Inpatient scores seem to be steady. The Trust has redesigned their response cards to make the process clearer for patients to complete and return and have also introduced free postage on the cards. The Trust has employed the Picker Institute to collate the Staff FFT which is a new CQUIN for 2014/ VTE Risk Assessments- This indicator has not been achieved for April, the new VTE committee is now in place to monitor and drive the indicator towards achievement. Issues with the Lorenzo recording coupled with a change in assessment process has impacted upon the performance, however the introduction of daily ward compliance and additional training in assessment and data collection processes have been implemented. 14. Emergency Re-Admission rates - An audit of 100 readmissions has been undertaken, which established that chronic disease management of chronic obstructive pulmonary disease, cardiac related issues and urinary tract infections accounted for the vast majority of cases. The Trust is working with the CCG to review and redesign out of hospital pathways. 137

138 Performance dashboard National operational standard Threshold 4 month trend key: Performance is improving No change to performance Decline in performance YTD Actual YTD RAG 4 month trend In month actual Referral to Treatment (RTT) times* Admitted 90% 90.0% G 90.0% G Non-admitted 95% 96.3% G 96.3% G Incompletes* 92% Diagnostics Test waiting times 99% 99.4% G 99.4% G A&E waits A&E waits - >4 hours 95% 96.4% G 96.4% G A&E trolley waits - >12 hours 0 0.0% G 0 G Cancer ** 2ww - 1st outpatient appoinment 93% 98.5% G 98.5% G 2ww - 1st outpatient appoinment (breast) 93% 97.4% G 97.4% G 31 days - first treatment 96% 100.0% G 100.0% G 31 days - subsequent treatment (surgery) 94% 100.0% G 100.0% G 31 days - subsequent treatment (drugs) 98% 100.0% G 100.0% G 62 days - first treatment 85% 86.6% G 86.6% G 62 days - screening to treatment 95% 62 days - first treatment after priority upgrade 85% Operational efficiency & HCAI MSA breaches 0 0 G 0 G Cancelled ops (binding date within 28 days) 0 2 R 2 R Cancelled ops (no. cancelled a 2nd time) 0 0 G 0 G MRSA (zero tolerance) 0 0 G 0 G C difficile 41 3 G 3 G RTT (52 weeks) 0 0 G 0 G VTE Risk Assessment 95% 93.5% G 93.5% G Formulary Yes Yes G Yes G Duty of candour Achieved Achieved G Achieved G NHS Number field - Mental Health and Acute*** 99% NHS Number - A&E*** 95% A&E handovers No. of handovers >30 minutes 0 39 R 39 R No. of handovers >60 minutes 0 3 R 3 R *Incompletes RTT data is not yet available due to to validation issues ** 62 days cancer data not yet available *** NHS Number field data not yet available In month RAG YTD Actual YTD RAG 4 month trend In month actual GM operational standard Threshold Domain 1: preventing people dying prematurely 80% patients spend 90% time on stroke unit 80% 72.7% R 72.7% R Stroke bed within 4 hours 80% 70.0% R 70.0% R TIA cases investigated in 24 hours 60% 35.7% R 35.7% R Maternity - % seen by 12 weeks and 6 days 90% 91.1% G 91.1% G Domain 2: Enhancing the quality of life of people with long-term conditions** Dementia awareness training* 98% Dementia patients discharge/transfer within 48hrs TBC Dementia patient case notes that have carer views recorded 50% Domain 4: ensuring that people have a positive experience of care Discharge summaries - A&E patients 95% 95.0% G 95.0% G Discharge summaries - inpatients 95% 77.3% R 77.3% R Discharge summaries - outpatients 95% 26.1% R 26.1% R Outpatient appmts - provider cancellation 3% 0.9% G 0.9% G Nutrition - >60 yrs who under go an assessment 90% 91.6% G 91.6% G Nutrition - >60 years with trtmnt plan agree with dietetics 90% Complaints - % responded to within timescale 95% 68.0% R 68.0% R Complaints - % acknowledged in 3 days 90% 100.0% G 100.0% G Domain 5: treating and caring for people in a safe environment and protecting them from avoidable harm VTE - RCA of all hospital acquired cases 100.0% 100.0% G 100.0% G Pharmacy - % medicines reconciled with 24 hrs*** 90.0% Pressure ulcers - % reduction per 100,000 bed days**** 50.0% Falls - % reduction per 100,000 bed days**** TBC UTI - % adults free from catheter induced UTI 95.0% 100.0% G 100.0% G Methicillin sensitive Staphylococcus Aureus (MSSA) TBC 0 G 0 G E. coli bloodstream infections TBC 0 G 0 G *Threshold of >98% is for year end, in month actual refers to October ** Dementia April data not yet available ***Pharmacy data to be provided quarterly ****Indicator to be defined YTD actual YTD RAG 4 month trend In month actual Local quality requirements Threshold Domain 1: preventing people dying prematurely EOL: 75% of patients diagnosed as dying* 75.0% Domain 2: Enhancing the quality of life of people with long-term conditions Palliative care - discharged within 24 hours once all needs are met 70.0% 100.0% G 100.0% G Improving completeness of Cancer Staging data* 90.0% Maintain compliance of the use of established care bundles for COPD 90.0% 94.1% G 94.1% G Domain 3: helping people to recover from episodes of ill-health or following injury % of antibiotic prescribing to follow TFT's antibiotic prescribing policy** 95.0% Defined daily dosages of high risk antibiotics* 126 Domain 4: ensuring that people have a positive experience of care MAU: <15 mins to PARS assessment for GP referrals* 90.0% Domain 5: treating and caring for people in a safe environment and protecting them from avoidable harm Sickness and absence of nursing & midwifery staff 3.0% 4.4% R 4.4% R Hand hygiene compliance via peer audit 97.0% 97.5% G 97.5% G *Data is to be supplied quarterly ** Data not yet available In month RAG In month RAG 138

139 T&G CCG - PENNINE CARE MH PERFORMANCE DASHBOARD - MAY 2014 ACTIVITY Threshold YTD Actual YTD RAG 3 month Trend / Average In Month Actual In Month RAG Inpatient Activity Service Specific KPIs Admissions VSMR Total Admissions No. of clients on caseload at month end* G Transfers into RHSD Wards Early Intervention CAMHS Admissions to Adult Wards (16-17) No. of New Cases of Psychosis 44 - R 5 R Gatekeeping complete 95% 100% G 100% G Patients in Assessment Phase Readmissions No. of People with Psychosis being seen at month end R 28 Day Readmissions Crisis Resolution 90 Day Readmissions Number of Assessments Mixed Sex Accomodation Number of Crisis Resolution Episodes G 64 G MSA Breaches 0 0 G 0 G Number of Individuals Treated by Crisis Resolution Delivering Single Sex Accomodation Survey Results - 100% G 100% G Health Visiting Length of Stay (LoS) & Bed Days Number of CPA discharges Average LoS (trimmed) - in days* No. of CPA Discharges followed up in 7 days Average LoS (untrimmed) - in days* % of CPA Discharges followed up in 7 days 95% 100% G 100% G Adult Wards - Length of Stay >=100 days IAPT KPIs** Older Wards - Length of Stay >=100 days % Entering into Treatment Occupied Bed Days inc home leave days (Adults and Older People % Moving into Recovery - Home Leave Days (Adults and Older People) **Prevalence and Recovery Data reported Quarterly Discharges Total Discharges (Adults and Older People) Delayed Discharges days *Average LoS is presented as an average across Adults and Older People only Threshold YTD Actual YTD RAG 3 month Trend / In Month Actual In Month RAG Threshold YTD Actual YTD RAG 3 month Trend / Average In Month Actual In Month RAG CAMHS Activity Admissions Total Admissions CAMHS Admissions to Adult Wards Readmissions 28 day readmissions Outpatient Activity Average Referrals & Appointments 90 day readmissions GP Referrals to Consultant Length of Stay (LoS) & Bed Days Other Referrals to Consultant Average LoS (trimmed) - in days* New Appointments - DNA Rate* % % - Average LoS (untrimmed) - in days* Follow Up Appointments - DNA Rate* % % - CAMHS Wards - Length of Stay >=42 days** Waiting Times - Adults Occupied Bed Days (inc home leave days) Seen Within 5 weeks 50% 100% G 100% G Home Leave Days Nothing reported in May Seen Within 11 weeks 100% 100% G 100% G Discharges Nothing reported in May Seen Within 13 weeks 100% 100% G 100% G Total Discharges Waiting Times - Older People *Average LoS is presented as an average across all units Seen Within 5 weeks 50% 65.30% G 55.30% G **Nothing reported - requested clarity from Provider Seen Within 11 weeks 100% 98.30% R 97.40% R YTD In month Threshold YTD RAG 3 month In month Seen Within 13 weeks 100% 100% G 100% G Exceptions Actual trend actual RAG *Please note, percentage given is for both adults and older people combined % Entering into Treatment (IAPT)** month trend key: % Moving into Recovery (IAPT)** Performance is Improving Seen Within 11 weeks (Older People Waiting Times) 100% 98.30% R 97.40% R No Change to Performance No. of New Cases of Psychosis 44 - R 5 R Decline in Performance No. of People with Psychosis being seen at month end R **Prevalence and Recovery Data reported Quarterly Threshold YTD Actual YTD RAG 3 month trend In month actual In month RAG 139

140 Performance dashboard T&G Community Healthcare (May 2014) Patient safety Threshold YTD Actual YTD RAG 4 month trend In month actual In month RAG HCAI No. of Cdiff cases with community provider contact No. of avoidable community acquired Cdiff cases 1 1 G 1 G No. of MRSA cases with community provider contact No. of avoidable community acquired MRSA cases 0 0 G 0 G No. of GDH cases with community provider contact No. of avoidable community acquired GDH cases 0 0 G 0 G No. of full RCAs with IP team input Incidents and never events No. of reported incidents is minimum 1100 per year No. of incidents categorised as a medication error No. of incidents categorised as wound care Number of SUIs Duty of candour (included in StEIS reports and RCAs) Number of never events Harm-free care Total no. of patients with grade 2+ pressure ulcer No. of patients in the inpatient unit with grade 2+ pressure ulcer (avoidable) <15 0 G 0 G Rate of patients on a caseload with a grade 2 or <50 per higher pressure ulcer R R No. of patients in the inpatient unit who have a fall resulting in moderate or greater harm <38 1 G 0 G % of venous ulcer wounds (grades 2-4) that have healed < 16 weeks from start of treatment 70% 79% R 39% R Patient experience Threshold YTD actual YTD RAG 4 month trend In month actual In month RAG Complaints & compliments Complaints received by T&G patients Complaints - % responded to within timescale 85% 84.60% R 80.0% - Complaints - % satisfied with outcomes 75% % G N/A - Compliments Staffing & training Staff turnover 13% 9.90% G 9.91% G Sickness level 4% 4.40% R 4.35% R % of staff trained to adult protection level 1 in past 12 months 95% 93.90% R 93.89% R % of staff trained in domestic abuse in past 12 months 95% 75.70% R 75.65% R % of staff trained in infection control in past 12 months 95% 93.90% R 93.89% R Health Visitors staffing level (wte)* R G Referral to treatment times (RTT) - overall 18 week maximum waits 95% % G 99.96% G 6 weeks maximum waits - diagnotics 99% 100% G % G *Please note, figure is for whole time equivalent staff level 4 month trend key: Performance is improving No change to performance Decline in performance Service specific KPIs - exceptions Threshold YTD Actual YTD RAG 4 month trend In month actual In month RAG Pulmonary rehabilitation Patients take up a pulmonary rehab programme R 23 R 75% of patients taking up complete the course 75% N/A R N/A - Tissue Viability 65% of venous leg ulcers heal within 20 weeks 65% 46.2% R 55.6% R Childrens SALT Increase no. of CAFs completed 36 4 R 4 G 140

141 Summary narrative 1. Pulmonary rehab only 23 patients take up the programme in May against a monthly target of 40. Year to date total is 34, which could indicate the year end total of 480 is unlikely to be met. There is no available figure for the percentage of patients completing the course for the year to date. This is under the threshold of 75%. Provider has developed a full action plan to improve performance. 2. Tissue Viability achieved healing rate of 25% within 20 weeks when the target should be 55.6%. While below target this is an improvement of April, where the healing rate was 25%. Provider advises shortages within the team have resulted in staff acting as a specialist resource providing leadership and advice, and having less patient contact, seeing more complex cases. An action plan to address the issues has been agreed 3. Health visiting 4 CAFs completed this month as opposed to a target of 3. However, none were completed the previous month, which means YTD, provider is below target. Provider has plans in place to address the shortfall with team leaders managing the process to ensure staff are aware of their targets and complete them as appropriate. 4. Sickness level in month staff sickness has increased 4.35 which is now above threshold. Year to date is 4.4% against a threshold of 4%. 5. Pressure ulcers rate of patients on a (DN) caseload with a pressure ulcer of grade 2 or higher has reduced significantly from April 2014 and now stands at 72.81, meaning the year to date actual is also over threshold (50 per 1,000) at Provider is investigating the causes of this Provider has indicated that this rise was outside their remit, with patients already having pressure ulcers on admission. The total number of patients with a grade 2+ pressure ulcer (known to T&G CH staff) was 0 in May 2014, as opposed to 47 in April Reported incidents the number of reported incidents in May 2014 for CCG commissioned services was 207. The Provider has been encouraged to report incidents as much as possible for reasons of transparency, therefore this represents good performance. 141

142 Children & Families % Infants % Infants Need to ensure Midwives engage more in Health Prevention in Primary care from booking onwards as they play a key role. 2011/12 Data shows that we have less mothers locally initiating breastfeeding ( 59.7% compared to the European average of 89.1%). wte 100% 95% 90% 85% 80% 75% 70% 50% 40% 30% 20% 10% Jun-13 Jun-13 Jun-13 % of infants for whom breastfeeding status is recorded at 6-8wk check Jul-13 Jul-13 Jul-13 Aug-13 Aug-13 Sep-13 Oct-13 Nov-13 There is a National impact as we are struggling to recruit across Greater Manchester. There is currently a national recruitment drive. Stockport Business Group (SBG) struggling to recruit partly because neighbouring Trusts offering enhanced pay and/or training rates. Dec-13 Tina Greenhough, Responsible CCG Governing Body Member Jan-14 Feb-14 Mar-14 Apr-14 Actual Trajectory Plan Aug-13 % of infants being breastfed at 6-8wks Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Actual Trajectory Plan Sep-13 Number of wte health visitors Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Actual Trajectory Plan May-14 May-14 May-14 % Children % 12/13 year old girls 95% 90% 85% 80% % of children receiving booster dose of tetanus, diphtheria and polio vaccine (teenage booster) 2012/ /14 YTD Plan Actual Years shown are school years. Vaccinations for the school year 2013/14 will run from November 2013 to July Data shown is up to May % Children 100% 90% 80% 70% 60% 50% 40% 100% 90% 80% 70% 60% 50% % of 12/13 year old girls who receive the human papilloma virus (HPV) vaccination for cervical cancer 2012/ /14 YTD Plan Actual % of children with height and weight recorded 2011/ / /14 YTD Plan Reception Year 6 Years shown are school years. Measurements for the school year start in January and finish in July. 2013/14 data is up to May 2014 of the school year. The 2012/13 NCMP for T&G PCT showed a participation rate of 97.9% (3,245 children) for reception aged children and 94.3% (2,589 children) for year 6 aged children. Prevalence in reception year of underweight children was 0.6%, healthy weight 76.4%, overweight 13.9% and obese 9.2%. Prevalence in year 6 of underweight children was 1.3%, healthy weight 65.9%, overweight 14.4% and obese 18.4%. The data will be published in December The CCG has a lower percentage classified as obese compared to the England average of 9.3% for Reception children and 18.9% for Year 6 children. Organisational Leads CCG: Clinical Lead: Tina Greenhough Manager: Clare Symons Rate per 1000 population /12 Q1 Improvement Impact Date: TBC Total Number of Indicators: 50 RAG Rating - Current Position: RAG Rating - Forecast Position: Although we are seeing a downward trend we are still a regional and England outlier. Plans include targeting resources on Looked After Children and on schools through Boards of Governors. Younger people are currently directed towards Sexual Health Clinics and older people to GPs; this may need to be reviewed. Outline Plan: Double the number of Pharmacies available to offer FREE condoms & Emergency Contraception; Commence with a pharmacy offer campaign to let YP know of the new services by January using online media; Ensure sexual health and contraception is escalated to members as a priority agenda; Improve FREE access to condoms; Improve knowledge about contraception choices; Explore LARC campaign options and operationalize; Secure GP leadership on sexual health and contraception. Recovery Milestones 2011/12 Q2 Under 18 Conception Rate 2011/12 Q3 Plan 2011/12 Q4 2012/13 Q1 2012/13 Q2 Actual 2012/13 Q3 2012/13 Q4 Review Health Promotion roles of midwives by 1/4/15 to improve Health Prevention roles. Review all children and families work programmes by 1/10/14 to include recommendations and actions from the SEND agenda. National Health Visitors recruitment - to receive recruitment trajectory plan from SBG by 1/4/15. Review how younger people access contraceptive services to improve access - by 1/4/15 with TMBC Public Health and YouThink. 26/06/

143 Lifestyle Choices Rate per 100,000 Population Rate per 100,000 Population May-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Tina Greenhough, Responsible CCG Governing Body Member Rate of Alcohol Related Harm Hospital Admissions Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Actual Trajectory Plan Emergency Admissions for Alcohol Related Liver Disease Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Actual Trajectory Plan Apr-14 Apr-14 Number screened 7, , , , , ,000.0 No. Adults on a Caseload who have been Screened for Alcohol Intake 2012/13 Q1 2012/13 Q2 2012/13 Q3 Actual 2012/13 Q4 2013/14 Q1 2013/14 Q2 2013/14 Q3 Plan 2013/14 Q4 The CCG has invested monies into a number of schemes/projects to be delivered jointly with TMBC. It is too early yet to be assured if the acute costs is greater than the AAT. Organisational Leads CCG: Clinical Lead: Tina Greenhough Manager: Clare Symons Provider: Clincial Lead: TBC Manager: TBC Recovery Milestones Improvement Impact Date: TBC Total Number of Indicators: RAG Rating - Current Position: RAG Rating - Forecast Position: Work in partnership with Local Authority and Public Health to review workstreams. Multi-Disciplined Approach to Brief Intervention. Supporting Business Intelligence as responsibility of other providers' data sources. NHS Health checks supporting this workstream. 5 Number of Quitters /13 Q1 Number of self-reported four-week smoking quitters all ages 2012/13 Q2 2012/13 Q3 2012/13 Q4 2013/14 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 Rate per 100,000 Population 4,000 3,200 2,400 1, Rate of Chlamydia Diagnoses per 100,000 young adults age /13 Q1 2012/13 Q2 2012/13 Q3 2012/13 Q4 2013/14 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 Actual Plan Tameside LA Rate Plan The CCG has invested monies into a number of schemes/projects to be delivered jointly with TMBC. It is too early yet to be assured if the acute costs is greater than the AAT. Chlamydia diagnosis has reduced on last year's figure for Tameside Local Authority. Some data for 2013/14 Q2 has not been submitted and will be included in next quarter's submission which should be available by the end of June /06/

144 Mental Health % Target % Target 70% 65% 60% 55% 50% 45% 14% 12% 10% 8% Tina Greenhough, Responsible CCG Governing Body Member Diagnosis Rate for People with Dementia 2011/ / / / /16 Plan Actual IAPT - Recovery following talking therapies-over /15 Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 % Target % Target 4% 3% 2% 1% 0% 100% 98% 96% 94% 92% 90% 2012/13 Q1 Proportion of People who have Depression/Anxiety who receive Psychological Therapies 2012/13 Q2 2012/13 Q3 2012/13 Q4 2013/14 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 Actual Trajectory Plan % of Patients on CPA Discharged from InpatientsCare who are followed up within 7 days 2013/14 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 Organisational Leads CCG: Clinical Lead: Tina Greenhough Manager: Clare Symons PENNINE: Manager: Stan Boaler SFT: John Schooling % Target 60% 50% 40% 30% 20% Improvement Impact Date: Total Number of Indicators: RAG Rating - Current Position: RAG Rating - Forecast Position: IAPT - % of People who Complete Treatment who are Moving to Recovery 2013/14 Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 24 Plan Actual Actual Plan Actual Plan Q1 just misses the target of 12%. Target set using National Dementia tool. The Dementia DES will support this measure. Whilst 39 of our practices have signed up to the Dementia DES to increase awareness; there are still a number of perceived barriers to the scheme. Locally plan to review predicted and recorded prevalence in primary care and wider integration across Health and Social Care to ensure patients with dementia supported in their own home or usual place of residence to enable greater independence. IAPT - Data source is the Mental Health Minimum dataset and the IAPT Access to Psychological Therapies dataset which we don't have access to. % People receiving Psychological Therapies - Consistently not meeting target. CPA Discharges followed up within 7 days - Achieved 100% for the last 3 consecutive months. % of People moving to recovery - Although not meeting Target, across GM we are one of the top performing CCGs for recovery. We had predicted a drop in performance for IAPT due to the large numbers coming through the service nationally with a view to a 15% prevalence rate by March 2015, it is unlikely that we will achieve this. The reasons for this are; capacity of the IAPT team and Economic downturn resulting in increase demand. Across GM we are one of the top performing CCGs. % Target 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% IAPT - Access to NHS health BME groups and Psychological Therapies BME Groups 2014/15 Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 NHS Health previous year Psychological Therapies Actual NHS Health Actual Psychological Therapies Plan Access to NHS Health BME Groups has increased compared to the same Quarter the previous year. Number of health checks (Cumulative) 1, Number of people with a learning disability receiving an annual health check Jan-13 Feb-13 Mar-13 Apr-13 May-13 Actual Jun-13 Plan is 474 by December Cumulative number of health checks by end of 2013 was 121, considerably below target. Jul-13 Aug-13 Sep-13 Oct-13 Plan Nov-13 Dec-13 Recovery Milestones Business case for the LES Learning Disability annual health checks is being developed as part of the Care Together workstream. The LD Self assessment framework was completed and the validation meeting was held in April T&G are one of the worst areas in the country for LD Annual Health Checks therefore targeted work is in place to get more GPs to sign up for the DES. Pennine care have been asked to provide an action plan for the IAPT trajectories for prevalence and recovery rates. They have also identified a capacity and demand tool to use and commissioners have requested that IAPT services across the footprint are prioritised. We are awaiting a report from the IAPT intensive support team. Increase referrals rates to IAPT service by minority groups ( older people, BME ) by actively promoting the service by targeting these groups. Pennine Care have just employed a member of staff who is from a BME background with a remit to increase this figure. A business case to support practices to take on the shared care of dementia patients, as part of Pennine Care s Shared Care Guideline for dementia is currently in development and, as part of this, practices will receive dementia training in line with the accreditation process /06/2014

145 Long Term Conditions % Target % Target 68% 66% 64% 62% 60% 100% 90% 80% 70% 60% May-13 % People Feeling Supported to Manage their Long Term Conditions Jun / /13 Jul-13 England Average Aug-13 Sep-13 Oct-13 Amir Hannan, Responsible CCG Governing Body Member Nov-13 Dec-13 T&G CCG % Patients with a personalised management plan within 10 days of initial assessment Jan-14 Feb-14 Mar-14 Apr-14 % Patients % Patients 100% 90% 80% 70% 60% 50% 100% 90% 80% 70% 60% 50% 40% 30% Apr-13 Apr-13 % of Patients who spend at least 90% of their stay on a stroke unit (THFT data) May-13 May-13 Jun-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Actual Trajectory Plan % of patients arriving in a designated stroke bed within 4 hours of arrival (THFT data) Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Mar-14 Organisational Leads CCG: Clinical Lead: Amir Hannan Manager: Alison Lewin % Diabetes Patients 100% 90% 80% 70% 60% 50% Improvement Impact Date: Total Number of Indicators: RAG Rating - Current Position: RAG Rating - Forecast Position: 2009/ / /12 49 Improving function with LTC - % of Diabetes Patients receiving all nine key processes of care Actual Trajectory Plan Actual Plan Actual Plan % People feeling supported to manage their LTCs - Annual GP Survey data. 2013/14 survey due to be published by the end of June % With Personalised Mgt plan consistently meeting target. The CCG continue to work with Tameside FT on their stroke improvement plan, and monitor delivery of the stroke indicators via the TFT performance and contract monitoring meetings. There are still no timescales for the implementation of the GM stroke pathways, which will have significant impact on local performance. We will continue to work with the strategic clinical network via the GM heads of commissioning Sourced from the National Diabetes Audit. 2010/11 data wasn't published until January 2013 so expecting 2011/12 data to be published January 2014 The new diabetes service for Tameside & Glossop goes live in February One of the performance indicators for this service is the delivery of improved performance against the 9 care processes target and should therefore deliver improved performance during Rate per 100,000 pop Under 75 Mortality Rate: CVD (Rate per 100,000 Population) CCG SHA Avg England Avg No. of the new Patients 2,800 2,400 2,000 1,600 1, GP Disease Registers - Increase in newly diagnosed patients for Atrial Fibrillation, Diabetes and COPD Plan 2013/14 Actual Recovery Milestones 2012 data released by the HSCIC December Therefore expecting 2013 data to be available December The latest CVD mortality data shows that the trajectory set by the PCT through the 2009 World Class Commissioning processes has been achieved. The aim was to reduce deaths from CVD to 91.7 per 100,000 population. The latest data (relating to deaths reported in 2012) shows that we have achieved a rate of 81.1/100,000. Although we have achieved a significant local reduction we are still an outlier when compared with NW and National data so still need to strive to make further reductions. Actual is as far as November However, target already achieved. Quality Premium Payment Local Indicator ( 150k) if achieved. We have developed the revised method to measure the increase in incidence of long term conditions and are taking these proposals through internal governance before requesting LAT approval. The mid-year figures against the proposed methods of measurement are positive and show that the indicators are achievable /06/2014

146 Planned Care & Cancer % seen within target weeks 100% 98% 96% 94% 92% Dr Guy Wilkinson / Dr Ram Jha, Responsible CCG Governing Body Member RTT / Diagnostics % seen within target weeks 100% 95% 90% 85% 80% 75% May-13 Jun-13 Jul-13 Aug-13 Sep-13 Cancer Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 2ww Plan 2ww Actual 31-days Plan 31-days Actual 62-days Plan 62-days Actual Apr-14 Improvement Impact Date: September 2014 Organisational Leads CCG: Clinical Lead: Guy Wilkinson / Ram Jha. Manager: Elaine Richardson Provider: Clinical Lead: ************ Manager: Kay Holland Total Number of Indicators: RAG Rating - Current Position: RAG Rating - Forecast Position: 49 90% 88% Jun-13 Jul-13 Aug-13 Sep-13 Admitted Plan Admitted Trajectory Non-Admitted Actual Incomplete Plan Incomplete Trajectory Diagnostics <6wks Actual Oct-13 Nov-13 Dec-13 Jan-14 Number of 52 week waiters for Incomplete Pathways (YTD to May 2014) Feb-14 Mar-14 Apr / / May-14 Admitted Actual Non-Admitted Plan Non-Admitted Trajectory Incomplete Actual Diagnostics <6wks Plan Diagnostics <6wks Trajectory EL FFCEs Above standard for 2 week wait 98.3% (93.5% nationally) 12 exceptions. 31 day first treatment 95.1% (98% nationally) 5 exceptions. Failed 62 day standard at 83.6% (85.7% nationally) 9 exceptions. Expect to achieve Quarter standards 3,000 2,750 2,500 2,250 2,000 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Elective FFCEs Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Actual Trajectory Plan Apr-14 OPFA 8,500 8,000 7,500 7,000 6,500 6,000 5,500 5,000 May-13 Jun-13 Jul-13 OP First Attendances Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Actual Trajectory Plan For Diagnostics, there were 66 patients waiting over 6 weeks in May (1.65%). THe Incompletes data excludes THFT. Whilst achieving aggregate standard there are issues in several specialities at several providers For April 2014 there were a total of 2,467 Elective admissions against a plan of 2,551. This was within plan by 3.29%. The plan for the year is 32,267 admissions. Currently we are 3.29% below plan at a total of 2,467. April 2014 has 6,693 first OP atts against a plan of 6,766, within plan by 1.08%. The plan for the year is 85,590. Currently we are1.08% below this at a total of 6,693. Of the 6,693 all first OP atts 4,703 (70.3%) were at THFT. % in less than 6 weeks 100% 98% 96% 94% 92% 90% 88% 86% Jun-13 Jul-13 Aug-13 Diagnostic Tests in less than 6 weeks Sep-13 Oct-13 Aggregate diagnostics was failed at 1.65% with issues in several providers. Endoscopy 2.8% of patients waited over 6 weeks (19 patients) for diagnostic tests. Of these 4 patients were waiting over 13 weeks. Non-endoscopy 1.4% (47 patients) waited over 6 weeks. Of these 47 patients, 1 patient was waiting over 13 weeks. Nov-13 Endoscopy Actual Non-Endoscopy Actual Plan Dec-13 Jan-14 Feb-14 Mixed Sex Accommodation Breach Rate (YTD up to May-14) Mar-14 Apr-14 May-14 Endoscopy Trajectory Non-Endoscopy Trajectory % in less than 6 weeks 100% 98% 96% 94% 92% 90% Jan-13 Feb-13 Mar-13 DEXA Scan in less than 6 weeks Apr-13 THFT data only. Consistently meeting Target. From October, Service no longer provided. % of Patients not offered another binding date within 28 days of a % cancelled operation (Q4 THFT data) May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Actual Trajectory Plan Dec-13 Recovery Milestones - Lorenzo is severely impacting on our ability to accurately understand what needs to be done to improve at THFT. - National focus on minimising 16+ week waiters at speciality level by end of September should improve our performance across all providers from Oct

147 Urgent Care % Seen within 4 hours No. A&E Attendances 100% 95% 90% 85% 80% 7,500 7,000 6,500 6,000 5,500 5,000 4,500 4,000 Jun-13 Jun-13 Jul-13 Jul-13 Aug-13 Aug-13 Sep-13 Oct-13 Nov-13 Dr Richard Bircher, Responsible CCG Governing Body Member A&E 4 hour Waits Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Actual Trajectory Plan Sep-13 A&E Attendances Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Actual Trajectory Plan May-14 May-14 % Target Minutes 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Apr-13 Apr-13 May-13 May-13 Re-attendance in 7 days / Left without being seen Jun-13 Jul-13 Aug-13 Sep-13 Left without being seen Actual Plan Re-attendance in 7 days Trajectory Jun-13 Jul-13 Oct-13 Nov-13 Dec-13 Total Time Spent in A&E (Minutes) Aug-13 Sep-13 Oct-13 Nov-13 Jan-14 Feb-14 Mar-14 Left without being seen Trajectory Re-attendance in 7 days Actual Dec-13 Jan-14 Feb-14 Actual Trajectory Plan Mar-14 Organisational Leads CCG: Clinical Lead: Dr Richard Bircher Manager: Elaine Richardson Provider: Clinical Lead: Manager: Mike Griffiths Assessment (Minutes) Apr-13 Improvement Impact Date: Total Number of Indicators: 34 RAG Rating - Current Position: RAG Rating - Forecast Position: Time to Initial Assessment / Time to Treatment (Minutes) May-13 Jun-13 Jul-13 Aug-13 Sep-13 Time to Assessment Trajectory Time to Treatment Actual Time to Assessment Plan Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Time to Assessment Actual Time to Treatment Trajectory Time to Treatment Plan Treatment (Minutes) Target achieved for A&E 4-hour wait in May 2014 (95.5%) Whilst time in A&E is being maintained around plan Time to assess has increased dramatically for December,January and February. 'Initial time to assessment' data has not been provided for October and November which makes trends impossible to establish. A&E Quality Indicators data from the trust has been delayed. Latest data available March % within Target minutes 100% 95% 90% 85% 80% 75% 70% 65% 60% Jun-13 Jul-13 Aug-13 Sep-13 Ambulance Response Rates Oct-13 CAT A 8mins Plan CAT A R1 8mins Trajectory CAT A R2 8mins Trajectory 19mins Actual Local Response rates are shown above. The CCG failed to meet the target of 75% for both the 8 min response rates. The CCG will be measured against the regional NWAS figures. May-14 figs: 75% Targets: CAT A 8mins R1 YTD 74.5% CAT A 8mins R2 YTD 75.2% 95% Targets: CAT A 19mins R2 YTD 95.9% Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 CAT A R1 8mins Actual CAT A R2 8mins Actual 19mins Plan 19mins Trajectory May-14 Number of Delays Jun-13 Jul-13 Ambulance Handover Delays / Crew Clear Delays Aug-13 Sep-13 Oct-13 Nov-13 Utilisation of the HAS screened 75.5% (March). Average handover times in week ending 1st June were Arrival -Notify 05:19mins, Notify-Handover 09:13mins and Handover to Crew Clear 12:47mins. Closer monitoring of this is expected as penalties will be applied in 14/15 Dec-13 Plan Amb Handover > 60mins Trajectory Amb Handover > 30mins Trajectory Crew Clear > 60mins Trajectory Crew Clear > 30mins Trajectory Jan-14 Feb-14 Mar-14 Apr-14 Amb Handover > 60mins Amb Handover > 30mins Crew Clear > 60mins Crew Clear > 30mins May-14 Recovery Milestones Recovery milestones are as specified in the ECN recovery plan. 147

148 Urgent Care No. Patients waited >12 hours in A&E from Decision to Admit (YTD to Apr) 0 Number of Urgent Operations Cancelled for a Second Time (Apr. data) 0 No. of Delayed Discharges May-13 Jun-13 Jul-13 Delayed transfers of care from hospital Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 % of Patients 100% 95% 90% 85% 80% 75% 70% 65% CARA - % of Patients remaining at home after 91 days after discharge May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 % Completed 100% 95% 90% 85% 80% 75% 70% 65% % of Nursing Assessments completed within 24 hours of Referral May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Actual Plan Actual Trajectory Plan Actual Trajectory Plan % Target 100% 95% 90% 85% 80% 75% 70% Delaying and reducing the need for care and support - Effectiveness of Reablement DATA CURRENTLY UNAVAILABLE - SEE COMMENTS BELOW Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 % of Patients 100% 80% 60% 40% 20% CARA - % of Patients Referred to Rapid Response maintained at home May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 % of Admissions Avoided 100% 80% 60% 40% 20% Apr-13 % of Admissions avoided for patients in A&E and MAU May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Actual Plan Actual Trajectory Plan Actual Trajectory Plan Data for the Effectiveness of Reablement has not yet been published. Delayed Discharges met target in Jan-Mar. The Rapid Response ind only reflects CARA data Nursing Assessments completed within 24 hours: Target not met in February (86.5%). Admissions avoided for A&E and MAU Patients: Consistently meeting target % of Patients 100% 80% 60% 40% % of patients discharged from Shire Hill remaining at home after 91 days Average LOS (Days) Average LOS of Patients at Shire Hill 20% 0 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Actual Trajectory Plan Actual Trajectory Plan Target not met in February (57.1%) Consistently meeting target 26/06/

149 End of Life % Patients 100% 95% 90% 85% Dr Richard Bircher, Responsible CCG Governing Body Member % Non urgent Patients referred to Macmillan Nursing seen within 10 days of date of referral Hospital Deaths Reduction in Expected Hospital Deaths Organisational Leads CCG: Clinical Lead: Dr Richard Bircher Manager: Alison Lewin Improvement Impact Date: Total Number of Indicators: RAG Rating - Current Position: 12 80% May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 RAG Rating - Forecast Position: Actual Trajectory Plan Actual Trajectory Plan % Patients 100% 95% 90% 85% 80% The services delivered in the community by the Specialist Palliative Care Team (Macmillan Nurses) was increased from 5 to 7 day provision in April The service has maintained its high level of performance against KPIs across 7 days. 100% May-13 % Urgent patients referred to Macmillan Nursing contacted as a minimum within 24 hours Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Actual Trajectory Plan Palliative Care & Respite - % Patients seen within 5 days for Non- Urgent and 24 Hours for Urgent Apr-14 Number of GPs Apr-12 GP sign up to "find your 1% campaign" / GP Practices using Gold Standard Framework operating at Level 4 of adoption Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 1% Campaign Actual Gold Standards Framework Actual 1% Campaign Plan Gold Standards Framework Plan Summary Hospital Level Mortality (SHMI) (Actual deaths divided by expected) * 100 No. Care Homes Apr-12 May-12 Jun-12 Recovery Milestones Number of Care Homes to be implementing the six steps care home programme Jul-12 Aug-12 Actual Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Plan Feb-13 Mar-13 % Patients 95% 90% 85% 80% May-13 Jun-13 Jul-13 Aug-13 Sep-13 Non-Urgent Actual Urgent Actual Plan Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 Non-Urgent Trajectory Urgent Trajectory Score / / /13 Sep-13 Actual Plan Consistently meeting target. Latest Data Available sourced from HSCIC is 2012/13. Data shown here is in Financial Years rather than Calendar Years. Hospital Standardised Mortality Ratio (HSMR) Actual deaths divided by expected * 100 (Plan = 100) YTD Mar /06/2014

150 Patient Experience % People 100% 90% 80% 70% 60% 50% 40% % of People with a Positive Experience of Primary Care 2011/ /13 Making an appt CCG Out of Hours CCG Dental Services CCG Making an appt Eng Avg Out of Hours Eng Avg Dental Services Eng Avg See comments below for all Amir Hannan, Responsible CCG Governing Body Member Score Patient Experience of Maternity Services England Avg. Score 2013/14 THFT Score QCQ Survey scores for lots of questions, with an overall score for 3 categories. Report shows the average of these 3 scores. Organisational Leads CCG: Clinical Lead: Amir Hannan Manager: Tracy Turley Improvement Impact Date: Total Number of Indicators: 19 RAG Rating - Current Position: RAG Rating - Forecast Position: Average Score Patient Experience of Hospital Care 2005/ / / / / / / /13 Hospital Care Actual A&E Actual Hospital Care Plan A&E Plan OP Care Actual Patient's Personal Needs Met Actual OP Care Plan Patient's Personal Needs Met Plan Many of the data is retrospective from GP surveys, so the current status will not change until next set of data available (expected end of June 2014). There is other evidence from other data recording and work streams that give patient experience information but this is from other forums and processes for example with children and young people via the productive ward process. The CCG have commissioned 'Patient Opinions' which will enable patient experiences from this tool to triangulate quality reporting in N&Q. The N&Q directorate are incorporating patient experience with patient stories into proposed reviews of services and business plans. The CCG patient engagement framework is now becoming more fully embedded within commissioning intentions and wider patient engagement and experience is being utilised. Score Patient Experience of Mental Health Services Plan Actual 2012 Latest data available sourced from HSCIC data due to be available by November Working with the Commissioners/Pennine Care to continue to improve performance. % Response Rate Performance Score 60% 50% 40% 30% 20% 10% 0% May-13 May-13 Jun-13 Jun-13 Jul-13 Friends & Family Test (Response Rate) - THFT Aug-13 Sep-13 Oct-13 Response Rate(A&E)Actual Response Rate (A&E) Eng.Avg Friends and Family Test for TFTH A&E: The CCG is working closely with TFTH to support implementation of FFT. From 1st January 2014 SMS messaging has been re-introduced by the Trust for all patients discharged from A&E, also there has been a more robust discharge process began with all nurses completing the FFT with patients through the discharge process. TFTH are confident that they can not only improve the net promoter scores but also sustain this.the Directorate continues to work with TFTH and there are internal processes being reviewed to monitor the A&E performance score. Maternity FFT is now being produced. Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Response Rate(IP)Actual Response Rate(IP)Eng.Avg Friends & Family Test (Scored Performance) - THFT Jul-13 Aug-13 Sep-13 Oct-13 Performance Score(A&E)Actual Performance Score(A&E)Eng.Avg Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Performance Score(IP)Actual Performance Score(IP)Eng.Avg Apr-14 Apr-14 Score Apr-13 Patient Experience - Children & Young People and Bereaved Carers May-13 Jun-13 DATA UNAVAILABLE - SEE COMMENTS BELOW Jul-13 Aug-13 Sep-13 Children & Young People - Actual Children & Young People - Plan Children and Young people: THFT collect feedback through the productive ward and another process currently bring used in paeds.there is a plan to survey children similar to the plans for adult patients using ipads and direct feedback. The equipment has been purchased and there is a plan for roll out. KS is working with the head of Children s services at THFT and also the Strategic Service Pathway lead in community services at SFT to discuss how this can be driven forward in respect of feedback from children and young people as currently there is no data or current process in the patient experience of children and young people. Bereaved Carers: Unable to source any data. CCG to meet with the bereavement team at THFT. Recovery Milestones Nursing and Quality Directorate to work collaboratively with TFTH and the work plan around FFT. There has been some improvement around this. Nursing and Quality Directorate to compile complaints report with themes and trends from providers to the CCG Quality Committee in February This is now been done. Nursing and Quality Directorate to continue to work with NHS England in the development of the patient experience clinical collaborative. Note: Complaints - There is ongoing work with TFTH SFT and the CCG is addressing this issue. The providers are addressing internal processes and this should impact upon improved response times. From a N&Q directorate perspective there is more work being commenced around the softer intelligence and themes from complaints that will allow themes and key issues to be identified. Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Bereaved Carers - Actual Bereaved Carers - Plan Mar-14 26/06/

151 Nursing & Quality % Target Due to the data recording being recorded being retrospective Total Provider Management are picking up this issue through contractual processes. Performance in this area will be monitored for improvement particularly for discharged summaries made to GPs within 5 days of discharge from provider. No. Cases 100% 80% 60% 40% 20% 0% Apr-13 Jun-13 May-13 Jul-13 Jun-13 Jul-13 Aug-13 Within 24 Hours from A&E Within 5 Days Aug-13 Sep-13 Discharge Summaries to GPs (THFT Data) Sep-13 Jamie Douglas, Responsible CCG Governing Body Member Work is under way with NHS England and locally to address area of HCAI and share best practice and explore ways to improve work and reduce incidents. T&G CCG are currently reporting 16 cases of C-diff against a YTD plan of 23 cases. This puts us 7 cases under plan as at May T&G CCG is achieving the target of zero reported cases of MRSA. MSSA is currently reporting a YTD figure of 6 against a YTD plan of 10, 4 under plan, and Ecoli is currently 4 under plan with a YTD figure of 21 against a YTD plan of 25. Oct-13 Nov-13 Dec-13 HCAI (MRSA, C.Difficile, MSSA, E.Coli) Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Within 24 hours for Inpatient Plan MRSA Actual C.Difficile Actual MSSA Actual E.Coli Actual MRSA Plan C.Difficile Plan MSSA Plan E.Coli Plan Jan-14 Feb-14 Mar-14 Apr-14 May-14 % Adults We are consistently meeting this target with Tameside recognised as the highest within VTE risk assessments for patients within the acute setting. Work is underway with Provider Quality Leads to continue to improve our performance beyond the target. Tameside will be encouraged at this meeting later this month to share best practice for other providers and CCG s. There have been issues with reporting on this KPI due to Problems with the Lorenzo IT system. TPM contract meetings and the Quality and performance meetings continue to discuss the issue with the trust with assurances being given that the situation is being resolved. The CCG is working Closely to monitor and seek assurance from TFT on the problematic implementation of Lorenzo and plans to mitigate risks. % Staff 100% 95% 90% 85% 80% 100% 80% 60% 40% 20% 0% Apr-13 Jun-13 Jul-13 % of Adults who had a Vte Risk Assessment on Admission (THFT Data) May-13 Jun-13 Aug-13 Jul-13 Sep-13 Aug-13 Actual % of Staff Receiving Training Oct-13 Sep-13 Nov-13 The Directorate is meeting with Learning and development leads in TFTH and SFT to look at improving uptake of mandatory % figures. This meeting has taken place and continues to be closely monitored. The Dementia and Domestic abuse training are new training that commenced in April The Directorate are working with providers and the training is a standing item on the safeguarding children and adult whole health meetings. Oct-13 Dec-13 Adult Protection Actual Domestic Abuse Actual Infection Control Actual Dementia Actual Mandatory Training Plan Dementia Plan Nov-13 Jan-14 Dec-13 Feb-14 Jan-14 Plan Mar-14 Feb-14 Apr-14 Mar-14 May-14 Organisational Leads CCG: Clinical Lead: Manager: Nikki Leach Provider: Clincial Lead: Lyndsey Stewart Manager: Mike Griffiths Recovery Milestones Improvement Impact Date: Total Number of Indicators: RAG Rating - Current Position: RAG Rating - Forecast Position: Nursing and Quality Directorate to continue to work with Total Provider Management in exploring the contractual monitoring regarding GP discharge information and summaries. Nursing and Quality to work in collaboration with the NHS England to standardise specific work streams and explicit areas of work Nursing and Quality to work with TFTH and their improvement board to implement actions Note : The VOICES data does give some indicators and measure of patients who expressed a preference of preferred place of death. There needs to be a quality audit undertaken by providers to incorporate this sensitive information. 64 Total Incidents / Med Errors Patient Safety Incidents (Rate per 100 admissions) - THFT 2012/13 Apr-Sep 2012/13 Oct-Mar Total Incidents Actual Incidents of Severe Harm Actual Incidents of Medication Error Previous Year It is noted that there is an increase in reporting and this was acknowledged at the Greater Manchester Quality Leads Clinical Collaborative meeting. Percentage of Deaths in Preferred Place of Care The figure above shows the % of deaths that occurred in the patient's usual place of residence and not necessarilty the place where they preferred to die Incidents of Medication Error Actual Total Incidents Previous Year Incidents of Severe Harm Previous Year 0 Incidents of severe harm %Patients 16% 12% 8% 4% 0% Jun-13 Jul-13 Aug-13 Reduction in the Prevalence of Pressure Ulcers Sep-13 Oct-13 Nov-13 The Directorate have been working with LAT regarding reporting mechanisms of Pressure ulcers; there is an issue from a GM perspective of the quality of reporting and the inconsistencies however work continues with the Local Area team to standardise reporting mechanisms and increase understanding of all pressure ulcers not just stage 3 and 4. A standard statement is to be inserted in all 14/15 provider contracts about pressure damage reporting requirements. Dec-13 Jan-14 Feb-14 Mar-14 Safeguarding adults remains high on the CCG agenda. TASP are introducing a pilot in May 2014 that will involve face to face interviews with adults who have been subject to safeguarding procedures this pilot will run for 12 months and following this it is envisaged that an agreed qualitative system will be rolled out in This will then provide more meaningful and quality data Hospital Standardised Mortality Ratio (HSMR) YTD Mar-14 Summary Hospital Level Mortality (SHMI) 2012/13 35% 34% Actual deaths divided by expected * Actual deaths divided by expected * Apr-14 Actual Trajectory Plan May-14 % Service Users 70% 65% 60% 55% 50% Tameside LA data Safeguarding Adults - Feeling Safe 2011/ /13 % Feel Safe Actual % Feel Safe due to Service Actual Sep /06/2014

152 GOVERNING BODY MEETING Title of Subject: Finance Report for May 2014 Date of paper: June 2014 Prepared By: Kathy Roe History of paper: To be presented to Finance Committee on 2 July 2014 Executive Summary: This paper provides Governing Body members with the financial performance and forecast at May Significant events this month: Other Secondary Care March (2014) Activity levels higher than anticipated resulting in a pressure of ( 377k) for Primary Care March (2014) GP prescribing lower than anticipated resulting in a cross year benefit of 96k. Small year to date underspend of 22k within running costs which is due to vacancies. The CCG planned surplus in is 9,999k, which comprises a 1% in year surplus of 3,263k and the return of previous years lodgement 6,736k. The CCG is on track to deliver this surplus. The Focus Report reviews End of Life Care and aims to provide an update on End of Life Care in Tameside and Glossop; including the training we are providing this year in order to meet our strategic aims and the plans so far on an integrated end of life care service. 152

153 Recommendations required of the Governing Body (for Information, Discussion or Decision) To note contents and approve the Month 2 Finance Report. QIPP principles addressed by proposal: Direct questions to: Yes Kathy Roe Chief Finance Officer 153

154 Financial Performance Update and Action Plan May Executive Summary Table 1: Key Performance Indicators Year to date Variance Year end Variance 000's Year End RAG Financial Surplus Target 0 0 Tameside FT Contract 0 0 Other Secondary Care 1 (427) (377) Primary Care Budgets QIPP Target 0 0 Running Costs Target 22 0 KEY: Performance: On target Below target Significant events this month: Other Secondary Care March (2014) Activity levels higher than anticipated resulting in a pressure of ( 377k) for Primary Care March (2014) GP prescribing lower than anticipated resulting in a cross year benefit of 96k. Small year to date underspend of 22k within running costs which is due to vacancies. 1 Includes independent sector contracts 2 Includes prescribing 1 154

155 2. Purpose of this report This report updates Governing Body members and key stakeholders on the latest financial performance and outlook for the CCG, in the context of key performance indicators and commissioning strategies. 3. Performance overview We have a statutory duty to break even; and CCGs are required by NHSE to deliver a recurrent surplus of 2.5%. The CCG planned surplus in is 9,999k, which comprises a 1% in year surplus of 3,263k and the return of previous years lodgement 6,736k. The CCG is on track to deliver this surplus. Quality Improvement Productivity Prevention (QIPP) target, internally set by the CCG, = 5,141k. The majority of QIPP schemes have now been built into contracts and will be monitored through the programme workstreams. Although the QIPP target in is 5,141k our commissioners are working towards a combined savings target of 74.1m to cover the wider health & social care deficit as part of the Care Together plan. Running cost target set by NHSE = 5,787k ( per head) The running cost allocation in has been reduced by 23k, resulting in an allocation of per head compared to 25 per head in The CCG is currently underspent by approximately 22k against its running cost allocation. Given the scale and pace of the Care Together Programme there is a need to commission extra consultnacy to help support this agenda. Therefore its anticpated this underspend would be utilised later in the year resulting in a break even position at the end of the financial year. Table 2: Summary Income and Expenditure Period April May 2014 Full Year Budget YTD 000s Actual YTD 000s Variance YTD 000s Annual Budget 000s Forecast Outturn 000s Forecast Variance 000s Admin Running Costs ,787 5,787 0 Total Admin Costs ,787 5,787 0 Programme Acute 29,936 30,363 (427) 179, ,996 (377) Mental Health 4,734 4, ,404 28,404 0 Primary Care 7,403 7, ,421 44, Continuing Care 1,873 1,908 (35) 11,384 11,582 (198) Community Health Services 4,268 4, ,608 25,608 0 Other 1,405 1, ,613 7,613 0 Earmarked Reserves ,317 12, Total Programme Costs 49,803 49,825 (22) 310, ,366 0 Total Net Costs 50,767 50, , ,153 0 Allocation 52,434 52, , ,152 0 Surplus/(Deficit) 1,666 1, ,999 9,999 0 Table 2 provides a summary of income and expenditure against budget, with further detail given in Sections 4 and 5. The CCG is on course to meet its financial surplus of 9,999k based on the month 2 position. The overall year to date position is break even, however there is no comparison of movement from prior month as this is the first report of the new financial year ( ). As reported in Table 1, Other Secondary Care providers are forecast to be overspent by ( 377k) at the end of the financial year. This is due to an increase in March activity levels in excess of the March accrual made within accounts. Although current figures are subject to change with the final freeze submission, it is not anticipated there will be any significant movements. We have also seen further pressures within CHC budgets which are forecast to overspend by ( 198k)

156 4. Acute The predominant cost in this section is NHS and independent sector hospital contracts, but ambulances, non contracted activity, high cost drugs and CATS are also included. Acute Budgets are forecast to overspend by ( 377k) by the end of the financial year. This is due to March (2014) activity levels exceeding the March accruals made within accounts. Further detail of the impact can be seen in table 3 below: Table 3: Financial Impact of March Activity levels vs March Year End Accruals Forecast Year end Position (Including M12 Accrual ) Final Position Potential (based on Flex Financial Provider Information) Variance Impact Commentary (Adv) / Fav (Adv) / Fav 000's 000's 000's 000's PENNINE ACUTE NHS TRUST 4,144 3, Block Contract in no benefit C MANC UNI HOS NHS FT 20,321 20,495 (174) (174) Contract not fixed ROYAL BOLTON HOSP NHSFT (7) 0 Agreed Fix position to plan for No pressure SALFORD ROYAL NHSFT 1,610 1,688 (78) (78) Contract not fixed STOCKPORT NHS FT 10,337 10,360 (23) (23) Contract not fixed TAMESIDE HOSPITAL NHSFT 116, ,644 1,056 0 Agreed year end fix position UNI HOSP SMAN NHS FT 4,696 4,716 (20) (20) Contract not fixed WRIGHT/WGN/LEIGH NHS FT (47) (47) Contract not fixed TOTAL RISKS 158, ,725 1,117 (342) Figure 1: Breakdown of Top 5 Acute Providers by Point of Delivery (POD) Plan ( ) Table 3 shows the financial impact to the CCG of the increased activity seen in March 2014 resulting in a pressure of approximately ( 342k). The biggest pressure is notably at CMFT ( 174k) which makes up 51% of the total pressure. This was due to an unplanned increase in Critical Care activity for March 2014, with one significant high cost patient of ( 104k). This is a volatile area of spend and by its very nature forecasting can be quite difficult. Critical Care had been significantly below planned levels throughout , with the March (2014) accrual based on the trend. However we didn t anticipate the spike in activity seen in March, which also appears to have continued into Critical Care is overperforming in April (2014) by approximately ( 20k) as seen in Appendix 1. The total budget of our 5 largest acute contracts totals 154.8m which represents approximately 86% of the total Acute Budget. Figure 1 shows the breakdown by Point of Delivery. Non Elective Admissions are the biggest area of spend with a budget of approximately 42.1m for Patient demand, GP and consultant referral behaviours and the effectiveness and efficiency of our care pathways are therefore key drivers of the financial position

157 Tameside FT Core Contract Year to date performance on the Tameside FT contract shows an underspend of approximately 268k, which is due to underspends within Elective 158k and Maternity 116k. There was on going data issues post implementation of Lorenzo in and there are still concerns that the most recent month 1 activity is not a complete data set. Lorenzo is now being monitored through the CCG Quality Committee, at the May meeting it was noted that members felt assurance is needed on the validity of information and have requested that further detail/assurance is provided. Figure 2: Breakdown of POD (YTD Variance) Tameside FT Core Contract Figure 2 shows the month 1 YTD variance by POD and the main headlines are discussed below: Elective surgery is currently underspending by 158k as seen in Figure 2. This is due to underspends within Trauma & Orthopaedics and General Surgery. Although this is quite a significant underspend at month 1, a significant increase in activity will be required to deliver the 18 Weeks RTT targets in Trusts are likely to come under increasing pressure to hit performance targets in NHS England s planning guidance for has urged CCG's to enforce penalties against trusts if targets are not met. Therefore we believe that the underspend seen in month 1 is unsustainable and forecast spend for future months will revert to planned levels. Figure 3: Breakdown of Maternity / NELNE by POD Maternity / Non Elective Non Emergency shows an underperformance of 116k. However births are significantly below expected levels, therefore it is anticipated that this underperformance will be removed once the final month 1 freeze data has been shared. The CCG has also not been charged for any sub acute stroke repatriation patients which will be adding to the underperformance in NELNE as seen in figure 3 (this has been flagged with the Trust). Similar to the maternity issue we fully expect activity levels to increase within NELNE in the final freeze data, resulting in a position which is consistent with planned levels

158 Tameside FT Core Contract (continued) Emergency Admissions show a marginal underperformance of 27k overall. Figure 4 shows a breakdown of this area by POD. Although it is too early to draw any firm conclusions from one month activity data the early signs are encouraging. Emergency admissions as a whole are underspending by 27k, which is against a baseline which has already been significantly reduced ( 1.9m) in relation to QIPP programmes. Figure 4: Breakdown of Emergency Admissions by POD We have seen overspends in NELSD and ambulatory care offset by a larger underspend in full NEL admissions. This is a positive sign for the long term as it is consistent with the aims and objectives of Care Together, which would be a more affordable and sustainable future for the Integrated Care Organisation. It is worth noting that Outpatients are overspending by ( 75k) which is predominately due to an overperformance in Pain Management ( 51k). Forecast Outturn: due to the validity of month 1 data It is too early at this stage to predict whether the underspends will continue. As previously mentioned it is anticipated a significant element of this underspend will be removed once the final month 1 freeze data is received. Therefore a breakeven position has been shown as the forecast position for Other Secondary Contracts There are no significant variances to report based on month 1 activity data (see Appendix 1). However we have seen marginal overspends at UHSM ( 45k) and PAHT ( 13k). The overspend at UHSM is due to an overperformance in Vascular Elective Surgery ( 41k). CMFT position shows a marginal underspend of 30k in month 1 due to underspends in relation to the maternity pathway. However due to pressures as mentioned in table 3 of this report it is anticipated there will be a forecast overspend of approximately ( 174k). No activity data has been received from Stockport FT. We have been notified that month 1 activity data will be submitted with month 2 data, this has been agreed with the lead commissioner (Stockport CCG). Due to the limitations of forecasting with only one month of activity data, it has been assumed that the main acute providers (as seen in appendix 1) will deliver to planned/budgeted levels for The current forecast overspend of ( 377k) within acute budgets (as shown in Table 1) relates to cross year pressures from as discussed in Table 3 of this report

159 Independent Sector In independent sector budgets within Acute total 2.92m.This was based on forecast outturn at month 10 in extrapolated. Initial indications highlight the continued growth in activity and a ( 35k) forecast pressure has been included in the position. The increase in activity is largely Mediscan and various smaller AQP providers above planned levels. 5. Primary Care GP Prescribing Prescribing budgets are currently underspending by 87k which is due to March (2014) prescribing data being lower than anticipated and accrued for within accounts creating a benefit in the current financial year. Due to the usual time lag in availability of prescribing data from the PPA, month 1 data was not available for month 2 reporting therefore it has been assumed that prescribing budgets will break even in Central Drugs Central Drugs is currently showing an underspend 57k as at the end of month 2, this is due to March (2014) invoices being below anticipated levels resulting in a benefit in The accrual made within the accounts was based on a rolling 3 month average however this has now proved to be somewhat overstated. Spend in this area appears to have reduced in recent months; we will continue to monitor this area closely in Continuing Healthcare (CHC) Budgets are currently overspent by ( 35k) at month 2. Further work has been completed on the CHC database, which has realised a cross year impact of ( 198k). This is due predominately to the unknown value of the fast track patients who started within the last half of the financial year. The ( 198k) has been reflected in the forecast outturn position for This is a volatile area of spend and therefore finance colleagues are working closely with the CHC team to make improvements to the database which will enable more robust forecasting in this area

160 6. Financial Risks QIPP does not deliver required 5.1m saving: this represents a significant financial risk to the CCG and has the potential to jeopardise its statutory financial duties. Surplus: The CCG has agreed to carry forward 2m more surplus than originally planned from to This is to help with pressures at a national level (e.g. specialist commissioning). There is a risk, though, that this will result in the CCG not being able to adequately pump prime the integration agenda in which could, in turn, lead to slippage on QIPP targets and delays in integration projects. If this happens, the CCG will approach NHSE for additional resources in year. Prescribing: The CCG began to see a sharp rise in prescribing expenditure from December 2013 due to an increase in the volume of prescribed drugs and increases in drug tariffs in some high volume, previously low value medicines. These price and volume pressures combined give rise to a real risk that prescribing will not be able to be managed within planned expenditure levels. Specialist Commissioning Drugs: There is still some confusion across the healthcare system in relation to the billing of PbR excluding drugs and as a consequence the CCG could be charged for drugs which are the responsibility of NSHE. GMCSU and CCG Medicines Management are currently seeking further clarity and assurances from the main acute providers that appropriate arrangements are in place in order to bill the correct commissioner. Continuing Health Care Restitution Risk Pool: Current guidance sets out that the CCG is to contribute to a national risk pool for the cash settlement of CHC restitution cases. Since the first planning update paper, NHS England has allocated an additional pressure onto the CCGs budget relating to legacy Continuing Health Care (CHC) provisions. CCGs have been informed that this was included in the uplift and as such we will be top sliced for a national risk pool by 0.4%, 1.2m. GP IM&T: Current information indicates that there will be a shortfall in the GP IM&T allocation transferred to CCG s from NHSE which will result in a cost pressure to the CCG. GM Risk Pool: Discussions are taking place at NHSE in relation to a potential risk share arrangement which will cover Specialist, GP IM&T and CHC (already highlighted above). The approach would be to increase the ring fenced 0.3% strategic levy in to 1%; however this is yet to be agreed. 7. Recommendations Members are asked to note the contents of the report focusing particular attention on the financial risks detailed above

161 Appendix 1 Top 4 Acute Summary (Excludes Stockport FT) Month 1 SLAM Sum of Price Plan Activity Plan Activity YTD Finance YTD Finance (forecast outturn) Activity (over) / under plan Variance as a % of plan Budget Actual (over) / under plan Variance as a % of Budget Budget Actual (over) / under plan Variance as a % of Budget Trust Desc Board Report Total Activity Activity % 000's 000's % 000's 000's % TAMESIDE HOSPITAL NHS FOUNDATION TRUST A&E 7,404,842 5,679 (77) (1.3) 609 (15) (2.4) 7, All other (PbR excluded, non activity services) 15,406,951 85, ,246 (3) (0.2) 15, Critical Care 4,331, , Elective: inpatients and day cases 18,968,832 1, , , Maternity/Non Emergency 10,276, , Non elective admissions 36,824,383 2,874 (386) (13.4) 2, , Outpatients 23,622,836 16,588 (1,570) (9.5) 1,805 (75) (4.2) 23, TAMESIDE HOSPITAL NHS FOUNDATION TRUST Total 116,835, ,837 (896) (0.8) 9, , CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST A&E 849, (30) (3.5) All other (PbR excluded, non activity services) 4,963, (623) (240.7) ,964 (20) (0.4) Critical Care 568, (30) (63.7) 47 (20) (42.8) Elective: inpatients and day cases 5,086, ,086 (92) (1.8) Maternity/Non Emergency 2,242, ,243 (211) (9.4) Non elective admissions 3,731, ,732 (36) (1.0) Outpatients 3,884,979 2,762 (232) (8.4) 296 (16) (5.6) 3, CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Total 21,327,301 4,646 (772) (16.6) 1, ,327 (174) (0.8) UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST A&E 77, (1) (12.2) 78 (0) (0.4) All other (PbR excluded, non activity services) 452,812 2 (0) (23.2) 38 (10) (27.2) 453 (5) (1.0) Critical Care 222, Elective: inpatients and day cases 1,664, (50) (57.2) 139 (50) (35.9) 1,664 (22) (1.3) Maternity/Non Emergency 354, Non elective admissions 753, (11) (18.9) 753 (5) (0.6) Outpatients 886, (103) (15.1) 74 (5) (6.6) 887 (2) (0.2) UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FOUNDATION TRUST Total 4,412, (122) (13.5) 362 (45) (12.5) 4,412 (20) (0.5) PENNINE ACUTE HOSPITALS NHS TRUST A&E 165, (7) (4.7) 14 (0) (3.5) All other (PbR excluded, non activity services) 578, (5) (7.7) 48 (6) (12.6) Critical Care 229, (15) (84.9) 19 (9) (47.1) Elective: inpatients and day cases 1,425, , Maternity/Non Emergency 248, (43) (263.6) 21 (9) (42.0) Non elective admissions 443, (5) (14.9) 37 (5) (13.2) Outpatients 583, PENNINE ACUTE HOSPITALS NHS TRUST Total 3,675, (13) (4.3) 3, Grand Total 146,250, ,284 (1,759) (27.4) 11, (12.1) 146,250 (194) (1.3) 8 161

162 Appendix 2 Locality Reporting System issues with SLAM have meant GMCSU have been unable to process data for the locality report this month. These issues will be resolved in time for month 3 reporting

163 Focus Report End of Life Care Introduction: Focus Report End of Life Care This paper aims to provide an update on End of Life Care in Tameside and Glossop; including the training we are providing this year in order to meet our strategic aims and the plans so far on an integrated end of life care service. Aims: From our CCG prospectus 2013/14 People dying in comfort with dignity At least two in five dying at home if they want to More patients writing down their wishes about the care and treatment they want at the end of their life From our CCG 5 year plan Identification of people approaching the end of their life and direction into appropriate specialist care which can prioritise comfort and dignity over active treatment Patients will be supported to set on record their choices about their care and treatment at end of life through advance care plans All our care homes accredited to deliver high quality end of life care 10% reduction in hospital deaths All our GPs delivering high quality end of life care From the Health and Well Being Strategy Dignity in Care Supporting people to die where they choose Providing good end of life care consistently Local Picture: Data from the Marie Curie Atlas 3 shows that 2.1% of the population in Tameside and Glossop is over 85 years old, and that 0.7% of our population have a palliative care need. It also shows that we had around 680 terminal admissions that were 8 days or longer (28% of all deaths) at a cost of approximately 2.5m. Nationally in England 49% of patients die in the community and 49% die in hospital but the end of life care profiles demonstrate that in we had a higher than average death rate in hospital for people over 85 and in addition we have the third highest count of our neighbouring CCGs 4. Local data for Tameside and Glossop confirms that 58% of our population died in hospital and 41% died in the community; the graphs are shown below. 3 Marie Curie Atlas 4 National end of life clinical intelligence network intelligence.org.uk/end_of_life_care_profiles/ccg_profiles

164 Focus Report End of Life Care Percentage of Deaths by Place of Death Tameside 2012 dec nov oct sept aug july june may april march feb jan 0% 50% 100% general hospital care home hospice elsewhere home Percentage of Deaths by Place of Death Tameside 2013* *December 2013 is not complete dec nov oct sept aug july june may april march feb jan 0% 50% 100% general hospital care home hospice elsewhere home Deaths by Place of Death Tameside 2012 Number of Deaths by Place of Death Tameside 2013* *December 2013 is not complete 493, 20% 30, 1% 183, 8% 340, 14% 1370, 57% hospital care home hospice elsewhere home 34, 1% 441, 20% 153, 7% 307, 14% 1283, 58% hospital care home hospice elsewhere home The way outcome measures are recorded varies between publications with some documenting the number of deaths at home and some documenting the number of deaths in their preferred place of care (PPC). It is not always clear what the definition of Home is and there may be some assumption that home is where the patient last resides, which could be a care home or the hospice. The PPC is not always documented and therefore there is an assumption again that this would be the place the patient last resides. In Tameside and Glossop 0.7% of our population have palliative care needs that are cared for by district nursing teams or specialist palliative care (SPC) teams. Not all palliative care patients need SPC. It is noted that a high proportion of patients known to the Macmillan SPC team or the Marie Curie cancer care team die in their PPC, with around 50% die at home. This is higher than the national data produced by Public Health England in June 2014 that shows 46% of people receiving SPC died in their own home. 5 The data table below shows the number of patients known to specialist services (Macmillan Nursing Team) who died in their PPC, which is 72% From April 2013 Jan Public Health England News Article palliative care services lead to more deaths athome

165 Focus Report End of Life Care Patients on End of Life Pathway dying in their preferred place of care Month 13/14 No. patients on EoL CP known to the Macmillan service No. dying in their preferred place of care % of patients known to the Macmillan service dying in their preferred place of care Apr % May % Jun % Jul % Aug % Sep % Oct % Nov % Dec % Jan % Feb* % March* % Total % *estimated figures based on average for the purpose of illustration Based on the figure that 0.7% of the population has a palliative care need, and our local population as of 1 st April 2014 was 241,919 the number of patients who may need palliative care is 1,693. This shows that 22% of patients with palliative care receive SPC, and the patients known to the SPC team get a very good service as 72% die in their PPC. In 2010 according to the Marie Curie Atlas we spent 1,178,400 on specialist palliative care which is around half of the average national spend, even though we had more than half the number of people needing specialist palliative care than the national average. The 2010/11 VOICES survey has been collated by Marie Curie and an atlas has been produced so that areas can be compared. This survey is completed by carers who have registered a death in the last 12 months and looks at their satisfaction of care at the end of life both in hospital and in the community, for the Greater Manchester Area. The sentences are coloured to represent how far away from the national average our local results are. 41% rated excellent or outstanding quality of care [amber] 29% rated that care was definitely co ordinated [red] 49% rated that pain relief was managed excellently [green] 46% of carers felt well supported [red] Integrated care: According to current data we must try and reduce hospital deaths and therefore reduce costs. A benchmarking exercise of the Salford end of life care pathway scheme found that 4.2% of patients aged 65+ who attend A&E

166 Focus Report End of Life Care are admitted and go on to die in hospital. If we align to this level were able to reduce admission to the Salford average, 174 admissions could be prevented, saving 600k. It is reported that the cost of specialist palliative care per death is 484 so compared to a hospital death this is a marked reduction. As demonstrated previously only 22% of patients are currently seen by the specialist palliative care team and therefore there could be a large portion of people with palliative care needs who could benefit from the service and achieve more efficient outcomes in terms of service and financially. This piece of work will be explored more robustly within the Care Together agenda. Other intangible measures such as quality and co ordination of care may improve with an increase in specialist palliative care teams including the care that people receive at home along with the communication with families and carers. End of Life Care is in Phase 2 of the Care Together Agenda, which means that an outline business case has to be ready by the end of August. We are holding some process mapping sessions to map the current as is pathway of care at end of life on 2 nd July and then following this we will be mapping the future or new pathway on 30 th July. Both sessions will be at Hyde Town Hall from 9:30 am 12:30pm. We would welcome any patient, carer or clinician attendances. If you have some feedback on services we provide for end of life care, or would like to attend please contact Carole Piddington, CCG c.piddington@nhs.net. Training and Development: The CCG have been awarded monies from the Clinical Network for the Multi professional Education and Training (MPET) Fund, which will help us to meet our priorities for improving End of Life Care in the area. The elements of the training plan are detailed below: udnacpr (unified Do Not Attempt Cardio Pulmonary Resuscitation) The unified DNACPR policy is to be implemented from 1 st November and training sessions will be run between September and October in various localities over lunch time and evenings. The sessions will be aimed at all professionals involved in DNACPR decisions and everybody will be expected to attend the training. GPs will need to complete the BMJ e learning module on Mental Capacity Act prior to the training sessions and submit evidence in order to receive a pack of DNACPR forms. intro/mental capacityact.html?moduleid= &searchterm=%e2%80%9cmental%20capacity%20%e2%80%9d&page=1&locale= en_gb NWAS would like the DNACPR decision to be recorded on ERISS (Electronic Referral Information Sharing System) so that they will know on arrival that a patient has specific requirements but the paramedic will still need to physically see the form on attendance. professionals/eriss (other conditions and end of life care information can also be recorded on ERISS)

167 Focus Report End of Life Care Individualised Plan of Care and Support for the Dying Person in the Last Days and hours of Life The Liverpool Care Pathway will be phased out from 1 st July. There will be no interim pathway or policy or process. The Strategic Clinical Network have emphasised that there should be a focus on the delivery of care rather than on protocols or processes and has outlined five priority areas of care. The priorities are equally important: 1. The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the person s needs and wishes, and these are regularly reviewed and decisions revised accordingly. 2. Sensitive communication takes place between staff and the dying person, and those identified as important to them. 3. The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants. 4. The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible. 5. An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co ordinated and delivered with compassion. Together the priorities should enable all individuals approaching the last few days and hours of their life to receive high quality care that is right for them as an individual. The Strategic Clinical Network is developing an Individual Plan of Care and Support for the Dying Person in the Last Days and Hours of Life, which will be used in the future. This plan of care is not a replacement for the LCP. It does not define a process for care delivery. It is a care plan that is used to record and evidence individualised care for the dying person and those close to them, delivered by compassionate and competent professionals. There will be training, awareness and peer review sessions for all professionals who may need to complete the end of life care plan, with dates over next few months. See appendix 1 for the principles of care document that will be circulated and followed by the hospital, community nursing teams and general practice. EPaCCS (Electronic Palliative Care Coordination System) This is an electronic end of life care record which will be populated by the GP, shared and viewed over a secure connection, between GPs, Out of Hours services and the Hospital. The GPs are currently being encouraged to populate the template with patients who could be on an end of life care pathway. Much of the information required for the template is already contained within the GPs clinical system and patient records. We are working with the EPaCCS steering group to promote the database to the GPs. Going for Gold We are sponsoring 20 General Practices through Level 4 Going for Gold Gold Standards Framework training who will receive accreditation by November Accreditation will follow a period of embedding the training programme and there are only currently 7 practices fully accredited in the country (although quite a few more are undertaking the training programme). The general outcomes of the training programme have shown to increase the number of patients who are identified earlier to ensure they have advance care planning discussions, and increasing the number of patients dying in their preferred place. Feedback from other areas

168 Focus Report End of Life Care who have completed the training with GSF have acknowledged better teamwork and co ordination within the practices. Following the launch session we have 20 practices signed up to follow the training programme over the next 6 months. Diploma in Palliative Medicine We have funded four GPs a place on the Diploma at Cardiff University, to commence the course in September. With the skills from the course we will be hoping to encourage the candidates to become leaders in End of Life Care for Tameside and Glossop, encouraging them to engage with peers, both in and out of hospital, and with the CCG to improve End of Life Care in their communities. Patient and Carer Engagement: Dying Matters Awareness Week th May Over 90 people attended the Dying Matters Awareness Event held at Ashton Town Hall in May Most attendees were health or social care professionals but many were also patients in the area. 97% of people felt more informed after the event and liked the networking opportunity the event allowed. The event has highlighted that it is important that information is communicated well to ensure we can meet Priority 6 of our Health and Wellbeing Strategy. It also showed that this is a two way communication so that people in our community have the opportunity to talk, listen and share ideas to make improvements, in order to support people and ensure there is good end of life care. A limitation of the event was the lack of patient engagement but in a positive light the people who attended will share their increased knowledge and awareness with their patient groups. Therefore professional engagement is key to passing on consistent messages within our community. Future events might take a different form to further engage the public and work is to be done on improving communication about end of life services and policies for professionals, carers and patients. Are we on target to meet our aims? The level of training we have secured around the new policies and the amount of awareness efforts we are putting in place should help to reach the aims of reducing the number of hospital deaths, improving patient s quality of life and ensuring patients, carers and families have a positive experience of care. In order to monitor our impact and improvement we will need to develop clear outcome measures. These will be discussed at the next end of life strategy group and will make up part of the outline business case for End of Life Care in the Care Together agenda

169 Focus Report End of Life Care Appendix 1: Principles of care and support for the dying patient, NHS England

170 Focus Report End of Life Care

171 Title of Subject: GOVERNING BODY MEETING Locality Leads Minutes Date of paper: 24 th June 2014 Prepared By: History of paper: Executive Summary: Alison Lewin n/a Items discussed included:- 5 per head business cases, PIQ processes, 2ww referrals, GM workforce data collection, GM event on federation Recommendations required of the Governing Body (for Information, Discussion or Decision) CCG are asked to note the minutes QIPP principles addressed by proposal: Direct questions to: All Richard Bircher 171

172 Tameside & Glossop CCG Locality Leads Meeting Minutes from the meeting held on Tuesday 24 th June 2014, Churchgate Surgery, Denton In Attendance Dr S Ahmed, Stalybridge locality lead Dr A Ali, Denton locality lead Dr J Bircher, Quality Improvement clinical lead Dr R Bircher, CCG Governing Body Member Dr A Hershon, Hyde locality lead Peter Howarth, Head of Medicines Management Ali Lewin, Deputy Director of Transformation David Milner, Head of FInance Heather Palmer, Commissioning Business Manager Dr N Riyaz, Ashton locality lead Elaine Richardson, Strategic Programmes Manager / Commissioning lead for planned care and cancer Louise Roberts, Commissioning Business Manager 1 Apologies Clare Symons Tracey Simpson 2 Notes of previous meeting Approved as a true record of the meeting 3 Matters arising Discharge letters still some issues with delays in information arriving with GPs examples cited of receipt this week of information from discharges in October, February and March. JB reiterated that GPs need to notify TFT of all such incidents. Agreed following some discussion that until there is absolute clarity of a single process to follow to notify the FT it would not be useful to send further communication to GPs. Care Together Message reiterated that GPs will now be reimbursed for attendance at care together service redesign meetings. This will not include the Phoenix City event. Payments will be made retrospectively for GPs who have already attended meetings before this decision was taken. Confirmation of attendance at the Phoenix City event has been low. AL to check with Sarah Hadfield how many people have confirmed attendance, who they are, and forward this information to the locality leads. Action: AL AL to review the list of topics to be covered at the locality meetings for the outline business cases and to notify the locality leads of any changes to the previously proposed schedule 172

173 Action: AL Locality Lead roles A discussion took place on the previous agreement to present proposals re the roles and funding (i.e. number of sessions) to PIQ. Locality leads asked that this is presented in July if possible. There was agreement that 46 weeks is the number of sessions the leads are contracted for, but some confusion over how the annual leave arrangements work, as the 6 weeks not worked are not paid. Action: AL to ensure the paper is on PIQ agenda for July and to discuss with CW the 46 week / annual leave issue 4 5 per head business cases A lengthy discussion took place where the locality leads fed back discussions from each locality and initial proposals / suggestions for schemes which could be the topic of business cases. AH outlined plans in Hyde and arrangements made with New Charter, Age UK, and the Carers Centre (amongst others) to discuss what support these organisations could provide to general practice and their registered over 75 patients. All were invited to attend this meeting on 4 th July. Clarity was provided in terms of the national guidance supporting the 5 per head funding. Locality leads felt that this is an opportunity to do something innovative and outside traditional general practice, and that the practices and localities should be encouraged to do this, but also recognised that the guidance does permit more traditional proposals than first thought, as long as there isn t any duplication with core GMS or DESs. Agreed that locality leads will continue to work with the practices in their localities to develop proposals for PIQ consideration. Hyde to produce an outline proposal in time for July PIQ to garner initial support for the ideas, with a full business case to follow. 5 PIQ processes A discussion took place reflecting on the May PIQ meeting and particularly the item where there was the requirement for all members to vote on the Co Commissioning proposals. It was felt that the challenge put to the CCG management team was appropriate and that it had been well received by Steve Allinson and Graham Curtis. It was agreed by the locality leads that there is no need to take any action in relation to PIQ terms of reference The co commissioning letter produced following PIQ was also discussed, with locality leads expressing concern at the level of detail included in the final expression of interest. It was agreed that the locality leads would communicate their concerns to Clare Watson. Action: Locality Leads 6 2ww referrals ER presented data which indicate an increase in 2ww referrals to Tameside FT the data was TFT activity in it s entirety and not T&G CCG GP referrals only. JB made reference to some data presented to the Local Improvement Group which showed 2ww referral information and conversion to positive diagnosis, by practice. ER and JB to share information outside the 173

174 meeting, but request from ER for any feedback from locality leads and member practices on potential reasons for the increases. 7 GM workforce data collection HP asked that locality leads encourage practices to complete the workforce return distributed by Health Education NW. Concern was expressed that this is a time consuming exercise for practices, and that there isn t clarity on the outcome or use of the data, or the benefits to the practice of completing it. 8 GM event on federation Information was shared on a GM event scheduled for July. RB confirmed that local discussions are ongoing, with the CCG arranging meetings with some of the interested parties in the area of GP federation. It was also thought that Dr Jha is arranging a further meeting for early July. 9 Feedback from localities It was reported that the majority of locality discussions were around the 5 per head proposals, so nothing further to feed back. 10 Feedback from CCG GB Nothing to be fed back in addition to the issues already discussed above 11 Any other business Salford Orthopaedics waiting times: ER reported issues with 18ww RTT at Salford Trust National RTT initiative: ER reported that there is a national push to ensure 18ww RTT targets are met and for CCGs and providers to give additional assurance that this will be the case for A discussion followed re the need to identify, and where possible utilise, some of the independent sector contracts to support delivery of the 18ww RTT in all providers. ER is working with the CSU to clarify alternative options and will then communicate with General Practice. Cataract Surgery ER confirmed that cataract surgery will return to the TGH site by the first week of August 12 Next meeting 29 th July, , Churchgate Surgery 174

175 TAMESIDE HEALTH AND WELLBEING BOARD ITEM NO: 3 13 March 2014 Commenced: 9.00 am Terminated: am PRESENT: IN ATTENDANCE: APOLOGIES: Councillor Kieran Quinn (Chair) Tameside MBC Councillor Allison Gwynne Tameside MBC Councillor Lynn Travis Tameside MBC Councillor Brenda Warrington Tameside MBC Steve Allinson Clinical Commissioning Group Stephanie Butterworth Tameside MBC Alan Dow Clinical Commissioning Group Linda Dunn Pennine Care NHS Foundation Trust Ben Gilchrist CVAT Tony Griffin Tameside MBC Angela Hardman Tameside MBC Warren Heppolette NHS England Tony Powell New Charter Housing Trust Andy Searle Tameside Adults Safeguarding Board Mike Tarver Tameside Safeguarding Children s Board Judith Westhead Stockport NHS Foundation Trust Debbie Bishop Tameside MBC Jacqui Dorman Tameside MBC Martin Garnett Tameside MBC Christina Greenhough Clinical Commissioning Group Doreen Hounslea Clinical Commissioning Group Teresa Jankowska Public Health Ben Jay Tameside MBC Sandra Stewart Tameside MBC (Monitoring Office Caroline Ball Greater Manchester Police Steven Pleasant Tameside MBC Clare Watson Clinical Commissioning Group 65. MINUTES OF PREVIOUS MEETING The Minutes of the Health and Wellbeing Board held on 16 January 2014 were approved as a correct record. 66. HEALTH PROTECTION GROUP MINUTES The Minutes of the meeting of the Health Protection Group held on 20 January 2014 were submitted for information. 67. REVIEW OF THE TAMESIDE STRATEGIC PARTNERSHIP Consideration was given to a report of the Executive Leader / Chief Executive suggesting an update to the structure and administration of Tameside Strategic Partnership (TSP), due to the developments in legislation and changes in the needs of the borough. 175

176 Particular reference was made to the following:- The Purpose of Tameside Strategic Partnership; Influencing Factors for Change in Structure; Proposed Shift in Responsibility; Health and Wellbeing Board; The Children s Trust; Crime and Disorder Reduction Partnership and Supportive Communities; Prosperous Board; and Local Public Service Executive. It was further reported that the brand and visual identity of the TSP would also be refreshed and recruitment would be sought from existing and potential new businesses, education establishments, transport providers to the membership of the TSP. With regard to communication, the TSP website was scheduled for review in 2014 and in order to keep all partners engaged, it could be beneficial to use a two way symmetrical communication model, utilising a socialised website. Further reference was made to the TSP Board meetings, which met biannually and the new proposal would consider alternative means of communication and that the TSP Board ceases in favour of this. RESOLVED That the proposed update to the structure and administration of the Tameside Strategic Partnership be noted. 68. HOMELESSNESS PREVENTION STRATEGY Consideration was given to a report of the Executive Member (Neighbourhoods and Health) / Assistant Executive Director (Community Services) detailing the Homelessness Prevention Strategy and outlining the key strategic themes around which the strategy had been organised. It was reported that preventing homelessness was one of the Council s biggest challenges and the new strategy was aligned with the Council s Community Strategy. It was a requirement under the Homelessness Act 2002 that the local authority undertook a review of homelessness in its area every 5 years and developed an effective strategy describing how the issue would be dealt with. The previous strategy was due to be completed in 2013 and a further strategy outlining the Council s key strategic priorities for the next 5 years was required. Reference was made to the Preventing Homelessness Forum which played a crucial role in overseeing the implementation of the strategy and promoting a partnership approach. The terms of reference for this Forum were appended to the report. The implementation plan for the Homelessness Prevention Strategy over the next five years would be organised under the following key strategic themes:- Early Intervention and Prevention; Accommodation and Access; Positive Move-on and Sustainability; and Improving Health and Wellbeing. Details were given of the consultation, outcomes of the consultation, equality and diversity with the Equalities Impact Assessment appended to the report; risks; implementation and financial implications. 176

177 RESOLVED (i) That the Homelessness Prevention Strategy be approved. (ii) That the implementation of the strategy be overseen by the multi-agency Preventing Homelessness Forum. 69. CARE TOGETHER PROGRAMME: UPDATE INCLUDING GOVERNANCE REVIEW Doreen Hounslea, Programme Director, presented a report which outlined the proposed governance arrangements for the Care Together work programme to ensure that a clear project delivery framework existed. In particular, Members of the Board were asked to note: The proposed overall strategic direction and governance arrangements together with the establishment of a Commissioning Executive. The strengthening of the CCG representation as part of the review of the Health and Wellbeing Board restructure provided further good governance to the integration agenda. The redesignation of the Team to Team meetings to form the Integration Board and the roles of the Executive Sponsor, Programme Sponsor and Programme Director to manage the programme delivery. The establishment of several work streams and for the Board to be regularly updated on progress of the integration agenda and impact on the health and wellbeing of local residents. RESOLVED (i) That the overall approach to service transformation and governance arrangements as outlined in the report be supported; and (ii) That the Board receives regular progress reports on the integration agenda. 70. JOINT STRATEGIC NEEDS ASSESSMENT The Executive Member (Health and Neighbourhoods) introduced a report, which explained that the Joint Strategic Needs Assessment (JSNA) had been developed in partnership by the Public Health team at Tameside MBC, Tameside and Glossop CCG within input from other strategic partners and diverse groups and communities. It had been overseen by the JSNA steering group, a subgroup of the Tameside Health and Wellbeing Board, and included representation from CCG Board Members, Tameside MBC Directors of Adult s and Children s Services and the Director of Public Health. RESOLVED That the verbal report be noted. 71. HEALTHIER TOGETHER UPDATE The Chair welcomed Leila Williams, Director of Services Transformation, who advised that Healthier Together programme was launched in February 2012 as part of the Greater Manchester Programme for Health and Social Care Reform, and aiming to provide the best health care for everyone in Greater Manchester. There were three elements to Healthier Together: Integrated and primary care; Community based care; and In-Hospital care. 177

178 Working in Partnership with social care partners, voluntary organisations and all 10 local authorities across Greater Manchester, the programme was clinically led and managed by the Service Transformation team accountable to the 12 Greater Manchester Clinical Commissioning Group. The future health and social care system would look substantially different and would provide consistent, joined-up, patient focused services linking primary care, social care and community based care services. RESOLVED That the update be noted. 72. EVERYONE COUNTS : CLINICAL COMMISSIONING GROUP PLANNING Consideration was given to a report of the Director of Transformation, Tameside and Glossop CCG, explaining that every CCG was required to submit their two year plan and draft five year strategy to NHS England by 4 April The plan included four elements; a plan on a page that reflected the vision; a key lines of enquiry document showing a greater level of detail against the Everyone Counts framework; an activity trajectory for separate provider organisations; and a trajectory for key performance indicators. The draft documents were submitted on 14 February 2014 and were all aligned with the Integration Plans submitted through the Better Care Fund submission. The vision was for an integrated care organisation clinically led and patient centric delivering holistic health and social care to the whole population of Tameside and Glossop. RESOLVED That the submitted plans be received and noted. 73. BETTER CARE FUND SUBMISSION: TAMESIDE LOCAL PLAN The Executive Member (Adults and Wellbeing) introduced a report and templates detailing the Tameside Better Care Fund draft plan submitted to NHS England (Local Area Team) and Local Government Association / Local Authority representatives on 14 February 2014 in line with the reporting timescales. Board had considered the first draft submission at its meeting in January 2014 as part of the local plan development and comments taken at that time had been incorporated into the final draft submission. NHS England (Local Area Team) and Local Government Association representatives would now be considering all submissions and liaising with Local Authorities and Clinical Commissioning Groups accordingly to finalise plans by 4 April RESOLVED That the content of the report be noted. 74. DRUG TREATMENT IN ENGLAND : FINDINGS AND IMPLICATIONS Consideration was given to a report advising that on 1 April 2013 national leadership for preventing and treating drug misuse transferred from the National Treatment Agency for Substance Misuse (NTA) to Public Health England (PHE). Local authorities were now responsible for commissioning substance misuse services to meet the needs of their communities, funded from their public health grant. PHE supports them with information and intelligence, expertise, evidence of what works and by benchmarking effective performance. The report provided an overview of how specialist drug treatment services in England performed during It also highlighted how treatment was facing a series of significant challenges and local plans for addressing them. 178

179 The vision would be to make recovery a reality for all people who wanted or needed to address their problematic drug use by developing a whole system response that would support people to take responsibility in maintaining their health and wellbeing. A service transformation was being undertaken of the drug and alcohol service with a view to having a model around vulnerable people and health inequalities across the life course as they related to domestic abuse, mental health, housing, education and employment. It was intended that the model would: Accommodate appropriate interventions for both drug and alcohol; Maintain high quality clinical services; Provide support that is sequential the right support at the right time, provided by the right people; and Reflect the life course approach to include prevention and ageing well. RESOLVED That the content of the report be noted. 75. PENNINE CARE NHS FOUNDATION TRUST Linda Dunn outlined an update report on current progress and challenges for the Pennine Care NHS Foundation Trust. She made reference to the Trust s vision, areas of particular interest including the Living Well Academy and community health development. The Trust was currently working with Tameside CCG on a different service model following the withdrawal of funding for social care in the Child and Adolescent Mental Health Team in Tameside. RESOLVED That the update report be noted. 76. HEALTH AND WELLBEING BOARD FORWARD PLAN The Director of Public Health submitted a report explaining that as from Board developed from the first year as a statutory committee, a forward plan was proposed to provide a clear structure to the work of the Board for to ensure it fulfilled its responsibilities. It was noted that the plan covered key issues associated with the Board s duties and terms of reference. Designed to be flexible, the plan suggested some standing items and annual items which would be timetabled as appropriate. It was proposed to review and update the plan at each meeting. RESOLVED That the forward plan be approved. 77. DATE OF NEXT MEETING To note that the next meeting of the Health and Wellbeing Board will take place on Thursday 19 June 2014 commencing at am. 78. URGENT ITEMS The Chair advised that there were no urgent items for consideration at this meeting. CHAIR 179

180 GM ASSOCIATION OF CCGs: Association Governing Group (AGG) Tuesday 3rd June PM SALFORD/WORLSEY SUITE, ST JAMES S HOUSE, SALFORD Attendance: Steve Allinson NHS Tameside & Glossop CCG Trish Anderson NHS Wigan Borough CCG Rob Bellingham GM LAT Ivan Bennett NHS Central Manchester CCG Wirin Bhatiani NHS Bolton CCG Alan Campbell NHS Salford CCG Tim Dalton NHS Wigan Borough CCG Andrea Dayson GM Association of CCGs Chris Duffy NHS Heywood, Middleton & Rochdale CCG Ranjit Gill NHS Stockport CCG Denis Gizzi NHS Oldham CCG Nigel Guest NHS Trafford CCG Gina Lawrence NHS Trafford CCG Su Long NHS Bolton CCG Wendy Meridith Bolton Council Public Health Lesley Mort NHS Heywood, Middleton & Rochdale CCG Stuart North NHS Bury CCG Kiran Patel NHS Bury CCG Roger Roberts NHS Stockport CCG Angela Lynch NHS England Specialized Commissioning Hamish Stedman (Chair)NHS Salford CCG Bill Tamkin NHS South Manchester CCG Simon Wotton NHS North Manchester CCG Kathryn Wynne-Jones NHS Tameside & Glossop CCG Apologies: Julie Daines NHS Oldham CCG Alan Dow NHS Tameside & Glossop CCG Michael Eeckelaers NHS Central Manchester CCG Alex Heritage Service Transformation Caroline Kurzela NHS South Manchester CCG Gaynor Mullins NHS Stockport CCG Clare Watson NHS Tameside & Glossop CCG Martin Whiting NHS North Manchester CCG Ian Wilkinson NHS Oldham CCG Leila Williams Service Transformation Ian Williamson NHS Central Manchester CCG Jenny Scott NHS England - Specialized Commissioning Page 1 of

181 In Attendance: Andrew Harrison NHS England Dan Cassell Service Transformation Sue Sutton NHS Blackpool CCG David Wilkinson GM Police Sandy Bering NHS Trafford CCG/GM Mental Health Lead 1. WELCOME & APOLOGIES FOR ABSENCE Members were welcomed to the meeting and apologies were noted. 2. MINUTES and MATTERS ARISING The Minutes of the last meeting were accepted as an accurate record with the following points noted:- Ranjit Gill had submitted slight amendments which will be circulated to members for information. Item 7.1: it was noted that Ranjit Gill and Wirin Bhatiani will be the clinical members of the Primary Care Transformation Group. Item 4.3: it was noted that a bid (for GP IT) has been submitted for transitional funding. When the outcome is known, it will be for CCGs to make a judgement whether to accept delegated responsibility. This will have to be expedited within a short timescale and SN agreed to coordinate opinion. The AGG: Agreed to the circulation of Ranjit Gill s comments on the previous minutes Noted Ranjit Gill and Wirin Bhatiani to join the Primary Care Transformation Group Agreed to SN coordinating opinion following the outcome of the transitional funding bid 3. Association of CCGs 3.3 Winter Planning/Year Round Resilience (feedback from Event) SN fedback to members the outputs of the Planning Event earlier this month as Urgent Care Lead. The event was aimed at Health and Social Care discussions to identify actions that will improve urgent care. Key themes were identified: Future service redesign Capacity demand modelling Discharge planning Communication Workforce Ambulance PES Data and Activity Page 2 of

182 The Urgent Care leads Chaired by Ian Mello will be taking forward actions from the event. SN also reported that there will be a forthcoming announcement from Simon Stevens confirming that all year funding has been secured to support winter planning. It is expected that the allocations will be announced by end of June and that this is new money. The AGG: Agreed to retain this item on the Action Log 3.1 Lead CO Responsibility: Ambulance Commissioning SN presented an overview of Ambulance Commissioning and the Healthier Together links with support from Sue Sutton as Interim Director of Ambulance Commissioning and Dan Cassell Transport and Access Manager for Healthier Together. This is to ensure that we have a combined approach to commissioning of the ambulance/transport services. For GM we can use the Urgent Care Leads forum that already exists to support ambulance governance and GM performance. This will support transformation and initiatives such as handover times, urgent care desk and pathfinder and all other plans that seek to avoid admission through NWAS. Sue Sutton provided the overview form the ambulance commissioning perspective: PES/PTS/111 NW Governance Arrangements were described in detail and the associated group that support CCGs with the Strategic Partnership Board being the decision making forum PES - National Response Time targets achieved for the last 3 years 3m CQUIN - Conveyance Reduction Jointly commissioned capacity review in 2010/11 identified: Existing service delivery model unsustainable System transformation required Commissioner Response: c 10m for activity increases provided in last 2 years to maintain performance and provide head room CQUIN used to develop initiatives such as the Urgent Care Desk and Paramedic Pathfinder to effect system change Following concerns raised by CCGs at CCG level performance, the SPB agreed to conduct deep dives for 2-3 CCGs per country footprint and within GM this will be undertaken for Bolton, Trafford and Tameside & Glossop. Data packs produced Understanding of CCG variability Working practice changes or additional financial investment Interim Report: Common Themes - Summer 2014 Followed by Final Report PTS - GM Contract: ATSL - 4m Savings Enhanced Standards & Operating Hours 2014/15: Second year of three year contract Performance Standards and Risk Share: Response time targets likely to continue to apply Page 3 of

183 Focus on reducing conveyance to E.D. Service reconfigurations expected to lead to more and longer journeys Possible increase in PTS activity due to repatriations CCG risk share arrangement? Although there has been some recent publicity it must be noted that the performance of ARRIVA has improved over the recent months. Need to consider option of PTS procurement in the near future: paper to be considered at the next Strategic Partnership board. Need to also consider options around lead commissioning arrangement and whether to keep the existing arrangement through NHS Blackpool as the CCG lead. The interface with ambulance and HT was discussed at length in that we need to ensure we have standards in place for patients with acute abdomen and sick children to ensure that there are no undue delays. This is compromised as currently NWAS will consider these patients as less urgent for transfer as they are already in a place of safety. Although not to be treated as a blue light they must also not fall into the category of delayed transfers due to the potential clinical risk requiring transfer. Dan Cassell presented a paper with the aim of highlighting a key potential risk to the health and social care reform agenda with regards to transport and access; PTS ensures transport is available where a patient s medical needs demand it. Outside of the PTS there is no duty on NHS commissioners (or any public body) to provide transport for patients in response to what are sometimes called their social needs. Feedback from Healthier Together pre-consultation patient and stakeholder engagement has revealed the same strength of feeling encountered in previous GM healthcare reconfigurations. Expectations and anxieties about transport and access remain high amongst people s concerns, and can be very difficult to dispel. It has the potential be a deal breaker and include people who are highly vocal and ready to mobilise their peers, politicians and other stakeholders. A recent analysis of transport access by GMCVO on behalf of Transport for GM brought together expert practitioners involved in planning sustainable transport an option was to connect expertise to: provide evidence, and support commissioning and service planning decisions connect expertise, experience and ideas, support the process of health and social care reform support GM bids for additional funding and resources (e.g. government grants and initiatives) as they become available Members felt that this should already be covered by HT and at this point did not feel they could support but requested the current TOR of the Transport groups. Comments AC commented that the gap was too wide and unacceptable across GM. We need to consider this in respect of HT and estimate the number of journeys (e.g. for top end surgery, urgent care access) / explore the gap and resource appropriately. IB noted the currently good transport service in place for stroke patients. He perceived the HT risks to be around acute abdomens/children and queried the arrangements in place though patient numbers expected to be low. DG referred to performance and the need to consider that local averages are incompatible with a collaborative approach. The current system is not sophisticated enough due to the variable Page 4 of

184 population across the region. He supported a contract tenure of 5-7 years with future proof models of care if we are changing the model of care will we have to keep changing the contract? HS noted the sensible comments made and asked what was the appropriate forum to pull this together. SN stated that we are presently using the UCCL and CO s/agg meetings to report any issues on Ambulance Commissioning. He queried whether acute abdomens/children would be part of the HT process and asked if there was general support for the establishment of the group proposed within Dan Cassell s paper. WB noted that HT had been commissioned to address this and therefore questioned the need for another subgroup. SN suggested that in the long term there would be a need for such a group but queried if its presentation was premature. It may be more appropriate to establish a group post-ht. DC emphasised the existing expertise around voluntary sector services and the value in seeking an external view which is non-nhs. TD queried the need for another transport group when one existed within the HT programme. AC suggested a way forward would be to request the ToR for the existing group and assess the deficit should it be disbanded. DC responded by saying that he would send the ToR to AD for onward circulation. HS summarised by saying this was a useful discussion and it highlighted a group of patients not funded by NHS and outside of NHS commissioners/any public body responsibility. It was important to assess the potential numbers involved and therefore should be placed on the Action Log and reported every 2 months. LM asked if we are clear about what HT is developing as there is a perceived gap. There is a need to question (a) if the solution in the paper is the right one and (b) clarify HT proposals. DC noted the political/patient perception in relation to transport, the lack of commissioning information and the need to understand the gap. SN noted that the need to review the Healthier Together ToR for the Transport Reference Group. SN will work with AC to ensure there is assurance in respect of the transport gap. WB emphasised the need for communication with CCGs, (citing a recent local press announcement of the loss of an ambulance) particularly when asked for a response and the need for impact assessment. SN responded that a previous meeting of the Strategic Partnership Board (SPB) had reviewed the ambulance cost improvement programmes and there had been an intention for the briefing to be presented through the Urgent Care Commissioning Leads (UCCL) meeting but the May meeting had been cancelled (due to event) and reassured that lessons had been learnt. The briefing has now been circulated and acknowledged the need for communications to ensure CCGs can respond to questions. SS stated that there is a set of narrative to assist with local media if members contact the Communications Team (Blackpool CCG). SL stated the open approach adopted at Board level to provide assurance but in circumstances of delegated authority it was less clear. SN stated that we have completed this exercise and have information which has not yet been shared. CCGs are Associates to the CIP and acknowledged the need to share assurance on savings made. Page 5 of

185 SN also referred to AC/KP/HS working with the local community in respect of Hatzolah (a non- CQC registered Jewish community emergency service) which had been prosecuted (decision subsequently overturned) for providing a blue light service. It is understood the staff involved have been trained in Israel but this requires confirmation. It is understood that there is a group within the Muslim community (Bury, Rochdale, Oldham) that is in discussion with the Jewish community with a view to setting up a separate service and there is concern in respect of assurance/quality. HS concluded by saying that we have learnt a lot from this discussion, there is a need for assurance around HT and emphasised the need for continued dialogue. The AGG: Noted the support through Bury in representing GM for Ambulance Commissioning Noted the detail in the paper and presentation which was helpful and informative Views of members required, particularly in respect of a) Risk Share (b) issues relating to peripheral areas to revise the current paper by 16th July This will then be presented at a future AGG Meeting. Agreed that we need to consider the transport gaps that may exist through HT implementation Requested that DC send to AD the ToR for the current HT Transport Reference Group and proposed new Group for onward circulation 5. Clinical Work Programmes 5.2 Specialised Commissioning. This Item moved up the agenda as Angela Lynch needed to leave early. Brief verbal update included (formal letter to follow): The national Specialised Commissioning Strategy is on hold until the Autumn The main issue continues to be the financial challenges Focus now on QIPP NHSE turnaround to seek financial balance Working closely across GM with Mike Burrows NHSE, Ivan Bennett and Alan Campbell (CCG leads for Specialised Commissioning) at how to develop GM programmes Need to still consider the 2 year plan but the 5 year plan as stated now on hold. Comments SW asked if each Trust had a group. Page 6 of

186 AL responded that the focus is on QIPP with groups set up with the main providers. The new governance framework will be described in the letter to be circulated shortly. 3. Association of CCGs 3.4 GM Police/GM Alcohol Strategy Sandy Bering the GM Mental Health Lead and David Wilkinson the GMP Strategic Mental Health Lead both presented an overview of mental health links with GMP and the Alcohol Strategy which focusses on joint working. GM Alcohol Strategy:- Work focused on the key aims of reducing alcohol-related crime and disorder, and reducing the negative health impacts caused by alcohol. Promoting diverse and vibrant night-time economies. Strategy is the first of its kind in the UK developed by a Key Leaders Group, mandated by the AGMA Wider Leadership Team as an important delivery vehicle against both the Growth and Reform elements of GM s Overarching Strategy. Work on Strategy, coordinated by New Economy, commenced in February 2014 and completed in May 2014, through a Public-Facing Consultation ensuring a visible and inclusive process. 12 Point Action Plan 1. Developing the GM Alcohol Strategy Brand and set of common key messages across Partners, while at the same time supporting more common practice across local Strategy Action Plans 2. Enhanced Data Sharing in support of the Strategy. 3. Developing and implementing a common approach to ensuring effective use of all relevant powers (such as within the Anti-Social Behaviour, Crime and Policing Act 2014). 4. Developing and evaluating interventions to address alcohol and wider substance misuse by offenders at the point of arrest, sentence and point of release. 5. Supporting the appropriate prioritisation of Domestic Abuse Victims within the GM approach to Complex Dependency through the GM PSR Programme. 6. Developing and supporting Local Recovery Organisations and Networks. 7. Implementing Best Practice in the delivery / uptake of alcohol brief Interventions and advice. 8. Delivering practical local alcohol education delivery in schools and colleges. 9. Roll-out collaborative evidence-based GM-wide commissioning approaches to deliver effective interventions addressing Complex Alcohol Dependency in hospital and health settings (e.g. RAID, RADAR and Mental Health/Alcohol Liaison services, Enhanced Liver Disease Care Pathways). 10. Continued lobbying for the implementation of Minimum Unit Price options. 11. Exploiting all the benefits of LAAA Support to maintain a focus on reducing alcohol related harm in GM s Night-time Economies (NTEs) including an option for the establishment of an alcohol Treatment Centre as proposed by GMP. 12. Consistent Use of Licensing Tools, Coupled with a Transformational Programme of Voluntary Activity with the Alcohol Trade. Page 7 of

187 Recurring theme from the scoping work is that the existing Pan-GM Alcohol Networks (primarily a GM DAAT Commissioner Type Group) will only be able to deliver real reforms with CCG colleagues locked into those discussions: Early intervention programmes Alcohol liaison models including Alcohol Link workers, RAID and RADAR Proposals tacking the Liver Disease challenge Comments HS stated this was a sense check for a bold aspirational programme of work, noting commissioner responsibility dispersed with Public Health in local authorities, the focus on liver disease and encouraged questions from members. WB commented that he was in favour of the described initiatives and supported the work. He referred to the Bolton Vision Partnership which had identified alcohol as a priority area with integration of key organisations developing an alcohol strategy. WB encouraged all 12 CCGs to prioritise this and find a way of disseminating and working together. TD welcomed the emphasis on all 3 areas (crime, health harm and safe night time communities) and queried if it was ambitious enough. He stated that the minimum unit price (MUP) was a difficult political debate and would like to see links between alcohol and MH agenda (eg RAID). SB responded by saying that he was the GM MH lead with Trafford as the lead CCG. He emphasised the link between MH and alcohol strategy. HS noted the need for metrics for the whole economy with expected reductions in abuse, crime /disease and increase in alcohol education. The outcome measures would provide a means of holding CCG/Police/Local Authority accountable. SB responded that plans are developing in respect of KPIs and sharing of data. HS noted that if you have a good story board then this will ensure public support and through Health & Wellbeing boards. SL felt that the appropriate forum may be through the GM (rather than local) Health & Wellbeing Boards (H&WBB). WM welcomed this combined solution and referred to MUP, the need to change social norms and endorsed a collective approach through the GM Health & Wellbeing board. AC felt that this would be a challenge for Public Health to come together at a GM level. There are local initiatives but the changes to the system have created a loss of focus. WM stated that with integrated care having a prominent focus there are some public health issues vying for space. AC asked what was on the commissioning radar. There are initiatives at local level which are not always well known. He cited the example of TB and would welcome a GM prioritisation strategy. CD reported that as a member of the GM Health & Wellbeing Board was unsure of its fit particularly as MUP dismissed nationally. He reported that he had been unaware of its presentation at the GM H&WBB and asked if it was to be presented to a future meeting. SB replied that it would be presented through the relevant committees. WM noted that the GM H&WBB is not a statutory organisation and therefore the work would need to be adopted by each CCG. Page 8 of

188 HS suggested that there is appetite for this and similar types of work to be undertaken and involvement at GM level, noting that although the GM H&WBB has no statutory responsibility it allows dialogue for matters such as this at GM level. GM Police:- David Wilkinson presented on overview of the current position but stipulated that there have been a number of pilots and one off funding which never then gets full support. We need a consistent approach to support the pilots that are shown to be effective in terms of managing mental health patients appropriately in the right place by the most appropriately trained staff. Current work includes: 24/7 Access provided to officers on the front line to support their decision making and reduce the number of Section 136s 24/7 Telephone Access for police to MH Trust information - officers can deal directly with trusts where possible and through Communications where the patients origin is unknown Navigation Centre - Police Innovation Bid submitted. Neighbourhood Mental Health Pilot Bolton and Salford Section 136 Suite and telephone triage Trafford Missing Patient Protocol Sanctuary - City wide Manchester service numbers now rising considerably. Offers phone and face to face support throughout the night. New hours of operation: 365 nights a year from 8pm through to 6am. Referral pathways in place with GMP s A/E divisions, British Transport Police and soon motorways. Conveyance arrangement in place with NWAS. Triage system to be trialled. This will be starting imminently. It will involve a 24/7 phone number and also the ability for officers to take patients voluntarily to Clare house, Ince where they can be assessed by mental health staff without utilising S136. Crisis intervention officers: skilling up of specific police frontline response officers in mental health issues whose role it will be to take more of a lead on mental health. This is just a summary of some of the work to improve the management of these patients and help to reduce conveyance to hospital, support more capacity and expertise and make sure that GMP time is used more effectively. It must also be noted that some of these initiatives are not across GM and if extended would continue to improve support required for mental health. Comments CD queried the Oldham phone triage project and the expansion plans into surrounding areas which did not include Rochdale and if this was due to the lack of A&E on the Rochdale site. DM responded that the role was dependent upon funding availability and that relationships in Rochdale were newer than in other areas. The AGG: Noted the GM support provided from both Sandy Bering and David Wilkinson Agreed to support the proposed approaches to the continued work across GM Requested update briefings at quarterly intervals to ensure continued support Page 9 of

189 4. Strategic Work Programmes 4.1 Healthier Together Update 4 WEEKS UNTIL PROVISIONAL CONSULTATION START DATE NHS England Assurance framework evidence requirements further defined PCBC part 2 draft circulated in advance of CiC meeting (21 st May) PCBC part 1 & Future Model of Care accepted at April CiC meeting with 11 of the 12 voting CCG s in favour in a Category 1 decision Risks: Interdependencies with work undertaken by Monitor, the national Trust Development Agency and NHS England. Working closely with NHSE team on a detailed daily plan to cross check and manage interdependencies. Strategic Risks includes: Failure to manage messages that the HT programme recognises the interdependencies with change programmes for Primary Care, Integrated care and Hospital services could lead to lack of support and/or missed opportunities to gain local/national support. Establish close working relationships across the 3 programmes to increase understanding and consistency of proposals to mitigate any risk. 3.2 Co-commissioning of Primary Care Letter from Rosamond Roughton/Barbara Hakin RB and SN describe the work that GM is leading on behalf of all CCGs to develop a framework in response to the co-commissioning letter. This has been developed in levels/stages as it is recognised that not all CCG are supportive and many may only wish to on take on smaller elements and possibly look to increase in a phased manner. This is available in draft format and will be discussed at Friday s COOs meeting. Area Team supportive of co-commissioning which is noted in the way that we work across GM. May be the possibility of increased funding concerns noted of the difficulties of managing further increased responsibilities without appropriate resourcing Noted that this is an expression of interest not a bid although it will be assessed by the Area Team Comments SN commented that there was an opportunity to access additonal resource for GM. DG stated that it makes sense to harness what is available but urged caution as the region did not have a good track record in respect of GM bids which in the past has worked for us /worked against us. He questioned whether it was more worthy to submit individual bids receive individual funding and then pool collectively. GL asked how we would prioritise this. RB stated that the Area Team (AT) will be asked to assess the bids. His personal view was the involvement of the AT would ensure a better chance of success unless the model changes. He did not believe there was any limit to the bids (and therefore 12 acceptable) but noted this was emerging policy. WB commented the additional resource was interesting and noted the capacity in all AT is tight and therefore guarded against accepting responsibility without resource. HS stated that there is an awareness that GM receives less resources than others and queried the possibility of cross pollinating with other Area Teams to determine the reasons why. It Page 10 of

190 appears that GM is looked on less favourably compared with others and noted that some pilot bids had failed. IB commented that we should not be downhearted and learn from our past experiences. He advocated a GM approach stating that we are better together. HS responded that he had felt in the past GM had got a rough deal but was not suggesting a fragmented approach only to use the most appropriate. RG referred to the co-commissioning budget and felt that there were 3 possible approaches:- o o Budgets out of scope Budgets in-scope 2 possibilities:- Nominal allocation per CCG for primary care (full or part to CCG) Pooled budget across GM o He queried the approach/policy direction of the AT. RB responded that this is being picked up by Claire Yarwood within the concept of place based commissioning with a unified budget sitting within different places. In terms of primary care at a GM level - what is the scope to move forward as the current allocation does not sit within this. AH stated there should be a principle based approach and there should not be any barriers to placing the funding in the right place. There is a need to agree the principles and nothing is out of scope except specialised commissioning. NG queried the scale of the proposal / how radical will we be? If we are going to be bold then this presents an opportunity to do so. However, if we co-commission on a small scale, will this create additional bureaucracy. He advocated the need for change on a large scale. SA commented that we needed a grand plan for GM with a clear vision but guarded against replacing like for like. CD noted that it was not sensible to rush a response by the 20th June We should flag which direction we should go forward in GM wide / local commissioning intentions are both do-able. RG stated that the principle based approach needs to connect with the HT standards /primary care budget. He expressed an element of frustration and queried who the Association should be talking to AT / NHSE there is a need to talk to the right part of the system in terms of HT Primary care context. He advocated the need for an equivalent HT for primary care/ queried how do we make this happen. RB informed that it is with Area Teams to recommend co-commissioning proposals/assurance and that the draft GM framework would be circulated to demonstrate how all the work fits. As a member of the national group (chaired by Amanda Doyle) he felt that GM was well connected to influence national policy. SL asked for a point of clarification that the framework being developed by Gaynor Mullins would be based on a proposal for levels of commissioning for CCGs. Each CCG to decide locally which level was appropriate and that there would not be a GM wide blanket (same level) approach. RB confirmed that SL s view was the correct one and used as an example: CCG A may be an entry level 1 with plans to work towards level 2. opportunity to comment on the framework. SW needed to have assurance on the resource element (need Manchester collective). HS stated that members were happy to be involved but with caveats:- Resource He noted that CCGs would have the Page 11 of

191 Locality based commissioning Managerial expertise o Greater Manchester can deliver on co-commissioning but need to meet the caveats. o There is a desire to have an aligned set of bids within an agreed framework with EOI submission by SN noted that a detailed discussion would take place at the CO s meeting on CCGs may take on some responsibilities in-year but funding is expected from It is key to have a consistent approach with support from the AT and to have different levels of approach. CD noted that members have different views and with expected support for funding from Secondary Care. WB stated that we needed to be clear what we are bidding for. This is extra work and responsibility without funding and therefore essential to clarify what we want to do together. SN reported that there are two issues:- o Resources to support admin/staff o Combining of commissioning resources (current spend secondary care/specialised commissioning) should influence funding directed from secondary to primary care (under PM s Challenge) SL noted that under the current arrangements there is the potential to deflect funding from secondary to primary care (without the need to submit a bid) and asked that further clarity be provided on the proportion of the budget under discussion. LM stated that the issue of accountability is missing from the letter, which references delegated rather than accountability and it is important to understand the implications/accountable responsibilities. NG emphasised that there were no further meetings prior to the 20th June 2014 and emphasised the need to see the GM Framework. SN stated that there should be twelve (or up to 12) single submissions of interest but we cannot have different approaches and therefore need 1-2 consistent approaches across GM. TD felt that all have the desire to move resources from secondary and tertiary care but it appears that specialised commissioning funding cannot be moved (only secondary care). Simon Stevens has indicated that there will still be a requirement to make savings so it is not possible to guarantee there will be additional resources and therefore urged caution. HS reiterated that individual CCGs should, using the GM framework, submit an EOI with the caveat that CCGs do not have to carry plans forward no EOI would represent a missed opportunity. The agreed framework would provide a consistent approach. GL clarified that the expectation was an EOI at this stage. LM stated that we should submit against the parameters outlined in the letter. RB commented that there is an approval process for EOI but if approved the decision to take forward would be for each individual CCG. DG stated that the combination of the GM Primary Care Strategy and the GM Framework should provide a useful guide through the process. He referenced Section C (Scope) of the Ros Roughton letter and in particular 5 th bullet point monitoring contractual performance and if this was a function that CCGs would wish to take on. Page 12 of

192 HS referred to the framework and that it was an individual decision whether to submit an EOI, for members to note that the adjudication would be undertaken by the AT and it would be for each CCG if EOI approved whether to progress to the next stage. The AGG: Noted: the work undertaken by Gaynor Mullins to produce a GM Framework Noted: Framework will provide a guide for CCG EOI submission. Noted: Following the outcome of the EOI process it is an individual CCG decision whether to continue forward. RB to circulate GM Framework for comment 4.2 Primary Care Budget ( Direct Commissioning Plan) The purpose of this paper to inform colleagues of the process and approach to setting area team budgets for 2014/15 on Direct Commissioning. Key matters: Requirement to make a higher surplus than the 1% as per the national planning guidance in lieu of other national pressures for NHS England specifically around Specialised Commissioning. Investments to meet the primary care strategy, which includes demonstrator sites, the forerunner to the challenge fund and baby teeth do matter, amongst other initiatives have not been set aside due to budget constraints. No funding is available to invest in recurrent and non-recurrent costs of capital in premises. The level of contingencies held does not fully mitigate the level of risk for The paper presented addresses Direct Commissioning budgets only, which are further analysed between primary care; public health; and secondary dental care. Last year NHS England allocated 765m for the Area Team for these budgets, this year the equivalent resource 778m. The allocation of resource has remained relatively fluid in some areas leaving planning to be delivered in a changing environment. In summary, based on the resources made available to the Area team for 14/15, there is a significant challenge to delivery of the financial requirements whilst delivering all our key objectives. All the budgets have been set using a zero-basing approach which reallocates the whole resource rather than applying incremental change to each budget line. For Primary care and Secondary Care Dental in setting the budgets and following national planning requirements we are required to achieve a 1% surplus and maintain a 0.5% contingency. For public health we are to provide for a 0.5% contingency and set aside resources to fund Health Visitor and Family Nurse Partnership expansion programmes. Whilst this was the initial requirement, there has been a subsequent call by NHS England to meet a further reserve requirement of 3.5m relating to changes in Primary Care contractor inflation uplifts, and further call of 7m for GM to support the current national overspend in specialised commissioning. At this point the plan displays a 5m contribution to this call, by using all DC budget underspends. For Page 13 of

193 GM this means that the forecast position on Secondary Dental Commissioning is all retained to deliver an increased surplus requirement. Primary care expenditure budgets total 631,549k contingency of 3,180k a QIPP target of 1,964k. Provided for a planned surplus of 8,232k (including requirement to set aside 3.5m) being the excess funding from the Doctors and Dentists Review Body (DDRB) contract settlement. Overall expenditure budgets have been set based on the expenditure position at month 9 and then adjustments made to remove non recurrent spend and apply the full year effect of recurrent spend. This removes 1,200k non recurrent funding identified in 2013/14 in relation to GP revalidation, which was not funded fully in the baseline exercise, and is an area of high risk in 2014/15. Risk to having plans based on M9 expenditure is the movement to year end, the view is likely to be a neutral position over the range of Primary Care budgets, but not confirmed. Assumptions on impact of inflation and contractual growth Cost inflation applied to primary care contracts in line with national planning assumptions. GP contract areas have adjusted for the national settlement of 0.28% and the dental contracts have been adjusted for the Doctors and Dentists Review Body (DDRB). Premises cost reimbursements increased by 3% replicating the real growth % seen in 2013/14. Demographic growth applied at 0.3% - ONS data suggests this could be 0.8% so a risk Non-demographic growth 4.32% applied to Pharmacy contract based on prescriptions dispensed 13/14 and ophthalmic spend estimate of 3.27% - patient vouchers for the same period. Secondary Care Dental Budgets total 47,533k contingency of 254k and a QIPP target of 125k for dental referral management scheme. Budgets were based on month 9 adjustments made for recurrent impact of contract variations and secondary dental activity plans agreed with providers. Assumptions on impact of inflation and contractual growth Provider efficiency/cost inflation applied to secondary care dental plan as per national guidance i.e. efficiency deflator (4%), inflation of 2.5% and 0.3% CNST giving an overall deflator of 1.2%. Public Health Public health budgets total 87,849k, including a reserve of 350k and a contingency of 424k. Budgets based on month 9 adjustments to remove non recurrent spend and full year effect of recurrent spend for health visiting, family nurse partnership and immunisation and vaccination programmes for 13/14 agreed expansion plans. Contracts with providers do not include the resources required to deliver the 14/15 expansion plans, even though we have now budgeted for this growth. Assumptions on impact of inflation and contractual growth 4% tariff deflator and inflation of 2.5% has been applied giving an overall deflator of 1.5%. Primary Care Budget setting down to individual contractor level to provide assurance on recurrent commitments, QIPP savings and reductions in costs on discretionary spend, decommissioning, quicker implementation of PMS and APMS contract changes. Page 14 of

194 Removed 8,500k investments\pressures from the expenditure plan and shown these costs as risks, with varying probabilities. Completed in lieu of the central requirements to achieve higher levels of surplus and contingency described in the executive summary. Investments Planned investments to meet the Primary Care Strategy Implementation have been removed to meet the increased surplus requirement. Remaining planned investments relate to pre commitments on premises developments of 120k recurrent investments and 80k non-recurrent. Capital is available and a proportion of rent abatement may occur as a result, there would still be a recurrent increase to rent, costs for non-domestic and water rates, meet stamp duty, project management costs, legal fees re leases may all occur, all historically funded. The key financial risks and a worst case position adopted as follows:- Primary Care unfunded risks total 15,935k GP Appraisal and revalidation 1,000k - 1.2m underfunded from original baseline exercise, less 0.2m added in investments Demographic Growth - 2,700k - ONS data states 0.8% have assumed 0.3% in line with 13/14 growth NHS Property services - 1,178k GP IT 2,824k Unfunded pressures based on fair shares basis of allocation and commitments, whilst this is a CCG issue, it has potential for representing a pressure to NHS E budgets if CCGs will not recognise the reduced level of funding to be delegated to them. Implementing the Primary Care Strategy 2,426 o Closing the Health Inequalities gap for GM - 500k o Improve Dental access - removed from plans 800k o Demonstrator schemes continuation (beyond 30 th September) - 1,126k Premises investments 843k Capital has been identified for grants in relation to developments and improvements. However the rent revaluation and additional rateable values for non-domestic rates, water rate; recurrent costs increase. No schemes unless CPO can be progressed. High reputational / political risk with GPs. No premises investments to meet estate / strategic need - 600k Under delivery of QIPP 1,964 QIPP targets have been set for GP services, Pharmacy and Ophthalmic. Risks to delivery are timescales, capacity and possibly overstating the financial level of savings anticipated in each year. Dental Income 1,000k - Risk that assumed dental income does not materialise Pharmacy Income 1,500k - Risk that income from prescriptions does not materialise Enhanced services 500k - enhanced services delivered increases with primary care strategy growth Secondary Care Dental unfunded risks total 295k Demographic Growth - 170k - ONS data states 0.8% we have assumed 0.45% Under delivery of QIPP - 125k - QIPP targets set for a dental referral management scheme. Contract validation - all charges are made correctly and challenging within flex / freeze timescales. CQUIN = Ensuring CQUIN is monitored and that any underperformance is recovered from providers Public Health unfunded risks total 3,059k Page 15 of

195 Tariff deflator - 400k - Pressure from providers not agreeing to the value of the deflator. School based childhood flu pilot - 203k - risk that no further allocations will be received. Immunisations and Vaccinations - 1,304k - relates to costs not fully funded in the baseline exercise. Child health information systems - 500k - relates to costs not fully funded in the baseline exercise. Diabetic retinopathy - 652k - relates to costs not fully funded in the baseline exercise ( 388k) and the potential investment for a common pathway to be developed for diabetic eye ( 264k). CQUIN - Ensuring CQUIN is monitored and that any underperformance is recovered from providers. Use of Contingency Primary Care Contingency of 3,180k set aside in primary care to fund pre-existing commitments to Demonstrator Schemes of 740k and revalidation funding of 1,000k. To fund small increases in premises costs as a result of grants given to meet CQC, safety and DDA compliance. Secondary Care Dental Contingency 254k in secondary care to fund any excess in activity/commitments primary care dentistry. Public Health Contingency of 424k set aside; initially be used to mitigate any risks that materialise. QIPP 2.1m of QIPP schemes which should realise cash releasing savings in year. Reviewing further savings which could be used to contribute to the 2m requirement but we have notified Region of the difficulty in doing this. Further list of potential schemes has been generated as possible areas to consider towards the 2m required surplus; the risks and practical implications of these areas are being worked through. Conclusion: Primary Care - We have not been able to set aside any investments to meet the primary care strategy, this includes continuation of the demonstrator sites and the forerunner to challenge fund. No investments have been set aside for the recurrent and non-recurrent costs of capital investments in premises so these cannot proceed unless funding is found elsewhere e.g. Healthier Together, CCGs. Secondary Care Dental - We have not been able to set aside any investments to meet the primary care strategy and although we are reporting a higher surplus than required (1% would be 0.5m for secondary care dental) of 3,194k, this position ensures that overall direct commissioning achieves the required level of surplus. Public Health - Resource has been set aside to meet national priorities, reserve of 350k available to fund the pharmacy flu programme. If risks did materialise at the level there is no surplus other than the contingency. Table presented the summary for Direct Commissioned Services with the planned surplus of 11,435k, and after deduction of the worst position on risks of 19,289, leaves a deficit of 7,854k. More work to be done to ensure that the commitments are robust and on risk mitigation, therefore this is the worst case position and further iterations will provide a likely and best case position. In addition the Area Team is being required to deliver an additional 2m surplus so these figures are expected to be revised. Members were clearly disappointed that Primary Care funding is being used to support the financial pressures caused through Specialised Commissioning and seen as bailing out tertiary services. However they acknowledge the transparency of the report and the difficult position that NHSE are trying to manage. Risks will be managed through use of the contingency and there will still be a deficit to manage. Need to make robust cases for movement of secondary care to out of hours Primary Care Page 16 of

196 services. Also consider the potential to lobby both local and national leaders to highlight continued financial pressures. Comments RG queried again who were the right people to talk to and expressed his concern that Specialised Commissioning is draining the system out of money (by setting their own prices). Primary Care money is being used to support secondary /tertiary care. He queried how we can have assurance from the Area Team when we are seeing money stolen from us by specialised commissioning. This leaves no funding for primary care premises and is an outrage. HS commented that a strategy is needed to take this forward. The AT will have to assure themselves and HT will fail if out of hospital services are not in place. TD acknowledged that the Area Team is in a difficult position, but under the old system, a PCT with a budget just described would have been put in special measures. This is funding that should have been set aside for out of hospital care and urged the need for a national discussion. IB stated that we needed to make a robust argument in respect of out of hospital care and believed more could be done by agreeing the Primary Care Strategy. AC queried the tactics which could be employed to get the message across as this issue is greater than the AT. Continuing care and specialised commissioning had taken a significant amount out of the budgets with others in the pipeline. He stated his intention to brief local MPs and lobby the NHS Assembly via the NHS Confederation. WB commented that there is a need to highlight the risk in respect of GPIT. He felt that we are at a critical stage with HT and decisions would be required at the CiC meeting He felt the budget paper presented today blows the primary care strategy out of the water. How would it be possible to deliver when no funding is available? What is the alternative? How can we take HT forward? How much of CCGs allocation is used for primary care as there is no investment from the AT? It is up to the Association to make the decision and quickly before promises are made to localities. RG felt that briefing politicians/the confederation would be futile but CCGs did have the legal power to change the way we budget. CCGs have the power to describe how primary care should look collectively. As an Association there is the ability to state over the next few months how much funding should be allocated to primary care which will consequently lead to a reduction in the funding available to secondary care. This would provide a signal to hospital providers that over the next year(s) there will be less funding available. There is a need to set spending plans over the next 2-3 years but the window to undertake this is fairly short. This approach does not rely on the AT as CCGs have the legal powers. RG argued for the establishment of a sub group to undertake this during the Summer (as permission of the AT is not required). SN stated that we needed to think through tactics for CIC (Committee in Common) and suggested further discussion on how to address this issue, provide assurance so that we can sign off this process. There is a need to consider the commitment to investments/how to present this to Boards/the need to share the budget information when it is an appropriate format. When considering the out of hospital agenda there is a need to recognise that acute trust budgets for are set in February/March and there will be political pressure in the system not to destabilise hospitals particularly before the general election. SN cited the recent stepping down of a CCG CO and Clinical Chair due to a relationship breakdown with the acute trust (Jon Develing appointed as interim measure). Page 17 of

197 IB noted that whilst removing funding from secondary care there needs to be a clear indication to the public that they will have access to the best primary care (as good as secondary care) and to ensure delivery. NG stated that this was a multi-faceted approach with national and local joined up strategy. A large disinvestment is a big turnoff to co-commissioning and in terms of tactics, HT is a weapon but careful thought is required on how it can be used. Integrated care is needed to keep activity out of secondary care but it needs to be realistic. HT links with integrated care and an increase in quality, access to primary care and how we use this as leverage needs serious discussion. AH noted there are key enablers to delivery and within secondary care agree funded pathways (and who does what primary care, community, secondary care). There is an opportunity for primary care as outlined in the Ros Roughton letter but there is a need to address secondary care payments. BT asked if other Area Teams were in a similar position. AH assured that other ATs are faced with the same difficulties. BT queried in view of this, if there was merit in taking this forward nationally. HS summarised discussions so far:- o Call to Arms advocated by RG o AH suggestion of funded pathways of care o The proposal to lobby en masse / locally o Healthier Together o How do we take this forward RG referenced NG s comments in relation to integrated care and discussions re: funded pathways of care. GM level tariffs could be set for whole pathways of care but there needed to be realistic budget levels. He felt it would be possible to develop this over a few months (Summer/early Autumn) which would act as a signal of the scale of change to providers. CD asked whether Governing body members would agree to this since there would be winners and losers and there could be difficult discussions within LMCs. RG it is important to give members something credible but then we have to deliver it. WM cautioned the need to control demand/supply within acute trusts who often have the means of filling capacity. KP stated some lobbying (without success) had been undertaken in Bury but supported the lobbying proposals voiced today. He felt it was important to engage with Providers at a GM rather than local level. HS summarised by thanking AH for the paper and noting:- o This was first sight of this paper o It had created a degree of angst/anger amongst members o The need for a strategy o The need for further discussion at the CiC meeting o Funding is required from secondary care as long as there is close down of other routes (control of demand/capacity) o Specialised commissioning needs more discussion o It is not possible to take this any further forward today. AH agreed to revise the paper/amend the wording to enable members to circulate widely. This is to be circulated to the AGG Members via AD. Page 18 of

198 The AGG: RG urged the need for discussion in Part 2 of the CiC with a proposal to set up a sub group and would canvass support from members. HS referred to the co-commissioning framework, the need for further discussion as there is significant risk to HT and the expected difficulties in respect of the HT Assurance process. SL indicated that a 1/10 th of the 10m budget would not have been sufficient to support delivery and it has always been known that a contribution to primary care would have to come from CCG budgets. WB asked if all were willing to commit funding from CCG budgets to ensure the success of HT. HS referred to:- o the framework for co-commissioning, o o the need for PbR funds to transfer into primary care, the need to work with the AT (avoid conflict of interest) and through the cocommissioning process to move funding from secondary into primary care. NG noted a need to define the tariff/if possible to do so and give notice to providers and align with co-commissioning framework. RG stated that we needed to get the group together as soon as possible. Andrew Harrison to revise the paper and send to AD for onward circulation to members Noted: the concern of members regarding the potential financial deficits and risk to HT. Noted: the need for a strategy to take this forward with further discussions to take place at the CiC meeting. Noted: the need for further discussion in respect of specialised commissioning funding. Noted: the need to work with the Area Team on the co-commissioning process to ensure funding is directed from secondary to primary care. 4.1 Primary Care Promises to be referred to as Standards The new Community Based Standard document has removed the 48 hours standard. Important to note that the standards are aspirational and that implementation will be variable across GM and therefore promise is not an appropriate representation. All agreed the standards back in February but still some concerns noted to the 2 hour and same day access for children and adults. Approximately 1/5 of the standards are currently being delivered. Possible use of contractual levers could be considered to ensure implementation. A number of members were not aware that the approval of the standards would mean that this would be the front facing aspect of HT. HT is about hospital reconfiguration that will be supported by improved access to Primary Care. Also noted that the standards will not be implemented at 100% there will need to be a threshold set as with the 4 hour A/E wait. Comments SW stated that North Manchester would commit funding to achieve this as the public would expect them to do so. Page 19 of

199 CD commented on the difficulty in having a carrot to leverage practices to deliver but no stick if they do not. He advocated the need to make this a contractual obligation but queried how this can be realised funding is available now to make the investments but how would this continue into the future. RB noted that not all GP practices will buy into this and this is an offer that is made to the community not an offer to all GPs. There are commissioning tools/tactics available for those that do not sign up. The NHSE / CCGs do not have recurrent funding but have the ability to change the balance of power more by diversion of funding from sector A to sector B. The solution is the long term diversion of funding from secondary into primary care. TD was concerned about describing something to the public before the models had been worked through. The risk would be measuring something we have not clearly defined. Is the access described acceptable are these the right parameters? Outcome focus should be aspirational. RB noted the importance of making promises to the public that CCGs can keep. He referenced the Wigan Borough CCG report noting that some of the standards are already being delivered. TA stated that the Wigan report is built on a model with aspirational standards and noted the need for caution in what is being promised as it is not possible for all to deliver across the patch as is the case in Wigan. WB stated that most GPs like standards and aspire to deliver them but the real issue is capacity. CCGs are talking about what we want to commit to primary care and locally (Bolton) there has been a shift with some bed closures but we are in catch up and therefore need to accelerate the funding into primary care. BT was pleased that the reference to promises had been removed and supported the standards. However, the past 18 months has been spent reviewing hospital reconfiguration (not primary care reconfiguration) and therefore he did not feel this could be used as a front for HT and to do so would be wrong. SL asked how it would be used as the AGG have identified the need for out of hospital services to be in place. BT noted work had been done on better outcomes and primary care will work to support this by working towards these standards. However, the primary focus is consulting on hospital configuration and therefore cannot put primary care as the front page. NG stated that as a public facing document it suggests the focus is on reconfiguration of primary care. He felt that this weakened HT and focused on primary care in order to sell the idea. It needed to be clear that we aspire to the standards and that it does not reflect integrated care and therefore in some respects is the wrong way round. SN noted that Primary Care in context is at the beginning and an element within integrated care. There is support for the standards but there is a need to be realistic at what level (%) they can be achieved. SA stated that the Health & Wellbeing Board has some concerns and is not sure how this will be received. We need to be careful (have a full understanding) around the language i.e. Primary Care vs GP Services. The standard be seen within 2 hours for an urgent problem seems to be too stretched and queried the appropriateness of standard relating to children under 5 yrs. Some standards to be built towards quality. CD referred to the offer of an appointment to the under 5 yrs was a selling point rather than an emphasis on self-care and should focus on appropriate attendance rather than drop-in. HS commented:- Page 20 of

200 o Broad consensus o Primary care standards are aspirational o Need to ensure credibility and focus on quality agenda o Will discuss at the CiC meeting o Need to ensure there is appropriate messaging (risk to HT) SL confirmed that there was a time constraint with this and needed in place standards all 12 CCGs can sign up to. HS stated that the aspirational element to the standards had to be clearly postulated. SL noted the AT passed development to the AGG which AGG agreed and therefore if something different is required there is a need to act quickly. HS noted that primary care had not been agreed as the story board for HT. Primary care is not the leader in this (HT hospital configuration is) and standards are aspirational. He reiterated that further discussion to take place at the CiC. RB noted that due to the tight timescale and although not a member of CiC volunteered to attend to progress discussions. IB emphasised that there had been some misunderstanding and does not mean delivery 100% of the time. It would be prudent to set a level for each with an improvement trajectory. But the main point is to offer the public these statements of care. HS summarised by saying the comments made by IB had been helpful, there is a need to repackage the statements and be open on the ability to deliver. BT agreed with HS s remarks. SW felt it was a good message that members should be able to accept. IB confirmed that we needed to re-package the statements so each area can deliver in their own way. The AGG: Noted: the figure in paragraph 3 is 20m. Action: RB to circulate the work undertaken with the CFOs. Noted: that the lead story for HT was hospital configuration (not primary care). Noted: the Primary Care Standards are aspirational. Noted: RB offer to attend the CiC meeting Agreed to discuss further at the CiC meeting 6. PAPERS TO APPROVE: It was noted that the GMMMG and EUR policies are presented to the AGG as per governance process. 6.1 GMMMG Approved through HoCs & CFOs Summary Paper of Recommendations made by the Interface & New Therapies Sub Group Psoriatic Arthritis & Ankylosing Spondylitis Pathway 6.2 EUR Approved through HoCs & CFOs Hyaluronic Acid Injections for Osteoarthritis Page 21 of

201 The AGG: Approved the GMMMG & EUR policies. 7. ANY OTHER BUSINESS It was noted the concern raised by LM in respect of the HT narrative which has already been prepared to ensure it is appropriately worded in respect of primary care standards. DATE/TIME OF NEXT MEETING The next meeting will be held on 1st July pm in the Salford/Worsley Suite on the Mezzanine St James s House, Salford. Page 22 of

202 3.1 Leads CO Responsibility : Ambulance Commissioning ACTION LOG Requested that DC send to AD the ToR for the current HT Transport Reference Group and proposed new Group for onward circulation SN to liaise with AC to ensure there is assurance regarding a possible transport gap. DC SN OWNER 3.2 Co-Commissioning of Primary Care Letter from Rosamond Roughton/Barbara Hakin RB to circulate the GM Framework for comment RB 4.2 Primary Care Budget ( Direct Commissioning Plan) 4.1 Primary Care Promises to be referred to as Standards Andrew Harrison to revise the paper and send to AD for onward circulation to members. RB to circulate the work undertaken with the CFO s AH RB Page 23 of

203 Shared Minutes of the Healthier Together Committees in Common Agenda Item Number A1.4 Date of meeting: 18 th June 2014 Date of paper: 06 th June 2014 Subject: Healthier Together Committees in Common Decision / Opinion Required: For approval Author of paper and contact details: Minutes of Committees in Common Meeting held in Public on 4 th June 2014 Purpose of paper: For record of the Shared Minutes of the Healthier Together Committees in Common meeting held in public on 4 th June The item has been discussed previously at these meetings: n/a 203