A G E N D A. Meeting Title Governing Body Meeting Date Wednesday 14 February Chair Dr Julian Povey Time 9.30am

Transcription

1 William Farr House Mytton Oak Road Shrewsbury Shropshire SY3 8XL Tel: A G E N D A The meeting is to be held in public to enable the public to observe the decision making process. Members of the public will be able to ask questions at the discretion of the Chair Meeting Title Governing Body Meeting Date Wednesday 14 February 2018 Chair Dr Julian Povey Time 9.30am Minute Taker Mrs Tracy Eggby-Jones Venue / Location Seminar Room 5, Shropshire Education & Conference Centre, Royal Shrewsbury Hospital, Mytton Oak Road, Shrewsbury, SY3 8XL Reference Agenda Item Presenter Time Paper GB Apologies Ed Rysdale Julian Povey 9.30 verbal GB Members Declaration of Interests Julian Povey 9.30 verbal GB Introductory Comments from the Chair Julian Povey 9.30 verbal Minutes of Previous Meetings GB Meeting held on 10 January 2018 Julian Povey 9.35 enclosure GB Matters Arising Julian Povey 9.40 verbal Patient Voice GB Patient Voice Meredith Vivian 9.50 enclosure Clinical and Financial Sustainability GB Progress Report on Quality, Innovation, Productivity & Prevention (QIPP) schemes Claire Skidmore enclosure GB Transfer of Out of Hours number to NHS 111 Julie Davies enclosure GB Midwife Led Unit (MLU) Consultation Jessica Sokolov verbal GB Out of Hospital Transformation Programme Julie Davies enclosure GB Questions from Members of the Public Pertaining to Clinical & Financial Sustainability agenda items only Julian Povey verbal Page 1 Shropshire CCG Governing Body meeting Agenda 14 February 2018

2 BREAK Corporate Performance Reports GB Financial Report Claire Skidmore enclosure GB Corporate Performance report Julie Davies enclosure GB Contract Performance report 2017/18 Gail Fortes-Mayer enclosure GB Contract Process 2018/19 Gail Fortes-Mayer enclosure GB Quality Report Dawn Clarke enclosure GB Quality Strategy & Delivery Plan 2018/19 Meredith Vivian/ Dawn Clarke enclosure GB Audit Committee 31 January, including revised Gifts, Hospitality & Sponsorship policy William Hutton enclosure Strategic Planning Reports GB Sustainability & Transformation Plan (STP) Phil Evans enclosure GB Governance Risk Management Policy, including revised Governing Body Assurance Framework (GBAF) For Information Only/Exception Reporting Sam Tilley enclosure GB Clinical Commissioning Committee 20 December Sarah Porter enclosure GB Quality Committee 20 December Meredith Vivian enclosure GB Finance & Performance Committee 3 January Keith Timmis enclosure GB Primary Care Commissioning Committee 3 January Keith Timmis enclosure GB A&E Delivery Board 28 November Julie Davies enclosure GB Locality Boards North Locality Board 23 November South Locality Board 15 November Shrewsbury & Atcham Board 16 November Tim Lyttle Shailendra Allen Deborah Shepherd enclosure verbal enclosure GB Questions from Members of the Public Julian Povey verbal At the discretion of the Chair questions from members of the public will be invited If you would prefer to put this in writing, by noon Tuesday 13 February to Dr Julian Povey, Clinical Chair, Shropshire CCG, Somerby Suite, William Farr House, Mytton Oak Road, Shrewsbury, SY3 8XL or via SHRCCG.CustomerCare@nhs.net GB Any Other Business Julian Povey verbal Page 2 Shropshire CCG Governing Body meeting Agenda 14 February 2018

3 Date of Next Meeting Wednesday 14 March 2018, time and venue to be confirmed TO RESOLVE: That representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest. (Section 1 [2] Public Bodies [Admission to Meetings] Act 1960). Dr Julian Povey Clinical Chair Dr Simon Freeman Accountable Officer Page 3 Shropshire CCG Governing Body meeting Agenda 14 February 2018

4 Agenda Item GB CCG Governing Body Shropshire Clinical Commissioning Group MINUTES OF THE SHROPSHIRE CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY MEETING HELD IN ROOM SGH026, THE UNIVERSITY CENTRE, FRANKWELL QUAY, SHREWSBURY, SHROPSHIRE, SY3 8HQ Present Dr Julian Povey Dr Jessica Sokolov Dr Simon Freeman Mrs Claire Skidmore Dr Finola Lynch Dr Steve James Dr Deborah Shepherd Dr Shailendra Allen Dr Tim Lyttle Mr Kevin Morris Dr Julie Davies Mrs Sam Tilley Ms Dawn Clarke Mrs Gail Fortes-Mayer Dr Ed Rysdale Professor Rod Thomson Mr Keith Timmis Mr William Hutton Mr Meredith Vivian Mrs Sarah Porter Mrs Tracy Eggby-Jones AT 9.30 AM ON WEDNESDAY 10 JANUARY 2018 (CCG Chair) (Deputy Clinical Chair & Clinical Director Women & Children s Services (Accountable Officer) (Chief Finance Officer) (Clinical Director Communications & Engagement) (Clinical Director - Primary Care) (Chair Shrewsbury & Atcham Locality) (Chair South Locality) part meeting (Chair North Locality) (General Practice Representative) (Director of Performance & Delivery) (Director of Corporate Affairs) (Director of Nursing, Quality and Patient Experience) (Director of Contracting & Planning) (Secondary Care Clinician) (Director of Public Health) part meeting (Lay Member Performance) (Lay Member Governance & Audit) (Lay Member Patient & Public Involvement) (Lay Member Transformation) (Corporate Services Manager - Minute Taker) In Attendance Mr Graham Shepherd Mrs Jane Randall-Smith Mr Jonathan Bletcher Mr Charles Millar Mrs Lisa Wicks Mrs Claire Old (Shropshire Patient Group Observer) (Healthwatch Shropshire Observer) (Head of Assurance & Delivery, NHS England) (Head of Planning Performance and Contracting) agenda item GB (Head of Out of Hospital Commissioning) agenda items GB and GB (Urgent Care Director Shropshire, Telford & Wrekin) agenda item GB Dr Povey welcomed members, observers and the public to the Shropshire Clinical Commissioning Group (CCG) Governing Body meeting being held in public. Dr Povey specifically welcomed Mr Bletcher from NHS England. Minute No. GB Apologies 2.1 Apologies were noted from: Mrs Nicky Wilde (Director of Primary Care) Minute No. GB Declarations of Interest 3.1 Dr Povey reported that Members had previously declared their interest, which were listed on the Governing Body Register of Interest and available to view on the CCG s website ( However, Dr Povey asked Members to confirm any declarations of interest they had in relation to the agenda items. These were noted as follows: Page 1 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

5 Professor Thomson declared that he was the Director of Public Health at Shropshire Council and Deputy President of the Royal College of Nursing. Mr Vivian declared that his wife was an employee of Shrewsbury & Telford Hospital NHS Trust (SATH). Dr Allen declared that he was a GP partner at Highley & Broseley Medical Practices. Dr Lyttle declared that he was a GP partner at Bridgewater Family Medical Practice and Claypit Street Medical Practice. Mr Morris declared that he was a managing partner at Cambrian Medical Practice and his wife was an Executive Director at Telford & Wrekin CCG. Dr Lynch declared that she was a locum GP at Bishops Castle Medical Practice and her husband was an employee of Shropdoc. Dr Povey declared that he was a GP partner at Pontesbury Medical Practice. Dr Sokolov declared that she was a GP partner at Market Drayton Medical Practice and her father was a County Councillor and Governor on the Board at West Midlands Ambulance Service (WMAS). Dr Rysdale declared that he was an Emergency Medicine Consultant at University Hospital North Midlands (UHNM) and that his wife was a GP partner at Beeches Medical Practice, Bayston Hill. Mrs Tilley declared that she had a relative who worked at SATH. 3.2 There were no other declarations of interest raised. Minute No. GB Introductory Comments from the Chair 4.1 Dr Povey reported that following the Prime Minister s Cabinet reshuffle Mr Philip Dunne MP was no longer a Minister for Health and would return to his elected role as Conservative MP for Ludlow. Dr Povey also reported that Mr Jeremy Hunt had been appointed as Secretary of State for Health and Social Care as of 8 January Dr Povey noted that he would formally write to Mr Dunne thanking him for his work as Minister for Health. ACTION Dr Povey to write letter to Mr Philip Dunne MP thanking him for his work as Health Minister. Minute No. GB Minutes of the Previous Meeting 13 December The minutes of the Governing Body meeting held on 13 December 2017 were presented and approved as and true and accurate record, subject to the following minor amendments: a) Page 4 Paragraph 8.2 Mrs Skidmore highlighted that IN&E should read I&E (income and expenditure) and that the word collected should be changed to reported. RESOLVE: MEMBERS FORMALLY RECEIVED AND APPROVED as an accurate record the minutes of the meeting of Shropshire Clinical Commissioning Group (CCG) held on 13 December 2017, subject to the minor amendments noted above. Minute No. GB Matters Arising from the Minutes of the Previous Meeting 6.1 An update on the matters arising from the previous meetings were noted as follows: Page 2 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

6 a) GB Matters Arising (GB ~A&E Delivery Board Minutes) Ms Clarke reported that the requested Business Continuity and Escalation Plan covered both Shropshire and Telford & Wrekin CCGs as well as SATH and had been presented to the Clinical Quality Review Meeting (CQRM) and Planned Care Working Group (PCWG) meetings. Ms Clarke advised that due to its size she would circulate a copy to Members via . b) GB Corporate Performance Report Dr Davies suggested that the evaluation of Winter money initiatives, Marginal Rate Emergency tariff and Readmissions tariff penalty be presented to the February Finance & Performance Committee. This was supported by Governing Body Members. c) GB Questions from Members of the Public Ms Clarke advised that the CCG had not been made aware of the current position in relation to access to Midwife Led Services/Units following the temporary closure of the Oswestry and Royal Shrewsbury Hospital Mid-Wife Led Units, but agreed to pick this up with SATH and feedback to next Governing Body meeting Dr Freeman confirmed that there had not been any changes in service provision by Shropdoc to community hospitals. 6.2 There were no other matters arising noted. ACTION Ms Clarke to circulate copy of SATH s Business Continuity and Escalation Plan to Governing Body Members. Ms Clarke to ascertain what the current position was in relation to access to Midwife Led Services/Units following the temporary closure of the Oswestry and Royal Shrewsbury Hospital Mid-Wife Led Units and feedback to next Governing Body meeting.. CLINICAL AND FINANCIAL SUSTAINABILITY Minute No. GB Progress Report on Quality, Innovation, Productivity & Prevention (QIPP) schemes 7.1 Mrs Skidmore presented a progress report on the current position in relation to the CCG s Quality, Innovation, Productivity & Prevention (QIPP) programme for 2017/18, as at Month 8, and reported that the CCG had an outturn delivery of m against the target of 17.71m. This was an increase in forecast from Month 7 of 14.98m reported. Mrs Skidmore advised that a breakdown of the delivery was contained within the report. 7.2 Mrs Skidmore reported that the movement in the position was mainly attributed to the worsening position of Value Based Commissioning (VBC)/Musculoskeletal (MSK) and Continuing Healthcare (CHC), but there had been an improvement due to the removal of costs associated with No Cheaper Stock Obtainable (NCSO) drugs from the QIPP reporting, as these inflated prices had suppressed the reported savings position. 7.3 Mrs Skidmore explained that the deterioration in VBC/MSK did not relate to changes in the programme of work but due to a timing issue of counting activity for inclusion in the report and, therefore, they had depressed the forecast. In relation to CHC, Mrs Skidmore advised that CHC was forecasting to deliver 5.5m of savings against an original QIPP target of 4m, however, after reassessing the position at Month 8 it was agreed to downgrade the forecast outturn rather than include this as a risk. 7.4 Mrs Skidmore noted that given the position in the year, the CCG was likely to achieve minimal further savings and that the key focus was developing QIPP schemes for 2018/ Mr Timmis recognised the significant work undertaken to deliver a m QIPP to date, but noted that the CCG was unlikely to achieve its target of 17.71m. Mr Timmis felt that the CCG needed to reflect on what lessons had been learnt in the development and management of QIPP schemes for 2017/18, which could be used to assist with future planning. Mrs Skidmore agreed to take this into consideration. Page 3 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

7 7.6 Dr Povey referred to the Prescription Ordering Service (POD), which he noted was currently below trajectory and asked if this was due a delay in rolling out the programme to GP practices. Mrs Skidmore and Dr James reported that the POD was having a positive impact, with 4 practices already live and a 10-15% reduction in waste to date. It was planned to bring other GP practices on board as soon as possible, although it was noted that some practices had IT issues that required resolution beforehand. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the current position in relation to the QIPP schemes as at Month 8, with a predicted outturn delivery of m against the target of 17.71m, which was an increase in the reported forecast from Month 7 ( 14.98m). ACTION Mrs Skidmore to reflect on lessons learnt from 2017/18 QIPP schemes and ensure these are taken into consideration when setting 2018/19 schemes. Minute No. GB Sustainable Neurology Services 8.1 Dr Davies presented a short briefing report on the current position in relation to neurology services at Shrewsbury & Telford Hospital NHS Trust (SATH). Key points were noted as follows: SATH neurology service Referral to Treatment Time (RTT) was reported as 100% at the end of October SATH forecast that all Consultant-delivered overdue follow-ups would be eradicated by the end of December SATH have requested the CCG supports the re-opening of neurology services through a phased approach to manage demand against current limited capacity. To begin the re-opening, SATH have begun booking in patients who had been diagnosed with a neurological condition out-of-area and who wished to be repatriated to the neurology services in Shropshire and Telford & Wrekin for follow-up care. Communications would be sent to Primary Care shortly to inform them of the re-opening of neurology services at SATH for patients who wish to be repatriated. Commissioners and SATH are working closely together to define details of options for managing demand based on clinical need before a decision is made to open to new referrals. This was planned to go to the CCG s Clinical Commissioning Committee (CCC) on 17 January The neurology service at SATH would not fully re-open until arrangements have been made with another provider to secure extra capacity at SATH to ensure a sustainable service was in place for the CCG s population. It was anticipated that arrangements would be made with another provider by end of March Patients who were already on a neurology pathway with out-of-area providers shall continue on these pathways until a diagnosis or decision to discharge was made. 8.2 Dr Davies reported that she welcomed the fact that SATH was undertaking a phased re-opening of neurology services due to the limitations of current capacity at the Trust and on-going negotiations with another provider to secure additional capacity. Dr Davies reported that priority would be given to repatriating patients who had been diagnosed out-of-county during the period of suspension and who wish to receive their long-term follow-up back in-county. 8.3 Dr Davies also reported that the Walton Centre had commenced working with Robert Jones & Agnes Hunt Orthopaedic Hospital (RJAH) to provide additional capacity. 8.4 Discussion took place with regards to the additional new capacity at SATH and how this would be utilised, as Members expressed concern that the phased re-opening of the service and additional capacity may not be used in the most effective way and thought that patients who had not yet had a diagnosis should be prioritised. Dr Davies advised that predominantly those patients who had been diagnosed and had chosen to be repatriated in-county would see a Clinical Nurse Specialist and gave assurance that the limited additional new capacity would be prioritised for the most clinically urgent patients. Dr Davies advised that the additional capacity equated to 15 new consultant appointments per week for Shropshire, Telford & Wrekin and Powys patients. Dr Davies stated that she was working with the Trust with regards to developing a clinical criteria for prioritising patients in order to utilise the appointments appropriately. A proposal would be presented to the Clinical Commissioning Committee on 17 January Page 4 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

8 8.5 Dr Freeman questioned why the service was re-opening to new referrals when assurance had not been received about the long-term sustainability of the service. Dr Davies advised that the CCG had not supported the re-opening and would not do so until an agreement had been reached by the CCC on the management of the additional capacity and how patients would be prioritised. Furthermore, Dr Davies advised that the CCG needed assurance on the development of the hub and spoke model, which had been agreed previously, and confirmation that discussions with the Walton Centre were progressing. 8.6 Dr Lynch noted that the Local Medical Committee (LMC), at their recent meeting, had raised concern with regards to access to support services for neurology patients who had been diagnosed and were being seen out-of-county. Dr Davies advised that as far as she was aware patients should have access to the necessary support services and asked Dr Lynch to provide her with specific examples so that she could investigate them. 8.7 Members were concerned that the Trust had issued a statement on the re-opening of the service prematurely and that the CCG, as the commissioner of neurology services, was not clear on what the Trust was proposing in terms of timeframes and how the additional Consultant and Clinical Nurse Specialist capacity would be prioritised. It was agreed that Dr Freeman should write formally to SATH s Chief Executive to clarity the position. In the meantime, the proposal would be considered by the CCC on 17 January Dr Povey acknowledged the work of Dr Davies and her team in establishing a local sustainable neurology service. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the current position in relation to neurology services at SATH. ACTION Dr Lynch to provide Dr Davies with specific examples of out-of-county patients not being able to access the necessary support services following their diagnosis, in order for these to be investigated. Dr Freeman to formally write to Chief Executive, SATH, to clarify the position in relation to the phased re-opening of neurology services at the Trust. Minute No. GB Emotional Wellbeing Service update 9.1 Mrs Lisa Wicks, Head of Out of Hospital Commissioning, was in attendance for this item. 9.2 Dr Davies presented a briefing paper which provided Members with background information on the commissioning of the new 0-25 Emotional Health and Wellbeing service. The paper also identified the issues which had recently emerged and the work undertaken to address them. 9.3 It was noted that, following a successful procurement exercise between Shropshire and Telford & Wrekin CCGs and both local authorities, a contract was awarded to South Staffordshire & Shropshire Healthcare Foundation Trust (SSSFT) as the prime provider for the 0-25 Emotional Health and Wellbeing service from May The partnership included Shropshire Community Health NHS Trust (SCHT), Kooth, Healios and the Children society. The contract included online support, early intervention, learning disabilities, neuro development service as well as a specialist mental health service. 9.4 Dr Davies reported that, following concerns raised by commissioners, a Contract Performance Notice (CPN) had been issued under the standard NHS contract on 30 November 2017 with a requirement for the Trust to develop a Remedial Action Plan (RAP). Dr Davies advised that key workstreams encompassed in the RAP included single point of access, assessment and treatment, management of change and communication. 9.5 It was noted that SSSFT had also commenced a service review of the specialist mental health elements of the service and had taken a very proactive approach to identifying issues and put in place mitigating actions where possible. This included the Trust taking quick action to change the relationship with the incumbent provider and staff were moved to the direct employment of SSSFT using the Transfer of Undertaking of Protected Employment arrangements (TUPE). This had helped to provide a more sustainable service, greater support and quicker change. Page 5 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

9 9.6 The Trust has also identified additional clinical capacity, leadership and project management support to ensure robust safe implementation of new processes. The additional capacity had provided a detailed review of the clinical practice which exposed some issues. These were raised with commissioners on 16 November The Trust was now confident that their proactive approach had identified the full extent of the problems and the remedial work required had commenced, but it was recognised by the Trust and commissioners that further action would be needed to fully address the problems. 9.8 Dr Davies acknowledged that the service the SSSFT had inherited was significantly challenged and that lessons could be learnt in relation to future service transfer arrangements. Dr Davies recognised the work undertaken by SSSFT to date to reduce the backlog of patients waiting and advised that the CCG was seeking assurance that the patients still waiting were being clinically assessed to ensure they were not coming to harm. 9.9 Dr Davies advised that the CCG would continue to monitor the implementation of the RAP and provide regular updates to the Governing Body on current service performance. Progress reports would be presented to future Governing Body meetings Mr Hutton expressed concern that the issues identified were fundamental and that he felt there was a lack of due diligence on the part of the CCG and Trust and asked how this was being addressed. Dr Davies explained that Telford & Wrekin CCG were the lead commissioner of the service and that Shropshire CCG was working very closely with them and agreed that lessons could be learnt, particularly in terms of due diligence in assessing the inherited service and implementation of transition arrangements, but felt that the RAP would provide assurance that mitigating actions were being implemented to address the concerns raised Mr Timmis sought assurance on the degree of risk currently associated with the service. Ms Clarke acknowledged that patients seen by the service were often very vulnerable and had complex needs. Ms Clarke reported that both CCGs with were working collaboratively with the local authorities to minimise any risks to this cohort of patients and identify any potential gaps. Ms Clarke emphasised that the challenges associated with the service were not unique to Shropshire but nationally there were significant issues with service provision Dr Lyttle noted that a communications plan was in development to ensure service users, parents and professionals were clear about what they can expect from the service over the coming months and years. Dr Lyttle felt that this needed to be extended to primary care, particularly with regards to clarifying the referral pathway for GPs Dr Povey referred to the RAP and noted that this was due to be drafted in November and asked if this had been developed and, if so, were there agreed timelines. Dr Davies reported that the Trust had developed the RAP within the agreed timescales and that the CCG had seen two iterations to date, but had asked for greater clarity on specific issues. The revised version was due to be signed off by the CCG shortly, Dr Davies agreed to pick this up with Dr Freeman and Mrs Fortes-Mayer outside the meeting in order to gain assurance on the timeframe for approving the RAP by commissioners Dr Sokolov felt that the report did not articulate the significance of the issues identified and that it was unacceptable that the RAP had not yet been approved. Dr Davies advised that she would feedback the comments and concerns of the Governing Body to the Executive Lead at Telford & Wrekin CCG Mr Vivian raised several points in relation to the report around data/record keeping and monitoring of the RAP. Mr Vivian also felt that the Trust should ensure user involvement was incorporated in the RAP, not just encouraged to do so as stated. Dr Povey advised that he was assured by the work being undertaken by the Trust specifically with regards to data and reporting and noted that the RAP would be monitored through the normal CCG contractual process Mrs Wicks also reported that a significant amount of service user engagement had been undertaken by the Trust in developing its new name - Bee U. Dr Davies confirmed that there was a specific communication workstream within the RAP Mrs Randall-Smith advised that Healthwatch would be willing to support the Trust in engaging and obtaining feedback from service users 9.18 Members acknowledged the significant work undertaken by SSSFT and felt that there had been improvements in some areas, particularly with regards to access, due to the implementation of the single point of access service in December 2017 and reduction in waiting times. Page 6 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

10 RESOLVE: THE GOVERNING BODY RECEIVED the briefing report on the commissioning of the new 0-25 Emotional Health and Wellbeing service and NOTED the service issues identified and actions taken to date by both SSSFT and Commissioners, including the monitoring of progress of the implementation of the Remedial Action Plan. THE GOVERNING BODY AGREED to support the provider with the remedial actions and NOTED the significant work required to bring the service up to the required level, whilst continuing to ensure delivery of the service specification and good practice standards. ACTION Dr Davies to provide regular updates to the Governing Body on current performance of the 0-25 Emotional Wellbeing Service and progress against the Remedial Action Plan. Dr Davies, Dr Freeman and Mrs Fortes-Mayer to meet and seek assurance that the Remedial Action Plan for the 0-25 Emotional Wellbeing Service had been approved by commissioners and that timelines were agreed. Dr Davies to feedback concerns and comments from Governing Body Members on the current performance of the 0-25 Emotional Wellbeing Service to the Executive Lead at Telford & Wrekin CCG. Minute No. GB NHS Mr Charles Millar, Head of Planning, Performance and Contracting, was in attendance for this item Dr Davies presented a report that identified the possible consequences of the expansion of the NHS111 service and the potential impact it would have on ambulance activity, A&E activity and residual Shropdoc activity Dr Davies advised that concern had been expressed that such an expansion would produce significant increases in ambulance dispositions and consequently additional pressure on A&E and that the report summarised a number of analyses that had been undertaken and definitive conclusions had been drawn from these as to the potential impact and scale of such a move 10.4 It was noted that the potential areas of impact were spread across a number of services and organisations and consequently have required the investigation of a number of differing data sources. These have included data from A&E, West Midlands Ambulance Service (WMAS), NHS111 and Shropdoc Dr Davies highlighted that inevitably there were inconsistencies and definitional differences in the data sets and algorithms used which were difficult to reconcile. In addition, the service models for NHS111 and Shropdoc were quite different in that NHS111 operated as a patient direction service and Shropdoc offers direct clinical contact (either by phone and face-face). As a result, the collection of data, labelled very similarly, may have had an entirely different meaning and some of the data was likely to have been recorded by both services at different stages of a patient pathway Dr Davies reported that, following the analysis of the data, it could reasonably be concluded that: a) An increased use of NHS111 was likely to produce some increase in ambulance dispositions partly as a result of increased use of NHS pathways and partly as a result of some probable previous under-recording; b) The impact was likely to be at the marginal because of the relatively small proportion of ambulance activity which came through from NHS111 compared to other sources; c) The increased activity seen in the ambulance contract was likely to be being generated for reasons other than the NHS111 expansion; d) The impact on A&E was likely to be marginal, as the data indicated that only around 30% of activity was delivered from the ambulance service; e) Similarly, the proportions of patients advised to attend A&E directly were small and so any increase would only have a marginal impact; f) The majority of patients attending A&E were doing so without recourse to NHS111 or the ambulance service so the concern should be more focussed on why this was happening; Page 7 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

11 g) There were clearly other factors shaping patient behaviour in terms of deciding to go to A&E and these factors seemed to be producing differing trends between Shropshire and Telford & Wrekin and between Royal Shrewsbury Hospital (RSH) and Princess Royal Hospital (PRH); h) Current levels of activity and behaviour would suggest Shropdoc would need to deal with around 4500 calls per month referred from NHS Dr Davies noted that it appeared the impact for Telford & Wrekin was higher than that of Shropshire CCG, particularly at Princess Royal Hospital (PRH) Dr Davies drew Members attention to the proposed next steps in the report, which were noted as follows: a) Clarify with the lead commissioner for WMAS, the outcome of the analysis of why ambulance activity had increased significantly above plan. It was noted that this would be progressed by the Lead Executive from Telford & Wrekin CCG. b) Continue to monitor NHS111 activity and the rate of ambulance dispositions. c) Progress discussions with Shropdoc around the expected levels of out-of-hours activity being referred from NHS Mr Hutton referred to chart 2 (page 5) of the report and noted that there appeared to be an increased number of ambulance dispositions from Shropdoc calls and asked if this was as a result of changes to working practices of Shropdoc or a case mix change from the use of NHS111. Dr Davies explained that a significant proportion of lower level calls were filtered by NHS111, which had therefore resulted in the higher level cases being triaged by Shropdoc and an inevitable increase in ambulance dispositions Mr Hutton also sought clarification with regards to paragraphs 14 and 15 of the report, which he felt contradicted each other. Mr Millar provided an explanation Dr Povey requested a copy of the audit report referred to in paragraph 14, which tested 10 scenarios to see if there were any differences in behaviour of call handlers between NHS111 and Shropdoc. Dr Davies agreed to forward a copy to Dr Povey Mr Hutton drew attention to paragraph 17 of the report and sought clarification with regards to the figures quoted. Mr Millar gave a brief explanation but advised that he would draft a clarification statement on this and present it to the next Governing Body meeting Mr Shepherd advised that he had been involved in various meetings with key stakeholders for urgent care and out-of-hours providers, including Shropdoc and NHS111 and noted that the data he had received from the meetings appeared to be inconsistent with the figures quoted in the report. Dr Davies suggested that a meeting with Mr Shepherd, Mr Millar and Mrs Emma Pyrah was convened to compare the data and raise any discrepancies with the Regional Commissioner Dr Lyttle was mindful that both Shropdoc and NHS111 had sufficient capacity to manage demand. Dr Davies acknowledged that it was difficult to specifically identity the cause and effect of the increase in demand given the ever changing environment and noted that workforce issues was one specific area of concern. Dr Davies gave assurance the local health system was working hard to mitigate the impact of the increase in demand Dr Povey noted that it was nationally mandated that the Shropdoc out-of-hours telephone number should be switched off and asked what the timeframe was for doing this. Dr Freeman advised that this could not be done until the issue of the Welsh border telephony system to access NHS111 was resolved. Dr Davies reported that it was hoped this would be resolved by June and that a plan to switch off the number would be presented to the Governing Body. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the report on the possible consequences of the expansion of the NHS111 service and the potential impact it would have on ambulance activity, A&E activity and residual Shropdoc activity. ACTION Dr Davies to provide Dr Povey with copy of audit report which tested 10 scenarios to see if there were any differences in behaviour of call handlers between NHS111 and Shropdoc. Page 8 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

12 Dr Davies and Mr Millar to check figures quoted in paragraph 17 of the report in relation to the percentage of ambulance dispositions and present a clarification statement on this to the next Governing Body meeting. Dr Davies to ask Mr Millar and Mrs Pyrah to arrange a meeting with Mr Shepherd with regards to comparing NHS 111 data he had in order to establish if there were any discrepancies with the CCG data and feedback to the next Governing Body meeting. Dr Davies to present update to future Governing Body meeting on progress towards switching off the Shropdoc out-of-hours number following the cross-border technical issues. Minute No. GB Out of Hospital Programme 11.1 Mrs Lisa Wicks was in attendance to present progress of the Community Services Review (CSR) and Out of Hospital (OOH) programme over the last three months. Key points from the report were noted as follows: a) There was a Case for Change for Minor Injuries, Diagnostics, Assessment and Access to Rehabilitation and Treatment (DAART) and Community Services b) Pre-engagement work had begun with the local community c) The Case for Change would be updated to reflect the pre-engagement work underway and planned and reissued by the end of January 2018 d) The Programme Board have recommended that work relating to DAART and Community Beds should continue as part of the Out Of Hospital work e) As a result of the above recommendation, the governance arrangements for the CSR would need to be amended to reflect the change and would be brought back to a future Governing Body meeting f) The Minor Injuries Service commissioned from Shropshire Community Health NHS Trust (SCHT), and Primary Care as an Enhanced Service, would be re-specified 11.2 Mrs Randall-Smith noted that she had been involved in the pre-engagement work in relation to the Case for Change for the Community Services Review but asked how this linked with other out of hospital and community resilience workstreams taking place, particularly with the local authority. Dr Freeman reported that the Neighbourhood work currently being undertaken was a separate workstream to that of the CSR and OOH programme Dr Sokolov explained that the initial CSR encompassed Minor Injuries, Community Beds and DAART, but in order to support this the OOH programme had been developed, which was looking at all other services provided outside a hospital environment (eg District Nursing, Integrated Community Services) due to their interdependencies. Dr Sokolov noted that the Midwife Led Unit (MLU) review was being undertaken separately Dr Rysdale welcomed the work being undertaken to review community beds and out of hospital services, as he noted that the impact on secondary care was significant Mr Vivian felt that there still appeared to be some misunderstanding by stakeholders, patients and public on the purpose of the CSR and OOH programme and that there needed to be further effective communication in this regard Mrs Wicks reported that a Patient Engagement workshop was held on 7 December as part of the planned engagement and the case study work was undertaken to inform The vision and strategic objectives for the Out of Hospital Programme Outcomes required from the model It was noted that a further Patient Engagement workshop was planned for early February to develop the wider programme engagement strategy Mrs Wicks drew Members attention to Appendix 1 of the report which detailed the timeline for forthcoming work. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the progress report on the Community Services Review and Out of Hospital programme and dates for the forthcoming preengagement sessions/events. Page 9 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

13 Minute No. GB Urgent Care update 12.1 Mrs Clare Old, Shropshire, Telford & Wrekin Urgent Care Director, was in attendance to give a presentation on the pressures facing urgent care in the county during December The presentation covered A&E performance, ambulance attendances, hospital admissions and discharges, and bed occupancy Key points from the presentation were noted as follows: a) There were 11% more ambulance arrivals than the same period in 2016, 7% more ambulance arrivals than November 17 b) Escalation beds were open and at full capacity resulting in an extra three patients on some wards at the times of high pressure, c) Although patients were medically fit for discharge each day, the number of patients made ready for discharge was lower and patients were discharged onto Discharge to Assess (DtA) pathways on average within 48 hours of being made ready. d) Hospital Ambulance Liaison Officers (HALOs) supported A&E department to keep patients safe and allow swift patient handover. e) There were more admissions than discharges f) Bed occupancy only reached 85.6% on 24 December and rose again immediately g) There were additional pressures due to unfilled shifts for nurses and doctors, due to difficulties in getting agency staff over the holiday period h) Most neighbouring hospitals had the same problems so could not provide a deflect when needed. i) PRH had sustained pressure and did not recover as quickly as usual A copy of the presentation was available to download from the CCG s website at Dr Povey acknowledged the pressure that A&E, ambulance service and out-of-hours providers faced during the Christmas and New Year period and expressed his thanks to all the doctors, nurses and healthcare professionals who had worked above and beyond the call of duty to keep patients safe Members noted that the number of discharges made against target had not been achieved for both the complex and simple discharges and was concerned by the variation in numbers each week. Mrs Old advised that there were several factors that impacted on the discharge targets, but that it was mainly due to workforce issues and noted that Shropshire s allocation of junior doctors was the lowest in the country, which inevitably had a significant impact on discharging patients. Mrs Old reported that SATH were trying to address the issue through a recruitment campaign Ms Clarke noted that the Neighbourhood work would be key to supporting simple discharges. Dr Rysdale also noted that the time of day (ie before 12.00noon) for discharging patients was fundamental to support patient flow. It was felt that improved technology and access to therapists, particularly for frailty patients, would also help patient flow and discharge Mrs Old reported that Shropshire had the first Nurse Consultant in the country and that there needed to be further enhancement of the skills of health professionals in order to help with clinical discharge arrangements Mrs Old reported that over the next 3 months the following plans were being developed: a) CCG Governing Bodies and Local Authorities would perform demand and capacity modelling in health and social care. b) Dr Ian Sturgess would be visiting the acute trust for 5 days from 11 of January 2018 to look at systems and processes around stranded patients. c) Increased concentration on the frailty model across health and social care d) Assessment against 10 areas for focus in Good practice guide: Focus on improving patient flow Dr Povey thanked Mrs Old for her presentation and work to develop safe, effective and sustainable solutions for urgent care provision across Shropshire, Telford & Wrekin. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the presentation on urgent care performance in Shropshire, Telford & Wrekin during December Page 10 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

14 Minute No. GB Questions from Members of the Public 13.1 Dr Povey opened the meeting to questions from members of the public pertaining to Clinical & Financial Sustainability agenda items only. The following questions were noted: a) Mrs Sylvia Jones, Clunbury Parish Council Mrs Jones expressed concern with regards to redesigning services and contracts, which she felt were being driven by cost and developed without proper analysis of the impact to patients. Mrs Jones particularly mentioned the 0-25 Emotional Wellbeing Service. Dr Povey advised that the retendering of the 0-25 Emotional Wellbeing Service was not cost driven and that the former service was poor in terms of access to services due to long waiting lists. As reported earlier, Dr Povey highlighted that the new provider had made significant improvements which had improved the quality of service. Mrs Jones reported that she was involved in the Out of Hospital programme and sought assurance that there would be greater investment in community service provision rather than acute care. Dr Povey advised that the CCG had limited resources in which to invest and that there was no new available funding. Dr Davies noted that admission avoidance work currently being undertaken would support the Out of Hospital programme b) Mr David Sandbach Mr Sandbach felt that there was a great opportunity through the Out of Hospital programme to redesign services that were fit for the future and that he had drafted a report around step up/step down beds and asked if his report had been included in the work. Dr Freeman confirmed that Mr Sandbach s report had been included as part of the programme of work. Mr Sandbach advised that he remained confused by the wider Out of Hospital programme and its links with the Community Service Review (CSR) Dr Freeman gave a brief synopsis of the development of the CSR and reported that the review had been initiated to look at minor injuries, DAART and community beds only. However, advised that as the review progressed it was realised that due to their interdependencies a wider piece of work was required on out of hospital provision. Dr Freeman noted that the MLU review was being undertaken separately. c) Councillor Madge Sheinton Councillor Sheinton agreed that community services needed to be pulled together and felt that the work was not being done speedily enough and that better communication with patients and public was required. Mrs Wicks reported that the process of reviewing the services was at the beginning and that having Patient Engagement workshops formed part of gathering vital information to support the review. Mrs Wicks advised that they were also seeking the views of primary care and the outcome of this would be fed into the review. Mrs Wicks advised that she was working with Mr Vivian in relation to communicating with patients and the public. Dr Davies acknowledged the frustration in the delay in completing the review, but emphasised the need to ensure that the process was robust and that services were fit for the future Dr Freeman offered to meet with Mr Sandbach, Mr Shepherd, Mrs Randall-Smith and Councillor Sheinton in relation to the ongoing work of the Out of Hospital programme. ACTION Dr Freeman to meet with Mr Sandbach, Mr Shepherd, Mrs Randall-Smith and Councillor Sheinton in relation to the ongoing work on the Out of Hospital Programme. Page 11 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

15 CORPORATE PERFORMANCE REPORTS Minute No. GB Finance and Contract Report to 30 November 2017 (Month 8) 14.1 Mrs Skidmore presented the Finance and Contract Report to the Governing Body. The report reflected the finance and contract position as at 30 November 2017, which was the Month 8 financial position for 2017/ The following key points noted were: a) Shropshire CCG continued to be in directions and in formal financial recovery. b) The overall financial position to 30 November 2017 was forecasting an in year deficit of 19.4m which was in line with the agreed control total. This reflected the gap in the CCG s current plan as a result of planned expenditure exceeding resource allocation. c) The risk profile for the organisation had been reviewed this month and the previous assessment of a net unmitigated risk position of 5m being maintained. d) The cumulative financial position for 2017/18 was forecasting 52.0m deficit which included brought forward 32.6m from previous years. e) The CCG entered 2017/18 with a number of known significant risks and had a QIPP target of 17.71m. A number of unforeseen pressures had materialised since the start of the financial year which were unknown at the time of producing the finance plan and budget. These have contributed to the cost pressures that underpin the net unmitigated risk currently reported f) The CCG had achieved all of its targets within Better Payment Policy for the month. g) The CCG was achieving its cash target to date; each month so far had ended with cash levels less than 1.25% of the monthly draw down Mrs Skidmore reported that following a review of forecasts the gross forecast in a number of areas had deteriorated since month 7, further detail on this was outlined in Appendix 1 of the report. This had resulted in a net unmitigated risk position of 5m. Mrs Skidmore noted that this excluded the impact of No Cheaper Stock Obtainable (NCSO) as national guidance on this was awaited Mrs Skidmore advised that there had been significant movement in the CCG s financial risk assessment over the past weeks, which would be reflected in the Month 9 report, and although she was unable to report the formal position, she stated that the level of risk had reduced from 5m to approximately 2.1m following the year end agreement with SATH. Mrs Skidmore felt that the best case year-end position for the CCG was likely to be balancing the remainder of the unmitigated risk (ie 2.1m), but noted that this excluded the impact of NCSO. The worst case was in the region of 1-2m unmitigated risk Mrs Skidmore gave assurance that the Executive Team was working hard to reduce the unmitigated risk, so that the impact on the 2018/19 was kept to a minimum Mr Timmis referred to page 8 of the report and noted that there had been an increase in the reported Continuing Healthcare (CHC) figures, which had been raised as a concern at the Finance & Performance (F&P) Committee. Mrs Skidmore advised that the Finance Team were currently analysing the data to establish the reason for the increase Mr Timmis also asked, on behalf of the F&P Committee, if the cancellation of elective activity at SATH would have an impact on 2018/19, as he noted that a year-end position had been agreed with the Trust. Mrs Skidmore advised that discussions were ongoing in this regard and modelling was underway to establish if there was any potential impact to 2018/19. Dr Freeman advised that SATH had not had to cancel a large number of elective surgery during January Mr Hutton felt that there was potential for some misunderstanding in the report in relation to the forecast outturn (FOT) and level of unmitigated risk reported, as he thought on one hand there appeared to be an improvement in the FOT but an increase in the unmitigated risk and asked if there could be further detailed narrative in future reports to explain this. Mrs Skidmore agreed to include this in future financial reports Mr Hutton noted that the CCG s running costs were showing a year to date over-spend of 1.285m with a yearend forecast of 0.752m overspend. Mr Hutton sought an explanation of this. Mrs Skidmore advised that she did not have the information to hand but would provide Mr Hutton with the details outside the meeting. Page 12 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

16 14.10 Dr Sokolov referred to page 9 of the report, where the she noted the Primary Care budget was forecasting an underspend of 2.162m and asked if this related to prescribing. Mrs Skidmore advised that the figure referred to the non-delegated budget and that the key driver of the underspend was prescribing, but highlighted that there were some areas of overspend, as outlined in the table on page 9 of the report. RESOLVE: THE GOVERNING BODY RECEIVED and NOTED the contents of the report and NOTED the financial position to end November 2017 (Month 8)... ACTION Mrs Skidmore to ensure modelling of winter pressures and cancellation of elective activity at SATH was conducted to ensure there was no potential impact to 2018/19. Mrs Skidmore to include further detailed narrative on Forecast Outturn (FOT) vs unmitigated risk in future Financial reports. Mrs Skidmore to provide Mr Hutton with information on increased running costs of 0.5m in Month 8. Minute No. GB Corporate Performance Report 2017/ Dr Julie Davies presented the Corporate Performance Report 2017/18 which outlined the CCG s performance to date against the key performance indicators that the CCG was held accountable for with NHS England. The report also provided assurance on performance achievement against targets/standards at CCG and provider level as appropriate, and the delivery and contractual actions in place to address areas of poor performance 15.2 Key standards that had not been achieved were noted as follows: a) Cancer Targets The 62 day referral to treatment (RTT) and screening and 2 week breast symptoms cancer performance targets for the CCG were not being achieved, although SATH, the CCG s main provider, continued to achieve all targets except the 62 day RTT which had slipped below target year to date (YTD) for the first time at Month 7. The CCG achieved breast symptoms target for the first time this year in October. The CCG s overall cancer performance remained affected by out of county providers and this was continually progressed through the corresponding lead commissioners via the contract team with support as required from NHS Improvement. b) A&E 4 hour target A&E performance remained significantly challenged, with November only marginally up on October s performance and consequently remained significantly behind the recovery trajectory. Demand remained broadly on plan for Shropshire. Workforce and levels/ timeliness of patient discharges remained the key underlying issues. The system wide action plan to improve complex discharge levels agreed in October was now being implemented and complex discharges for the CCG/Shropshire Council were at their highest ever levels and broadly on plan through November. It was noted that Delayed Transfers of Care (DTOC) remained under target levels at both RJAH and SATH as a result of the excellent work between the CCG and Local Authority. The system wide Director of Urgent Care had spent the first four weeks across all parts of the system looking at how and where improvement could be made. Additional expertise was being brought in from the national Emergency Care Improvement Programme (ECIP) team as required to support system recovery. See Urgent Care update provided under Minute No. GB c) Ambulance Handovers There had been a continued deterioration in the over 1 hour ambulance handovers in November despite SATH s new handover arrangements with WMAS introduced in October. WMAS have now placed HALOs at both sites as part of their winter resilience plans in an effort to further support a reduction in ambulance handovers. Early indicators showed that performance had improved in December. d) Referral to Treatment (RTT) The CCG achieved the RTT target for the first time this year in October and SATH continued to deliver. Page 13 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

17 It was noted that in order to alleviate winter pressures and, following national guidance, elective surgery had been cancelled for the first two weeks of January at the acute trusts. Dr Davies advised that this was would reviewed on a weekly basis, with permission from NHS England and that the CCG would need to be mindful of any impact this may have on 2018/19. e) >52 week waiters The CCG had 2 over 52 week waiters at University Hospital North Midlands (UHNM) and Wye Valley in October. Full contractual levers were implemented against poor performance with any provider and the CCG performance lead now received a forward look of all >40 week waiters at all providers to try and minimize such breaches in the future Mr Vivian referred to the additional monitoring of patients waiting >40 weeks and asked what action was being taken to minimise the breaches. Dr Davies advised that the CCG was notified of any patients that hit the >40 week threshold and as a consequence contacted the relevant provider to establish the reason for the delay and where necessary contractual levers would be used to ensure the patient was seen at the earliest opportunity Dr Freeman advised that the 18 week RTT target was set nationally at 92%, which allowed for patients requiring complex or specialised treatment to be seen in an appropriate time outside 18 weeks, but that he would not expect patients to exceed 40 weeks, unless it was due to patient choice Dr Sokolov referred to ambulance handover performance and noted that there did not appear to be any significant improvement in the 30 minute handover performance, despite additional resources being made available to the ambulance service. Dr Davies advised that the resources had been used primarily to address the over 1 hour ambulance handover target and that there had been an improvement in performance in December 2017 (approximately 90 patients waiting over 1 hour) compared to December 2016, where 156 patients had waited longer than an hour. Dr Davies reported that the implementation of Corridor Nurses and HALOs had seen an impact in performance Professor Thomson referred to section 14 of the report, in relation to the Improved Access To Psychological Therapies (IAPT) performance and noted that SSSFT had cited capacity as one of the factors in the monthly variation in performance. Professor Thomson asked what sort of issues the Trust was experiencing. Dr Davies reported that clinical capacity was a key driver and noted that the CCG had requested an action plan from the Trust to address unwarranted variation in performance Dr Davies noted that there had been performance issues associated with specific services within SSSFT and although the Trust had a block contract, each individual service area was being closely monitored by the Contract Team. Dr Davies advised that she would circulate an update in this regard to Governing Body members when available Mrs Randall-Smith sought clarity with regards to the Red and Green RAG rating on the IAPT Roll Out (table on page 4) and thought that given the performance it would be all RAG rated as Red. Mrs Skidmore explained that a phased roll out plan had been agreed and that individual targets had been set for each month and the Green/Red RAG rating denoted if the monthly target had been achieved. RESOLVE: THE GOVERNING BODY RECEIVED the CCG s Performance Report 2017/18 and NOTED the key standards that were currently not being met and the mitigating actions put in place to recover performance. THE GOVERNING BODY AGREED the following actions: Dr Davies to continue chairing monthly Planned Care Working Group meetings with RJAH and SATH to oversee recovery and sustainability of RTT and cancer performance. Dr Davies and Dr Freeman to continue to attend A&E Delivery Board to ensure system delivery of the A&E recovery trajectory. ACTION Dr Davies to circulate performance update to Governing Body Members on the specific services associated with SSSFT. Page 14 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

18 Minute No. GB Contract Performance Report 16.1 Mrs Fortes-Mayer presented the Contract Performance report to the Governing Body. The report summarised the current major contract performance reports detailing the activity as at Month 7 (October 2017) for the CCG s four main contracts: Shrewsbury and Telford Hospital NHS Trust (SATH) Robert Jones and Agnes Hunt NHS Foundation Trust (RJAH) South Staffordshire and Shropshire Healthcare Trust (SSSFT) Shropshire Community Health Trust NHS Trust (SCHT) 16.2 Key points from the report were noted as follows: Shrewsbury & Telford Hospital NHS Trust (SATH) a) A final year end position had been agreed with SATH. b) SATH activity was on plan, although there was a slight over performance in day cases, first and follow up outpatient attendances. Elective, non-elective and critical care were all under plan c) There was now only one Contract Performance Notices (CPN) currently open with SATH, for failure to achieve the constitutional targets in relation to A&E performance. d) Contractual prior approvals have been in place for the treatments contained in the Value Based Commissioning (VBC) policy since October The final figure for VBC challenges in Month 4 was 12,466. e) The Ophthalmology Task & Finish Group met fortnightly and an action plan had been agreed. A phased reopening for the closed specialities was now being planned by SATH. f) A Neurology Task & Finish Group was now in place with SATH. A phased reopening of this service was now been finalised. An update on this was presented under Minute No. GB g) New coding guidance was out for review for Sepsis and the adjustment would be made based on new methodology from NHS Digital. Robert Jones and Agnes Hunt Trust (RJAH) h) Month 6 activity at RJAH was 5% below plan. The largest variance in activity was day cases where activity was 21% below plan i) The summary financial position on the RJAH contract at Month 7 was an overspend of 0.072m which was 0.4% over plan. The forecast overspend for year-end was 2.845m j) The Trust had raised an Activity Query Notice (AQN) with regards to the referral growth in the Spinal Disorders Service. k) Contractual prior approvals have been in place for the treatments contained in the VBC Policy since October Currently the VBC figures for RJAH for months 1 to 4 were undergoing a final validation. l) The contract challenge value had dropped considerably from Month 5 as the amount of VBC challenges had reduced. This was due to the Trust ensuring patients are issued a prior approval code before commencing treatment. m) It was noted that there had been a shift in case mix which had resulted in an increase in elective activity at the Trust and discussions were taking place as part of the 2018/19 contract negotiations. South Staffordshire & Shropshire Healthcare NHS Foundation Trust (SSSFT) n) The contract was currently 8.3% under the activity target at Month 7 with a 50,121 underspend once the financial adjustments had been applied. The CCG was in discussions with the Trust in relation to the underspend and both CCGs would be looking to rebase the contract for 2018/19. o) A Contract Performance Notice (CPN) had been issued to SSSFT regarding the performance of the Early Intervention in Psychosis Pathway indicator.a CPN had been issued to SSSFT due to concerns regarding the 0 to 25 Emotional Wellbeing service. Shropshire Community Health Trust p) The Month 7 financial position was 65k underspent. q) A Contract Performance Notice remains open with SCHT for the breach of RTT Incompletes at specialty level for the Telford Community MSK service (TEMs) which is provided under a separate contract with SCHT Out of County Contracts Page 15 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

19 r) There are a number of contract challenges with out of county providers to ensure a rigorous approach to managing the contract. s) Worcester Acute and Wye Valley Trust were the major contracts that were over performing and this was mainly in outpatients and emergencies. Detailed reports for all out of area contracts were now circulated internally West Midlands Ambulance Service (WMAS) t) An AQN had been raised through the lead commissioner following significant over performance in activity with WMAS. u) It was noted that Shropshire CCG had provided 2% additional resources to the contract for activity Mrs Fortes-Mayer noted that although the CCG had agreed a year-end position with SATH, the Contract Team continued to monitor performance against the mandated targets contained within the contract. Mrs Fortes-Mayer reported that there had been a significant improvement in SATH s contract performance and the contract would have been within 1% of the forecast outturn Dr Povey noted that Shropdoc and 0-25 Emotional Wellbeing Service was not included in the report. Mrs Fortes-Mayer agreed to include this in future reports Dr Allen referred to the over performance at RJAH and sought clarity with regards to how this was broken down. Mrs Fortes-Mayer advised that the over performance was mainly case mix driven and a breakdown of the activity was outlined on page 7 of the report Mr Timmis referred to activity forecasting at SATH and noted that it was broadly on plan, but was concerned that the activity would go up next year which would inevitably have associated costs. Mr Timmis particularly made reference to the potential cost pressure of Sepsis. Mrs Fortes-Mayer advised that the CCG was awaiting the national decision in relation to Sepsis and at this stage it was unclear what financial impact this would have. Ms Clarke noted that Public Health England had produced a report which outlined the number of cases of Sepsis and reported that SATH was slightly higher than the national average Dr Povey made reference to internal patient transport between RSH and PRH for non-elective cases and asked if the Trust was picking up the associated costs and if the Non-Emergency Patient Transport Service (NEPTS) was being utilised fully. Mrs Fortes-Mayer advised that the CCG was currently having discussions with the Trust in this regard and that she would provide a briefing to Governing Body Members on this. RESOLVE: THE GOVERNING BODY RECEIVED the Contract Performance Report for Month 7 (October 2017) and NOTED the current performance and actions being taken with each of the four main providers.. ACTION Mrs Fortes-Mayer to include update on Shropdoc contract and 0-25 Emotional Wellbeing Service in future Contract Performance Reports presented to the Governing Body. Mrs Fortes-Mayer to provide Governing Body Members with an update on the use of Non-Emergency Patient Transport Service (NEPTS) by SATH for inter-site transfers and associated costs. Minute No. GB Quality Exception Report 17.1 Ms Clarke presented the Quality Exception Report which provided assurance to the Governing Body that processes were in place to monitor quality performance within the CCG s commissioned services, ensure remedial action was in place where concerns had been identified and to escalate where appropriate Ms Clarke highlighted the following key points from the report: a) West Midlands Academic Health Science Network (WMAHSN) The CCG was working with WMAHSN as part of the West Midlands Patient Safety Collaborative, and a meeting had been organised on 17 January 2018 with providers and other agencies Patients and public were also welcome to attend. The aim of the joint working was to improve quality and safety in care Page 16 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

20 and drive down the risk of harm through the creation of an open and transparent culture. This would also support continual, system-wide improvements in safety. b) 12 Hour Trolley Breaches It was noted that SATH had experienced increasing pressure in its A&E departments in December, and there were 9 x 12 hour trolley wait breaches reported. Site visits were undertaken by the CCG Nursing Team who had provided assurance that patient safety was maintained during these times through regular monitoring by front line staff. c) SATH Workforce - As reported previously, Health Education England (HEE) had been working with SATH on its workforce planning. NHS England and NHS Improvement - North Midlands have written to HEE to request formally that they consider the allocation of Junior Doctors at SATH due to the number of vacancies within the organisation. A meeting took place in December to consider further how this might be achieved, but it was noted that this would not be resolved in time for the January intake. d) Shropshire Community Health NHS Trust (SCHT) The Trust ran an Observe and Act Training session during November. It was noted that their new approach, led by Patient Volunteers and staff, had received NHS Improvement and NHS England regional acclaim and was being actively progressed. The training was for both clinical/non clinical staff and volunteers to look at a person s total experience of a service from the user/carer perspective, learn from it, share good practice and where necessary act to make improvements Mr Timmis sought further detail in relation to the West Midlands Ambulance Service (WMAS) restructure referred to in paragraph 18 of the report. Dr Davies noted that the WMAS was undertaking a restructure but did not have the details to hand and advised that she would pick this up with Mr Millar who attends the WMAS meetings on behalf of the CCG Dr Povey asked if there was an update on the deep dive the CCG was undertaking in relation to the unexpected deaths at SSSFT. Professor Thomson reported that the review of the cases were continuing and that he would provide the Governing Body with a copy of the final report when available Dr Povey referred to section 23 of the report where it was noted that Shropdoc had raised an increasing number of Health Professional Forms (HPF s) in relation to concerns that the dispositions or referrals from NHS 111 were not always appropriate for the condition and that a more urgent response such as 999 ambulance would have been more appropriate. Dr Povey was concerned that this would increase pressure on both on the ambulance service and A&E. Ms Clarke reported that the CCG had carried out an unannounced quality visit to Care UK, who were the provider of the NHS111 service, and assurance gained in relation to the systems and processes in place to support staff in following the correct pathway. In addition a meeting was scheduled between Shropdoc and Care UK to further improve understanding of the issues which had resulted in the generation of the HPFs. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the key issues outlined in the Quality Report and actions being taken. ACTION Dr Davies to obtain details on planned restructure of West Midlands Ambulance Service (WMAS) and provide update to next Governing Body meeting Professor Thomson to provide Governing Body Members with copy of SSSFT s report into unexpected deaths when available. Minute No. GB Quality Strategy & Delivery Plan 18.1 Mr Vivian gave a verbal update on the development of the CCG s Quality Strategy and Delivery Plan and reported that this was a recommendation from the review undertaken by the West Midlands Quality Review Service (WMQRS) Mr Vivian advised that the Quality Team had been very proactive in the Strategy s development and that it contained clear objectives, values and mission statement. It was proposed to present the final draft Strategy to the Quality Committee in January for approval and would then be presented to the February Governing Body meeting Mr Vivian highlighted that the Delivery Plan set out the work required, but noted that consideration would need to be given on prioritising the key areas of work given the limited resources the Quality Team had to deliver them. Page 17 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

21 RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the verbal update in relation to the development of the CCG s Quality Strategy & Delivery Plan. ACTION Mr Meredith and Ms Clarke to present Quality Strategy & Delivery Plan to February Governing Body meeting. Minute No. GB Safeguarding Children s Board Annual Report 19.1 Ms Clarke presented the Children Safeguarding Annual Report for 2017, which provided a summary of the accountabilities in place and the safeguarding activity undertaken by Shropshire CCG s Children Safeguarding Team. Ms Clarke noted that the report also provided assurance that the CCG had discharged its statutory responsibility to safeguard the welfare of children including Looked After Children (LAC) across the health services it commissions Ms Clarke began by expressing her thanks to Mr David Coan (Designated Nurse Safeguarding Children) and Ms Maria Hadley (Designated Nurse Looked After Children) for their work and proactive approach to collaborative working to resolve issues in challenging and complex situations 19.3 Ms Clarke drew Members attention to the actions that had been undertaken during 2017, which included: a) Raising awareness in primary care b) Providing evidence that our providers have effective safeguarding arrangements in place. c) The CCG completed and submitted to the Local Safeguarding Children Board (LSCB) the Section 11 Children Act audit which fulfils part of the legal duty to monitor the effectiveness of local safeguarding arrangements. Actions had been implemented as per plan. d) The CCG had refreshed the safeguarding children standards and key performance indicators in all the CCG contracts for its health providers. Additional requirements included for this year were for providers to provide information on Child Sexual Exploitation (CSE) referrals and of specific safeguarding children supervision information by service Ms Clarke reported that there were approximately 450 Looked After Children (LAC) placed in Shropshire from other areas. The Designated Nurse Looked After Children had been part of the working group to look at cross agency working with the Local Authority to ensure that an improved understanding was evident around the transition of out of area children into Shropshire and a piece of work is being undertaken by Shropshire Council regarding the internal systems where data was held It was highlighted that Shropshire Children s services had been rated as good overall by Government Inspectors Ofsted, following a four-week inspection in September and October 2017 which included the CCG. The inspection looked at services for children in need of help and protection, looked-after children, and care leavers. The good rating was an improvement from the adequate rating that was awarded following the last Ofsted inspection in November Only 46 councils were currently rated as good for their children s services, and only three have achieved the top rating of outstanding. This means that Shropshire safeguarding children s services were now in the top 30% nationally Mr Vivian asked what evidence providers were required to provide as part of the assurance process. Ms Clarke reported that there were national and local statutory guidance related to safeguarding children and that evidence supplied would need to provide assurance that these standards were being met, this included ensuring staff were trained to the appropriate level With regards to training, Dr Povey sought assurance that all CCG staff were completing their mandatory training in relation to safeguarding. Ms Clarke reported that all CCG staff were required to complete the child safeguarding level 1 E learning package and compliance against this was monitored by the Commissioning Support Unit (CSU). It was noted that some staff, given their role in the organisation, were also required to attend a Level 2 and 3 safeguarding children face-to-face training session which was facilitated by the Designated Nurse Safeguarding Children. The aim of the additional session was to ensure key staff were familiar with challenges around modern slavery, domestic violence and local referral processes and policies around escalation process. Ms Clarke and Mrs Tilley agreed to raise awareness with CCG staff of their responsibility to undertake their mandatory training in relation to safeguarding and provide an progress report to the next Governing Body meeting. Page 18 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

22 19.8 Mr Vivian referred to section 7.1 of the report in relation to the Child Protection Informatics System (CP-IS) and asked if the proposed go live date of October 2017 with SATH and the Walk-in Centre had been implemented. Ms Clarke confirmed that the system had gone live and explained that CP-IS was a national system in England that delivered the capability to share key information as to whether a child was subject to Child Protection Plan (CPP) or was a Looked After Child (LAC). Ms Clarke noted that Shropshire and Telford local authority went live with the system in July 2016 and SCHT and RJAH had integrated the system into their alerts process Dr Shepherd also referred to training and development and made particular reference to the training of GPs and noted that although, as independent NHS contractors, GPs were responsible for ensuring they were up to date with all safeguarding training, she felt the CCG had a duty to monitor compliance. Dr Shepherd highlighted that the completion of safeguarding training was not mandatory as part of the GP appraisal process Dr Povey felt it would be helpful to have a reference sheet for GPs to use in order to assist them with accessing services for Looked After Children (LAC). Ms Clarke reported that recent guidance had been published to support GPs with Looked After Children, which was being presented to the Primary Care Operational Group meeting and would help support GPs. RESOLVE: THE GOVERNING BODY RECEIVED the Children Safeguarding Annual Report for 2017 and NOTED the actions taken by the CCG to ensure that it had effective safeguarding arrangements in place that comply with all statutory guidance related to safeguarding children. ACTION Ms Clarke and Mr Coan to develop reference sheet for GPs to assist with accessing services for Looked After Children (LAC). Ms Clarke and Mrs Tilley to raise awareness with CCG staff of their responsibility to undertake mandatory safeguarding training in order to ensure the CCG was 100% compliant and present progress to next Governing Body meeting. Minute No. GB Governing Body Assurance Framework (GBAF) 20.1 Mrs Tilley presented the latest iteration of the Governing Body Assurance Framework (GBAF) and asked the Governing Body to note the detail of the GBAF risks Mrs Tilley reported that the GBAF was presented at the Governing Body meeting on 8 November 2017 and had since been reviewed by Executive Directors and Sub Committees prior to its presentation to the Governing Body. Recent updates were noted in the document in red text and showed progress in relation to a number of risk mitigations and the stabilisation of risk ratings. Mrs Tilley felt that it demonstrated the significant amount of work undertaken in what had been a difficult set of circumstances and advised that positive movement in actions to mitigate risks continued to be evident in the GBAF In addition, Mrs Tilley reported that the CCG s Risk Management Policy had been reviewed and the updated version was due to be presented to the Audit Committee at the end of January, Subject to their approval the policy would be presented to the February Governing Body meeting. RESOLVE: THE GOVERNING BODY RECEIVED the latest iteration of the Governing Body Assurance Framework (GBAF) and NOTED the detail of the GBAF risks ACTION Mrs Tilley to present Risk Management Policy to February Governing Body, subject to approval by Audit Committee. STRATEGIC PLANNING REPORTS Minute No. GB Future Fit 21.1 Dr Freeman gave a verbal update in relation to the Future Fit Programme and advised that confirmation on capital funding was still awaited. Dr Freeman stated that Programme Board was not aware of the national timetable for this, but noted that until this was confirmed the public consultation could not be launched. Page 19 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

23 21.2 Ms Clarke highlighted that at the recent discussions with Health Education England it was indicated that there was a reduced appetite for junior doctors to come and work in Shropshire and that by having clarity on the Future Fit proposals could potentially help with recruitment of doctors in the future. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the verbal update in relation to Future Fit. Minute No. GB Sustainability & Transformation Plan (STP) 22.1 Dr Freeman, on behalf of Mr Phil Evans, gave a verbal update in relation to the STP. It was noted that a copy of the STP Programme Director s report had been circulated with the agenda papers Dr Freeman reported that the Chairs and Chief Executives of the STP had met on 20 December 2017 with the Kings Fund to discuss the strategic aims of the STP, in particular provider/commissioner consolidation. Dr Freeman noted that a further meeting was planned on 24 January Dr Freeman advised that that major programmes of work for sustainability included MSK, complex care and community services Mr Shepherd also reported that the STP Delivery Board had held a meeting with the Kings Fund, with a further meeting planned after the 24 January Members expressed concern that to date STP delivery had been very slow and felt there was no definitive strategic direction. Dr Sokolov noted that the CCG formed part of the STP and as a commissioner, felt that the CCG should be leading the process. Members noted that in order to deliver the significant transformational change required all organisations needed to be fully engaged in the process and that there was limitations to what the CCG could do Dr Povey expressed concern that the CCG was undertaking some of the work which he thought was the role of the STP and highlighted the STP Team structure on page 3 of the report. Mrs Skidmore advised that she was undertaking a review of expenditure associated with the STP, including staffing and running costs, and that she would present the findings to Governing Body Members Dr Lynch felt that the vision of the STP was not articulated in the Programme Director s report but that it could be found in the workstreams currently taking place, particularly with regards to frailty and community services review Members felt that there needed to be greater communication and engagement from the STP Team in order to ensure the key messages were communicated appropriately. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the update in relation to the Sustainability & Transformation Plan (STP). ACTION Mrs Skidmore to undertake a review of expenditure associated with the STP, including staffing and running costs, and present findings to Governing Body Members. Minute No. GB Healthwatch Report 23.1 Mrs Randall-Smith gave a verbal update in relation to the activities of Healthwatch Shropshire (HWS) during October to December 2017, as follows: a) HWS Annual Event The annual event ( Who s Talking ) was held on 23 November 2017 and all organisations that had been in receipt of the HWS research grants gave a presentation on how the grants had been used and what they had found as part of their research. The organisations included Autonomy, Stillbirth & Neonatal Death (SAND) charity, Parent & Carer Council (PACC) Shropshire, Profoundly deaf and Marches Energy Agency (MEA) fuel poverty. It was noted that the next Annual Event was likely to be Who s Listening. b) Hot Topics The Hot Topics included Neurology and Podiatry. Mrs Randall-Smith advised that the Neurology report had been published on the HWS website and shared with SATH. A wide range of comments had been received between different conditions, with positive comments Page 20 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

24 received from MND patients. Themes identified included access to hospital services, quality of staffing, quality of treatment, staff attitudes, lack of information about support and waiting times. In relation to Podiatry, a report was currently being drafted following comments received, which would be shared with the CCG and SCHT. Most common themes were access to services and some misunderstanding about the closure of service at Princess House. The current hot topic was Speak Up, where patients and the public were being encouraged to share their experiences of services in order to help improve care. Other Intelligence Mrs Randall-Smith reported that HWS had received a number of comments in relation to car parking at SATH, which mainly focussed on the increased charges and availability of car parking spaces. HWS was meeting with SATH next week to discuss the concerns raised. c) Community Engagement HWS continued to support the Midwife Led Unit (MLU) and Community Services reviews. d) Enter & View Visits Mrs Randall-Smith advised that Observe & Act had been incorporated into HWS s Enter & View visits and that 10 visits had recently been carried out, which included several GP practices and Pain Management Solutions (PMS). The PMS report was due to be published shortly. In addition, two visits had been undertaken at GP practices in relation to compliance with Access to Information Standards (AIS). Mrs Randall-Smith advised that there was a lack of awareness about of the AIS and felt that this was an area that needed to be addressed. Mrs Tilley advised that she would pick this up with Mrs Nicky Wilde, Director of Primary Care. HWS had also undertaken four visits to various hospital wards, including: Ophthalmology - RSH Ward 21 RSH Holly Ward The Redwoods Ward 22 RSH Furthermore a number of care home visits had taken place, with reports either published or due to be published, these included: Old Rectory Care Home Hendra House Beech House 23.2 Dr Povey acknowledged the significant work undertaken by HWS and asked when the outcome of the tendering process would be known. Mrs Randall-Smith confirmed they were hoping to hear next week. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the verbal update on the activities of Healthwatch Shropshire (HWS) during October to December ACTION Mrs Tilley to raise issue of lack of awareness of Accessible Information Standards (AIS) by GPs with Mrs Nicky Wilde as Director of Primary Care. FOR INFORMATION ONLY/EXCEPTION REPORTING Minute Nos. GB to GB The following minutes of the Governing Body Committees were received and noted for information only: Clinical Commissioning Committee 15 November Quality Committee 29 November Finance & Performance Committee 6 December Page 21 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

25 Primary Care Commissioning Committee 6 December 24.2 There were no specific points raised in relation to the minutes. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the minutes as presented above. Minute No. GB Questions from the Public 25.1 Dr Povey advised that he had received written questions from Mr David Sandbach in relation to vascular surgery (copy attached as Appendix 1). Dr Davies gave a verbal response and advised Mr Sandbach that she had spoken to Mr Antony Fox, SATH s Deputy Medical Director and Vascular Surgeon, who confirmed that vascular surgery formed part of Specialised Commissioning. However, the both Shropshire and Telford & Wrekin CCGs and Powys Local Health Board were meeting with SATH to analyse the data and undertake an impact assessment of any potential decision. Mr Sandbach responded and expressed concern that more and more services were being moved out of Shropshire and asked what could be done to stop this. Dr Povey advised that for some specialities having access to more specialised centres and treatment gave better outcomes for patients. However, each speciality needed to be individually assessed and that the CCG needed to act in the best interest of its patients Dr Povey opened the meeting to verbal questions/comments from members of the public not relating to the Clinical & Financial Sustainability agenda items. The following questions were noted: a) Mr Chris Deaves Mr Deaves reported that he shared the concerns of Governing Body Members in relation to the output of the Shropshire, Telford & Wrekin STP and referred to a report published by the Kings Fund following STP pilots and suggested that the STP Team consider the findings from the report and provide the Governing Body with a briefing on what the Team were doing to address the inhibitors identified from the pilots. Dr Povey confirmed that the local STP Programme Board was working closely with the Kings Fund to develop the collaborative working required in order to improve services and quality of care for patients. b) Mrs Sylvia Jones, Clunbury Parish Council Mrs Jones expressed concern with regards to Shropdoc cover at community hospitals as she felt there was conflicting information with regards this and drew Members attention to the Governing Body minutes from 13 December 2017 and South Locality Board minutes of 5 October 2017 and asked if a Quality Impact Assessment (QIA) on the changes had been conducted. Dr Freeman explained that for the out-of-hours service as a whole Shropdoc were utilising Urgent Care Practitioners (UCPs) to provide additional support, as there was insufficient GP cover. Dr Freeman advised that although a GP may not be stationed overnight at community hospitals, they would still have access to out-of-hours GP services, as previously. With regards to GP cover in the day at community hospitals, this would continue to be provided by a local GP practice. Ms Clarke reported that although a QIA had not been conducted in relation to the use of UCPs by Shropdoc, she gave assurance that the practitioners were highly skilled individuals who were bound by a Code of Conduct and had to complete a competency framework Dr Povey thanked members of the public for their comments and closed the meeting to questions. Minute No. GB Any Other Business 26.1 There were no items of any other business raised. Page 22 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

26 DATE OF NEXT MEETING The next scheduled meeting of the CCG Governing Body is: CCG Governing Body Meeting (open to the public) Wednesday 14 February time and venue to be confirmed. SIGNED.. DATE Page 23 Minutes of the CCG Governing Body Meeting 10 January 2018 TEJ Shropshire Clinical Commissioning Group

27 Shropshire Clinical Commissioning Group ACTIONS FROM THE CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY MEETING 10 JANUARY 2018 Agenda Item Action Required By Whom By When Date Completed/ Comments GB Introductory Comments from the Chair GB Matters Arising Dr Povey to write letter to Mr Philip Dunne MP thanking him for his work as Health Minister. Dr Julian Povey Immediately GB A&E Delivery Board Minutes Ms Clarke to circulate copy of SATH s Business Continuity and Escalation Plan to Governing Body Members. Ms Dawn Clarke As soon as possible GB Questions from Members of the Public Ms Clarke to ascertain what the current position was in relation to access to Midwife Led Services/Units following the temporary closure of the Oswestry and Royal Shrewsbury Hospital Mid-Wife Led Units and feedback to next Governing Body meeting. Ms Dawn Clarke February Governing Body meeting Press release issued MLU relocating to another part of RSH GB Progress Report on Quality, Innovation, Productivity & Prevention (QIPP) schemes Mrs Skidmore to reflect on lessons learnt from 2017/18 QIPP schemes and ensure these are taken into consideration when setting 2018/19 schemes. Mrs Claire Skidmore As part of the 2018/19 QIPP programme Will form part of the QIPP 2018/19 report presented to the March Governing Body meeting GB Sustainable Neurology Services Dr Lynch to provide Dr Davies with specific examples of out-of-county patients not being able to access the necessary support services following their diagnosis, in order for these to be investigated. Dr Finola Lynch & Dr Julie Davies Immediately Ongoing/in progress Dr Freeman to formally write to Chief Executive, SATH, to clarify the position in relation to the phased re-opening of neurology services at the Trust. Dr Simon Freeman Immediately Page 24 Minutes of the CCG Governing Body Meeting 13 December 2017 TEJ Shropshire Clinical Commissioning Group

28 Agenda Item Action Required By Whom By When Date Completed/ Comments GB Emotional Wellbeing Service update Dr Davies to provide regular updates to the Governing Body on current performance of the 0-25 Emotional Wellbeing Service and progress against the Remedial Action Plan. Dr Davies, Dr Freeman and Mrs Fortes-Mayer to meet and seek assurance that the Remedial Action Plan for the 0-25 Emotional Wellbeing Service had been approved by commissioners and that timelines were agreed. Dr Julie Davies Dr Julie Davies, Dr Simon Freeman & Mrs Gail Fortes-Mayer Future Governing Body meeting As soon as possible, by the end of January Future Governing Body meetings Completed Dr Davies to feedback concerns and comments from Governing Body Members on the current performance of the 0-25 Emotional Wellbeing Service to the Executive Lead at Telford & Wrekin CCG. Dr Julie Davies Immediately Completed GB NHS 111 Dr Davies to provide Dr Povey with copy of audit report which tested 10 scenarios to see if there were any differences in behaviour of call handlers between NHS111 and Shropdoc. Dr Julie Davies Immediately Completed Dr Davies and Mr Millar to check figures quoted in paragraph 17 of the report in relation to the percentage of ambulance dispositions and present a clarification statement on this to the next Governing Body meeting. Dr Julie Davies & Mr Charles Millar February Governing Body meeting On 14 February agenda Dr Davies to ask Mr Millar and Mrs Pyrah to arrange a meeting with Mr Shepherd with regards to comparing NHS 111 data he had in order to establish if there were any discrepancies with the CCG data and feedback to the next Governing Body meeting. Dr Julie Davies, Mr Charles Millar & Mrs Emma Pyrah As soon as possible Dr Davies to present update on progress towards switching off the Shropdoc out-of-hours number following the crossborder technical issues. Dr Julie Davies February Governing Body meeting On 14 February agenda Page 25 Minutes of the CCG Governing Body Meeting 13 December 2017 TEJ Shropshire Clinical Commissioning Group

29 Agenda Item Action Required By Whom By When Date Completed/ Comments GB Questions from Members of the Public Dr Freeman to meet with Mr Sandbach, Mr Shepherd, Mrs Randall-Smith and Councillor Sheinton in relation to the ongoing work on the Out of Hospital Programme. Dr Simon Freeman As soon as possible GB Financial Report Mrs Skidmore to ensure modelling of winter pressures and cancellation of elective activity at SATH was conducted to ensure there was no potential impact to 2018/19. Mrs Skidmore to include further detailed narrative on Forecast Outturn (FOT) vs unmitigated risk in future Financial reports. Mrs Claire Skidmore Mrs Claire Skidmore As soon as possible Future Financial reports presented to the Governing Body Addressed at Finance & Performance Committee In Month 9 Financial Report GB Corporate Performance Report Mrs Skidmore to provide Mr Hutton with information on increased running costs of 0.5m in Month 8. Dr Davies to circulate performance update to Governing Body Members on the specific services associated with SSSFT. Mrs Claire Skidmore As soon as possible Dr Julie Davies As soon as available February Governing Body meeting GB Contract Performance Report Mrs Fortes-Mayer to include update on Shropdoc contract and 0-25 Emotional Wellbeing Service in future Contract Performance Reports presented to the Governing Body. Mrs Gail Fortes-Mayer Future Contract reports presented to the Governing Body Completed Mrs Fortes-Mayer to provide Governing Body Members with an update on the use of Non-Emergency Patient Transport Service (NEPTS) by SATH for inter-site transfers and associated costs. Mrs Gail Forest-Mayer February Governing Body meeting Circulated to Governing Body Members GB Quality Report Dr Davies to obtain details on planned restructure of West Midlands Ambulance Service (WMAS) and provide update to next Governing Body meeting. Dr Julie Davies February Governing Body meeting On 14 February agenda Professor Thomson to provide Governing Body Members with copy of SSSFT s report into unexpected deaths when available. Professor Rod Thomson As soon as available Page 26 Minutes of the CCG Governing Body Meeting 13 December 2017 TEJ Shropshire Clinical Commissioning Group

30 Agenda Item Action Required By Whom By When Date Completed/ Comments GB Quality Strategy & Delivery Plan GB Safeguarding Children s Board Annual report Mr Meredith and Ms Clarke to present Quality Strategy & Delivery Plan to February Governing Body meeting. Ms Clarke and Mr Coan to develop reference sheet for GPs to assist with accessing services for Looked After Children (LAC). Mr Meredith Vivian & Ms Dawn Clarke Ms Dawn Clarke & Mr David Coan February Governing Body meeting As soon as possible On 14 February agenda Ms Clarke and Mrs Tilley to raise awareness with CCG staff of their responsibility to undertake mandatory safeguarding training in order to ensure the CCG was 100% compliant and present progress to next Governing Body meeting. Ms Dawn Clarke & Mrs Sam Tilley February Governing Body meeting Completed GB Mrs Tilley to present Risk Management Policy to February Governing Body, subject to approval by Audit Committee. Mrs Sam Tilley February Governing Body meeting On 14 February agenda GB Sustainability & Transformation Plan (STP) Mrs Skidmore to undertake a review of expenditure associated with the STP, including staffing and running costs, and present findings to Governing Body Members. Mrs Claire Skidmore February Governing Body meeting Completed GB Healthwatch Report Mrs Tilley to raise issue of lack of awareness of Accessible Information Standards (AIS) by GPs with Mrs Nicky Wilde as Director of Primary Care. Mrs Sam Tilley Immediately Completed Page 27 Minutes of the CCG Governing Body Meeting 13 December 2017 TEJ Shropshire Clinical Commissioning Group

31 Appendix 1 Member of the public - questions from D Sandbach Question 1: Are members of the CCG aware of the following? Vascular Surgery UK Workforce Report 2014 Results of a Survey of the Consultant Vascular Surgery Workforce in the UK Acute NHS Trusts who wish to host a vascular surgery service must provide 24/7 availability of the facilities necessary to assess, diagnose, and treat vascular emergencies. To provide 24/7 vascular emergency care in a safe and sustainable way we will need larger teams working in fewer hospitals, ideally linked with acute stroke, cardiothoracic, renal and major trauma services. Source: Question 2: Are members of the CCG aware of this advice? The high volume arterial hospital for the network should provide the following facilities: a) A 24/7 consultant on-call rota for vascular emergencies of 1:6 or greater, covered by a combination of vascular surgeons and interventional radiologists to ensure adequate care. b) A 24/7 critical care facility with ability to undertake mechanical ventilation and renal support and with 24/7 on-site anaesthetic cover. c) Wards for dedicated vascular patients should be available. d) At least one endovascular theatre or theatre specification endovascular suite is required, preferably with high quality imaging, advanced applications, and a dedicated X-ray table. (MHRA guidance) e) A minimum number of 60 AAA and 40 carotid procedures (elective and emergency) are undertaken per annum. It is recommended that hospitals performing less cases than this, averaged over a 3 year period, should not continue to offer these procedures. Commissioners should monitor these numbers in the round. f) The population covered by the network should be sufficient to generate the required volume of procedures at the arterial centre. A minimum of 800,000 is usually required for this. g) An on-site vascular laboratory should be available. h) Hospitals, vascular surgeons and interventional radiologists should submit cases to the National Vascular Registry (NVR) and publish their outcomes in line with the National HQIP programme. Actions should be taken to ensure all outcomes are satisfactory. i) Vascular surgeons should undertake regular review of their practice and outcomes (morbidity and mortality / governance meetings). Source: Question 3 Are CCG Board Members aware of this local data? 28

32 Source: Source: Question 4: Do members of the CCG think it would be a good idea to engage with the local Consultant vascular surgeons to agree a policy for vascular surgery in the County bearing in mind the consequences for the up-coming consultation period associated with the PCBC and Future Fit? 29

33 Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: Responsible Director: Patient Experience Account End of Life Pathway for Care at Home Ms Dawn Clarke, Director of Nursing, Quality and Experience Author of the report: Ms Jane Blay, Patient Experience Lead Mr Phil Stredwick, Patient Insight Officer Presenter: Mr Meredith Vivian, Lay Board Member Patient and Public Engagement Purpose of the report: For the Board to receive an experience account which highlights the real experiences of the individuals who use and deliver the services for which we are responsible. Key issues or points to note: The excellent end of life care provided within a home setting and the difference this made for all concerned A need for the population as a whole to be encouraged to consider their own advanced end of life planning A need to raise awareness of the availability of supported end of life care within the community with patients, families and carers A need to ensure that requisite medication is easily available particularly during out of hours to minimalise any associated distress for the family and carers Actions required by Governing Body Members: Reflect on this Experience Account and review their associated level of influence to ensure that patients are fully supported with their advance planning for end of life care aligned to the Gold Standard Framework. Support the wider Local Health Economy to ensure that patients end of life wishes are upheld Proactively address and ensure that all learning outcomes are systematically identified and acted upon to ensure improvements are made for the benefit of all.

34 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required Yes/No 2 Health inequalities If yes, please provide details of the effect upon health inequalities Yes/No 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement 5 Patient and public engagement If yes, please provide details of the patient and public engagement 6 Risk to financial and clinical sustainability If yes how will this be mitigated Yes/No Yes/ No Yes/ No Yes/ No

35 Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: QIPP Update, M9: December 2017 Responsible Director: Claire Skidmore, Chief Finance Officer Author of the report: Kim Morris, Head of PMO Presenter: Claire Skidmore, Chief Finance Officer Purpose of the report: To inform the Governing Body of the performance of the QIPP programme to date as incorporated in the month 9 finance position. Key issues or points to note: At month 9, an outturn delivery of m against the target of 17.71m has been reported. The forecast from month 8 remains unmoved. Project managers are focusing energies on development of schemes for 2018/19 as the QIPP target for the year will be significant based on current budget projections. Actions required by Governing Body Members: To note the reported Month 9 position. 1

36 Introduction 1 The purpose of this report is to provide information and assurance to the Governing Body on the progress of the 17/18 QIPP Programme. QIPP programme for 2017/18 2 At month 9, an outturn delivery of m against the target of 17.71m has been reported. There has been no change in the forecast position since month 8 3 The table and graphs below demonstrate month on month progress against plan for 2017/18. 4 Table /18 schemes Year to Date and forecast outturn Graph 1 Monthly QIPP Delivery v s Plan Graph 2 Cumulative QIPP Delivery v s Plan 2

37 Table 1 QIPP SUMMARY M09 - December 2017 Area of Spend (NHSE) Scheme Ref Scheme Description Scheme Type Planned Start Date Plan '000 Year to Date Annual 2017/18 Actual Variance Plan Forecast Variance '000 '000 '000 '000 '000 Acute Services ACU01 SaTH Contract QIPP Successful challenges as part of the monthly contracting process Transactional Apr (888) 1,651 - (1,651) ACU02 Value Based Commissioning (VBC) excl MSK The objectives of the musculoskeletal review are to right size the orthopaedic spend Transactional May-17 1, (849) 2, (1,231) through the development of a service model that sees the shift of musculoskeletal activity to primary and community care and offers supported self-management to patients. ACU03 MSK excl RJAH MSK QIPP The objectives of the musculoskeletal review are to right size the orthopaedic spend Transactional Aug-17 1, (849) 3,000 1,128 (1,872) through the development of a service model that sees the shift of musculoskeletal activity to primary and community care and offers supported self-management to patients. ACU04 NEL variation reduction by P Care Practice based incentive scheme to reduce unecessary variation in emergency Transactional Oct (581) 1,276 - (1,276) admissions ACU06 Shropshire Orthopaedic Outreach Service (SOOS) Redesign and expansion of Shropshire Orthopaedic Outreach Service (SOOS) Transactional Jan ACU07 Contract Challenges Report by Monmouth indication significant savings through contract challenges Transactional Jan ACU08 Service Redesign Release of Reserve. Transactional Apr ACU09 MSK VBC New model of care with single organisation responsible for MSK pathway including Transformational Apr (80) review to de-commission non-evidenced treatment + introduce thresholds for nonspecialised procedures outside national benchmarking ACU10 DEXA tariff adjustment DEXA tariff reduction Transformational Apr ACU11 Biosimilars/Med Mgt/OPFU-Exogen Efficiency savings jointly delivered in following areas: Transformational Apr (110) (129) - Exogen bone stimulation - Biosimilars incl anti TNF drug alternatives ACU12 HISU To support HISU to access the most appropriate health and social care, reducing demand on urgent and emergency care services - ambulance conveyance, A&E attends and NEL admissions Transformational Jul Acute Services Total 5,487 2,235 (3,253) 9,100 3,997 (5,103) Community Health Services COM01 Growth management Joint work on service change/ cessation with the provider to develop an operating budget that does not require the 1,301k growth monies identified Transformational Apr (106) 1,301 1,301 (0) COM02 CCG QIPP schemes The CCG to identify an additional 300k QIPP schemes Transformational Apr (231) (310) Community Health Services Total 1, (337) 1,611 1,301 (310) Primary Care Services PRI Prescription Ordering Direct (POD) The POD will provide an additional method for patients to order their repeat prescriptions, enabling increased patient empowerment and the ability for patients to take control of their repeat medication requirements. Synchronise quantities of all repeat medication to the same length of treatment Amend quantities to ensure that patients do not have excess of their medication Remove items to past if they have not been ordered for 6 months or more Refuse prescriptions that are requested more than 7 days ahead of the due date. Discontinue any medicines that the patient reports they are no longer using and informing the Practice clinician Transactional Apr (247) (322) PRI Scriptswitch A continuation of using the existing ScriptSwitch technology to identify potential Transactional Apr , ,947 1,497 drug switches to GPs for potential drugs switches. ScriptSwitch is a prescribing decision support tool which integrates into practices clinical systems. This is the tool chosen by the CCG to implement key formulary decisions. Impact of W1 is expected to be 344, Expect impact of W2 is expected to be 155,315 PRI Care home and domicillary services To promote the safe and effective use of medicines in care homes by advising on processes for prescribing, handling and administering medicines. Transactional Apr (105) (96) Recommend how care and services relating to medicines should be provided to people living in care homes. NICE have produced guidance helping organisations improve quality, cost effective prescribing and administration in care homes. (1) Many Medicines Management teams have developed their Care Home service to good effect (2) Proposal Service to cover the 130 Care Homes with operational management of medicines within the Home along with improvements in quality, reduction in risk and realisation of savings. Provide access to clinical pharmacist input within 48 hours of admission/discharge from Home. Develop formal links with CHAS scheme so as to provide holistic medicines review service to Care Homes. Costs - 180k for Care home review Pharmacists, Technician, nursing and dietetic input with admin support. Savings - Based upon existing services, savings of 163,000 per 0.6WTE Pharmacist input. As we will be utilizing the services of nurse and dietician also, we believe we will achieve in year drug savings of 675k. PRI Board backed approach to meds mgt savings QIPP enabler, no direct savings Transactional Apr ,151 1, (200) PRI Prescribing restrictions looking into the value of medicines prescribed on the NHS that are for self-limiting Transactional Apr conditions are generally less expensive to purchase than to fund on an NHS prescription e.g. Paracetamol PRI Oral Nutritional Supplements (ONS) To improve the management of malnutrition and prescribing of oral nutritional Transactional Apr (73) (67) supplements in SCCG. Reduce expenditure on Oral Nutritional Supplements (ONS) by restricting use in Care Homes, and use of MUST screening tools and "Food first" options. To continue ongoing work of existing Dietician. Targeting of COPD patients at risk of Hospital admission and mortality <75yrs NICE has identified that improving the treatment and identification of people who are malnourished will result in substantial cost savings to the NHS PRI Effective approach to local decision-making QIPP enabler, no direct savings Transactional Apr (529) (825) PRI08 Practice incentive success part payment Gain share monies for GP practices achieving their targets Transactional Apr-17 (217) (180) 37 (339) (339) - NCSO 2,175 2,175 2,900 2,900 Primary Care Services Total 1,923 5,230 3,307 3,000 6,248 3,248 Continuing Care Services CHC01 Joint Assessment Tool Application of the Telford Tool to achieve a revised and lower health contribution Transactional Apr-17 1, (140) 2,100 1,063 (1,037) percentage similar to that employed bu other CCGs including the neighbouring Telford & Wrekin CCG. Use of the revised assessment tool to commence 1st April 2017 and apply to all review cases. CHC02 Hospice extension Extend Hospice schem from last years pilot Transactional Apr CHC03 Baseline review Quality and efficiency care packages Transactional Apr , ,075 2,204 1,129 CHC04 Backlog To accelerate timely reviews Transactional Jul CHC05 OOA MH To develop packages of care closer to home in collaboration with SSSFT Transactional Jul Continuing Care Services Total 2,107 2, ,000 4, Other Programme Services ACU05 BCF Pathway 3 Beds Beds funded by local authority Better Care Fund Transactional Jul Other Programme Services Total Grand Total 10,720 10, ,711 16,224 (1,487) 3

38 Graphs 1 & 2 QIPP Performance and Monitoring 2017/18 5 During December there have been weekly Director sessions held by Simon Freeman supported by the Turnaround Director to review 17/18 scheme finance profiles, risks and issues for escalation. 6 Directors and scheme leads are developing 18/19 business cases including financial profiles and modelling to present to Executive as part of the governance framework for sign off. 4

39 7 An interim appointment has been recruited to produce a Lessons Learned report. This will be presented to the Finance & Performance Committee along with an action plan for improvement in March Risks Project Risk - Finance 8 At month 9, a risk of 0.549m was reported for the QIPP Programme. This is attributable to the potential for VBC benefits to not be realised from acute contracts outside of Shropshire. The CCG s contracts team continue to pursue these challenges Programme Risk 9 The programme risks are as follows: - Project Managers do not have the resource or capacity to lead QIPP schemes. - Evolving schemes delay overall delivery plan. 10 Mitigations are as follows: - SROs actively supporting Project Managers, reviewing any resource or capacity challenges to delivery. - Programme Board meets monthly with SROs in attendance to facilitate assurance of 17/18 schemes and discuss proposals for 18/19 onward. - Early identification and discussion of proposed schemes will ensure capacity and resource are identified earlier. - Regular sessions with SRO's, AO and CFO are highlighting potential delays or risks in delivery of schemes in order that action can be taken Summary and Conclusion 11 Delivery of the plan remains challenging for the CCG and the organisation will continue to remain proactive in supporting schemes to deliver savings to mitigate any shortfall. 12 At month 9, the CCG has no room for any further slippage in the QIPP programme. If QIPP risks do materialise, the CCG does not currently have sufficient mitigations at its disposal to protect the delivery of its control total. Recommendations The Governing Body are asked to: note the reported Month 9 position. 5

40 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required No 2 Health inequalities If yes, please provide details of the effect upon health inequalities No 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement 5 Patient and public engagement If yes, please provide details of the patient and public engagement 6 Risk to financial and clinical sustainability The CCG is reliant on delivery of a substantial QIPP target to ensure that it meets its financial control total and as part of its trajectory to regain financial balance. No No No Yes 6

41 Agenda item: GB Shropshire CCG Governing Body meeting: 14 th February 2018 Title of the report: Transfer of Out of Hours number to NHS 111 Responsible Director: Dr Julie Davies Author of the report: Presenter: Fran Beck, Executive Lead for Commissioning Telford and Wrekin CCG as Senior Responsible Officer (SRO) for the Out of Hours Procurement Dr Julie Davies Purpose of the report: This paper builds on the previous papers submitted to CCG Boards in Shropshire and Telford and Wrekin about the transfer of the phone number from Shropdoc Out of Hours provider to NHS 111. Key issues or points to note: CCG Boards in Shropshire and Telford & Wrekin are part of a consortium of commissioners across the West Midlands who have, via the lead commissioner in Sandwell and West Birmingham, designed a regional model to integrate NHS111 and out of hours services to provide a Integrated Urgent Care Service in line with the national mandate. The contract was awarded to Care UK to run the service from November For the Out of Hours component, both CCGs agreed to continue with the existing provider Shropdoc and issued a Contract Variation (CV) to incorporate the new Service Specification in the Shropdoc contract. The Boards also agreed to continue with a direct patient telephone number to the GP OOH service due to the risk that more patients could have an Emergency Department or 999 disposition if they called NHS111. Since that time, the national and regional teams have completed further work to reduce the likelihood of patients who do not need an ED or 999 being given that disposition by designing a Clinical Assessment Service as part of the central NHS111 service. In the West Midlands the CAS has demonstrated that by involving clinicians in the 111 process helps ensure the patient disposition is appropriate to their needs. CCG Boards are being asked to support the handover of the number to NHS 111 from 3 rd July 2018 for the reasons set out in this report. There are considerations for the Welsh border patients which need to be worked through prior to the proposed change. Local commissioners will work with the regional and Welsh commissioner to ensure that clear and agreed pathways/protocols are in place between the English and Welsh NHS111 services for patients who are registered with a Shropshire GP but live in Wales (and vice versa) to ensure these patients are directed to the most appropriate local service to meet their needs. 1

42 Actions required by Governing Body Members: The CCG Boards are asked to approve the timescale for the transfer of calls from Out of Hours to NHS 111 so that these will be managed by Care UK from Tuesday 3 rd July 2018 subject to the impact on the Care UK contract being fully offset by a contract variation with Shropdoc. 2

43 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications Yes The transfer of the number requires a transfer of resources from Shropdoc to the Care UK contract. 2 Health inequalities If yes, please provide details of the effect upon health inequalities 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement 5 Patient and public engagement A Communication Plan has been produced to support the procurement and other activities around changes to Shropdoc. This is being led by the Engagement lead from the CSU (on behalf of T&W CCG) with leads from Powys and Shropshire CCG. No No No Yes A patient representative will be included in the procurement Evaluation Panel members. 6 Risk to financial and clinical sustainability The risks include:- 1. Care UK not being ready to take on this function 2. Increase in urgent care demand 3. Ensuring continuity for patients living on the Welsh border These are being managed by the project group including commissioners and both providers. Yes 3

44 Introduction Telford and Wrekin and Shropshire CCGs Governing Body Report February 2018 Transfer of Out of Hours number to NHS National policy for England has been advocating a different model for supporting patients needing urgent care that is not an emergency since 2011/12. The high level model is illustrated in the following diagram. National overview diagram 2. CCG Boards in Shropshire and Telford & Wrekin are part of a consortium of commissioners across the West Midlands who have, via the lead commissioner in Sandwell and West Birmingham, designed a regional model to integrate NHS111 and out of hours services to provide a Integrated Urgent Care Service in line with the national mandate. 3. Board members will recall that it took two attempts to procure a provider to deliver the NHS111 component of the integrated service, and that a contract was finally awarded to Care UK to run the service from November At that time several CCGs used the opportunity to test the market and procure a new Out of Hours provider. As agreed at a joint board meeting in February 2016, Shropshire and Telford & Wrekin CCGs agreed to continue with the existing provider Shropdoc and issued a Contract Variation (CV) to incorporate the new Service Specification in the Shropdoc contract. 4

45 5. At the same meeting it was agreed that for the time being we would continue to have a separate Shropdoc Out of Hours number. There were concerns at the time about the risk that more patients could have an Emergency Department or 999 disposition if they called NHS111, and given the urgent care performance in Shropshire plus the fact there was no access to 111 in Wales which would disadvantage patients on the border with regard to the border telephony which would direct patients based on location, we agreed to delay the transfer of the number to a later date. 6. In the meantime the national and regional teams have completed further work to reduce the likelihood of patients who do not need an ED or 999 being given that disposition by designing a Clinical Assessment Service as part of the central service, as shown in the national overview diagram above. In the West Midlands the CAS has demonstrated that by involving clinicians in the 111 process helps ensure the patient disposition is appropriate to their needs. Proposed handover of call handling to NHS CCG Boards are being asked to support the handover of the number to NHS 111 from 3 rd July 2018, for the following reasons:- Shropdoc has been proactively signposting patients/carers to NHS111 from April This was to help them manage their workload but has had the impact of encouraging more patients to start using that alternative number already. The data analysis completed so far does not demonstrate that increasing numbers of patients accessing ED or WMAS services is directly related to calling NHS111. There has been an increase for T&W CCG ED activity, while SCCG ED activity has been largely stable since April, and both have seen increases in WMAS activity. Both CCGs have reviewed the data available. Analysis suggests that ED increases are linked with Primary Care access, compromised earlier in 2017 for some practices in T&W. WMAS increases are related to other factors, for example double counting of ambulance dispatches, and inter-site transfers. The ambulance increases cannot be explained by 111 activity which is still relatively small in comparison. Work is in progress with the lead commissioner to tighten WMAS contract further as it is far more likely that coding practices have changed rather than activity alone. We are now alone in not offering patients a free call via NHS111 and need to be compliant with national requirements. Shropdoc has recently been struggling to maintain financial sustainability and the CCGs together with Powys Local Health Board have been working closely with the organisation to maintain stability of Out of Hours Services. The proposed changes will help protect Shropdoc capacity to focus on provision of out of hours clinical care for patients who need it. Powys are planning to adopt the Welsh NHS111 from 1 st July The Shropshire CCGs are embarking on a procurement process as the current Out of Hours contract ends on 30 th September 2018, and we want to stage the changes during the next few months to avoid a Big Bang of the change of number and a new contract all starting on 1 st October

46 Finally Tuesday 3 rd is the ideal date for Care UK given Mondays are often very busy, and this does not clash with any public/school holidays. 8. There are several considerations which need to be addressed:- Q What happens if the Welsh roll out of NHS 111 is delayed beyond July 2018? A We are all working to a handover date of 3 rd July 2018, and a communications plan is being developed to ensure all patients are aware of these changes. Commissioners in Powys have confirmed they are confident that the timescale will be delivered. The Powys lead has also confirmed that if there is any risk of delay their Business Continuity Plan would be implemented. Q. Once NHS 111 is available for Shropshire and Powys what are the implications for Welsh residents with a Shropshire GP and for Shropshire residents with a Welsh GP (assuming all commissioners have moved to NHS 111 in England and Wales)? A. The proposed timescale assumes that both English and Welsh patients will be able to access NHS111. The Directory of Services used by NHS111 is based on the patient s locality. There are therefore considerations for the Welsh border patients which need to be worked through prior to the proposed change. Local commissioners will work with the regional and Welsh commissioner to ensure that clear and agreed pathways/protocols are in place between the English and Welsh NHS111 services for patients who are registered with a Shropshire GP but live in Wales (and vice versa) to ensure these patients are directed to the most appropriate local service to meet their needs via the appropriate Directory of Services. Q How is the Directory of Service kept up to date? A We have agreed with Powys that we will continue to work together on this to ensure that the Directory is a live document. Q. What are the financial implications? A. We will be required to fund Care UK for the additional activity from 3 rd July 2018, but this should be cost neutral. Q. Are Care UK ready to take on this work? A, Yes this has been a contractual detail established with Care UK when they took on the NHS 111 contract. Care UK are currently engaged in regular meetings with Shropdoc and both regional and local commissioners to develop an implementation plan to transfer the activity between the two providers. 9. Recommendation The CCG Boards are asked to approve the timescale for the transfer of calls from Out of Hours to NHS 111 so that these will be managed by Care UK from Tuesday 3 rd July 2018 subject to the impact on the Care UK contract being fully offset by a contract variation with Shropdoc. 6

47 Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: Responsible Director: Author of the report: Presenter: Out of Hospital Transformation Programme Julie Davies, Director of Performance & Delivery Lisa Wicks, Head of Out of Hospitals Commissioning & Redesign Lisa Wicks, Head of Out of Hospitals Commissioning & Redesign Purpose of the report: To outline the strategic intent for the out of hospital transformation programme. Key issues or points to note The work completed by Optimity (2017) and Deloitte (2016) illustrate Shropshire s overdependence on in-patient resources secondary to historically commissioned services which have grown organically and failed to take into account key factors such as demographic changes. Optimity data enables extrapolation of 65+ admission avoidance (AA) figures (4,586 instances per year), whilst David Harry, Interim Business Intelligence expert, projected 3,120 instances for this age band. However, existing Future Fit parameters have necessitated AA performance targets be constrained to 2,689 instances per year. The programme target admission avoidance is set at 4,586. Key Programme Priorities Phase 1 Frailty Front Door (presently operational). Phase 2 Primary Care Development including Local Enhanced Services and Case Management (collaborative design by March 2018 Risk stratification to commence as soon as possible). Phase 3 Hospital at Home/Crisis Intervention/Rapid Response/DAART and Step UP Community Beds (Collaborative design by June 2018). Approach We are going to be collaborative and will involve all our partners throughout the process. We shall communicate what we are doing, why we are doing it, when it will be done and how people can get involved as we go. We shall be transparent and open throughout the process and explain the rationale for our decisions at all times. Actions required by Governing Body Members: To acknowledge and endorse the programme approach.

48 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications No 2 Health inequalities No 3 Human Rights, equality and diversity requirements An equality and privacy impact assessment will be required as part Yes of the program. 4 Clinical engagement Clinical engagement is required through the programme 5 Patient and public engagement Engagement is required with patients and the public in relation to the new service delivery model. 6 Risk to financial and clinical sustainability Yes Yes No 2

49 NHS Shropshire CCG Executive Team Meeting Out of Hospital Transformation Programme Author: Lisa Wicks 1 The vision for the out of hospital transformation programme for Shropshire is: Using all available resources to commission integrated health and care services that are clinically effective and cost-efficient and as close as possible to where people with the greatest need live. Development of a new and sustainable model of community care 2 We are going to review the current provision of community based services and make the necessary changes to the overall system that is required to better deliver services closer to home. 3 This supports the delivery of the The Five Year Forward View that advocates collaborative whole system solutions. Out of hospital care will become a much larger part of what we do across the Shropshire health and care economy. Rationale 4 The work completed by Optimity (2017) and Deloitte (2016) illustrates Shropshire s over dependency on in-patient resources secondary to historically commissioned services which have grown organically and failed to take into account key factors such as demographic changes. Optimity (2017) suggest that through shifting secondary service utilisation by a 5 year age band will reduce emergency usage of secondary services by 385 cases per 5,000 head of population within the 65+ age band equating to 4586 admission avoidances. 5 Based upon the existing parameters surround the Future Fit Outline Business Case the target admission avoidance for this age band is set at 2,689. The work produced to inform the target for the Frailty Intervention Team focused upon the 75+ population of Non-elective admissions during previous years. This methodology has been expanded to include patients 65+, and this has provided an admission avoidance target of circa 3,000. The detailed modelling methodology for the programme is attached at Appendix 1. 6 The following table presents the potential admission avoidance for the phases of the programme: 3

50 Optimity Admission Avoidance Figures Considered Against Resources Required to Meet Need over a 1 Year Period Admission Avoidability Service Usually Sometimes avoidable avoidable Total Hospital at Home 1, ,141 Hospital at Home or Crisis Response/Step up beds 1,796 1,215 3,011 Hospital at Home or Crisis Response/Step up beds or Admission Crisis Response/Step up beds Crisis Response/Step up beds or admission Total 2,963 2,085 5,048 7 Some of the service rows in the above table illustrate the level of difficulty surrounding the task of projecting service demand. It is therefore crucial that the reader understands that these projections reflect best guess methodology as detailed in Appendix 1. Although it is entirely possible that admission avoidance could be achieved for the sometimes avoidable cohort, the Usually avoidable cohort will be used to project the community resource requirement to achieve the target circa 3,000 admission avoidance. Key priorities of the Programme 8 Phase 1 Frailty Front door (presently operational) - A dedicated Multi-Disciplinary Team (MDT) based in the Emergency Department who are responsible for the early identification, treatment, risk assessment and planning for frail and long term condition patients. This improvement will facilitate appropriate triage of patients to either the acute/community/home setting. This team will liaise and work with existing teams in the community such as intermediate care and Care Co-ordinators etc. DAART is a key focus for this process in terms of linking into existing acute frailty expertise, resources and skills, providing a responsive ambulatory care function. The target admission avoidance for this phase of the Programme is 558 in 2018/19. 9 Phase 2 Primary Care Development including Local Enhanced Services and Case Management (Collaborative design by March 2018 Risk stratification to commence as soon as possible) built around general practices with a core Locality Team including district nurses, care co-ordinators, allied health professionals, social care and matrons. This element of the service will identify the case management cohort of service users, develop personalised care plans, provide the day to day care and support including wider services as necessary. For stable service users this will be the default range of services. It will provide a named lead for each service user to generate emergency care plans and to design the escalation services necessary to manage any exacerbation. The community matrons are key in the education and competence building of wider staff. 10 Practice level prevalence of long term condition type and comorbidity has been extrapolated based on NHS Digital population profiles and has been used to determine a 65+ population of 24.3% across the county. This group requires risk stratification at 4

51 practice level to identify Mild/Moderate/Severe long term conditions (LTC) population for case management. *This is a gap in the current commissioned service. 11 Phase 3 Hospital at Home/Crisis Intervention/Rapid Response/DAART and Step Up Community Beds (Collaborative design by June 2018) Where care needs escalate beyond the core teams, service users will move into a Hospital at Home element of the service. This will incorporate the step-up element of the intermediate care team and community beds with an enhancement to medical cover arrangements (which could include in-reach from acute consultants or alternative medical governance models) and access to IV Antibiotics etc. within the community. The specialist frailty and long term conditions teams will be part of this element of the service, both in terms of care delivery to manage exacerbations and also in an educational role to cascade skills into the core teams. A rapid response team will be established to enable intervention at pace across the Hospital at Home and Crisis functions. This team will make full use of the re-specified DAART and community bed provision. This service will manage the cohort of patients indicated by Optimity (2017) as 4,586 and David Harry (2017) as 3,120 (patients identified sometimes and usually could be managed elsewhere). *The Hospital at Home Team/Crisis Intervention/Rapid Response are gaps in current commissioned Services. DAART and Community Beds will need to be redefined to meet the needs of this work, the Sturgess Review (2018) and the Urgent Care Capacity & Demand Modelling (2018) which are underway. 12 Practice level modelling has been undertaken to establish the number of patients to be case managed based on age and comorbidities to meet the admission avoidance target. Work is required within the locality task and finish groups (using Simul8) to model the impact of the Crisis Intervention/Rapid Response element of the programme using point prevalence data at a practice level. 13 The assumptions within the programme on case management are based on the evidence from the United States, reflecting the fact that case management programmes have been established there for longer. For example, the Promoting Action for All-inclusive Care for the Elderly (PACE) case management programme has been associated with reduced hospital utilisation and nursing home use. When compared with a control group, older people enrolled in the PACE programme showed a 50 per cent reduction in hospital use and were 20 per cent less likely to be admitted to a nursing home. 14 PACE patients, however, used more ambulatory care services (Kodner and Kyriacou 2000). Evaluations of Guided Care have similarly found evidence of reduced care costs, reduced hospital admissions and visits to A&E, and lower lengths of stay compared with control patients not case managed (Kings Fund 2011) Approach We are going to be collaborative and will involve all our partners throughout the process. We shall communicate what we are doing, why we are doing it, when it will be done and how people can get involved as we go. We shall be transparent and open throughout the process and explain the rationale for our decisions at all times. 5

52 Clinical Commissioing Committee 15 We will use the process outlined within HM Treasury Green Book Methodology for our option appraisal process (which includes collaborative design, option development, weighting criteria and shortlisting of options) and we are working with our stakeholders to develop our engagement and consultation strategy (a workshop is planned for 28 th February 2018 to continue this work). 16 The Community Services Review work will continue as follows: Option development for DAART and Community Beds will form part of the programme at Phase 3; Option development for Minor Injuries Services will move to the CCG s Urgent Care Portfolio for development alongside the system s urgent care agenda. Programme Management & Governance 17 The programme will be managed using a project management approach and overseen by the following governance arrangements: Locality Task & Finish Groups CCG Out of Hospital Programme Board Patient Engagement Forums CCG Out of Hospital Programme Working Group 18 Terms of reference for the groups have been developed and the membership identified (Attached as Appendices 2 and 3). These will be ratified at the Clinical Commissioning Committee in February The governance reports into the neighbourhood work of the Sustainability & Transformation Plan. Timescales 19 The proposed timeline for the work is as follows: Design complete by Phase 2 (March 2018) Phase 3 June 2018 (long list of options) Option Appraisal process June 2018 (Phase 2) September 2018 (Phase 3) Consultation commence September 2018 (Phase 2) December 2018 (Phase3) 6

53 20 To ensure a robust consultation process it is proposed that the programme be divided into the phases listed above. The phased approach will also allow primary care (as part of the collaborative design) to validate the modelling assumptions for case management (Kings Fund 2011) and admission avoidance numbers identified by Optimity (2017). 21 The programme will then shift focus to address the shift of planned care to the community (out-patient appointments, hub clinics etc.) and development of the community services for Children s. The table below details the planned programme timeline subject to review and approval from the Board. Phase 2 Phase 3 Design Complete March 2018 June 2018 Options Appraisal June 2018 September 2018 Possible Consultation September 2018 December

54 Appendix 1 The table below outlines the figures that were originally modelled for the Out of Hospital Case management. Table 1 Locality July July with 1+ LTC Case Management numbers (assuming 20% NEL admission avoidance) 2019/ / /22 Case Case Management NEL NEL Management numbers Admission Admission numbers (assuming Avoidance Avoidance (assuming 28% 24% NEL Target Target NEL admission admission avoidance) avoidance) NEL Admission Avoidance Target North 23,190 19, Central 22,135 17, South 27,962 22, Total 73,287 58, Method for establishing the above: Practice prevalence of 65+ populations is based upon NHS Digital July statistics; Size of 65+ LTC cohorts is based upon Age UK (2017) statistics; Size of cohorts with 1, 2, 3, 4, 5, 6, and 7+ LTC s is based upon locally produced data (Optimity, 2017); All non-elective (NEL) admission data for 65+ people with LTC s is derived from the Secondary Users Service (SUS) data; All NEL admissions registered with non-shropshire GP Practices have been excluded; Total numbers of NEL admissions for people over 65 with between 1 and 3 LTC s have been established in order to understand a benchmark to work against for the purpose of NEL admission avoidance; Target admission avoidance has been set at 10% of these figures for 2019/20, 20% for 2020/21, and 24% for 21/22. Additional Work Undertaken 23 The work undertaken to establish the projected hospital avoidance figures to occur as a consequence of the Frailty Intervention Team (FIT) focused upon NEL admissions in the 75+ cohort. Based upon the ICD10 codes used by Optimity, CCG Business Intelligence have projected within this group, admissions that could usually be managed out of hospital, those that could sometimes be managed out of hospital, and those where hospital admission is not avoidable. 24 This report has been re-run to include all 65+ NEL admissions, and this method indicates the following: 8

55 Total NEL Admissions 14,556 August 16 July 17 Admission Avoidability Unavoidable 9,508 Sometimes avoidable 2,085 Usually avoidable 2, Based upon the above figures, the target Admission avoidance will be set at circa 3,000 patients, equating to 20.6% of the total NEL admissions reported for the timeframe. Data underlying the original modelling demonstrates that of the 14,556 NEL admissions recorded, 8,987 were for individuals with between 1 and 3 LTC s. Our expectation is that the 3,000 circa admission avoidance target will be realised within this cohorts of patients meaning 33.4% admission avoidance (AA) needs to be achieved. This has been broken down as follows: 65+ NEL Admissions with between 1 and 3 LTC s between August 16 and July 17 Number of LTC s Numbers of NEL admissions 3,481 3,299 2,207 Target % of AA 45% 33.4% 15% Numbers of AA Based upon Optimity figures, the scope of primary care risk stratification will include all 65+ registered patients, equating to around 240 patients per 1,000 head of population registered. Of this 240 patients, it is expected (based upon initial modelling) that around 50% will have between 1 and 3 LTC s requiring case management in order to achieve the admission avoidance target. 27 The table below indicates what this would look like at a locality and county level Numbers for Case management based upon projected volume of people with 1-3 LTC s Locality % of population Numbers for case management North 31.6% 2,782 Central 30.2% 2,656 South 38.2% 3,355 Total 100% 8, Considering the ICD10 codes constituting the Optimity reporting, CCG medical resources have been drawn upon to help determine where those admissions identified as sometimes and usually avoidable would best be managed in the Out of Hospital context. The table overleaf indicates what this would look like in terms of numbers requiring input from which community resources: 9

56 Optimity Admission Avoidance Figures Considered Against Resources Required to Meet Need over a 1 Year Period Admission Avoidability Service Usually Sometimes avoidable avoidable Total Hospital at Home Hospital at Home or Crisis Response/Step up beds Hospital at Home or Crisis Response/Step up beds or Admission Crisis Response/Step up beds Crisis Response/Step up beds or admission Total Some of the service rows in the above table illustrate the level of difficulty surrounding the task of projecting service demand, it is crucial therefore that the reader understands that these projections reflect best guess methodology. This approach will be robustly tested within the locality task and finish groups. Although it is entirely possible that admission avoidance (AA) could be achieved for the sometimes avoidable cohort, the Usually avoidable cohort will be used to project the community resource requirement to achieve the target circa 3,000 AA s. 30 In order to discern the proportionate split of the Hospital at Home or Crisis Response/Step up beds row pertaining to Usually avoidable admissions, the following will be assumed: Based upon the target of 45% of this cohort having 1 LTC, it will be assumed that 45% of this row (808 AA s) will be enabled by the hospital at home service. This equates to 64.2% of the services required to achieve the AA target being Hospital at Home. The following table provides the resource breakdown required to achieve the circa 3000 AA target by locality: Locality Overview of projected model for achieving target 3000 AA s per year Numbers for Numbers for % of Target AA case Hospital at population Numbers management Home (64.2%) Numbers for Crisis Response/Step up beds (35.8%) North 31.6% 2, Central 30.2% 2, South 38.2% 3, Total 100% 8, end- 10

57 Appendix 2 Shropshire Clinical Commissioning Group Out of Hospital Programme Board Terms of Reference Project Details Project Name Shropshire Out of Hospital Transformation Programme Dr Jessica Sokolov SRO (Sponsors) Dr Julie Davies Lisa Wicks Commissioning Team Pete Downer Barrie Reis-Seymour Document Details Version Status (Draft or Approved) Date Author/Editor Details of changes v0.1 Draft 8/1/18 Barrie Reis-Seymour First Draft V0.2 Revisions 30/1/18 Lisa Wicks Second Draft V0.3 Final amendments 5/2/18 Barrie Reis-Seymour Third Draft Associated Documents (that this document should be read in conjunction with) Version Title of Document No/File Date Name Out of Hospital Transformation Strategy on 2 Pages V2 8/1/18 Out of Hospital Transformation Project Plan V1 8/1/18 Out of Hospital Transformation Timeline V1 8/1/18 Out of Hospital Transformation Options Map V1 8/1/18 Out of Hospital Transformation Governance Framework V1 8/1/18 Page 1 of 8

58 1 PURPOSE OF DOCUMENT BACKGROUND STRATEGIC CONTEXT PROGRAMME GOVERNANCE PROGRAMME STRUCTURE PUBLIC ENGAGEMENT OBJECTIVES SCOPE REVIEW DELIVERABLES CONSTRAINTS, ASSUMPTIONS AND DEPENDENCIES INTERFACES... 8 Page 2 of 8

59 1 PURPOSE OF DOCUMENT The purpose of this document is to set the terms of reference for the Shropshire Out of Hospital Transformation Programme Board. 2 BACKGROUND NHS Shropshire Clinical Commissioning Group (SCCG) is focused on making sure patients receive the highest standard of care in a consistent and efficient manner. The primary goals of the Transformation programme are: improving the long term health of the population; improve patient choice and outcomes; providing a model of community based patient-centred care; ensuring services are fit for purpose; empowered and competent workforce; In line with the 5 Year Forward View provision of accessible care within the community with clear and simple pathways, to minimise escalation of healthcare needs. Commissioners must be able to deliver this goal in the context of Shropshire; notably its aging population and rurality with the access issues that this creates for many residents of the county. The additional challenge for Shropshire CCG is that it has a recurrent overspend of almost 20m and an in-year deficit of 24m and therefore the review needs to take into account value for money and affordability within the context of improving patient outcomes and access to services for all patients. Patients within Shropshire currently have access to a wide range of community-based services including inpatient beds, and there are a range of challenges in providing these services under the current operating model. The community beds are in a number of locations, which impacts on efficiency and are on occasion, vulnerable to short-term staffing challenges. A number of CCG commissioning intentions and the direction of the Shropshire, Telford & Wrekin Sustainability & Transformation Plan (STP) call for more services to be provided in community settings, but some of these services face structural challenges in terms of recruiting and retaining an appropriate workforce. The transformation programme will require extensive engagement with GP s, the public, Community Health Trust, staff and all organisations for whom the Community assets play a part of their care or service model. 3 STRATEGIC CONTEXT In 2016, Shropshire and Telford & Wrekin Clinical Commissioning Groups, Local Councils, Acute providers, Community service providers and Mental Health Service providers were asked to work together to produce a Sustainability and Transformation Plan (STP) outlining how they intend to develop and deliver viable health and social care services. This included proposals for improving services for local people and making the most of advances in care and in technology. The STP, published in December 2016, explained that the causes of ill health are rooted in the community, and that the health economy would focus its efforts on developing place-based care, increased community care and greater integration/working with partners. Page 3 of 8

60 This programme will be reviewing and redesigning a range of Out of Hospital care services that will transform the availability and effectiveness of accessible community-based patient centred care to prevent escalation of healthcare needs, and minimise the need for admission to an acute hospital setting, and will form part of the overall community services development programme supporting the strategic direction of the STP. 4 PROGRAMME GOVERNANCE The Shropshire Out of Hospital Transformation Programme Board will provide strategic leadership and direction to, and scrutiny of this programme of work and ensure visible senior commitment to the programme. The Programme Board will be accountable to the Shropshire CCG Governing Body and decisions on recommendations from the Programme Board will be taken by the CCG Governing Body. The Programme Board will be clinically-led and its responsibilities are described below. Accountability The Shropshire Out of Hospital Transformation Programme Board will be accountable to the Shropshire CCG Governing Body and decisions on recommendations from the Programme Board will be taken by the CCG Governing Body; 4.2 Programme Board Purpose To deliver the objectives of the review as described in section 6 below; The Programme Board will provide strategic leadership and direction to, and scrutiny of the overall programme and ensure visible senior commitment to the programme. 4.3 Programme Board - Terms of Reference To agree and deliver the objectives of the transformation programme as described in section 6, below; Approve programme delivery plans and monitor adherence to the agreed plan in terms of time, quality and cost; Provide guidance and insight into current services, ensuring that all relevant considerations are being made throughout the review; Develop, agree and monitor the communications strategy and plan to ensure it is being delivered effectively and that engagement is being achieved, reviewed and considered at the correct level for each of the different stakeholder groups throughout the review process; Ensure that resources to deliver the agreed plan are available; Monitor and review risks to the successful delivery of the programme or the delivery of any objectives; Resolving any issues escalated to the Programme Board; Authorise any changes to the programme in terms of scope, deliverables, benefits, quality or cost; Ensure that a post programme review is planned and completed, including any lessons learned during the programme and that these lessons are shared through the Programme Management Office; The Programme Board will operate as a working group of Shropshire CCG Clinical Commissioning Governing Body; The Programme Board will meet monthly and be quorate with the minimum attendance of: The Chair or Vice Chair; One CCG Executive member; A lay member of Shropshire CCG Governing Body A member from each Stakeholder group If members of the Programme Board are unable to attend they can nominate a deputy from Each member of the Board, with the exception of the project manager has a decision making vote. In the event of a tied vote the Chairperson will have the deciding vote; The Programme Board will be supported by the corporate office and will make formal Page 4 of 8

61 reports to the Shropshire CCG Governing body; The Programme Board may approve the formation of any sub-groups to support the delivery of the programme and will agree the terms of reference, membership and governance and reporting structures for any such groups Project Board Membership Name Job Title Organisation Role in Project Dr J Sokolov GP & Board Member Shropshire CCG Clinical Lead & Chair of Programme Board Dr F Lynch GP & Board Member Shropshire CCG Clinical Lead, Frailty & Vice-chair of Programme Board Dr J Davies Director of Strategy Shropshire CCG Senior Responsible Officer Dr S Freeman Accountable Officer Shropshire CCG Programme Assurance Jane Randall-Smith Chief Officer Shropshire Healthwatch Service User Graham Shepherd Chair Shropshire Patients Group Service User William Hutton Lay Board Member Shropshire CCG Programme Assurance Lisa Wicks Out of Hospital Commissioning and Redesign Lead Shropshire CCG Commissioning & Redesign Lead for Out of Hospital Services Pete Downer Commissioning & Redesign Lead for Out of Hospital Integration Page 5 of 8 Shropshire CCG Commissioning & Redesign Lead for Out of Hospital Services Dr Deborah Shepherd GP Locality Chair Shrewsbury Locality Assurance Dr Shailendra Allen GP Locality Chair South Locality Assurance Dr Tim Lyttle GP Locality Chair North Locality Assurance Andrea Webster Programme Manager Shropshire STP STP Programme Lead Andrea Harper Head of Communications & Engagement Shropshire CCG Communication and engagement Erica Crisp Senior Contracts Manager Shropshire CCG Contracting Ben Banks Finance Shropshire CCG Finance Helen Bailey Lead Nurse for Integrated Clinical Care & Safety Shropshire CCG Representatives from Shropcom Quality & Safety x 2 Shropcom Assurance Meredith Vivian Board Member Shropshire CCG Representatives from SSSFT Representatives from SaTH Representatives from Shropshire Council Patient & User Assurance x 1 SSSFT Assurance x 1 SaTH Assurance x 1 Shropshire Council Assurance

62 Name Job Title Organisation Role in Project Representative from Stakeholder x 1 Engagement Group 5 PROGRAMME STRUCTURE 5.1 Supporting the Programme Board are two groups: The Locality Task & Finish Group(s) led by the Commissioning & Redesign Lead for Out of Hospital Services (supported by a clinical lead and CCG financial and operational staff. The group(s) will ensure that the most appropriate and up to date information is available and to support the delivery of the programme at an operational level The Programme Working Group, led by the programme clinical leads supported by GPs from each of the three CCG localities. This group will clinically assess existing services to determine whether they are delivering effective clinical outcomes and if there is a clinically robust case for change. If a case for change is proven the group will determine a process for clinically evaluating options and will be part of the options development and assessment process. Shropshire CCG Governing Body Shropshire CCG Clinical Commissioning Committee Out of Hospital Transformation Programme Board (programme design authority) Out of Hospital Transformation Programme Working Group Locality Task & Finish Group(s) Page 6 of 8

63 6 PUBLIC ENGAGEMENT The Shropshire Clinical Commissioning Group has a statutory duty to make arrangements to involve service users, carers and the public in the work of the organisation. The Shropshire CCG Constitution states that it will Make arrangements to secure public involvement in the planning, development and consideration of proposals for changes and decisions affecting the operation of commissioning arrangements by: Ensuring that patients and the public are fully consulted and involved in every aspect of the commissioning cycle in line with the Duty to Involve 1. The Integrated Out of Hospital Care Transformation Programme will, as set out in the associated Communications & Engagement Plan, ensure that there is early and regular engagement with patients and public throughout the programme and that patients and the public are represented on the Integrated Out of Hospital Care Transformation Programme Board. 7 OBJECTIVES The objectives for this phase of the project are to:- 7.1 High Quality & Safe Services: Develop and agree a structure for how care needs to be delivered across the county, enshrined within the principles of patient centred care; Engage with; inform; involve patients and their representatives in this work. 7.2 Partnership Working: Develop provision of joined up services led by the healthcare needs of a person; Working to understand how this needs to look in different parts of the county as we understand a one-size fits all approach will not work. 7.3 Innovative Services: Exploring ways of using available technology to help us achieve optimal patient care; Embed social prescribing to empower people towards better self-management; Build upon the principles of local quality assurance, fundamental to social prescribing; Exploring the means by which we can safely develop care providers wishing to innovate. 7.4 Empowered Workforce Working with existing service providers to understand the present capabilities of the workforce along with the local appetite for skill development; Use this information to determine how we will work as a system to develop a sustainable and motivated workforce. 7.5 Responsive Services: Reviewing how we use our resources to meet the needs of our local people in the community setting to ensure that services are fit for purpose; This will enable a strong, reliable and safe model of community based care to emerge. 1 NHS Shropshire Clinical Commissioning Group Constitution Page 7 of 8

64 8 SCOPE The scope of this work will include the contents of what is detailed within the block contract. 9 REVIEW DELIVERABLES 9.1 The commissioning strategy for Out of Hospital How the service is delivered in the four localities Who uses the service and with which GP practice s they are registered 9.2 Outcomes framework The outcomes required for the population What patient experience and satisfaction audits are telling us about the service What local GPs feel is important to their population What Health & Wellbeing outcomes are being measured for patients using the service 9.3 Affordability and Sustainability The sustainability of the service will be assessed on the activity at each unit, the operating hours and the number and expertise of staff required delivering the service Affordability of the service will be assessed on the cost to Shropshire CCG per patient visit, to provide the services in each location. 9.4 Options & Impact Review - This phase will use the information developed at previous stages along with best practice and learning from others and public and stakeholder engagement to co-develop a number of potential options that can then be fully evaluated Any potential options for change will be evaluated using Shropshire CCGs Prioritisation & Value for Money Methodology Impact Assessment - Alongside the Options will be an Impact Analysis of proposed changes that will assess the impact of recommendations on patients, the wider public, staff and service providers. Such Impacts will be fully explored and explained to enable commissioners and patients to make the most informed decisions. The impact assessment will also include a Quality Impact Assessment and an Equality Impact Assessment. 10 CONSTRAINTS, ASSUMPTIONS AND DEPENDENCIES 10.1 Constraints will be identified as work progresses. 11 INTERFACES 11.1 The interface between the Neighbourhood workstream of the STP and this Shropshire Out of Hospital Transformation Programme is to be defined. DOCUMENT END Page 8 of 8

65 Appendix 3 Shropshire Out of Hospital Transformation Programme Programme Working Group Terms of Reference January 2018 Background Patients within Shropshire currently have access to a wide range of community-based services including four community hospitals with inpatient beds. There are a range of challenges in providing community services under the current operating models. Each community hospital operates from a variety of bed bases which impacts on efficiency and is on occasion vulnerable to short-term staffing challenges, as are other services operating from these sites. The community contract is held by Shropshire Community Trust as a block contract and service line reporting is not evident. A number of CCG commissioning intentions and the direction of the Shropshire, Telford & Wrekin Sustainability & Transformation Plan (STP) call for more services to be provided in community settings, but some of these services face structural challenges in terms of recruiting and retaining an appropriate workforce. Accountability The Shropshire Out of Hospital Transformation Programme Working Group will be accountable to the Shropshire Out of Hospital Transformation Programme Board. Purpose NHS Shropshire CCG has decided to transform the out of hospital services. The purpose is to redesign and transform a range of out of hospital services that will ensure Shropshire people receive the right services at the right time in the right place. Where possible, these services will exist in their communities; where care will be person-centred recognising patients and their carers as part of the care team, they will be of the highest quality, safe, reliable, efficient, effective and caring. The anticipated outcomes of this transformation will be an effective and fit for purpose healthcare model, with integrated care services offering patient centred care, with a competent & empowered workforce, improving patient choice and outcomes. The Out of Hospital Transformation Programme Working Group will review each programme workstream with the purpose of: Ensuring any changes agreed to implement are clinically robust; Determining a process for clinically evaluating options; To determine, review and agree issues for a case for change for the programme workstreams; Using the Shropshire CCG Prioritisation & Value for Money Methodology scoring system to assess potential options, identifying a preferred option; Considering the clinical and operational impact of options and consider any further work required; Making recommendations to the Shropshire Out of Hospital Transformation Programme Board regarding the preferred clinical model that should be put forward for public consultation; 1

66 Providing clinical expertise to ensure clinical models offer the best opportunity to realise benefits; Ensuring clinical leadership that supports the clinical redesign of services across organisations to meet the needs of local residents. Membership Dr Jessica Sokolov Chair and Programme Clinical Lead Dr Finola Lynch GP & Board Member Dr Deborah Shepherd GP Locality Chair (Shrewsbury) Dr Shailendra Allen GP Locality Chair (South) Dr Tim Lyttle GP Locality Chair (North) Lisa Wicks Head of Out of Hospital Commissioning & Redesign Pete Downer Commissioning & Redesign Lead for Out of Hospital Integration Meredith Vivian Board Member 3 representatives Shropcom 2 representatives SSSFT 2 representatives SaTH 2 representatives Shropshire Council Frequency of Meetings This Programme Working Group will meet monthly or as required and will be quorate with at least one of the joint chairs and one GP from each of the three CCG localities. Decisions The remit of this Programme Working Group is to put forward clinically sound recommendations. Any commissioning decisions will be ultimately made by Shropshire CCG Governing Body. DOCUMENT END 2

67 Governing Body Meeting Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: Finance and Contract Report to 31st December 2017 Responsible Director: Claire Skidmore - Chief Finance Officer Author of the report: Ilse Newsome Deputy Chief Finance Officer Presenter: Claire Skidmore - Chief Finance Officer Purpose of the report: The purpose of this report is to articulate the year to date and forecast finance position and highlight any areas of risk within the reported figures. Key issues or points to note: Shropshire CCG continues to be in Directions and in formal financial recovery. The overall financial position to 31st December 2017 is forecasting an in year deficit of 19.4m which is in line with the agreed control total. This reflects the gap in the CCGs current plan as a result of planned expenditure exceeding resource allocation. The CCG currently has a level of unmitigated risk of 5m. This will deliver a risk adjusted outturn of 24.4m in year deficit if all identified risks and mitigations were to occur. A worst case position of 25.5m is delivered if all risks crystallise but mitigations are enacted. The cumulative financial position for 2017/18 is forecasting 52.0m deficit which includes brought forward 32.6m from previous years. The CCG entered 2017/18 with a number of known significant risks and has a QIPP target of 17.71m. The CCG has achieved all of its targets within Better Payment Policy for this month. The CCG is achieving its cash target to date; each month so far has ended with cash levels less than 1.25% of the monthly draw down. Actions required by Governing Body Members: Members are asked to; o Note the content of this report. Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 1

68 Governing Body Meeting Executive Summary and Actions Required Shropshire CCG continues to be in Directions and in formal financial recovery. The overall financial position to 31st December 2017 is forecasting an in year deficit of 19.4m which is in line with the agreed control total. This reflects the gap in the CCGs current plan as a result of planned expenditure exceeding resource allocation. The CCG currently has a level of unmitigated risk of 5m. This will deliver a risk adjusted outturn of 24.4m in year deficit if all identified risks and mitigations were to occur. A worst case position of 25.5m is delivered if all risks crystallise but mitigations are enacted. The cumulative financial position for 2017/18 is forecasting 52.0m deficit which includes brought forward 32.6m from previous years. The CCG entered 2017/18 with a number of known significant risks and has a QIPP target of 17.71m. It should be noted that a number of unforeseen pressures have materialised since the beginning of the Financial Year and these were not included in the financial plan. The main areas that have created pressures are; HRG4+ tariff increases, challenges within the Shropdoc Out of Hours provider, specific drug pressures on NCSO Prescribing and additional Running Costs incurred during the recent Senior Management transition. Actions required by Governing Body Members: Members are asked to; Note the content of this report Introduction 1. The purpose of this report is to articulate the year to date and forecast finance position and highlight any areas of risk within the reported figures. 2. NHS Shropshire CCG continues to be in Directions and in formal financial recovery and is in close dialogue with NHE England colleagues in this respect. 3. The overall financial position to 31 st December 2017 is a forecast in year deficit of 19.4m which is in line with the agreed control total. This reflects the gap in the CCG s current plan as a result of planned expenditure exceeding resource allocation. 4. The cumulative financial position is 52.0m deficit which includes a brought forward deficit of 32.6m from previous years. 5. The CCG is reporting a net unmitigated risk position of 5.0m. This will deliver a risk adjusted outturn of 24.4m in year deficit if all identified risks and mitigations were to occur. A worst case position of 25.5m is delivered if all risks crystallise but mitigations are enacted. Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 2

69 Governing Body Meeting Main Body of the Report Overall Financial Position The table below gives the summary level financial position to 31st December This position has been reported to NHS England and is consistent with the position held within the Integrated Single Financial Environment (ISFE), the ledger system. Appendix 1 provides information on detailed service lines. Hence, if the unmitigated risk cannot be reduced, the CCG will end 2017/18 with a deficit of 24.4m. Income and Expenditure Resources The current CCG revenue resource is m. This includes (32.624m) deficit brought forward from previous years. Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 3

70 Governing Body Meeting Acute Services The following is a summary of the contract position. It draws upon month 8 data to inform the month 9 position. Note 1: The Shrewsbury and Telford Hospitals NHS Trust position includes both Contract and Non Contract values. (Activity and Finance Tables reported elsewhere may reflect the contract position only) Shrewsbury and Telford Hospitals Trust YTD 1.778m over: FOT 5.085m overspend 1. At month 9 position, Shrewsbury and Telford Hospitals contract is reporting a year to date overspend of 1.778m and a forecast overspend of 5.085m at the year end. This position is now fixed and will therefore not move again in the financial year. Shrewsbury and Telford Hospital Trust Shropshire CCG Position at Month 09 - Finance (Per Month 8 SATH Monitoring adjusted) POD Ytd Cost Plan Ytd Plan v Actual ( ) FOT Plan v Actual ( ) Ytd Cost Actual Ytd Cost Variance Cost Variance as % of Total Cost Variance Cost Plan Cost FOT FOT Cost Variance FOT percentage Variance above Plan (01) Day Case 10,868,046 11,108, , % 14,580,263 14,902, , % (02) Elective 5,573,773 5,527,007 (46,766) (0.8%) 7,245,540 7,184,747 (60,792) (0.8%) (03) Emergency 39,442,736 40,952,217 1,509, % 52,443,620 55,160,022 2,716, % (04) Non Elective Other 6,137,883 5,094,353 (1,043,531) (17.0%) 8,099,281 6,722,284 (1,376,997) (17.0%) (05) Regular Admissions % % (06) Critical Care 2,339,891 1,662,464 (677,427) (29.0%) 3,150,655 2,238,502 (912,153) (29.0%) (07) Outpatient Firsts 6,944,358 7,030,463 86, % 9,352,773 9,468, , % (08) Outpatient Follow Ups 5,242,442 5,353, , % 7,058,634 7,208, , % (09) Outpatient Procedures 5,285,675 5,050,308 (235,366) (4.5%) 7,005,319 6,693,378 (311,941) (4.5%) (10) Accident and Emergency 5,774,587 5,916, , % 7,636,399 7,824, , % (11) Non PBR Variable 10,362,803 13,905,057 3,542, % 13,822,835 18,547,810 4,724, % (12) Non PBR Block 785, , % 1,047,219 1,047, % (13) CQUIN 1,391,822 1,391, % 1,855,762 1,855, % Total 100,149, ,777,816 3,628, % 133,298, ,853,828 5,555, % Emergency Threshold 0 (2,289,193) (2,289,193) 0 (3,083,397) (3,083,397) QIPP 0 (735,788) (735,788) (2,358,000) (1,050,204) 1,307,796 Risk Assement (Critical Care) , ,000 IR Reconciliation Adjustment (121,617) 0 121,617 CQUIN Reserve 927, , ,237,000 1,237,000 0 Q1 CQUIN Reconciliation 0 (23,000) (23,000) (23,000) (23,000) Prisoners 95, ,750 19, , ,000 26,135 Total Over/(Under) performance 101,172, ,772, , % 132,182, ,487,227 4,304, % Year End Deal Adjustment 0 585, , , ,070 Year End Deal 101,172, ,950,473 1,778, % 132,182, ,267,297 5,084, % Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 4

71 Governing Body Meeting Shropshire CCG Position at Month 09 - Finance (Per Month 8 SATH Monitoring adjusted) POD Ytd Activity Plan Ytd Plan v Actual (Activity) Ytd Activity Actual Ytd Activity Variance Activity Variance as % of Total Activity Variance Activity Plan FOT Plan v Actual (Activity) Activity FOT FOT Variance FOT percentage Variance above Plan (01) Day Case 17,996 18, % 24,142 24, % (02) Elective 2,174 1,827 (347) (16.0%) 2,830 2,375 (455) (16.1%) (03) Emergency 19,898 20, % 26,801 27, % (04) Non Elective Other 3,137 2,472 (665) (21.2%) 4,139 3,262 (877) (21.2%) (05) Regular Admissions % % (06) Critical Care 2,087 1,679 (408) (19.6%) 2,810 2,260 (550) (19.6%) (07) Outpatient Firsts 43,109 44,135 1, % 58,060 59,442 1, % (08) Outpatient Follow Ups 66,611 67,809 1, % 89,687 91,300 1, % (09) Outpatient Procedures 38,369 36,858 (1,512) (3.9%) 50,852 48,849 (2,003) (3.9%) (10) Accident and Emergency 43,689 43, % 57,775 58, % (11) Non PBR Variable % % (12) Non PBR Block % % (13) CQUIN % % Total 237, , % 317, , % Total 237, , % 317, , % Robert Jones and Agnes Hunt NHS Foundation Trust YTD 2.089m overspend : FOT 3.393m overspend 1. For Month 9, Robert Jones and Agnes Hunt NHS Foundation Trust contract is forecasting an overspend of 3.393m at the end of the year, which is an increase of 198k compared to the previous month. Robert Jones and Agnes Hunt Hospital Trust Shropshire CCG Position at Month 09 - Finance (Per Month 8 RJAH Monitoring adjusted) Ytd Cost Plan Ytd Plan v Actual ( ) FOT Plan v Actual ( ) Ytd Cost Actual Ytd Cost Variance Cost Variance as % of Total Cost Variance Cost Plan Cost FOT FOT Cost Variance FOT percentage Variance above Plan POD (01) Day Case 4,171,610 4,135,458 (36,151) (0.9%) 5,636,903 5,588,054 (48,849) (0.9%) (02) Elective 8,185,050 9,054, , % 11,060,080 12,234,723 1,174, % (04) Non Elective Other 709, ,890 (74,796) (10.5%) 958, ,897 (101,069) (10.5%) (05) Regular Admissions 157, ,416 45, % 212, ,515 61, % (07) Outpatient Firsts 1,907,570 1,733,133 (174,437) (9.1%) 2,577,611 2,341,902 (235,708) (9.1%) (08) Outpatient Follow Ups 2,629,353 2,604,264 (25,089) (1.0%) 3,552,923 3,519,022 (33,902) (1.0%) (09) Outpatient Procedures 458, , , % 619, , , % (11) Non PBR Variable 3,736,633 3,781,290 44, % 5,049,139 5,109,482 60, % (12) Non PBR Block 1,712,467 1,712, % 2,330,636 2,330, % (13) CQUIN 535, ,863 10, % 723, ,599 13, % Total 24,203,436 25,012, , % 32,721,641 33,814,819 1,093, % Anticipated QIPP Delivery (1,580,451) 0 1,580,451 (2,712,000) 0 2,712,000 CVs Pending (110,925) 0 110,925 (147,900) 0 147,900 Contract Challenges 0 (411,759) (411,759) 0 (560,188) (560,188) Total position 22,512,060 24,600,687 2,088, ,861,741 33,254,631 3,392, % Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 5

72 Governing Body Meeting Shropshire CCG Position at Month 09 - Finance (Per Month 8 RJAH Monitoring adjusted) Ytd Plan v Actual (Activity) FOT Plan v Actual (Activity) Activity Variance as % of Total Activity Variance FOT percentage Variance above Plan POD Ytd Activity Plan Ytd Activity Actual Ytd Activity Variance Activity Plan Activity FOT FOT Activity Variance (01) Day Case 1,939 1,837 (103) (5.3%) 2,621 2,482 (139) (5.3%) (02) Elective 1,561 1, % 2,109 2, % (04) Non Elective Other (32) (17.5%) (44) (17.5%) (05) Regular Admissions % % (07) Outpatient Firsts 15,495 15,135 (359) (2.3%) 20,937 20,451 (486) (2.3%) (08) Outpatient Follow Ups 40,328 41, % 54,494 55,584 1, % (09) Outpatient Procedures 2,315 2, % 3,129 3, % Total 62,016 62, % 83,799 85,052 1, % Total 62,016 62, % 83,799 85,052 1, % Other Acute Contracts 1. At Month 9, Other Acute contracts are reporting a forecast over-spend of 0.333m. There is however a further 1.3m unmitigated risk attributed to this reporting line as a result of likely over performance. Actions are being undertaken to review and challenge contract details in order to mitigate risk. Community Health Services - YTD 0.085m overspend: FOT 0.448m overspend Ytd Budget '000 Ytd Actual '000 YTD Performance M09 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Shropshire Community Trust 40,125 30,094 30, , (8) 197 Other Community Services 3,506 2,630 2,490 (140) 3, Palliative Care 2,343 1,757 1, , Childrens Special Placements Community Health Services Total 45,974 34,481 34, , At month 8, Community Health services are reporting an over-spend of 0.085m and forecasting an over-spend of 0.448m. 1. In relation to the other community services we have seen deterioration on the FOT position of 143k this month. The main drivers of the over performance here is Intermediate Care as well as the community ophthalmology service. Continuing Healthcare YTD 1.186m overspend FOT 0.426m underspend Year to date performance M09 Budget Year to Actual Year to Variance Year to Outturn Outturn In month Previous month FOT Date - month 9 Date - month 9 Date - month 9 Expenditure Variance movement Variance Annual Budget Continuing Healthcare Complex Care 25,618 19,213 19, ,767 (851) (308) (543) Funded Nursing Care 7,534 5,651 5, , (650) Complex Care Team (75) 0 (75) Reablement (2) 461 Continuing Healthcare Total 34,373 25,737 26,923 1,186 33,947 (426) 439 (807) Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 6

73 Governing Body Meeting 1. The forecast for CHC has moved adversely by 0.439m this month (at month m underspend was reported). There have been additional costs included at month 9, predominantly relating to new patients and contract extensions. The CHC and finance team are currently reviewing the list of cases to ensure that costs charged or accrued are appropriate. 2. The tables below illustrate year on year trends for both finance and patient activity numbers. *Once 17/18 Budgets have been adjusted for growth, inflation and reduced for QIPP, the final budget is similar to 16/17 final budget and therefore undistinguishable on graph above. *The patient numbers relate to all patients who are in receipt in month of a current CHC Package. Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 7

74 Governing Body Meeting Mental Health Services YTD 0.051m underspend FOT 0.022m underspend YTD Performance M09 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 South Staffordshire and Shropshire FT 30,026 22,519 22, ,790 (236) (183) (53) Other NHS Mental Health Contracts (436) 458 (250) (200) (50) Mental Health NCA's , Mental Health Special Placements Mental Health - Winter Resilience Mental Health - Other 1,457 1, (140) 1,385 (72) 153 (225) Mental Health Services Total 32,802 24,601 24,550 (51) 32,780 (22) (144) At month 9, Mental Health services are forecasting an underspend of 0.022m. 2. This position is being driven by two areas. The first is the over performance within the Mental Health NCAs. One of the main drivers here is activity at South London and Maudsley where we currently have two high cost patients. Primary Care Services (Non Delegated) YTD Performance M09 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 Prescribing 50,167 37,697 37,661 (36) 47,174 (2,993) 0 (2,993) Central Drugs 1, (47) 1, Oxygen Enhanced Services 2,044 1,529 1, , Out Of Hours 4,233 3,175 3, , Primary Care Commissioning Schemes 1, , ,242 (30) (30) 0 Hospice Drugs Prescribing Incentives (143) (143) 0 Care Home Advanced Scheme (15) Primary Care Team 2,490 1,748 1,333 (415) 2,402 (88) (89) 1 Primary Care Services Total 62,788 47,042 47, ,364 (2,424) (262) (2,162) Primary Care Services YTD 0.108m overspend: FOT 2.424m underspend 1. According to the sixth monthly detailed report from the Business Support Agency (BSA), prescribing expenditure has come in at levels that are lower than budget profile. This is consistent with measures that are being put in place to secure efficiencies. 2. Nationally, there are significant increases in prices for commonly prescribed, and usually very inexpensive, drugs. The DOH places certain items on an increased price list when there seems to be No Cheaper Stock Obtainable (NCSO). As per the PMD reports, the CCG has seen increases in the cost of 6 drugs which the prescribing lead will continue to monitor. 3. The forecast outturn includes anticipated income for coverage of the NCSO price increases articulated above and cost impact has been included as an unmitigated risk for the first time in this month s position. 4. Graphs comparing monthly costs and number of scripts issued for this year and last year are presented below for information. Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 8

75 Governing Body Meeting Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 9

76 Governing Body Meeting Enhanced Services 1. The forecast outturn for Enhanced services includes 0.325m to reflect the additional 1/head of population payment agreed for practices for 2017/18 only. 2. For month 9, the out of hours forecast outturn is showing a 0.505m overspend. This is a reflection of the current agreement between the CCG and Shropdoc, to sustain service delivery whilst contract discussions take place. Other YTD 0.076m underspend FO 0.033m overspend YTD Performance M09 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 Patient Transport 3,123 2,343 2,235 (108) 3,021 (102) (191) 89 NHS Referral Assessment Service Team (116) Community & Care Co-ordinators (71) NHS Property Services Better Care Fund 8,005 6,004 6, , Other (60) 109 Other Total 12,678 9,509 9,433 (76) 12, (251) At month 9, Other services are reporting an underspend of 0.076m and forecasting an over-spend of 0.033m. The forecast outturn reflects latest available information for this area. Primary Care (Delegated) YTD Performance M09 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Ytd Annual Budget '000 Budget '000 Dispensing & Prescribing 2,301 1,437 1, , Enhanced Services (79) 864 (90) 0 (90) General Practice APMS 1,799 1,193 1,185 (8) 1,788 (11) 0 (11) General Practice GMS 26,542 17,536 17,508 (28) 26,433 (109) (0) (109) General Practice PMS (11) 352 (18) 0 (18) Other GP Services 1,008 1,107 1, , (0) 93 Premises Costs Reimbursements 5,335 3,801 3,589 (212) 5, QOF 4,087 2,725 2, , Reserves 523 (31) (484) (152) (332) Co Commissioning Total 42,919 28,611 28, ,919 (152) (152) 0 Co-Commissioning YTD 0.012m underspend: FO 0.152m underspend 1. Primary Care Co-Commissioning was 0.012m underspend year to date to M9. The main areas of underspend relate to Premises costs associated with Rates rebates, plus prior year Enhanced services savings and the release of an unallocated reserve and part of the delegated contingency. These savings are partly offset by cost pressures relating to Dispensing charges, Locum fees, and Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 10

77 Governing Body Meeting QOF payments. Increased levy and indemnity charges for GPs were not known at the planning stage and have materialised during the financial year. These are also taken into account in the forecast outturn. 2. It is now expected that the year-end position will show a 152k underspend which mainly relates to unallocated prior year accruals. Running Costs YTD 1.837m overspend: FO 0.286m overspend YTD Performance M09 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 Corporate Costs 2,393 1,794 2, , (73) 753 Strategy & Service Redesign 1,721 1,291 1, , Governance (48) 273 (73) 16 (89) Finance 1,923 1,470 2,713 1,243 1,467 (456) (352) (104) Nursing & Quality (62) (70) 88 Running Cost Total 6,546 4,937 6,774 1,837 6, (466) The Running Cost element of the CCG allocation is showing a year to date overspend of 1.837m with forecast of 0.286m overspend. One area of overspend is due to expenditure relating to a number of senior interim appointments which has continued in the first part of pending the commencement of recently appointed substantive Executives. 2. It should be noted that the current establishment of posts classified as Running Costs are in excess of the budget available and this is subject to stringent review by Executives. Additional work to review the forecast outturn and develop mitigations for the potential overspend are in progress. 3. A vacancy and expenditure freeze has been mandated across the CCG with immediate effect in order to restrict levels of additional expenditure. Reserves YTD Performance M09 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 Commissioning Reserve 6,661 1,716 (788) (2,504) 699 (5,962) (513) (5,449) 0.5% Non Recurrent Reserve 1, , % Contingency 1, (1,922) 0 (1,922) Reserves Total 10,505 1,716 (788) (2,504) 2,621 (7,884) (513) (7,371) 1. A summary of all reserves budgets are provided in the table above The 0.5% contingency and 0.5 % of the 1% non-recurrent reserve (discretionary element) have been released to support the financial position. Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 11

78 Governing Body Meeting Statement of Financial Position (SOFP) The Statement of Financial position has been prepared in accordance with International Financial Reporting Standards (IFRS) and the Month 9 position is summarised in Appendix 2. Cash 1. The CCG is required to estimate its cash requirement prior to the start of each month and drawdown cash funding. In line with guidance, the CCG must ensure cash levels each month remain below 1.25% of the monthly draw down. 2. The actual level of cash held in the bank at the end of December was 0.133m. This is within the levels required by NHS England and demonstrates a successful management of cash balances which is detailed in the cash report at Appendix 3. Better Payment Policy Statistics 1. The requirement of the Better Payment standard is that 95% of invoices should be paid within 30 days of receipt by an organisation. 2. NHS BPPC has remained above the target of 95%. 95.9% by number and 99.9% by value. Non NHS BPPC has remained above target of 95%. 97.2% by number and 96.5% by value. (05N) NHS SHROPSHIRE CCG NHS Period: Dec 2017 Invoices Paid Percentage Compliance Within Limit Outside Limit Total Paid This Month Year to Date Number Value Number Value Number Value Number Value Number Value APR ,363, , ,368, MAY ,085, , ,183, JUN ,588, , ,634, JUL ,384, , ,627, AUG ,386, , ,610, SEP ,845, , ,864, OCT ,533, , ,567, NOV ,028, , ,167, DEC ,351, , ,354, TOTAL 2, ,568, ,179 2, ,379, NON NHS Invoices Paid Percentage Compliance Within Limit Outside Limit Total Paid This Month Year to Date Number Value Number Value Number Value Number Value Number Value APR 2,120 11,775, ,325 2,126 11,868, MAY 2,070 9,826, ,786 2,091 9,837, JUN 1,012 9,671, ,491 1,021 9,679, JUL 955 9,627, , ,699, AUG 951 8,424, ,176 1,003 8,831, SEP 1,232 10,552, ,059 1,257 11,111, OCT 1,008 8,877, ,887 1,029 9,676, NOV 1,133 9,521, ,458 1,166 9,937, DEC 2,034 10,365, ,937 2,093 10,741, TOTAL 12,515 88,641, ,740,023 12,778 91,381, Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 12

79 Governing Body Meeting Risk and Mitigations 1. The CCG is required to provide an analysis of potential risks and mitigations as part of the monthly Non ISFE return to NHS England. The summary reported to NHSE is included at Appendix 4 and it can be seen that the organisation has a risk profile of 6.116m and mitigations against this risk of 1.116m. This results in the balance of residual unmitigated risk of some 5.0m. 2. The position of the CCG can be assessed against a best/worst/likely scale as follows: Scenario m (deficit) Notes Likely (19.4) No risks or mitigations; achieves control total. Best Case (highly unlikely) (18.4) Risks do not materialise and mitigations achieved; exceeds control total. Risk Adjusted Case (24.4) Reported risks and mitigations occur; CCG misses control total. Worst Case (25.5) No mitigations achieved but risks materialise; CCG misses control total Summary and Conclusions 1. The overall financial position to 31st December 2017 is a forecast in year deficit of 19.4m which is in line with the agreed control total. This reflects the gap in the CCG s current plan as a result of planned expenditure exceeding resource allocation. 2. The CCG is reporting a net unmitigated risk position of some 5.0m. A thorough review of all expenditure is underway with a view to improving the reported position for 17/18 where possible. This will also minimise the adverse impact of any slippage in 2017/18 position on future years. Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 13

80 Governing Body Meeting Appendix /18 Financial Summary Position as at Month 9 RESOURCES 2017/ / / /18 Variance Annual Budget Year to Actual Year to Date - Year to Outturn Outturn Budget Date - month 9 month 9 Date - Expenditure Variance Risk Mitigation Net Risk month Recurrent Allocation 390, , , , Non Recurrent Allocation Deficit Brought Forward 16/17 (32,624) (24,468) (24,468) 0 (32,624) 0 0 Co-Commissioning Allocation 42,919 31,944 31, , Total resource limit 401, , , , EXPENDITURE Acute Services Shrewsbury and Telford Hospitals NHS Trust 132, , ,950 1, ,267 5,084 0 Robert Jones and Agnes Hunt FT 29,862 22,512 24,601 2,089 33,255 3,393 0 West Midlands Ambulance Service Contract 11,417 8,564 9, , Other Acute Contracts 24,179 18,134 19,686 1,552 24, ,549 (280) 1,269 Acute NCA's 4,250 3,187 3, , Acute Special Placements (14) 32 (19) 0 Winter Resilience 1,973 1, (991) 1, Future Fit Acute services - Other (57) 489 (1) 0 Acute Services Team Acute Services Total 204, , ,488 5, ,089 10,139 1,549 (280) 1,269 Community Health Services Shropshire Community Trust 40,125 30,094 30, , Other Community Services 3,506 2,630 2,490 (140) 3, Palliative Care 2,343 1,757 1, , Community Health Services Total 45,974 34,481 34, , Continuing Healthcare Complex Care 25,618 19,213 19, ,767 (851) 0 Funded Nursing Care 7,534 5,651 5, , Complex Care Team (76) 0 Reablement Continuing Healthcare Total 34,374 25,737 26,923 1,186 33,947 (427) Mental Health Services South Staffordshire and Shropshire FT 30,026 22,519 22, ,790 (236) (200) (200) Other NHS Mental Health Contracts (436) 458 (250) 0 Mental Health NCA's , Mental Health - Other 1,457 1, (140) 1,385 (72) 0 Mental Health Services Total 32,802 24,601 24,550 (51) 32,780 (22) 0 (200) (200) Primary Care Services Prescribing 50,167 37,697 37,661 (36) 47,174 (2,993) 2,900 2,900 Central Drugs 1, (47) 1, Oxygen Enhanced Services 2,044 1,529 1, , Out Of Hours 4,233 3,175 3, , Primary Care Commissioning Schemes 1, , ,242 (30) 0 Hospice Drugs Prescribing Incentives (143) 0 Care Home Advanced Scheme (15) Primary Care Team 2,490 1,748 1,333 (415) 2,402 (88) 0 Primary Care Services Total 62,788 47,042 47, ,364 (2,424) 2, ,900 Other Patient Transport 3,123 2,343 2,235 (108) 3,021 (102) 0 NHS Referral Assessment Service Team (116) Community & Care Co-ordinators (71) NHS Property Services Better Care Fund 8,005 6,004 6, , Other (60) (60) Other Total 12,678 9,509 9,433 (76) 12, (60) (60) Reserves Commissioning Reserve 6,661 1,716 (788) (2,504) 699 (5,962) 666 (575) % Non Recurrent Reserve 1, , % Contingency 1, (1,922) 0 Reserves Total 10,505 1,716 (788) (2,504) 2,621 (7,884) 666 (575) 91 Running Costs Corporate Costs 2,393 1,794 2, , Strategy & Service Redesign 1,721 1,291 1, , Governance (48) 273 (73) 0 Finance 1,923 1,470 2,713 1,243 1,467 (456) 1,000 1,000 Nursing & Quality (62) Running Cost Total 6,546 4,937 6,774 1,837 6, , ,000 Co-Commissioning 42,919 32,188 32,174 (14) 42,767 (152) 0 Co Commissioning Total 42,919 32,188 32,174 (14) 42,767 (152) Total Expenditure 453, , ,269 6, , ,115 (1,115) 5,000 Budget (Surplus) / Deficit 52,024 38,449 44,858 6,409 52, ,115 (1,115) 5,000 Total Resource Limit 401, , , , Total Expenditure 453, , ,269 6, ,536 (152) 6,115 (1,115) 5,000 Total 52,024 38,449 44,858 6,409 52,024 (152) 6,115 (1,115) 5,000 Deficit Brought Forward (32,624) (24,482) (24,482) (32,624) In Year Deficit 19,400 13,968 20,377 6,409 19,400 6,116 (1,115) 5,000 Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 14

81 Governing Body Meeting Appendix 2 Month 2016/17 Apr17 May17 Jun17 Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18 Mar18 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Property, Plant & Equipment IT P&M Networked Assets Total PP&E Receivables Accounts Receivable Ledger 3,364 3,603 2,819 2,231 2,110 1,438 1, , Accrued Income 1, ,057 2,568 1,715 2, Bad Debt Provision Other Receivables Payments on Account 3, ,628 1,036 1,717 3, , Prepayments ,613 7,956 6,511 2,493 1, Total Receivables 5,162 7,676 6,796 5,413 5,362 8,133 10,809 11,387 3,955 4, Cash & Bank Cash & Bank Accounts Payable Accounts Payable Ledger -1,593-1,591-2,118-2,496-3,788-3,784-1,997-3,313-2,718-3, Accruals -11,181-11,047-11,071-9,724-9,562-12,667-17,357-18,951-16,508-16, Prescribing -8,491-4,643-8,807-8,846-8,847-8,755-8,618-8,712-8,719-8, Prescribing Incentive Deferred Income Payroll Related - PAYE Payroll Related - NI Payroll Related - Pension Payroll Related - Other Partly Completed Spells -1,368-1,368-1,368-1,368-1,367-1,367-1,367-1,367-1,367-1, Total Payables -23,430-19,486-24,705-23,562-24,795-28,209-30,907-34,000-30,776-30, Total Assets -18,062-11,459-17,476-18,018-18,946-19,954-20,006-22,482-26,472-25, General Fund B/fwd 2016/17-14,455-18,064-18,064-18,063-18,063-18,063-18,063-18,063-18,063-18, Allocation 36,153 71, , , , , , , , B/fwd Deficit Allocation 0-5,440-8,156-10,875-13,593-16,312-19,031-21,749-24, Net Allocation 36,153 66,024 98, , , , , , , Timing Adjustments\ Deficit Funding 32,626 2,391 8,873 12,426 15,678 18,823 23,354 26,655 31,263 36, Net Parlimentary Funding 446,575 38,544 74, , , , , , , , YTD Net Expenditure -450,184-31,939-74, , , , , , , , Cummulative Surplus\(Deficit) -32,624 4,214-8,285-12,381-16,561-20,714-25,297-31,074-39,672-44, In Year Surplus\(Deficit) 4,214-2,845-4,225-5,686-7,121-8,985-12,043-17,923-20, Total Equity -18,062-11,459-17,476-18,018-18,946-19,954-20,006-22,482-26,472-25, Originator of Report: Claire Skidmore Author of Report: Ilse Newsome 15

82 Governing Body Meeting Appendix /18 Shropshire CCG Month 9 - Cash Report Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD YTD Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Forecast Plan Forecast Plan Forecast Plan Actual,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000 C/fwd ,225 Drawdown 32,679 35,346 33,158 32,697 32,674 32,869 33,158 32,869 33,158 32,869 32,675 33,545 33,549 32,869 33,067 33,769 33,539 35,369 33,542 33,542 32,099 32,099 37,878 37, , ,202 Council BCF Receipts Other Receipts , ,559 Total Reciepts 32,740 36,132 33,219 33,989 32,735 33,961 33,219 33,379 33,219 33,996 32,736 33,780 33,610 32,947 33,128 34,125 33,600 35,677 33,603 33,603 32,160 32,160 37,939 37, , ,987 Expenditure RFT Runs 20,610 23,816 21,090 23,748 20,606 20,467 21,090 19,477 21,090 21,434 20,607 18,464 21,089 19,646 20,607 20,061 21,089 21,186 21,090 21,090 19,647 19,647 21,139 21, , ,299 BACs & Pos 8,203 5,309 8,202 5,751 8,202 8,784 8,202 8,489 8,202 8,163 8,202 8,765 8,594 8,276 8,594 9,312 8,584 8,386 8,585 8,585 8,585 8,585 12,863 12,863 74,986 71,236 BCF CHAPS / Faster Payments 0 2, , , , , ,915 Co Commissioning 3,456 3,456 3,456 3,456 3,456 3,456 3,456 3,456 3,456 3,461 3,456 3,461 3,456 3,461 3,456 3,461 3,456 3,461 3,456 3,456 3,456 3,456 3,465 3,465 31,104 31,129 Cheques Salaries ,115 2,345 Pensions Tax & NI ,101 Total Expense 32,679 35,865 33,158 33,640 32,674 33,930 33,158 33,093 33,158 33,949 32,675 33,760 33,549 32,888 33,067 34,081 33,539 35,544 33,542 33,542 32,099 32,099 37,878 37, , ,750 Total Cleared Cash ,237 BACs not Cleared Total Cleared Cash , BSA Cash Prescribing 4, , , , , , , ,166 3,564 4,305 3,539 4,305 4,305 3,890 3,890 4,310 4,310 38,188 31,676 Oxygen

83 QIPP Performance Issues Prescribing Other TOTAL RISKS Delay / Reduce Investment Plans Other Mitigations TOTAL MITIGATIONS Governing Body Meeting Appendix 4 Risks and Mitigations Schedule Forecast Net Expenditure RISKS (enter negative values only) MITIGATIONS (enter positive values only) CCG RISKS & MITIGATIONS Plan Actual Variance Variance TOTAL NET (RISK) / MITIGATION Of Which: RECURRENT Risk Adjusted Forecast Variance Prior Month Risk Adjusted Forecast Variance Movement m m m % m m m m m m m m m m m % m m REVENUE RESOURCE LIMIT (IN YEAR) REVENUE RESOURCE LIMIT (CUMULATIVE) Acute Services (9.967) (4.9%) (0.549) (1.000) (1.549) (1.269) (1.269) (11.236) (5.5%) (12.554) Mental Health Services % % (0.031) Community Health Services (0.447) (1.0%) (0.447) (1.0%) (0.312) (0.135) Continuing Care Services (2.235) (7.2%) (2.235) (7.2%) (3.612) Primary Care Services % - (2.900) (2.900) (2.477) (0.053) (0.1%) (2.638) Primary Care Co-Commissioning % % Other Programme Services % - (0.666) (0.666) (0.606) (0.616) % Commissioning Services Total % (0.549) (1.666) - (2.900) (5.115) (4.000) (1.885) (3.714) (0.8%) (3.244) (0.470) Running Costs (0.286) (4.4%) - (1.000) (1.000) - (1.000) (1.000) (1.286) (19.6%) (1.752) Unidentified QIPP % - - TOTAL CCG NET EXPENDITURE % (0.549) (1.666) - (3.900) (6.115) (5.000) (2.885) (5.000) (1.1%) (4.996) (0.004) IN YEAR UNDERSPEND / (DEFICIT) (19.400) (19.400) % CUMULATIVE UNDERSPEND / (DEFICIT) (52.024) (52.024) % 17

84 Governing Body Meeting Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications As noted in the report 2 Health inequalities If yes, please provide details of the effect upon health inequalities 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements No No 4 Clinical engagement If yes, please provide details of the clinical engagement No 5 Patient and public engagement If yes, please provide details of the patient and public engagement No 6 Risk to financial and clinical sustainability Yes As noted in the report 18

85 Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: Governing Body SCCG Performance Report 2017/18 Responsible Director: Julie Davies, Director of Performance & Delivery Author of the report: Julie Davies, Director of Performance & Delivery Presenter: Julie Davies, Director of Performance & Delivery Purpose of the report: To update the governing body on the CCGs performance to date in 2017/18 against the key performance indicators that the CCG is held accountable for with NHS England. This overview provides assurance on performance achievement against targets/standards at CCG and provider level as appropriate, and the delivery and contractual actions in place to address areas of poor performance. Key issues or points to note: The attached report sets out Shropshire CCG s performance against all its key performance indicators for early 2017/18. They key standards that are not currently being met YTD for SCCG are :- 62 day cancer RTT 62 day wait screening 2wk wait (Breast) A&E 4hr target Ambulance handovers >30mins and >1hr >52 wk waiters The 62 day RTT, Screening and 2wk Breast symptoms Cancer performance targets for the CCG are not being achieved but SaTH, its main provider, continues to achieve all targets except the 62day RTT which remains just below target YTD at Month 8 despite being achieved for the month. SCCG failed both Breast symptoms and the screening target by just one breach each. The CCGs overall cancer performance remains affected by out of county providers and this is continually progressed through the corresponding lead commissioners via our contract team with support as required from NHSI. A&E performance remains significantly challenged and December was the lowest performance year to date. Demand remains on plan for Shropshire at Month 9. Workforce and levels/ timeliness of patient discharges remain the key underlying issues. The system wide Director of Urgent Care spent the first four weeks across all parts of 1

86 the system looking at how and where improvement can be made. Six priority action areas have been agreed with the A&E Delivery Board in January. These each have an exec lead from across the system and work plans are now being drawn up to present back to the Delivery Board in February. Additional expertise is continuing to be brought in from the national ECIP team as required to support our system s recovery. There has been an improvement in the over 1hr ambulance handovers in December compared to the previous months and compared to the same period last year. This is as a result of improved working between the HALOs, the SaTH corridor nurses and ED staff. The CCG had 3 over 52 wk waiters (2 at Wye Valley and 1 at Worcester) in November, all were T&O. Full contractual levers are implemented against poor performance with any provider and the CCG performance lead now receives a forward look of all >40wks waiters at all providers to try and minimize such breaches in the future. The CCG achieved the RTT target for the second time this year in November and SaTH continued to deliver. This will be at risk from January due to the nationally agreed extended period of cancellations during the month of January to allow the system to better manage winter pressures. Actions required by Governing Body Members: J.Davies to continue chairing monthly planned care working group meetings with RJAH and SaTH to oversee recovery and sustainability of RTT and cancer performance. J.Davies to be the Exec lead for the system demand and capacity action area within the system A&E recovery plan. S.Freeman to continue to attend A&E Delivery Board to ensure SCCGs contribution to the A&E recovery trajectory is delivered. 2

87 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: A: CCG Aims and Objectives Yes/ No 1 Objective 1 Deliver continually improving Healthcare and Patient Experience Yes Achievement of the performance metrics will improve outcomes and patient experience 2 Objective 2 Develop a true membership organization (active engagement and clinically led organization) No 3 Objective 3 Achieve Financial sustainability for future investment 4 Objective 4 Visible leadership of the local health economy through behavior and action 5 Objective 5 Grow the leaders for tomorrow (Business Continuity) No No No B: Governance Yes/ No 1 Does this report: Provide Shropshire CCG with assurance against any risk in the BAF? Have any legal implications? Yes Promote effective governance practice Risk no. 73/16 NHS Constitution 2 Additional staffing or financial resource implications The CCG would fail to get its full Quality Premium Payment if it fails any of its key performance premium indicators. 3 Health inequalities The action taken by the CCG to deliver all its constitutional targets will address any health inequalities currently present in the areas the performance targets are not being met 4 Human Rights, equality and diversity requirements 5 Clinical engagement 6 Patient and public engagement Yes Yes N/A N/A N/A 3

88 Governing Body Shropshire Clinical Commissioning Group (CCG) Performance Report February 2017/18 INTRODUCTION 1. This performance report provides an overview of the key performance indicators (KPIs) that the CCG is held accountable for with NHS England during 2017/18. They are part of the CCG s Improvement and Assessment Framework (IAF) for 2017/18 detailed under the Better Care section and linking in with the six national clinical priorities. These are mental health; dementia, learning disabilities, cancer, diabetes and maternity. 2. The monthly data reported is for November 2017 and December 2017 where data is available. 3. Some of the CCG Improvement and Assessment Framework indicators have been updated where new data has been made available. 4. The overview provides assurance on performance achievement against targets/standards at CCG and provider level as appropriate, and the delivery and contractual actions in place to mitigate. DASHBOARD 5. The dashboards below provide details of indicators and their RAG rating against national and local standards within service areas. Following these, there are details of the high risk indicators and the mitigation in place. 6. Where key standards were not achieved in 2016/17, trajectories have been set as part of the Sustainability & Transformational Fund (STF), in the 2017/18 planning round. For Robert Jones and Agnes Hunt Hospital and Shrewsbury and Telford Hospital Trust, these included; A&E 4 Hour Wait 18 Weeks RTT Incompletes Cancer 62 day Waits Page 1

89 Cancer Latest Baseline Position Outturn/St andard Standard/ Target Shropshire CCG KEY PERFORMANCE INDICATORS Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Cancer Diagnosed at Early Stage - % of cancers diagnosed at Stage 1 & 2 Cancer 62 Day Waits - % of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer Cancer 62 Day Waits - % of patients receiving first definitive treatment for cancer within 62 days of referral from an NHS Cancer Screening Service Cancer 62 Day Waits - % of patients receiving first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status Cancer 2 Week Wait - % of patients seen within two weeks of an urgent referral for suspected cancer Cancer 2 Week Wait - % of patients seen within two weeks of an urgent referral for breast symptoms 2016/ % 85% 89.2% 89.2% 76.2% 82.6% 79.0% 81.9% 77.9% 89.3% 82.9% 2016/ % 90% 100.0% 100.0% 60.0% 80.0% 100.0% 100.0% 86.7% 85.7% 89.1% 2016/ % No National Standard % (England 52.4%) 86.1% 87.8% 88.5% 93.1% 86.1% 83.9% 84.8% 87.8% 87.2% 2016/ % 93% 94.2% 93.5% 92.5% 93.0% 92.0% 93.1% 94.2% 93.6% 93.3% 2016/ % 93% 92.1% 91.8% 92.6% 92.9% 90.0% 92.6% 93.5% 91.9% 92.2% Cancer 31 Day Wait - % of patients receiving first definitive treatment within 31 days of a cancer diagnosis 2016/ % 96% 98.5% 98.0% 97.9% 99.4% 99.5% 98.7% 100.0% 100.0% 99.1% Cancer 31 Day Wait - % of patients receiving subsequent treatment for cancer within 31 days where that treatment is surgery Cancer 31 Day Wait - % of patients receiving subsequent treatment for cancer within 31 days where that treatment is anti cancer drug regimen Cancer 31 Day Wait - % of patients receiving subsequent treatment for cancer within 31 days where that treatment is radiotherapy treatment course One-year survival for all cancer Cancer patient experience of responses, which were positive to the question "Overall, how would you rate your care?" 2016/ % 94% 90.9% 100.0% 100.0% 97.5% 95.2% 100.0% 97.7% 97.5% 97.5% 2016/ % 98% 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% 99.8% 2016/ % 94% 100.0% 98.1% 100.0% 97.8% 100.0% 100.0% 98.6% 98.1% 99.0% (England) % (England 70.4%) (CCG) Page 2

90 CANCER 9. As at November 2017, 2 cancer indicators did not achieve the standard in the month: 62 week wait Screening Service, 85.7% against 90% standard 2 week wat Breast, 91.9% against 93% standard 10. For the Cancer 2 week wait (Breast) in November 2017 there were 6 breaches - all breaches were due to patient choice. The CCG only missed this target by 1 breach. For the 62 day Screening target, there were only 7 referrals in the months and again only 1 breach. 11. SaTH achieved all cancer targets in November. Analysis has shown that breaches are due to a combination of complex cases and patient choice issues relating to ability to attend appointments. Work is ongoing to improve the timescales for diagnostic reports to ensure patients are progressed more rapidly and additional patient information material is being considered for inclusion with appointment correspondence to emphasise the importance of attending appointments within the target timescales. 12. The cancer dashboard also details 3 further indicators, which are all reported on an annual basis. As national data becomes available this will be updated. These indicators are; diagnosis at early stage 1&2, one year survival and cancer patient experience. Baselines and the latest position are shown. The patient experience RAG rating is based on a survey where patients are rating their care (excellent or very good) the overall care rating for Shropshire CCG is 8.7 compared to 8.7 for England 13. There were day cancer breaches reported for November All long wait cancer patients are reviewed through CQRM to ensure the delays are not likely to have caused harm and that any systemic reasons for delay should be investigated, understood and remedied. Page 3

91 Mental Health Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD IAPT Roll Out - Proportion of people that enter treatment against the level of need in the general population (CCG/SSSFT) 2016/ % 15% 1.9% 1.4% 1.2% 1.2% 1.6% 1.3% 1.1% 1.1% 1.1% 11.9% IAPT Recovery Rate (CCG/SSSFT) 2016/ % 50% 59.5% 60.5% 54.8% 52.8% 60.0% 53.3% 52.7% 52.4% 54.7% 55.7% 75% of people with relevant conditions to access talking therapies in 6 weeks (CCG/SSSFT) 95% of people with relevant conditions to access talking therapies in 18 weeks (CCG/SSSFT) New target 2016 ** SSSFT 75% 97.3% 95.5% 93.9% 88.9% 91.9% 82.3% 94.7% 93.7% 98.4% 92.4% 95% 100.0% 100.0% 100.0% 100.0% 100.0% 91% 98.2% 99.5% 100.0% 98.4% 50% of people experiencing first episode of psychosis to access treatment within 2 weeks (CCG/SSSFT) Children & Young People's Mental Health Services Transformation Crisis Care & Liaison mental health services transformation Out of Area placements for acute mental health inpatient care - transformation Mental Health - Care Programme Approach (CPA) - % of patients under adult mental illness on CPA who were followed up within 7 days of discharge from psychiatric patient care 2016/17 68% 50% 50% 0% 50% 50% 0% 100% 50% 33.0% 100.0% 36.8% 5 Questions: 2 fully Compliant 2 Partially Compliant 1 Not Compliant 15 Questions: 6 fully Compliant 3 Partially Compliant 6 Not Compliant 3 Questions: 3 fully Compliant 5 Questions Fully Compliant 15 Questions Fully Compliant 3 Questions Fully Compliant Q4 2016/17 85% Q4 2016/17 50% Q4 2016/17 100% 2016/ % 95% 100.0% 96.2% 96.4% 97.3% Page 4

92 MENTAL HEALTH IMPROVED ACCESS TO PSYCHOLOGICAL THERAPIES (IAPT) 14. Performance for IAPT is as follows: Roll Out standard 15%. Performance for December is reported as 1.1%, the same as the previous month, with a year to date position of 11.9% which is still on target. The monthly inconsistency of achievement levels has been raised with SSSFT. The Trust has cited capacity issues as being a factor in the monthly variation in performance and is developing a plan to address this. Details of the plan will be assessed by the CCG when it is received. The Recovery rate rose to 54.7% in December and is still above target for Q There are now three indicators in the Mental Health Dashboard where a service baseline has been set, and progress is due during 2016/17. These relate to children s and young people s mental health, crisis care and liaison and out of area placements. MENTAL HEALTH CARE PROGRAMME APPROACH (CPA) 16. As at Q3, 2017/18, 96.4% patients on CPA were followed up within 7days against the 95% standard. The YTD position is 97.3%. Page 5

93 Dementia Latest Baseline Position Outturn/ Standard Standard /Target Maternity Latest Baseline Position Outturn/ Standard Standard /Target Learning Disability Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Reliance on specialist inpatient care for people with a learning disability and/or autism (per million pop) Monitoring commenced in 2016/17 Trajectory 1.19% Q2 2017/18 62 Proportion of people with a learning disability on the GP register receiving an annual health check 2015/ % (England) 46.5% (2015/16: CCG) Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Neonatal mortality and still births per 1,000 population 2015 Women's experience of maternity services (2015: CCG) 82.1 (2015: CCG) Choices in Maternity Services Monitoring commenced in 2016/ % (2015 CCG) Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Maintain a minimum of two thirds diagnosis rates for people with dementia 2016/ % 67% 69.4% 69.8% 69.8% 68.0% 70.1% 70.3% 71.4% 71.1% 69.9% 69.9% The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months 2015/16 80% (2015/16: CCG) Page 6

94 LEARNING DISABILITIES (LD) 17. There are two indicators relating to LD: At Q2, 2017/18, the rate for reliance on specialist inpatient care for people with a learning disability and/or autism was reported as 200 per 1m population. In absolute terms this is 62 patients. 18. Nationally people with mild LD are being identified in mental health services as part of the Transforming Care reporting criteria. Funding has been secured from NHSE for refurbishment of premises at Church Parade which will allow improvements to be achieved on this measure. The position on the leasehold arrangements has been clarified and the scheme is mow progressing. Additional capital bids for the improvement of other properties within the TCP footprint are also being progressed. MATERNITY 19. The maternity indicator position is reported annually. There are three indicators in the dashboard, with data now populated. These have not yet been updated from 2015 data and show the CCG in the middle range of the national distribution. DEMENTIA 20. Dementia diagnosis continues to perform above the national standard. Page 7

95 Urgent and Emergency Care Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Achievement of milestones in the delivery of an integrated urgent care service 6 Inequality in unplanned hospitalisation for chronic ambulatory care sensitive conditions Q3 2016/ (England) Q1 2017/ A&E Waiting Time - % of people who spend 4 hours or less in A&E (SaTH) 2016/ % 95% 84.5% 77.5% 79.6% 78.6% 76.6% 77.6% 73.3% 73.7% 63.9% 77.8% Trolley Waits in A&E - Number of patients who have waited over 12 hours in A&E from decision to admit to admission (SaTH) 2016/17 17 Zero Tolerance Ambulance Handover time - Number of handover delays of >30 minutes (RSH + PRH) 2016/ Zero Tolerance Ambulance Handover time - Number of handover delays of > 1 hour (RSH + PRH) 2016/ Zero Tolerance Page 8

96 URGENT & EMERGENCY CARE A&E 4 HOUR WAIT & AMBULANCE HANDOVERS 21 For November 2017, the SaTH A&E 4 Hour Wait target has not been achieved and is reported as 73.7% and 63.9% in December. This is significantly below the target trajectory. 22 Performance in November and December failed to meet the planned STF trajectory at SaTH. Actual attendances at A&E are below the expected numbers in the STF trajectory, but breaches are higher than expected. SCCG attendances were 4% below plan at SaTH for the month of December. Full YTD to Month 9 the CCG is just 8 attendances above plan. 23 Following assessment of the local system by the Urgent Care Director the following 6 key action areas were presented to the A&E Delivery Board in January as the projects to focus our collective efforts on: Frailty Stranded patients ED Processes Getting SAFER as standard including red to green Demand and Capacity Working towards an integrated discharge team The Board accepted these as the key priority projects and the A&E Delivery Group has since assigned Executive leads to each one and specific work plans are being formulated to take each of these priority areas forward. Julie Davies is the executive lead for the Demand and Capacity project. 24 Staffing continues to be a problem and the option of foreign recruitment of consultants is being explored but to date has not proved successful. An additional 10 ECPs have been offered posts and SaTH are awaiting confirmation of acceptance from them. 25 Patient flow through the hospital remains problematic despite some reduction in the number of stranded patients. Achieving the target numbers of discharges before midday is proving challenging. 26 ECIP is working with the Trust to develop a demand and capacity model which is due for completion by the end of March. 27 There have been 9 12 hour trolley waits reported in A&E at SaTH in December. RCA analysis of these has been received by the CCG and is reviewed at the contract CQRM meeting with the Trust. Page 9

97 Urgent and Emergency Care Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Category 1 (mm:ss): 90th Percentile WMAS 00:11:22 00:11:45 00:11:48 00:11:47 00:12:21 00:11:59 00:11:19 00:11:41 00:12:10 00:11:36 New 15mins metric SCCG 00:17:44 00:18:31 00:18:34 00:19:56 00:19:56 00:20:35 00:20:04 00:20:22 00:19:55 00:20:33 Category 2 (mm:ss): 90th Percentile WMAS 00:16:43 00:18:39 00:18:10 00:19:21 00:19:52 00:22:17 00:21:09 00:21:36 00:24:16 00:21:38 New 36mins metric SCCG 00:25:16 00:29:40 00:28:18 00:32:14 00:30:55 00:34:05 00:31:32 00:33:58 00:34:50 00:32:37 Category 3 (mm:ss): 90th Percentile WMAS 00:28:59 00:39:53 00:38:01 00:44:57 00:46:05 00:76:27 00:64:15 01:07:15 1:32:57 00:69:48 New 90mins metric SCCG 00:36:29 00:45:17 00:41:27 00:46:17 00:49:06 00:68:06 00:57:03 1:02:13 1:15:13 00:62:54 Category 4T (hh:mm:ss) : 90th Percentile WMAS 01:00:32 01:20:12 01:18:45 01:35:33 01:30:59 01:34:53 01:27:17 1:21:06 1:66:15 01:31:34 New 180mins metric SCCG 00:41:07 01:08:07 01:04:21 01:06:27 01:20:44 01:08:57 01:15:55 1:32:19 1:03:17 01:13:25 Crew Clear delays of > 30 minutes (RSH + PRH) 2016/ Crew Clear delays of >1 hour (RSH + PRH) 2016/ Delayed Transfers of care attributable to the NHS (LA) 2016/ Zero Tolerance Zero Tolerance Reduction 2016/17 Outturn DTOC Rate (SaTH) 3.5% 2.3% 2.9% 2.8% 3.3% 3.1% 2.4% 3.0% 3.7% 2.4% DTOC Rate (RJAH) 3.5% 4.8% 4.3% 4.2% 4.2% 3.2% 2.3% 0.5% 3.2% 2.3% Population use of hospital beds following emergency admission Q3 2016/ (England) Q3 2016/ (Rolling Year) Page 10

98 URGENT & EMERGENCY CARE AMBULANCE RESPONSE TIMES, CREW CLEAR AND DELAYED TRANSFERS OF CARE 28 New performance standards have been defined for the 4 categories of call and are planned to be formally introduced to national monitoring form 1 st April WMAS have reported these new measures since September. The standards are shown below. Call Category Standard (mean) 90 th Percentile Category 1 Mean 7:30 minutes 90 th Percentile 15 minutes Category 2 Mean 18 minutes 90 th Percentile 36 minutes Category 3 90 th Percentile 90 minutes Category minutes 29 The CCG failed to meet the standards for the Category 1 calls and for the average target response time for Category 2 calls in December but, encouragingly, continued to achieve the standards for all other Call category standards. Category 1 calls account for around 5% of total calls to the ambulance service 30 DTOC (SaTH) In November 2017, the number of delayed days was 3.7% of occupied bed days. This is above the 3.5% target at SaTH and was manly due to an increase in Powys delays in the month. The position at RJAH in November was 3.2%, still ahead of target. At SCHT, the November value was 6.5%, deterioration from the previous month. The Trust is re-calibrating its DTOC improvement plan which is being monitored through the contract meetings. 31 Target levels for delayed transfers of care have been agreed with the Local Authority. These are expressed as a rate per day per 100,000 population over the age of 18. The November attainment for this was a rate of 6.9 per day per 100,000 population which is ahead of target. Whilst the overall rate is on target, there are some difficulties in ensuring that patients requiring NHS packages of care are being progressed through the system quickly enough to avoid delays. The system demand and capacity work will help identify any capacity gaps that will help reduce these delays. Page 11

99 Elective Access Latest Baseline Position Outturn/Stand ard Standard/Targ et Primary Medical Care Latest Baseline Position Outturn/S tandard Standard/ Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Inequality in emergency admissions for urgent care sensitive conditions Q3 2016/17 1,758 (England) Satisfaction with the quality of consultation at a GP practice (Jan-Mar & Jul- Satisfaction with the overall care received at the surgery Sept15) - Published 89.8% Satisfaction with accessing primary care Jan % Extended access to GP services on a weekend and evening Primary care workforce: Number of GPs and Practice Nurses (full-time equivalent) per 1,000 weighted patients by CCG March 2017 Sep % (England) 1.04 (England) Q3 2016/ (Jul-Sept15 and Jan-Mar16) Published July % (Jul-Sept15 and Jan-Mar16) Published July % This is based on a bi-annual survey undertaken in March and September March 2017 (CCG): 9.3% 1.15 (September 2016: CCG) Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD RTT - incompletes (CCG) 2016/ % 92% 88.6% 89.4% 89.4% 88.9% 89.8% 90.7% 92.0% 92.2% 90.5% RTT - incompletes (SaTH) 2016/ % 92% 85.8% 87.8% 88.2% 88.9% 90.8% 93.2% 94.5% 94.9% 90.2% RTT - incompletes (RJAH) 2016/ % 92% 91.3% 91.5% 90.1% 89.2% 88.7% 88.1% 89.1% 89.2% 89.7% No. of 52 Week Waiters (CCG) 2016/17 56 Zero Tolerance Diagnostic Test Waiting Time < 6 weeks (CCG) 2016/17 1.8% 1% 0.3% 0.5% 0.4% 0.5% 0.6% 0.9% 0.7% 1.0% 0.6% Diagnostic Test Waiting Time < 6 weeks (SaTH) 2016/17 1.7% 1% 0.0% 0.1% 0.0% 0.0% 0.1% 0.7% 0.7% 1.0% 0.3% Diagnostic Test Waiting Time < 6 weeks (RJAH) 2016/17 0.2% 1% 1.0% 0.1% 0.3% 0.5% 0.4% 0.7% 0.3% 0.5% 0.5% Cancelled Operations - no. of patients re-admitted within 28 Zero 2016/17 5 days (SaTH) Tolerance Cancelled Operations - no. of patients re-admitted within 28 days (RJAH) 2016/17 2 Zero Tolerance Page 12

100 PRIMARY MEDICAL CARE 32. Access to, and satisfaction with, Primary care services continues to be rated highly by Shropshire patients and compares well with the overall England position. 33. Extended access at weekends and evenings is an area where improvement is indicated for the CCG as it is below the national average and therefore is a section within the GP 5yr forward view work stream. ELECTIVE ACCESS 18 WEEKS RTT, 52 WEEK WAITERS, AND < 6 WEEKS DIAGNOSTICS 34 The CCG achieved performance of 92.2% in November, which is the second time in successive months that the CCG has been able to achieve the target. This was made up of 94.9% achievement at SaTH, 89.2% at RJAH and 88.3% at all other providers. This indicates that all providers continue to struggle to achieve the target. 35 SaTH achieved their overall RTT target in November for the third time this year at 94.9% and is now achieving in all but two specialties. 36 Requirements from NHSE to restrict non-urgent operations may have some impact on the ability to continue to achieve the standard over the winter months. The impact of this is being assessed by SaTH and is due to report back to the CCG by the 7 th February. The system has completed a return to bid for some central money to support the additional costs of rebooking this activity before the end of March. 37 RJAH have indicated some capacity issues and have a revised recovery trajectory which shows achievement of the standard by the end of the financial year. 38 In November there were 3 52 week waiters reported for the CCG. These were at 2 T&O patients at Wye Valley and 1 T&O patient at Worcester Acute. 39 Performance against the 99% standard for waiting time for a Diagnostic Test was achieved by the CCG in December with a level of 99.3%. Page 13

101 Additional Indicators Requiring Focus Latest Baseline Position Outturn/ Standard Standard /Target NHS Continuing Healthcare Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD People eligible for standard NHS Continuing Healthcare per 50,000 population. Consistent application across the country is the measurement 2016/17 Q (England) Q3 2016/ Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Healthcare acquired infection (HCAI) measure (MRSA) 2016/ Healthcare acquired infection (HCAI) measure (Clostridium difficile infection) 2016/ E coli bacteraemia 2016/ Page 14

102 NHS CONTINUING HEALTH CARE (CHC) 40 Performance for CHC at CCG level for Q is at 42.7% against a national figure of 45%. This national data has been recently published as part of MyNHS dashboard. HEALTH ACQUIRED INFECTION MRSA AND CDIFF 41 For 2017/18 there have been no incidences of MRSA reported at CCG level in Q1 & Q2 2017/ C Difficile for 1718 to December 53 incidences were reported which may put the year end position at risk. 43 E Coli infections were slightly below target in December. The annual target for the CCG is 205 with the final year position now at risk. The anonymised data of these cases will be analysed and shared with the Local Health Economy E coli BSI Reduction Group and the Local Health Economy IPC Group to identify opportunities and potential interventions to reduce the risk of E. coli BSI in the CCGs population and achieve the ambition to reduce all E coli BSI reported at CCG level by 10% or greater by March NHS The CCG is now receiving data direct from the regional commissioning lead for NHS 111. There were 3218 calls triaged by NHS 111 registered to Shropshire in December Of these 26.5% (854) were triaged by CA. Of the triaged calls 39.5% were referred to OOH service and 13.05% to the ambulance service. RECOMMENDATIONS 47 The Governing Body is asked to NOTE the contents of the report and the CCG actions contained within to recover performance in those areas which are currently below target. Page 15

103 Agenda item: GB Governing Body meeting: : Title of Report: November 2017 Major Contract Performance Month 8 Responsible Director: Gail Fortes-Mayer, Director of Contracting & Planning Author of the report: Charles Millar, Head of Contracting, Planning & Performance Meryl Flaherty, Head of Contracting Presenter: Gail Fortes-Mayer, Director of Contracting & Planning Purpose of the report: This report summarises the current contractual position at Month 8 for the CCG s four main contracts; highlighting key contractual issues for review by the Governing Body. Key issues or points to note: SaTH Activity is on plan, there is slight over performance in Daycases, First and Follow up Outpatient attendances. Elective, Non-Elective and Critical Care are all under plan. Daycase at Robert Jones and Agnes Hunt Trust is continuing to underperform by 20% A Contract Performance Notice has been issued to SSSFT regarding the performance of the Early Intervention in Psychosis Pathway indicator. A Contract Performance Notice has been issued to SSSFT due to concerns regarding the 0 to 25 service An Activity Query Notice (AQN) has been raised through lead commissioner following significant over performance in activity with WMAS ; Actions required by Members: To note the current performance and actions. 1

104 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications Yes/No 2 Health inequalities 3 Human Rights, equality and diversity requirements 4 Clinical engagement 5 Patient and public engagement 6 Risk to financial and clinical sustainability There is over-activity in the out of county providers particularly in Outpatients and Emergency Admissions notably at Wye Valley and Worcester Yes/No Yes/No Yes/ No Yes/ No Yes/ No 2

105 NHS Shropshire CCG Governing Body November 2017 Major Contract Performance Month 8 (November 2017) Authors: Charles Millar, Head of Planning & Performance and Meryl Flaherty, Head of Contracting Executive Summary and Actions Required 1 This report summarises the current contractual position at Month 8 for the CCG s main contracts; highlighting key contractual issues for review by the Finance & Performance Committee. Members are asked to note the current performance and actions. Introduction 2 This report summarises Shropshire CCG s (SCCG) position with respect to its contracts with its main providers outlining the actions underway. Note: This paper should be read in conjunction with the Finance and Contract Report. Contracts Overview Shrewsbury and Telford Hospital NHS Trust (SaTH) Activity 3 The overall the contract activity is on plan. The areas of over performance are similar to the contract from 16/17, namely: Daycases, First and Follow Up Outpatient attendances. 4 There are also areas of underperformance that have continued in Elective, Nonelective and Critical care, bringing the activity back in line with plan. Table 1. SaTH Activity Month Point of Delivery (POD) Plan Actual Variance % Variance Day cases % Elective % Emergency % Non Elective % Critical Care % First Outpatients % Follow Up Outpatients % Outpatient Procedures % A&E Attendances % Total % Figures 1 & 2. Emergency activity 3

106 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 5 The charts below show a 32 month activity and cost trend. 5,500,000 Emergency Actual Cost 5,000,000 4,500,000 4,000,000 3,500,000 3,000,000 6 The over performance is both activity and casemix driven. The chart above indicates that cost has slowly been increasing over the last 32 months. There was a significant activity and casemix increase in November. This is being reviewed 4

107 Table 2. Sepsis Counting and Coding Notice Sepsis Counting and Coding Notice Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 YTD Totals 69,814 94,254 62,987 76, ,263 71,635 13, ,425 Sepsis has new coding guidance out for review at present and the adjustment will be made based on new methodology from NHS Digital for 2018/19 and the nationally mandated approach to the recording of Sepsis. Figures 3 & 4. Daycase activity 7 The charts below show a 32 month activity and cost trend. The chart indicates that activity has been increasing over the last 32 months. Some of this is a displacement form Elective Inpatients but this does not explain all of the increase. Despite the activity increase, the cost increase has been contained through alterations in the tariffs for daycases. 5

108 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Referrals 8 SATH referrals continue to be on a slight downward trajectory. The referral data is analysed in detail at the Activity & Finance Group and discussed at a speciality level. There is particular focus on the consultant to consultant referrals to ensure they are within the CCG Policy. Figure 5. Referrals to SaTH SaTH Referrals Referrals Linear (Referrals) Finance Although a year-end financial agreement has been made with SaTH for planning purposes a summary financial position on the for SaTH contract continues. 6

109 At Month 8 there is an overspend of 1,676,993 which is 1.9% over plan.this is based on the Contract Monitoring Information submitted for Month 8. MRET is now included in the Non PbR Variable line. 9 This does not include all adjustments for contract challenges. Contractual Actions Contractual Challenges Raised 10 Flex and Freeze is being fully operated within the SaTH contract in line with the National Secondary Uses Service (SUS) timetable. The CCG will not fund activity that has not been reconciled through SUS, or in the case of activity or payments not liable for SUS submission. The CCGs will pay only on reconciliation of Service Level Agreement Manager data (SLAM) with Patient Level Data. Challenges Raised 11 The formal Month 7 challenge position is as follows: Table 3. Challenge Values Full value challenge Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 463, , , , , , , Month 8 formal challenges will be issued on 31 st January Activity Query Notices (AQN) 13 The Trust has raised an Activity Query Notice with regards to data issues supplied by the CSU contained in the month 2 challenge letter. The CSU have acknowledged there were duplicates contained in the backing data supplied with the challenge letter. Additional validation took place in September to ensure the Month 3 backing data was accurate; the CGG is now expecting the notice to be closed. Contract Performance Notices 14 There is now only one Contract Performance Notices (CPN) currently open with SaTH for failure to achieve the constitutional targets: The percentage of A & E attendances where the Service User was admitted transferred or discharged within 4 hours of their arrival at an A&E department. 15 A monthly teleconference between the CCG, SaTH, NHSE & NHSI is now in place to cover the major performance issues. 16 It should be noted that financial sanctions attributed to A&E performance cannot be applied under the contract as part of the national STF (Sustainability and Transformation Fund) process 7

110 Contractual Prior Approvals - Value based Commissioning (VBC) 17 Contractual prior approvals have been in place for the treatments contained in the VBC Policy since October Contractually the commissioner is not required to pay for activity carried out without an appropriate prior approval. Figure 6 - Outcomes - VBC requests submitted by SaTH. 18 The CCG is working with SaTH to implement Blueteq, an electronic approval system, to minimise any additional administrative burden associated with the prior approvals process, once the details of approval forms and requirements are finalised. Key actions summary from Monthly Contract Meetings National Variation the National Variation for 2018/19 has now been included in the contract. This includes: o Never Events cease to be accompanied via a contractual penalty from 1st Feb o From October 2018 the Provider does not need to accept (and will not be paid for) any first outpatient attendance resulting from referrals by GPs to Consultant-led acute outpatient services made other than through the NHS e-referral Service. The CCG needs to ensure that GPs are made aware of this process. o The Parties must have regard to the Mental Health Crisis Care Concordat and must reach agreement on the identification of, and standards for operation of, Places of Safety in accordance with the Law, the 1983 Act Code, the Royal College of Psychiatrists Standards and the Urgent and Emergency Mental Health Care Pathways. o Nationally mandated changes in coding and counting (diagnosis codes, procedure codes, point of delivery rather than HRGs which are about grouping rather than coding) still require notification and financial neutralisation. 8

111 o Chargeable overseas patients where the patient pays in advance (i.e. for planned care) then the commissioner no longer has to pay the 75% of tariff. Elective Activity Suspension Due to the high volume of emergency cases the Trust has been required, under national direction, to temporarily suspend elective activity. The impact on the RTT position is being progressed via the Planned Care Working Group. Activity Plan for 2018/19. The Activity plan for 2018/19 is currently being negotiated with the Trust for sign off by 20 th February. Ophthalmology Action Plan - Task and Finish Group now meets fortnightly. A phased reopening for the closed services is now being planned by SaTH. Two new permanent consultants have been now commenced with the Trust. Neurology A fortnightly task and finish group is in place with SaTH. A phased reopening of this service is now been finalised by SaTH. Additional capacity has been commissioned at the Robert Jones and Agnes Hunt Trust. 7 Day Working There is a working group within the Trust to plan, identify workforce gaps, financial implications and develop business plans for each area to enable implementation of the four key standards by March These are: o o o o Clinical Standard 2 Time to first Consultant Review Clinical Standard 5 Access to Diagnostics Clinical Standard 6 Access to Interventions Clinical Standard 8 Ongoing Consultant-directed Review. The Trust supply a full update at the Clinical Quality and Review Meeting Roof at Maternity Unit RSH Following the snow damage at RSH the Maternity Unit is closed to deliveries. Further damage has occurred and the service has now moved to a different ward within the Hospital. Repairs to the roof are ongoing Robert Jones and Agnes Hunt NHS Foundation Trust (RJAH) Activity 19 Month 8 activity at RJAH is 5% below plan. The largest variance in activity is Day cases where activity is 20% below plan. Also it is encouraging to note that Follow-Up Outpatients are below plan at this stage. Table 4. RJAH Month 8 Activity Point of Delivery (POD) Plan Actual Variance % Variance Day cases % Elective % Non Elective % Regular Day cases % First Outpatients % Follow Up Outpatients % Outpatient Procedures % Total % 9

112 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov The underperformance is activity driven. The chart below shows the 20 month activity trend. Figure 7. Daycase activity N Daycase Activity Trend Elective YTD variance over plan Referrals 21 The over performance is mainly case mix driven due to the impact of the VBC process removing some types of activity. As activity is only 2% over plan. 22 October 2017 has seen an above trend increase in referrals. This is mainly in Upper Limb, Arthroplasty and Foot & Ankle. The trend is monitored at the monthly contract meetings and at the Planned Care Working Group. Figure 8. RJAH Referrals RJAH Referrals Total Linear (Total) 10

113 Finance 23 The summary financial position on the RJAH contract at Month 8 is an overspend of 222,451 which is 1.0% over plan. 24 This does not include any adjustments for reconciliation, agreed contract challenges and particular contract variations. 25 QIPP Plans have now been allocated to the appropriate POD s. Contractual Actions Contractual Challenges Raised 26 Flex and Freeze is being fully operated in line with the National Secondary Uses Service (SUS) timetable. The CCG will not fund activity that has not been reconciled through SUS, or in the case of activity or payments not liable for SUS submission, the CCG will pay only on reconciliation of Service Level Agreement Manager, data (SLAM) with Patient Level Data. 27 The formal Month 7 challenge position is as follows: Table 5. Challenge Values Full value challenge Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 223, , , ,365 68,825 99, , Month 8 formal challenges are being issued on 31 st January Activity Query Notices (AQN) 29 There are currently no Activity Query Notices open at RJAH. Contract Performance Notices 30 There are no Contract Performance Notices currently open. Value based Commissioning (VBC) 31 Contractual prior approvals have been in place for the treatments contained in the VBC Policy since October Contractually the commissioner is not required to pay for activity carried out without an appropriate prior approval. 32 At the end of December 2017 the CCG undertook an Audit of three VBC procedures to test the compliance against the VBC Policy. Table 6 VBC Audit Results VBC Procedure Activity M1-7 17/18 Estim ate FOT 2017/1 Numbe r audited Complia nt Not complia nt Unclea r % Not complia nt / Unclear Average cost of procedu re Scalable challenge 11

114 8 o % 3, ,107 Therapeutic Arthroscopy 4.11 Excision % 3,866 47,128 of Acromio- Clavicular Joint 4.12 Joint % ,390 injection site of procedure Total ,624 It can be assumed from the table above that the level of non-compliance with the full year impact of policy compliance is c. 307,624; this is now being challenged with RJAH. 33 Key actions summary from Contract Meetings SOOS (Shropshire Orthopaedic Outreach Service) The funding for SOOS has been agreed and the update has been made to the contract. RTT The Trusts trajectory is to meet the 92% referral to treatment target in February Full updates are given at the Planned Care Working Group.National Variation As outlined in the SaTH section the National Variation for 2018/19 has now been included in the contract. Shropshire Community Health Trust 34 The Month 8 financial position is a 80k underspend. Table 7. Activity and Finance Area Activity Plan Activity Actual % Variance (Activity) Value Variance ( ) PBR 22,437 22, % - 83,513 Non PbR 344, , % 3,216 Total 366, , % - 80,297 PbR YTD 37.5% Inpatient under-activity against plan (-72) = - 67, % under-activity against plan in Outpatients (-974) = - 103,813 23% under-activity against plan in Radiology (-244) = - 10, % over-activity against plan in MIU (1,056) = 68, % over-activity against plan for Welsh patients in MIU (454) = 29,553 12

115 Inpatient and outpatient under activity is mainly due to reductions in capacity as a result of workforce issues. 35 Contractual Actions There are discussions taking place with SCHT in relation to policy wording relating to age restriction within the service specification for Community Neuro-Rehabilitation Service and the need to ensure compliance with Age Discrimination Laws. 36 Contractual Challenges Raised No Contract Challenges have been raised. 37 Activity Query Notices (AQN) No activity query notices were open at the end of November Contract Performance Notices Two Contract performance Notices have been issued in January 2018 concerning Unplanned closure at MIUs The failure to deliver the Out of Hours District Nursing service A Contract Performance Notice remains open with SCHT for the breach of RTT Incompletes at specialty level for the Telford Community MSK service (TEMs) which is provided through a separate contract with SCHT. The Trust returned to compliance for this service at the end of November Key actions summary from Contract Meetings ICS Specification Collaborative work continues in order to refine the ICS specification. This needs to be expedited to ensure SCCG is receiving value for money. Both the directly commissioned community services and those commissioned through BCF need to have greater clarity and focus on delivery via a robust service specification and metrics Non-consultant waiting lists The Trust has started reporting from Month 8 onwards. Physiotherapy Waiting Times - The Trust is supplying a monthly report of waiting times for Physiotherapy at each clinic and this is being circulated in the G.P. Newsletter South Staffordshire and Shropshire Healthcare Trust 40 Activity The contract is currently 8.9% under the activity target at Month 8 with a 46,405 underspend once the financial adjustments are applied. The financial adjustment is the application of the 5% cap and collar and the upper and lower tolerances. 13

116 Table 8 Activity and Finance M8 Activity plan Activity Actual % Variance Activity YTD Finance Variance YTD Financial adjustment MH Admitted Care 15,056 11,978 (20.4%) ( 1,552) ( 260) MH Non Admitted Care 824, ,163 (7.9%) ( 1,288,811) ( 47,031) MH Non PbR 15,358 16, % 92,670 8,882 Specialist & Family Services 1,300 1,174 (9.7%) ( 38,302) ( 2,066) Learning Disability Service 5,877 6, % 143,410 ( 6,424) Other 17,661 0 Total 861, ,419 (7.7%) ( 1,074,924) ( 46,899) PICU % 35,673 0 PICU Nurse Specialing * The marginal rate does not apply to PICU but there is an upper tolerance limit of 20%. 41 Nurse specialling is where a patient requires 2:1 nursing (or more) and is included in the price of PICU Contractual Actions The Q2 CQUIN submission has been reviewed and the Provider informed that they have not achieved all the milestones for Q2 42 Contractual Challenges Raised No Contract Challenges have been raised. 43 Activity Query Notices (AQN) An AQN issued in relation to the significant under activity in community services has now been closed following a joint investigation into activity levels. Shropshire CCG has written formally to the Trust to initiate the process to revise the activity levels and agree the financial impact. An executive meeting with the Trust is scheduled for the end of January. 44 Contract Performance Notices A Contract Performance Notice was issued due to concerns about the ability to achieve the Early Intervention in Psychosis (EIP) target that 50% of Service Users experiencing a first episode of psychosis should commence a NICE-concordant package of care within two weeks of referral. Also, data submissions were not reconciling as they should with regard to the figures for this target. SSSFT are implementing a remedial action plan to rectify the situation which is being monitored by Commissioners in the monthly Contract meetings. SSSFT have 14

117 also produced a Reporting Assurance Process in association with NHS Digital. A Contract Performance Notice has been issued concerning the 0-25 Emotional Health and Well-being Service. SSSFT are implementing a Remedial Action Plan which is being closely monitored by Commissioners. The new Single Point of Access for the service opened on 4 th December Key actions summary from Contract Meetings CRISIS Care Building/redesign work on the Section 136 suite is nearing completion. Pathways to support changes to the Police and Crime Act are being developed. The Single Point of Access is up and running and changes to configuration of inpatients units are nearing completion. New model for Learning Disabilities Services - A new model for Learning Disability services and service specifications are in development. Commissioners are in discussions with SSSFT to progress. IAPT Service Tariff Development A group of stakeholders including Staffordshire CCGs are working together with the Trust to develop tariffs for the IAPT services. It has been agreed to build the tariff based on real costs of individual services and compare to national reference costs Emotional Health & Well Being Service Executive to Executive meeting held on 26 January 2018 agreed close monitoring of the RAP and follow up meetigs with GPs through locality events. Shropshire Doctors Co-operative Ltd. (Shropdoc) 46 The Out of Hours service is commissioned on a block contract basis from Shropdoc. Table 9. Performance Metrics LQR In-time Total % 1 % calls abandoned 95 4, % 2 % answered in 60 seconds 4,281 4, % 4 % calls passed to 999 within 3 minutes % 12 % calls triaged within 20 mins (urgent) 992 1, % 13 % calls triaged within 60 mins (routine) 2,206 2, % 9 % emergencies consulted within 1 hour % 10 % urgent consulted within 2 hours % 11 % routines consulted within 6 hours 1,184 1, % 9 % emergencies visited within 1 hour % 10 % urgent visited within 2 hours % 11 % routines visited within 6 hour % 47 For the purposes of achieving the incentive payments the requirement is for base appointment and home visits to be counted as face to face contacts and the figures are as follows Table 10. Local Quality Requirements LQR In-time Total % 9 F2F All - 1 hour % 10 F2F All - 2 hours % 15

118 11 F2F All - 6 hours % 48 Contract Actions Shropdoc have shared their model of service delivery implementing the use of Urgent Care Practitioners as well as GPs. The Commissioners are monitoring the impact of the new model. 49 Activity Query Notices There are no Activity Query Notices open. 50 Contract Performance Notices There are no Contract Performances Notices 51 Key Actions Summary from Contract Meetings Out of Hours Medical Cover in Community Hospitals Shropdoc noted that this element of the service was not in the service specification of the current contract with commissioner. It is a local agreement between Shropshire Community and Shrop Doc; outside the jurisdiction of the CCGs. This continues to be negotiated with Shropdoc. Out of Hours District Nursing Shropdoc gave notice to Shropshire Community Health Trust on delivering this sub-contracted arrangement as it was no longer viable once Telford and Wrekin CCG had given notice on the service. Whilst negotiations take place between the two Providers and the CCG, Shropdoc are continuing to provide the service on behalf of the Community Trust. Falck Medical Services (NEPTS) Provider 52 Table 11 Falck Finance Position Planned Budget YTD (M8) Actual Cost YTD (M8) Variance % Variance Falck Medical Services 1,988,054 2,032,322 44, % 53 The committee is asked to note the current performance of the provider. Falck Medical Services are currently over performing by 2.23% against budgeted plan. Contractual Actions 54 Indicative Activity and Expected Contract Values will be remodelled based on outturn for this financial year to reflect current performance. A contract variation will be issued to action these changes. 55 A previous agreement required the CCG to fund NEPT costs for out of area patients and then reclaim from the relevant commissioners. The current position for this is shown in Table 12. This arrangement is being reviewed with the provider to an alternate arrangement whereby the provider would bill the external commissioners directly. Table 12 Out of Area Costs 16

119 Out Area Activity Top 5 Highest Costs Actual Cost (M1-M6) Powys LHB 47,470 NHS Stoke on Trent CCG 2,239 NHS Stafford and Surrounds CCG 2,210 NHS West Cheshire CCG 1,612 NHS Herefordshire CCG 1,146 Other CCGs (59 in total) 14,193 Total Cost 68,870 Contractual Actions 56 To mitigate this cost Finance has raised invoices to recharge Powys LHB for their responsible cohort of patients. Moving forward Powys will become a party to the current contract with Falck Medical Services. The provider will then charge Powys directly for their cohort of patients. 57 For English commissioners a letter has been issued to the provider informing them from 1 st February 2018 Shropshire CCG shall only be charged for activity relating to their patient population. This will remove the need for Finance to recharge English commissioners. 58 Key Performance Indicators are currently being reviewed. 59 Contract Notices None open in month 8. Other Providers 60 Table 13 - Other providers activity Provider Planned Activity Actual Activity Activity Variance Betsi Cadwaladr University Health Board Daycase & Regular Day Admissions Elective Emergency and Non Elective st Outpatient Follow Up Outpatient Other The Royal Wolverhampton NHS Trust Daycase & Regular Day Admissions Elective Emergency and Non Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances

120 Other University Hospitals Birmingham NHS Foundation Trust Daycase & Regular Day Admissions Elective Emergency and Non Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other University Hospitals of North Midlands NHS Trust Daycase & Regular Day Admissions Elective Emergency and Non Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other Worcestershire Acute Hospitals NHS Trust Daycase & Regular Day Admissions Elective Emergency and Non Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Wye Valley NHS Trust Daycase & Regular Day Admissions Elective Emergency and Non Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other Mid Cheshire Hospitals NHS Foundation Trust Daycase & Regular Day Admissions Elective Emergency and Non Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other

121 Grand Total Worcester Acute, UHNM and Wye Valley Trust are the major contracts that are over performing and this is mainly in Outpatients and Emergencies. Detailed reports for all Out of Area contracts are now reviewed by contracts and performance team internally. West Midland Ambulance Service Table 14 WMAS Activity Provider Planned Actual Variance % Variance Activity Activity Activity West Midland Ambulance Service 28,491 30, % Contractual Actions 62 An activity query notice has been raised through the lead commissioner in respect of over-performance on the WMAS contract. Although several other commissioners are also experiencing above plan performance, there is no clear indication as to the causal factors behind this. Locally, there is some evidence that the introduction of the NHS111 service has increased the propensity for calls to be directed through to the ambulance service Recommendations 63 The committee is asked to note the current performance and actions. 19

122 Agenda item: GB Shropshire CCG Governing Body meeting: 14 th February 2018 Subject: NHS Guidance Update Contract Process 2018/19 Refreshing NHS Plans for 2018/19 Report Compiled by: Meryl Flaherty Head of Contracting Presented by: Responsible Director: Gail Fortes Mayer Director of Planning & Contracting For decision For performance monitoring Other please specify For Information KEY POINTS IN REPORT The paper outlines the planning guidance for 2018/19 for health economies published on 2 nd February RECOMMENDATION TO THE BOARD To note the current position and issues. CONTEXT AND IMPLICATIONS Performance implications As identified in the report. Quality Implications Financial implications HR/Personnel implications Promoting equality and equity implications What patient and public involvement has there been in this issue, or what impact could it have on patient/public experience? As identified in the report. As identified in the report None. Equality and equity by each provider is implicit as part of the CQR processes and commissioning for quality, safety and a good patient experience As identified in the report. 1

123 Refereshing NHS Plans for 2018/ NHS England & NHS Improvement released the updated planning guidance on Friday 2 nd February 2018, it sets out a number of assumptions for the planning round..below are the highlights contained the document: Financial Framework 2. Resource needs to be available for: Realistic emergency activity in plans Additional elective activity to tackle waiting lists Universal adherence to Mental Health Investment standard Transformation commitments for cancer services Transformation commitments for primary care. CCGs no longer have to hold 0.5% of their allocation in reserve. This is lifted for Commissioner Sustainability Fund a new fund of 400m has been identified to where support CCGs where it is agreed that they will be unable to operate within its recurrent allocation for 2018/ Such CCGs will be required to commit to a credible plan, agreed and aligned at STP level. 5. All CCGs will be expected to achieve a minimum of financial balance withzero deficits following deployment of any CSF allocations. 6. Provider Sustainability Fund a fund of 650m will be added to the 1.8 billion to increase the fund to 2.45 billion % of the 2.45 billion will be linked to A&E performance; the provider will need to achieve A&E performance in 2018/19 that is the better of either 90% or the equivalent quarter for 2017/ NHSE are to consult on performance sanction exemptions, looking to extend the performance indicators that CCGs cannot fine (e.g., Mixed sex accommodation breaches and cancelled operations 9. National Tariff - Tariff remains as previously reported, however local systems are encouraged to consider local payment reform, in particular to introduce appropriate local tariffs for emergency ambulatory care. (As required for the Ambulatory Care QIPP) Underlying assumptions 10. CCGs should assume that the current high level of discretionary process for generic drugs in short supply will not persist in 2018/ A public consultation has been launched (closes 20 th March 2018) on reducing prescription over the counter medicines. It is assumed this could save the NHS up to 136 million a year. 2

124 12. Planning Assumptions for emergency care and Referral to Treatment Times Allocation for 2018/19 allows for: 2.3% Non-Elective Admissions and Ambulance growth 1.1% A&E attendances. 4.9% Total Outpatients 3.6% Elective admissions. 13. Also assumes GP referrals will increase by 0.8%. (Local figures may differ and these are currently being modelled by the BI team within the CCG). 14. Emergency Care 15. Linked to point 6 above, there is an expectation that four-hour A&E target is above 90% for the month of September 2018 (SaTH December 2017 performance 73.83%) and the majority of providers achieving the 95% standard by the month of March Organisations will be required to plan and report non elective admissions of less than one day separately from those of one day or more. 17. Plans will be collected on planned bed numbers to ensure sufficient capacity is available throughout the year to meet anticipated demand for emergency and elective care. 18. Commissioners and provider plans will be expected to demonstrate how they will complete the implementation of the integrated Urgent Care Strategy, including: Reduce DTOC to 3.5% Focus on patients with a length of stay of over seven days (stranded patients) and over 21 days (super stranded patients) Providers of Community services will be invited to participate in a new local incentive scheme in conjunction with their CCG whereby they will be able to reinvest savings from acute excess bed day costs to expand community and intermediate care. 19. Referral to Treatment Times 20. CCGs and providers are required to plan that their RTT waiting list, measured as the number of patients on an incomplete pathway, will be no higher in March 2019 than in March 2018 and where possible should be reduced. 21. The number of patients waiting more than 52 weeks for treatment should be halved by March 2019 and eliminated where possible 22. Organisations to ensure their RTT plans are robust and realistic 23. Integrated System Working 24. STPs are expected to take an increasingly prominent role in planning and managing system wide efforts to improve services 25. To encourage the move towards system working though STPs and the voluntary roll-out of integrated Care Systems, NHSI and NHSE will focus on the assurance of system plans for Integrated Care systems rather than organisation level. STPs that can demonstrate their readiness to join the 3

125 Integrated Care System programme need to submit an expression of interest by March 2018.It is envisaged that over time Integrated Care Systems will replace STPs 26. Process and Timetable Timetable 2 nd March 2018 Local decision to enter into mediation 8 th March 2018 Draft 2018/19 operating plans submitted 8 th March 2018 Draft 2018/19 STP contract/plan alignment return 23 rd March 2018 National deadline for 2018/19 contract and CVs 27 th April 2018 Expert determination papers shared by all parties 30 th April 2018 Final Governing Body approved Operational Plans submitted 30 th April /19 winter demand and capacity plans submitted 30 th April 2018 Final STP contract/plan alignment return 8 th June 2018 Final outcomes of expert determinations Where commissioners and providers fail to reach timely agreement the dispute resolution process in the contract should be followed. Starting with escalated negotiation, the process then moves to mediation. Where agreement cannot be reached organisations will be expected to follow the Expert Determination process The draft and final operating plans must be consistent and triangulate with provider expectations and organisations will be required to do a further STP level triangulation of contracts and plans. CQUIN/Quality Premium Changes to the 2018/19 CQUINs will be published soon. The Proactive and safe discharge indicator is suspended in 2018/19. This change will have implications in Community providers, CCGs are expected to take this opportunity to include a local CQUIN in their contracts. The 0.5% risk reserve CQUIN will be withdrawn and be added to engagement CQUIN which will increase to 1%. NHSI & NHSE are trialling a new triangulated provider / commissioner finance return to confirm whether CQUIN awards have been earned during the year. 210 million of CCG Quality Premium incentive funding will be contingent on performance on moderating demand for emergency care. The method of monitoring will be the level of growth in non-elective activity compared to the agreed plan. Updated guidance will be published shortly. Winter Demand & Capacity There will be no additional winter funding for 2018/19 4

126 Guidance on submitting the winter plans will be available by March /19 Deliverables The CCG needs to test which of these require investment and building into the Long Term Financial Model (LTFM) Mental Health Additional funding has been built into CCG 2018/19 allocations to support the expansion of services outlined in the planning guidance and the specific trajectories set for 2018/19 to deliver the Five year Forward View for Mental Health. Progress to be made against all deliverables. Each CCG must meet the Mental Health Investment Standard (MHIS) by which their 2018/19 investment in mental health rises at a faster rate than their overall programme funding. Cancer Ensure all eight waiting time standards for cancer are met including the 62 day referral-to-treatment cancer standard. The release of the cancer transformation funding in 2018/19 will continue to be linked to the delivery of the 62 day cancer standard. Primary Care Providing extended access to GP service, including at evenings and weekends for 100% of their population by 1 st October Urgent and Emergency Care The four hour A&E standard is at or above 90% by September 2018 and the majority of providers are achieving the 95% standard by March Transforming care in LD continue to reduce inappropriate hospitalisation of people with a learning disability. Maternity deliver improvements in safety towards the 2020 ambition to reduce stillbirths, neonatal deaths, maternal death and brain injuries 5

127 Week Commencing Action 05/02/ /02/ /02/ /02/ /03/ /03/ /03/ /03/ /04/ /04/ /04/ /04/ /04/2018 Indicative Activity Plan / Contract Value Agree baseline figures with Providers Model Planning Guidance growth figures Model RTT figures Agree final values Mediation Local decision to enter into mediation for 2018/19 contract variations QIPPs Agree Ambulatory Tariff with SaTH Insert the Biosimilar agreement in the contract Operational Plan Draft 2018/19 Organisational Operating Plans submitted Final Operating plan approved at Governing Body Control total / Assurance Statement ICS system control total changes and assurance statement submitted Contract Variations CV CQUIN indicators update and submission dates for 2018/19 CV the VBC Policy into all Providers CV Serious Incident update into Contracts CV C-Diff update into Contracts Expert Determination Expert Determination paperwork completed and shared by all parties Winter Demand / Capacity Plan 2018/19 Winter Plan & Capacity Plans submitted STP Contract Final 2018/19 STP contract and Plan Alignment template submitted 6

128 Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: Quality Exception Report Responsible Director: Dawn Clarke, Director of Nursing, Quality and Patient Safety Author of the report: Sara Bailey- Lead Nurse Quality & Patient Safety and members of the Nursing, Quality and Safeguarding Team Presenter: Dawn Clarke, Director of Nursing, Quality and Patient Safety Purpose of the report: The CCG must ensure that commissioned services, including joint-commissioned services are being delivered in a high quality and safe manner, ensuring that quality sits at the heart of everything it does. A wide range of reports pertaining to the quality agenda are received and considered at the Quality Committee in accordance with the terms of reference of the Committee. The purpose of the report is to provide assurance to the Governing Body that the processes are in place to monitor quality performance within our commissioned services, to ensure remedial action is in place where concerns are identified and to escalate where appropriate. Key issues or points to note: The Trust reported four 104 day cancer breaches in December Harm proformas have been received for 3 of which 2 identified no harm was caused to the patients. A full root cause analysis is in progress for the third case and the findings will reported via the CQRM. The CCG has requested receipt of the outstanding harm proforma from the Trust. As are many acute providers, the Trust has experienced increasing pressure in its Emergency Departments. In December, 12 hour trolley wait breaches were reported. The CCG has now received and reviewed the breach root cause analysis reports for theses. In all cases there was no harm to patients identified however, assurance is being sought as to how further breaches can be avoided. The Trust has received positive verbal feedback following a Neo-natal review by NHS England and the Neo-natal Network. There were no major safety concerns and many areas of good practice reported including nursing care and support and systems and processes in place Child and Adolescent Mental Health Services provision: the CCG s continue to raise concerns with the provider in the absence of quality and safety data reported to provide an acceptable level of assurance in terms of providing a safe and high quality service. A formal remedial improvement action plan is now in place to address the many concerns identified which include; robust management and governance structures, patient information systems, workforce resources, access to services for crisis response as well as routine referrals and 1

129 waiting times Provision of Looked After Children s Services provided by Shropshire Community Health Trust was raised previously as a concern with assurance provided that progress had been made. Progress has not been as timely as expected and the formal contracting route is currently be considered in order to ensure risks are minimised.. The CCG Quality Team are working in collaboration with Telford and Wrekin CCG and SaTH to hold a Partners in Care nurse conference to be held on Tuesday May 15th This will be an exciting opportunity to showcase our work on Leading Change, Adding Value. There will be an open invitation for participation from all our nursing and allied health professionals across the Health Economy. Actions required by Governing Board Members: Board members are asked to note the key issues above, to note the actions being taken and to receive the report. 2

130 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required No 2 Health inequalities If yes, please provide details of the effect upon health inequalities 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement No No Yes Medical and non- medical clinical input routinely provided 5 Patient and public engagement If yes, please provide details of the patient and public engagement Yes Healthwatch are members of the Quality Committee 6 Risk to financial and clinical sustainability If yes how will this be mitigated No 3

131 Quality Committee Governance 1 The CCG must ensure that commissioned services, including joint-commissioned services are being delivered in a high quality and safe manner, ensuring that quality sits at the heart of everything it does. 2 A wide range of relevant reports pertaining to the quality agenda are received and considered at the Quality Committee in accordance with the terms of reference of the Committee. 3 As part of the revised reporting arrangements, in January, the Quality Committee received the revised Quality Strategy for The Quality Strategy and the supporting delivery plan will be presented at the February Governing Body. CCG Quality and Safeguarding Assurance 4 At the December Quality Committee a CCG self-assessment report was presented on mortality and reducing avoidable deaths. As part of our monitoring responsibilities, the Learning from Deaths policies have been received from our providers. 5 These policies include details of the processes required and the engagement of families and carers. These policies are available if required. All Shropshire CCG s main providers SaTH, RJAH, SCHT and SSSFT have Learning from Deaths policy in place and compliance is monitored via the Clinical Quality Review meetings. 6 The CCG Quality team are working in collaboration with Telford and Wrekin CCG and SaTH to hold a Partners in Care nurse conference to be held on Tuesday May 15 th This will be an exciting opportunity to showcase our work on the National Framework for nursing, midwifery and care staff (May 2016), Leading Change, Adding Value and there will be an open invitation to all our nursing and allied health professionals across the Health and Social Care Economy within the STP. 7 As reported by all providers at the Clinical Quality Review meetings, achieving mandatory training targets of 95% continues to be a challenge. Training days are reported to be stood down due to clinical pressures across the whole system. All providers continue to be fully committed to work on achieving their targets by year end. Quality in Commissioned Services. Shrewsbury and Telford Hospital NHS Trust (SaTH) 8 As are many acute providers, the Trust has experienced increasing pressure in its Emergency Departments. In December, 12 hour trolley wait breaches were reported. The CCG has now received and reviewed the breach root cause analysis reports for theses. In all cases there was no harm to patients identified. Area of learning focus on system and process issues such as referrals from SATH to RAJH, administration systems, ambulance handovers, access to RAID services and diagnostic tests. The learning and actions the Trust is taking to address these issues will be monitored by the Quality Committee. 9 Site visits were continue to be undertaken by the CCG Nursing team who have provided assurance that patient safety is maintained during these times through regular monitoring by the front line staff. 10 As reported previously, Health Education England (HEE) has been working with Shrewsbury and Telford Hospitals NHS Trust (SaTH) on its workforce planning. 4

132 Regrettably the trust was unable to influence the February junior doctor allocations but is engaged in early conversations on reviewing options for August Progress with this is imperative to enable the required improvement. 11 At the CQRM in January the Trust reported further damage to the MLU roof at the RSH site caused by the high volume of rain and snow. Inpatient services have moved to PRH for births and post-natal care. Further leaks to the roof have since occurred and other services including community staffing and day assessment then moved to part of ward 19 at RSH.. Business continuity plan was initiated and refurbishment is now underway on ward 19. Space has been identified on ward 20 to enable the move of community, day assessment, some scanning facilities and early pregnancy services. During this difficult period, although inconvenient, the Trust has provided the CCG with assurance there has been no impact to the women. A press release was issued by the Trust last week to inform the public. 12 The 3 MLU s reopened on 2 nd January as planned. As previously reported, staffing arrangements for these 3 units remains a significant concern to both the Trust and CCG s. At present staff are undertaking additional hours to provide cover for all the shifts and the Trust has provided assurance to the CCG s the MLU s are safe. Maternity leave and sickness levels are also adding to the workforce issues. The Trust have reported to the CCG s these staffing arrangements are not sustainable and the Trust will be reporting this to their Governing Board. 13 The Trust has received positive verbal feedback following a Neo-natal review by NHS England and the Neo-natal Network. There were no major safety concerns and many areas of good practice reported including nursing care and support and systems and processes in place. A few slight minor recommendations were made included improvements in discharge planning. The Trust will receive a full report and further details will be presented at the CQRM and to the CCG Quality Committee when available. 14 As previously reported, to address the concerns identified within the Sentinel Stroke National Audit Programme and following the NHS England National Team Visit, (SSNAP) a Provider/Commissioner forum was established in November 2017 to oversee the implementation of system wide actions within the plan. Areas of improvement delivered to date include Improved access to TIA service Improvements in timely swallow screen assessments Amended Standard Operation Policy for CT scanner down time to improve access SaTH led 7 day thrombolysis service delivered further to withdrawal of regional service 15 At the January CQRM the Trust presented a thematic review on the stroke service and progress against the Stroke action plan. The Trust has now appointed a senior nurse lead at Executive level to take forward this work. Although some improvements have been made including arrangements to provide Consultant cover over 7 days, there remains much work to do and it therefore envisaged the re-submitted SSNAP data will remain the same rating D. The Trust acknowledges this is a concern but is committed and focused on continued improvements to include actions to address ongoing workforce issues, improved access to thrombolysis and the rationalisation of community support post discharge. 16 As reported in December, Healthwatch published its Enter and View Visit Report of the SaTH ward 22- Trauma and Orthopaedics. The ward has implemented a successful falls prevention programme resulting in fewer inpatient falls. Furthermore, the Trust has provided the CCG with a level of assurance of the falls prevention improvement work undertaken which has taken place. Improvements include; review assessment of falls 5

133 documentation and post fall care bundles assessments. NHS Improvement Falls lead is assisting with this work to review all falls assessments and post fall care bundles. 17 At the January CQRM the Trust reported they have been successful in the recruitment of 2 Consultant ophthalmologists. An advert is currently out for a further Ophthalmologist Consultant post. 18 The Trust has reported to the CCG there is refurbishment work taking place at the crematorium and mortuary which has resulted in a reduction in capacity. The Trust has acknowledged this has impacted on bereaved family members during such a difficult time. It is not known when the work will be completed. 19 The Trust reported four 104 day cancer breaches in December Harm proformas have been received for 3 of these. 2 of which identified no harm was caused to the patients. A full root cause analysis is in progress for the third case and the findings will reported via the CQRM. The CCG has requested to receive the outstanding harm proforma from the Trust. The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (RJAH) 20 At the January CQRM the Trust continues to report positive and above the national published figures for the Friends and Family Test results. There were 946 responses collected in November with a breakdown as follows: 941 positive - giving a rate of 99.47% would recommend the Trust to friends and family 1 negative - giving a rate of 0.11% would not recommend the Trust 4 responses as "neither likely nor unlikely" or "don't know". 21 The Trust has reported no serious incidents during November Shropshire Community Health NHS Trust (SCHT) 22 As reported previously, a review of system and process by Shropshire Community Health Trust has been on-going to ensure that the health needs and quality assurance processes relating to looked after children are reviewed and amended to ensure they are stringent enough to extract performance data from relevant systems. This has been challenging for the Team who will be required to submit a national data set return by the end March 2018 and has led to gaps in data being available. This continues to be monitored by both Shropshire CCG and the Local Authority. Shropshire Community Health Trust Looked After Children Health Team have formulated a service recovery plan to assist with assurance around progression of work related to monitoring around the health of looked after children. Progress has not been as timely as expected and the formal contracting route will now be considered. 23 These risks have been reported to the Corporate Parenting Group, recorded on the CCG s risk register and to the CCG Quality Committee. 24 The Trust has reported a Dental Never Event when a wrong tooth was extracted. The CCG have received the root cause analysis report and this is scheduled to be reviewed by the CCG s Serious Incident Committee on 9 th February. The outcome will be shared with the Quality Committee. 25 As reported during a CCG quality and patient Safety visit in September 2017, the CCG has been informed the MIU continues to receive patients with acute chest pain for an ECG from GP practices. Since reporting to the Quality Committee in December, this issue has been addressed by the Provider and a new referral form has been introduced. This has stopped 6

134 ECG referrals from GP s to the MIU for patients in acute pain in accordance with national best practice guidance. South Staffordshire and Shropshire Healthcare NHS Foundation Trust (SSSFT) 26 The SSSFT Redwoods Centre Thematic Review of Patient Safety was reported on previously. The CCG has requested that further meetings take place with both the CCGs and CQC regarding reviewing the evidence of delivery and this was scheduled for the 18th January, Good progress has been seen and assurance received. 27 The CCG Quality Team continues with the deep dive analysis of the unexpected deaths reported by SSSFT during 2016 and This work is being undertaken in collaboration with the Director of Public Health. These unexpected deaths have been categories into the following three key themes for substance misuse, Carers/safeguarding and services relating to IAPT. The data has now be further analysed in collaboration with Public Health colleagues and will be presented to the Quality Committee and Governing Body. 28 The CCG CHC team have been undertaking a number of case reviews; it would appear compliance with section 117 policy has not been followed. This concern was formally raised at the SSSFT CQRM in January 2018 when the Trust s compliance of implementation of the Section 117 policy will be asked to be evidenced. 29 Child and Adolescent Mental Health Services provision: As reported previously, a number of senior professionals across children s services, the CCG and providers have been involved in discussions to address matters of concern within the service. Urgent action has been taken to review the situation further and ensure appropriate mitigating action is taken. An Executive to Executive meeting with SSSFT took place on 26 th January and a remedial action plan approved for delivery. 31 The Designated Nurse LAC was made aware of issues concerning access to the 0-25 Emotional Health and Wellbeing Service for out of area looked after children placed into Shropshire and Telford. Concerns have been escalated from out of area CCGs who are also experiencing provider challenges for the 0-25 service. The issue has been raised with NHS England and the Designated LAC Nurse will be attending the national network meeting in February. Physiological Measurements Ltd (PML) 32 The CCG were provided at the CQRM in January with assurance of PML s proactive management to identified capacity issues with effective clinical triage of patients and a responsive approach to improving clinic accessibility for patients. 33 PML provided evidence to the CCG of their compliance with Safeguarding and Prevent training. Falck Medical Services Ltd. (None urgent Ambulance) 34 Falck have reported a 21.6% decrease in the number of patients waiting over 2 hours during November A complete re-branding of the Company is currently in progress with the imminent implementation of a new software system which will enhance the organisation s reporting capability. 7

135 35 Flack has introduced a range of patient advisory leaflets which had recently been launched to ensure effective capture of patient feedback. West Midlands Ambulance Service (WMAS) 36 The following areas of good practice have been reported in January: Call abandonment rate is lower than national average and continue to perform well on call answer times. Although it should be noted that due to changes of performance monitoring within APR, the full range of national indicators cannot be reported at this time. Hear and Treat performance is the lowest in the country. That said, delays in handover times continue to be an area of significant challenge and where improvements are required. The CCG Quality Committee is fully cited on this and continue to monitor. Care UK - NHS A joint meeting was held between 111 (Care UK) and Shropdoc. The purpose of this meeting was for the providers to work together to improve understanding of Health Professional Form process (HPF s) with aim to maintain quality and ensure the number of HPF s submitted are appropriate to improving learning and outcomes 38 Care UK provide feedback to the national team on pathway issues which can take a long time for changes to occur. They also have a 6 monthly 111 clinical meeting to inform pathways of issues. Care UK emphasis that their pathways are a triage tool which requires clinical support rather than a diagnostic tool. 39 It was acknowledged that Shropdoc and Care UK need to gain more understanding of each other s pathways. Care UK has worked with Primecare to improve its understanding and to reduce the number of submitted Health Professional Forms. It envisages working with Shropdoc in the same way. Shropshire Doctors Co-operative Ltd (Shropdoc) 40 A large number of complaints were received in October, therefore Shropdoc carried out some further analysis. Out of the 19 complaints received, 7 were upheld, 8 were not upheld, 3 were partly upheld and 1 is still under investigation. 41 There were no themes or trends in the complaints, that can account for the increase, no particular clinician, base, day, service area, or time that links them. There was no increase in patient contact that month and no particular performance concerns. Conclusion 42 The Governing Body is asked to note the key issues above, to note the actions being taken and to receive the report. 8

136 Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: Quality Strategy and Delivery Plan Responsible Director: Author of the report: Presenter: Purpose of the report: Dawn Clarke- Director of Nursing and Quality Meredith Vivian- Chair of Quality Committee and Lay Member Dawn Clarke- Director of Nursing and Quality Quality Committee members Nursing, Quality, CHC and Safeguarding Team Meredith Vivian- Chair of Quality Committee and Lay Member Dawn Clarke- Director of Nursing and Quality Shropshire Clinical Commissioning Group s role is to plan and buy high-quality, safe effective, valuefor-money health care services from a range of healthcare providers on behalf of Shropshire people. A fundamental building block towards successful fulfilment of this role is to ensure that all services commissioned are of the highest possible quality as measured against national standards and by the people receiving those services. The Quality Committee has supported the Nursing and Quality Directorate to develop the strategic approach to its work, as set out within the Quality Strategy and Delivery Plan for The strategy is high level and allows for flexibility to take account of the fluctuating nature of the operating environment. The Strategy takes into account all key national and local policies, procedures and legislation Key issues or points to note: Improving quality is a wide-ranging agenda and in order for it to be implemented efficiently and effectively it is essential to maintain a strong leadership role across the entirety of the healthcare system, whether that be with large acute providers or diverse and more local provision. Our mission is to commission healthcare that is safe, cost and clinically effective and which delivers a positive experience for everyone in Shropshire. To deliver our vision we have set a number of Strategic Objectives (Quality Objectives- QO s) which represent our priorities over the next year. These objectives include: The development of a performance framework against which clinical outcomes of all commissioned services can be monitored, including the impact of QIPP programmes on quality To provide strategic clinical leadership and guidance for safeguarding children and adults at risk of harm To further develop and manage an integrated patient experience evidence system which supports data collection, analysis and investigation To ensure that Serious Incidents Requiring Investigation (SIRI) in commissioned services are Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

137 investigated and managed in accordance with national guidance To ensure that safety, clinical effectiveness and the patient experience are explicitly embedded into service redesign Actions required by Governing Board Members: Board members are asked to receive and approve the Quality Strategy and Delivery Plan for Implementation of the Delivery Plan will be monitored at Quality Committee with quarterly reports to Board. Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required No 2 Health inequalities If yes, please provide details of the effect upon health inequalities 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement No No Yes Medical and non- medical clinical input routinely provided 5 Patient and public engagement If yes, please provide details of the patient and public engagement Yes Healthwatch are members of the Quality Committee 6 Risk to financial and clinical sustainability If yes how will this be mitigated No Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

138 Quality Strategy and Delivery Plan Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

139 1 Shropshire Clinical Commissioning Group s role is to plan and buy high-quality, safe effective, value-for-money health care services from a range of healthcare providers on behalf of Shropshire people. A fundamental building block towards successful fulfilment of this role is to ensure that all services commissioned are of the highest possible quality as measured against national standards and by the people receiving those services. 2 Improving quality is a wide-ranging agenda and in order for it to be implemented efficiently and effectively it is essential to maintain a strong leadership role across the entirety of the healthcare system, whether that be large acute providers or diverse and more local provision. 3 The Governing Body of Shropshire CCG is committed to leading and delivering everimproving quality for Shropshire people. Some aspects of its delivery may be determined elsewhere but the mechanics of its delivery remain the CCG s role to manage. The CCG recognizes that improvements need to be demonstrable and measurable but not to the exclusion of less tangible but equally important aspects of health care which are less so e.g. listening to what patients, their carers the public and our system partners say; facilitating the learning and development of our staff, and, supporting all those involved in quality to get it right. 4 Improving quality requires the development and maintenance of a co-operative approach within both primary and secondary care and in partnership with other agencies and organisations, and, of course with the public. Shropshire CCG understands its leadership role in this context and will foster trust by always being willing to share good practice, lessons learnt from adverse experience, knowledge and skills. 5 In order for quality improvements to be achieved all partners need to operate as parts of a single system. Shropshire CCG will promote a culture whereby all stakeholders are consulted, allowed to prioritise and to set a pace of change that is comfortable and achievable by all. All quality systems and initiatives will be simple, practical, non-threatening, inclusive and negotiated. 6 To lead its quality responsibilities Shropshire CCG has a Nursing and Quality Directorate to which responsibility has been given to plan, deliver and review those activities that will assure the quality of commissioned services. 7 The Nursing and Quality Directorate has developed the strategic approach to its work, as set out below, through a process of engagement with members of the team, Quality Committee members and key partners. The strategy is high level and allows for flexibility to take account of the fluctuating nature of the operating environment. The Strategy takes into account all key national and local policies, procedures and legislation. These are included at Appendix 2. 8 Shropshire CCG s Quality Committee oversees the work of the Nursing and Quality Directorate and is responsible for assuring delivery of the strategy described below. 9 The strategic objectives described are for the period but our Mission Vision and Values shall remain constant Our Mission To commission healthcare that is safe, cost and clinically effective and which delivers a positive experience for everyone in Shropshire. Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

140 Our Vision People in Shropshire have absolute faith in their healthcare. Our Values We shall always: Strive for continuous improvement to the quality of Shropshire health services; Act swiftly and with courage when the quality of healthcare is substandard; Be credible, creative and ambitious on behalf of our local population; Work collaboratively with our partners; Respect everyone with whom we work; Be focussed, committed and hard working; Stay alert to the needs of all our population, particularly those who are most vulnerable; Operate with integrity and be trustworthy at all times; Encourage and support each other Our Quality Objectives 10 To deliver our vision we have set a number of Strategic Objectives (Quality Objectives- QO s) which represent our priorities over the next year: The more detailed delivery plan for is available with Executive Director and named leads responsible against each milestone at Appendix Underpinning the work to deliver the Quality Objectives is the drive to review progress made in reducing avoidable harm and to evidence how we have made a difference in quality, safety and patient experience. QO1: Ensure that all necessary quality indicators are incorporated into contracts for all providers Action for Revise contractual requirements to ensure appropriate indicators are included Ensure safeguarding quality and outcomes are embedded into new service specifications / and continue to ensure safeguards in place to protect vulnerable children and adults Review and, where necessary, strengthen the indicators in the Quality Schedule for all providers regarding mortality and serious incident reporting. Ensure contracts are in place with nursing care homes providing CHC funded care. Monitor quality requirements of care homes ensuring homes are supported in actioning any improvements and share best practice of good outcomes across the care home sector. QO2: Develop a performance framework against which clinical outcomes of all commissioned services can be monitored, including the impact of QIPP programmes on quality. Action for Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

141 Develop a quality and performance framework for monitoring clinical outcomes of all commissioned services ensuring that there is continued focus on improvements in health outcomes in line with the NHS Outcomes Framework Everyone Counts. Establish effective early warning systems to ensure detection and prevention of serious failures and harm Ensure that commissioned services have effective systems and processes to help keep children and adults safe from abuse and neglect. Implement a programme of quality site visits with clinical leads and lay members for all commissioned providers Ensure that the impact of productivity savings (QIPP and Cost Improvement programmes) on the quality of care delivered is monitored closely. QO3: Provide strategic clinical leadership and guidance for safeguarding children and adults at risk of harm. Action for Regular attendance at LSCB and LSAB to ensure that the CCG has the appropriate arrangements in place to cooperate with the Local Authority to ensure a shared responsibility for effective discharge of the functions of the Shropshire Children safeguarding board ( SSCB) and Keeping Adults safe in Shropshire board KASSB Aligned with the KASSB and SSCB joint safeguarding policies, establish a delivery plan, informed by local and national outcomes, to ensure that the CCG is able to meet its responsibilities in safeguarding Ensure that all providers play an active role in the KASSB and SSCB board and sub group working and report to the boards as required. Proactive input into Special Educational Needs and Disability (SEND) Strategic Board Ensure that all providers play an active part in the SEND delivery plan Establish a delivery programme to meet the priorities within the strategy to include - Improving quality of safeguarding practice by ensuring lessons learned and actions agreed as a result of safeguarding interventions are implemented by agreed timescales Please refer to QO3 in the Delivery Plan at Appendix 1 QO4: The development and management of an integrated patient experience evidence system which supports data collection, analysis and investigation Action for Align activity of Quality Committee with patient generated feedback to ensure there are no gaps in service delivery identified and intelligence is gathered and used effectively Review emerging national guidance and establish an improved framework Aligned to QO12 below QO5: Develop an evidence base to assure the CCG and Shropshire people that the services we commission are safe, clinically effective and deliver a positive patient experience and where they fall short to enable appropriate action to be taken Action for Ensure the care pathways issued by NICE are used by the CCG to support quality development as it seeks to deliver its strategic priorities. Ensure all new service improvement plans are evidence based and quality assured Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

142 Introduce a process for monitoring NICE compliance Work with CCG Medicines team and Clinical Leads to review clinical audit underway and agree programme of work to present at Quality Committee Please refer to QO 5 in the Delivery Plan at Appendix 1 QO6: Ensure that Serious Incidents Requiring Investigation (SIRI) in commissioned services are investigated and managed in accordance with national guidance. This includes ensuring any resulting actions are implemented Action for Maintain the Serious Incident, Complaints and Safeguarding Committee to ensure unsafe and poor quality practices and services are escalated and managed in a timely manner Finalise the recommendations of the internal CWaudit report on serious incidents and reaudit Prepare quarterly updates on SI s to Governing Body within the Quality report Participate in the Safeguarding investigation process into serious incidents for example Domestic homicide reviews and Children serious case reviews Please refer to QO 6 in the Delivery Plan at Appendix 1 QO7: Ensure that safety, clinical effectiveness and the patient experience are explicitly embedded into Service redesign. Action for Align a quality named lead to all new service redesign programmes and pathway work Complete quality and equality and diversity impact assessments and ensure national best practice evidence is incorporated and risk assessed QO8: The provision of Clinical leadership of Infection prevention and control Action for Continue leadership of the Strategic Health Economy Infection Prevention and Control and Antimicrobial Prescribing Group to oversee monitoring of robust and measurable infection prevention and control standards and infection rates within services commissioned by Shropshire CCG Promote learning and sharing of good practice across Shropshire and the wider community Proactively support antimicrobial stewardship across Shropshire Please refer to QO 8 in the Delivery Plan at Appendix 1 QO9: Prepare a CCG QIPP plan for Continuous Healthcare for Action for Prepare a QIPP plan for CHC 2018/19 to ensure financial stability, robust quality performance and risk management Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

143 Review the governance processes in place and develop the protocols and monitoring arrangements to ensure the CCG has suitable governance with relevant standard rules in place Ensure a monthly rolling audit programme is in place and adhered to Quarterly reports on audit outcome to Quality Committee Please refer to QO 9 in the Delivery Plan at Appendix 1 QO10: Establish a delivery programme to meet the national priorities to achieve the the local offer of Personal Health Budgets Action for Review the delivery programme to meet the national priority requirements to achieve the local offer of the Personal Health Budgets The local offer for PHBs to meet the mandate requirements published as required. A review of the next steps will be be undertaken in QO11: Ensure the implementation of an Individual Funding Policy and process Action for Establish a delivery programme to improve patient information and communication to GP practices Annual IFR report to be completed Please refer to QO11 in the Delivery Plan at Appendix 1 QO12:Ensure the implementation of an integrated clinical complaints management system including appropriate investigation and follow up, reporting and liaising with all relevant complaints teams both at Provider level and within the CCG Action for Work with Complaints Manager to ensure Quarterly reports are made to Quality Committee and Governing Body Annual reports to Quality Committee and Governing Body Monthly reports to Serious Incident Committee Agenda item at provider quality contract meetings To continue to proactively develop the complaints process ensuring that the organisation makes appropriate changes to ensure improvements in service delivery Please refer to QO12 in the Delivery Plan at Appendix 1 QO13: Ensuring delivery of the Caldicott Guardian requirements for Information Governance in accordance with the Data Protection Act and the new guidance to come into force in April 2018 Action for The Caldicott Guardian (alongside the Senior Information Responsible Officer) will oversee the Information Governance requirements of the CCG, and maintain the Caldicott Action Log Please refer to QO13 in the Delivery Plan at Appendix 1 Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

144 QO14: Assist and support the Primary Care Directorate in its duty to improve quality of services in primary care Action for Further develop the quality dashboard for primary care Support the implementation of the primary care workforce plan Quality review of the Local Commissioned Service contracts Quality engagement with developments of the new out of hospital model Please refer to QO13 in the Delivery Plan at Appendix 1 QO15: Ensuring the requirements of Equality and Diversity are integrated into provider contract performance Action for Establish a delivery programme to meet the statutory requirements for Equality and Diversity Quality Committee to prepare an annual report on compliance with the Public Sector Equality Duty for the CCG Board Monitor provider equality monitoring as per contractual requirements and present in provider exception reports annually Equality and Human Rights operational lead to report a review of arrangements relating to equality and human rights to the Quality Committee Please refer to QO15 in the Delivery Plan at Appendix 1 QO16: Ensure the CCG fulfils its research and development requirements Action for Review the requirements for Research and Development and provide an outline proposal for Quality Committee in March 2018 Shropshire CCG Quality Strategy and Delivery Plan [Type text] February 2018

145 1 Agenda item GB Appendix 1 CCG Governing Body January 2018: Appendix 1 Quality Strategy Delivery Plan Shropshire CCG Strategic objectives Our Quality Strategy not only covers the strategic objectives and priorities but all the areas of commissioning responsibility that the CCG has. Our commitment to quality is central to the CCG s values and our focus is on continually improving the quality of services and to be alert to the needs of all our population, including those who are most vulnerable. Embracing the NHS England Sign up to Safety culture, our focus is on improving quality, safety and individuals experience of care in all the services we commission, including children s services, mental health and learning disabilities and to improve consistency of care and reduce variability of outcomes and health inequalities Shropshire Priorities : SP1- Financial Recovery to raise patient outcomes and improve value for money SP2: Resetting the Organisation SP3: Nine Must Do s and the recovery of the Constitutional Standards SP4 Health Economy Sustainability with focus on IT, Workforce, Clinical design and communications SP5: Out of Hospital Sustainable Care Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 1 of 19 January 2018

146 2 Quality Objectives Objectives Milestones Progress to date By whom By when Completed Q1 Quality Indicators in contracts QO 1 Ensure that all necessary quality indicators are incorporated into contracts for all providers and that effective and measurable CQUINs are established Support the CCG in commissioning the highest quality health services for the local population, in particular the wider aspects of care provision and patient experience Recommendations from Francis/Keogh/Berwick: Winterbourne Review Commissioners have a responsibility for monitoring the delivery of standards and quality on behalf of and in partnership with patients Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis and must require the providers to provide quality information and to receive assurance Revise quality and safety contractual requirements to ensure appropriate indicators are included Review and, where necessary, strengthen the indicators in the Quality Schedule for all providers regarding mortality. Ensure quality and outcomes are embedded into new service specifications As part of new service development Named leads to be identified and evidence will be included in quarterly QC reports Provide assurance to the CCG Board on quality and patient safety through regular reporting by strengthening the existing quality report. Develop a delivery programme to monitor the implementation of the strategy Contracts revised and amended Contracts revised and amended Named quality leads to be identified for all new service developments The Quality Strategy Delivery Plan takes into a/c the requirements of the Sustainability and Transformation Plan (STP) and the STP Aide memoire on safety in order to meet the Operational Planning requirements. Lead Nurse for Quality in providers Nursing and Quality team Director of Nursing and Quality Director of Nursing and Quality Nursing and Quality Team January 2018 Quarterly as required As new service developments agreed Draft to Quality Committee October 2017 January 2018 January 2018 Ongoing Governing Body February 2018 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 2 of 19 January 2018

147 3 Quality Objectives Objectives Milestones Progress to date By whom By when Completed QO2 Develop a performance framework against which clinical outcomes of all commissioned services can be monitored, including the impact of QIPP programmes on quality. QO 2 Develop a performance framework against which clinical outcomes of all commissioned services can be monitored, including the impact of QIPP programmes on quality. Named leads within Nursing and Quality Team March 2018 Provide the CCG Board with an essential focus on quality, safety, effectiveness, efficiency and on-going improvement in service delivery against a background of significant reform of primary and community service provision ensuring effective systems are in place to manage the risks to the CCG in commissioning high quality services which are safe and effective for patients There remain a high number of deaths in England and Wales from causes considered Lead the development of a quality and performance framework for monitoring clinical outcomes of all commissioned services ensuring that there is continued focus on improvements in health outcomes in line with the NHS Outcomes Framework Everyone Counts. The framework will incorporate action to be taken to continue to establish effective early warning systems to ensure early detection and prevention of serious failures and harm Ensure that the impact of productivity savings (QIPP and Cost Improvement programmes) on the quality of care delivered is monitored closely. Establish programme of reports to Quality Committee as part of forward planner Establish programme of planned quality and safety site visits to providers to Established named quality leads against each of the QIPP schemes Named leads within Nursing and Quality Team Lead Nurse for Quality in Providers April and quarterly thereafter with monthly input into QIPP boards March 2018 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 3 of 19 January 2018

148 4 Quality Objectives Objectives Milestones Progress to date By whom By when Completed potentially avoidable through timely and effective healthcare or public health interventions. However, while a particular condition can be considered avoidable, this does not mean that every death from that condition could be prevented. Data serves to highlight areas of potential weaknesses in healthcare that could benefit from further in-depth investigation and a degree of caution is recommended when interpreting the data. The CCG Quality strategy is aligned to other CCG Strategies ensuring that the key principles and values of the NHS Constitution and NHS Mandate are integral to everything we do by providing safe care and ensuring people experience better care meet with front line staff with lay member and clinical lead representation Further develop the quality dashboard which includes all providers and prioritise quality input into contract meetings Develop a process to utilise patient experience feedback to improve quality and safety of commissioned services through the triangulation of information Maintain and update the quality and patient safety (including medicines management) risk register that is monitored by the Quality Committee Regular attendance at regional NHS England The CCG has worked and will continue to work with providers to review essential service standards and set enhanced quality standards as part of the Commissioning for Quality and Innovation (CQUIN) framework for 2018/19. Lead Nurse for Quality in Providers Lead Nurse for Quality in Primary Care and Care Homes Dr of N&Q With Chair of Quality Committee Nursing and Quality Team Dr of N&Q May 2018 May 2018 May 2018 Monthly Bi-monthly Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 4 of 19 January 2018

149 5 Quality Objectives Objectives Milestones Progress to date By whom By when Completed Recommendations Francis/Keogh Winterbourne and Berwick Review: Commissioners should have powers of intervention when substandard or unsafe services are being provided. Quality Surveillance Groups (QSGs) to share good practice and/or concerns. Reports to Quality Committee Escalate issues to CCG Board and to the relevant Strategic Commissioning groups to ensure concerns are addressed with providers Working with providers to review and reduce avoidable deaths Complete and present to Quality Committee the self assessment to ensure that appropriate further action can be taken to mitigate risks and reduce avoidable deaths Update quarterly Nursing and Quality Team in collaboration with T&W CCG and Public Health. Dr of N&Q Named leads within Nursing and Quality Team March 2018 December 2017 April 2018 and quarterly thereafter QO3 Provide strategic clinical leadership and guidance for safeguarding children and adults on behalf of the CCG QO 3 Provide strategic clinical leadership and guidance for safeguarding children and adults on behalf of the CCG DoN&Q and Safeguarding leads Quarterly Aligned to all commissioned services including children s services, mental health and Regular attendance at SSCB and LSAB Keeping Adults Safe In Shropshire Board (KASIB) to ensure that the CCG has the appropriate arrangements in place to cooperate with the Local Authority to ensure a shared responsibility for effective Completed Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 5 of 19 January 2018

150 6 Quality Objectives Objectives Milestones Progress to date By whom By when Completed learning disabilities Evidence of achievement to be included within quarterly reports to Quality Committee The CCG has worked with providers to support them in recognising and understanding their roles and responsibilities in safeguarding and, with the Council, we have brought an ever a greater focus on safeguarding in contracts; holding providers to more rigorous account for delivery. The CCG has prioritised the provision of effective safeguarding and looked-after children s health arrangements and commitment of resources into the establishment of a clear safeguarding and LAC infrastructure remains intact. discharge of the functions of the SSCB and KASISB Ensure all providers have arrangements in place to cooperate with local authority to ensure children and adults are safeguarded in Shropshire Ensure multi agency working continues to take place across health, local authority.police etc to ensure safeguarding both adults and children. Aligned with the SSCB and KASISB joint safeguarding policies, establish a delivery plan, informed by local and national outcomes. To ensure that the CCG is able to meet its responsibilities in relation to safeguarding adults, children and looked after children The ongoing utilisation of a safeguarding quality reporting system involving specific child and adult safeguarding dashboards ensuring compliance with NHS E assurance and outcomes framework. Safeguarding leads DoN&Q and Safeguarding leads Safeguarding leads DoN&Q and Safeguarding leads Quarterly exception reports to QC Quarterly exception reports to QC May 2018 Quarterly exception reports to QC Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 6 of 19 January 2018

151 7 Quality Objectives Objectives Milestones Progress to date By whom By when Completed Evidence included within quarterly reports to Quality Committee Establish a delivery programme to meet the priorities within the strategy to include - Improving quality of safeguarding practice by ensuring lessons learned and actions agreed as a result of safeguarding interventions are implemented by agreed timescales To ensure that provider Trusts are continuing to deliver their Prevent duties enshrined in statue and NHS contract To develop further quality measures and Channel Panel engagement by providers and for non NHS providers to also develop Prevent quarterly returns Proactive input into Special Educational Needs and Disability (SEND) Strategic Board Successful compliance with the new national reporting standard for NHS organisations achieved in Q Safeguarding leads Head of Adult Safeguarding DoN&Q and Safeguarding leads Safeguarding lead May 2018 Quarterly exception reports to Quality Committee Audited by LSBs annually April 2018 Ongoing Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 7 of 19 January 2018

152 8 Quality Objectives Objectives Milestones Progress to date By whom By when Completed QO4 Development and management of an integrated patient experience evidence system which supports data collection, analysis and investigation QO 4 4 The development and management of an integrated patient experience evidence system which supports data collection, analysis and investigation Review existing systems and agree a plan for strengthening this further DoN&Q with Chair of Quality Committee and Head of Communications April 2018 Guardianship of the patient experience across all care settings (including safeguarding children and adults) Recommendations from Francis/Keogh and Berwick Review: Commissioners should be accountable to the public for the scope and quality of the services they commission and fully involve and engage the public in their work. KASISB subgroub dedicated to wider public and patient engagement through the Citizen Engagement Group Subgroup established in 2017 and now meets quarterly to ensure wider dissemination of shared safeguarding concerns and consultation takes place e.g. work undertaken on a safeguarding including prevention awareness campaign KASISB members, D of N and safeguarding lead June 2018 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 8 of 19 January 2018

153 9 Quality Objectives Objectives Milestones Progress to date By whom By when Completed QO5 Clinical Audit and effectiveness: QO 5 Clinical Audit and effectiveness: Develop an evidence base to assure the CCG and Shropshire people that the services we commission are safe, clinically effective and deliver a positive patient experience and where they fall short to enable appropriate action to be taken Aligned to all commissioned services including children s services, mental health and learning disabilities Work with the CCG Medicines team to review clinical audit underway and agree a programme of work to present at Quality Committee Ensure the care pathways launched by NICE are used by the CCG to support quality development as it seeks to deliver its strategic priorities. Develop plan to ensure all new service improvement plans are evidence based and quality assured Action: Introduce a process for monitoring NICE compliance Completion of an embedding best practice in the Mental Capacity Act Audit utilising learning from Safeguarding Adult Reviews QO6 Learning from Serious Incidents Requiring Investigation (SIRI) QO6 Ensure that any Serious Maintain the Serious Incidents Requiring Incident, Complaints & Investigation (SIRI) for the Safeguarding Committee to CCG and from ensure unsafe & poor quality commissioned services practices and services are Audit template agreed with provider trusts. Audit completion Q Action plan then required Reports to Quality Committee Quality Lead for Primary Care Quality Lead Nurse for Providers Safeguarding Lead DoN&Q and Nursing and Quality Team May 2018 May 2018 March 2018 January 2018 and ongoing monthly thereafter Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 9 of 19 January 2018

154 10 Quality Objectives Objectives Milestones Progress to date By whom By when Completed are investigated and managed in accordance with national guidance. This includes ensuring any resulting actions are implemented escalated & managed in a timely way Finalise the recommendations of the internal cwaudit report on serious incidents Prepare quarterly updates on SI s to Governing Body within the Quality report Prepare bimonthly reports for confidential Governing Body For the safeguarding leads to be part of provider safeguarding quality meetings Completed Completed Director of Nursing and Quality and Quality lead Nurse for providers Quality lead Nurses for providers, primary care and care homes Quality lead Nurses for providers, primary care and care homes Safeguarding leads Re-audit March 2018 February 2018 QO7 Ensuring that quality, safety and effectiveness are clearly embedded into any Service redesign and commissioning care pathways and decommissioning Ensuring that quality, safety and effectiveness are clearly embedded into Align a quality named lead to all new service redesign programmes and pathway DoN&Q As required QO7 any Service redesign and commissioning care pathways and decommissioning work and decommissioning Complete quality and equality and diversity impact assessments and ensure Completed Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 10 of 19 January 2018

155 11 Quality Objectives Objectives Milestones Progress to date By whom By when Completed national best practice evidence is incorporated and risk assessed - Monthly updates to be included in exception report to Quality Committee The implementation of NICE guidance and quality standards is correlated with high quality NHS health and social care. However, the recommendations made by NICE are also associated with service delivery and financial risks for commissioners. Ensure that risks related to quality and patient safety are appropriately identified and incorporated into the corporate risk register Develop a plan to ensure all new service improvement plans are evidence based and quality assured DoN&Q with Nursing and Quality Team Nursing and Quality Team named leads for service delivery programmes Nursing and Quality Team named leads for service delivery programmes February 2018 and ongoing Monthly review of risk register Quarterly Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 11 of 19 January 2018

156 12 Quality Objectives Objectives Milestones Progress to date By whom By when Completed QO8 The provision of Clinical leadership of Infection prevention and control QO 8 The provision of Clinical leadership of Infection prevention and control Infection prevention and control - to provide professional leadership and assess the impact of all existing and new policies and plans and make recommendations for change where required, collaborating with both the Local Authority Public Health and Public Health England (PHE) Aligned to all commissioned services including children s services, mental health and learning disabilities Continue leadership of the Strategic Health Economy Infection Prevention and Control and Antimicrobial Prescribing Group to oversee monitoring of robust and measurable infection prevention and control standards and infection rates within services commissioned by Shropshire CCG and to support learning and sharing of good practice across Shropshire and the wider community Proactively support antimicrobial stewardship across Shropshire Through attendance at provider Infection Prevention and Control Committees monitor annual programmes aligned to The Health & Social Care Act 2008 Code of Practice on the Prevention and Control of Infections Approved Quality Premium E. coli Action plan considered at Quality Committee in October 2017 Lead Nurse for Infection Prevention and Control Lead Nurse for Infection Prevention and Control Lead Nurse for Infection Prevention and Control Quarterly reports to Quality Committee Quarterly reports to Quality Committee Quarterly reports to Quality Committee Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 12 of 19 January 2018

157 13 Quality Objectives Objectives Milestones Progress to date By whom By when Completed QO8 QO8 Attendance at Shropshire and Telford & Wrekin Health Protection Quality Assurance Group to advise of infection prevention and control activities Lead Nurse for Infection Prevention and Control Quarterly reports to Quality Committee Continue leadership and support of Shropshire & Telford & Wrekin wide Infection Control Link Nurse/worker collaborative Participate in programme of site visits to providers to meet with front line staff Lead Nurse for Infection Prevention and Control Lead Nurse for Infection Prevention and Control Quarterly updates to Quality Committee Q9: Prepare a CCG QIPP plan for Continuous Healthcare for QO9 Prepare a CCG QIPP plan for Continuous Healthcare for Establish and maintain robust systems for Continuing Health Care and Free Nursing Care and Complex Care and assume overall responsibility for ensuring service provision is within budget Aligned to all commissioned Prepare a CCG QIPP plan for CHC for to ensure financial stability, robust quality performance and risk management required improvements to population health and quality of service provision The cwaudit internal audit report in September 2017 provided Moderate Assurance with several actions. A robust rolling programme of CHC/FNC/High cost and fast track audit with clear internal DoN&Q with Head of CHC and Complex Care March 2018 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 13 of 19 January 2018

158 14 Quality Objectives Objectives Milestones Progress to date By whom By when Completed services including children s services, mental health and learning disabilities QO10 Personal Health Budgets QO 10 Personal Health Budgets Aligned to all commissioned services including : children s services, mental health and learning disabilities Review the governance processes in place and develop the protocols and monitoring arrangements to ensure the CCG has suitable governance with relevant standard rules in place Ensure monthly rolling audit programme is in place and adhered to Quarterly reports on audit outcome to Quality Committee - See also 28 day delivery plan Review the delivery programme to meet the national priority requirements to achieve the local offer of the Personal Health Budgets governance arrangements in place is being established. CHC is a complex area and challenges are varied. Overall the service provides high quality care for our patients. This will be an area of continued focus to drive efficiencies in Review of next steps needs to be undertaken in Head of Complex Care Head of Complex Care To be confirmed as PHBs cover Long term conditions February 2018 March 2018 Feb 2018 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 14 of 19 January 2018

159 15 Quality Objectives Objectives Milestones Progress to date By whom By when Completed QO11 Ensure the implementation of a robust Individual Funding Policy Process QO11 Establish a delivery programme to meet the priorities of clinical policy review to include improved patient information and communication to GP practices Annual IFR report to be completed Undertake audit of the process utilising the Blueteq system QO12 Ensure the implementation of an integrated complaints management system QO12 Ensure the implementation Quarterly reports to Quality of an integrated complaints Committee and Board management system Annual reports to Quality including appropriate Committee and Board investigation and follow up, Monthly reports to Serious reporting and liaising with Incident Committee all relevant complaints teams both at Provider level and within the CCG Aligned to all commissioned services including : children s services, mental health and learning disabilities Recommendations from Francis/Keogh and To continue to proactively develop the complaints process ensuring that the organisation makes appropriate changes to ensure improvements in service delivery taking into account the recommendations from the Francis and Clwyd Review DoN&Q and IFR Lead DoN&Q and IFR Lead DoN&Q and IFR Lead Complaints Manager Complaints Manager Complaints Manager Complaints Manager April 2018 June 2018 July 2018 In place July 2018 March 2018 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 15 of 19 January 2018

160 16 Quality Objectives Objectives Milestones Progress to date By whom By when Completed Berwick Review: Commissioners should agree a method for measuring compliance and redress for non-compliance of standards and when selecting indicators and the means for measuring compliance, commissioners must closely engage with patients to ensure their expectations and concerns are addressed QO13 Ensuring delivery of the Caldicott Guardian requirements for Information Governance QO 13 Ensuring delivery of the Caldicott Guardian requirements for Information Governance and in accordance with the Data Protection Act and the new guidance to come into force in April 2018; Aligned to all commissioned services including : children s services, mental health and learning disabilities Aligned with the work of the Senior Information Responsible Officer, the Caldicott Guardian to oversee the Information Governance requirements of the CCG, in partnership with colleagues in the Council with Social Services Responsibilities and partner organisations satisfy the highest practical standards for handling patient identifiable information. Maintain the Caldicott Action Log The Information Governance Toolkit selfassessment has been updated for publication in March 2017 and level 2 was maintained IG Sub group March 2018 Director of N&Q In place and quarterly ongoing Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 16 of 19 January 2018

161 17 Quality Objectives Objectives Milestones Progress to date By whom By when Completed QO14 Assist and support the Primary Care Directorate in its duty to improve the quality in primary care QO 14 Primary Care Activity arising from Board Assist and support the Membership of the Primary Care Directorate in Academic Health Science its duty to improve the quality in primary care Network to be considered as part of quality planning cycle Aligned to all commissioned services including : children s services, mental health and learning disabilities Recommendations from Francis/Keogh and Berwick Review: Recommendations : Medical training and education; Openness, Transparency and Candour, Nursing, Leadership, Professional regulation of fitness to practice, Caring for the elderly, Information and Coroners and Inquests QO15 Equality and Diversity Further develop the quality dashboard for primary care Support the development and implementation of the primary care workforce plan Implement and actively influence the STP workshop group to ensure primary care requirements are recognised Whilst progress has been made, this remains a challenging area for the CCG as additional resources are not available to support. Overall, our primary care services provide high quality services. audit and support etc. A quality dashboard has been developed and is to be presented at Primary Care operational group N&Q with Named Quality Lead Quality Lead Nurse for Primary Care Quality Lead Nurse for Primary Care Quality Lead Nurse for Primary Care March 2018 March 2018 February 2018 March 2018 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 17 of 19 January 2018

162 18 Quality Objectives Objectives Milestones Progress to date By whom By when Completed QO 15 Equality and Diversity Aligned to all commissioned services including : children s services, mental health and learning disabilities Establish a delivery programme to meet the priorities within the Equality and Diversity strategy Quality Committee to prepare an annual report on compliance with the public sector equality duty for the CCG Board Monitor provider equality monitoring as per contractual requirements and present in exception reports annually Equality and Human Rights operational lead to report a review of arrangements relating to equality and human rights to the Quality Committee Discussed with Director of Corporate Affairs as lead for CCG Equality and Diversity Dr of Nursing and Quality Named CCG Nursing and Quality Leads To discuss with Director of Corporate Affairs as lead for CCG Equality and Diversity April 2018 March 2018 May 2018 May 2018 QO16 Ensure the CCG meets its research governance requirements QO 16 Ensure the CCG meets its research governance requirements Aligned to all commissioned services including : children s services, mental health and learning disabilities Review the requirements for Research and Development and provide an outline proposal for Quality Committee Confirm additional actions as required DoN&Q March 2018 June 2018 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 18 of 19 January 2018

163 19 Shropshire CCG Governing Body Appendix 1: Quality Strategy Delivery Plan Page 19 of 19 January 2018

164 Agenda item: GB Shropshire CCG Governing Body meeting: 14 February 2018 Title of the report: Key Points from 31 January 2018 Audit Committee Meeting Responsible Director: Sam Tilley - Director of Corporate Affairs Author of the report: William Hutton Audit Chair Presenter: William Hutton Audit Chair Purpose of the report: To highlight to the Governing Body key issues arising from the 31 January 2018 Audit Committee Meeting and to agree any necessary actions that result. Key issues or points to note: A revised Risk Management policy, in line with discussions at the recent Governing Body development session was approved for submission to the Governing Body. A revised Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy was approved. The Internal Audit Review of Financial Systems gave Limited Assurance. The Internal Audit Review of Conflicts of Interest Management gave Significant Assurance. The likely Head of Internal Audit opinion for 2017/18 is Limited Assurance Waivers for three purchases with a total value of 95,700 were ratified by the Audit Committee Write-off of aged debt with a total value of some 248,000 was approved by the Audit Committee Actions required by Governing Body Members: The Governing Body is asked to : NOTE the contents of this report and in particular the findings from the Internal Audit reviews including the issues identified and agree any necessary actions. RATIFY the revised Gifts, Hospitality and Sponsorship Policy. 1

165 Shropshire CCG CCG Governing Body Meeting 14 February 2018 Key Points from Audit Committee Meeting 31 January Agenda Items Discussed 1.1 Governance Risk Management Policy Updated Gifts, Hospitality and Sponsorship Policy 1.2 Financial Month 9 Financial Accounts and Year End Preparation Annual Review of Accounting Policies Review of Losses, Special Payments and Waivers Aged Debt Write-Off Non Purchase Orders 1.3 Internal Audit Internal Audit Progress Report Recommendation Tracking Report Internal Audit Review Financial Systems Internal Audit Review Conflicts of Interest Management 1.4 External Audit External Audit Plans and Fee External Audit Progress Report 1.5 Counter Fraud Anti-Fraud Bribery and Corruption Policy Sanctions and Redress Policy 1.6 Audit Committee Operation & Workplan Audit Committee Annual Workplan 2. Key Points The key points for the Governing Body to note from the Audit Committee are listed below. Full minutes of this meeting are produced separately. 2.1 Risk Management Policy and Associated Risk/Issues Registers An updated Risk Management Policy was presented and approved. The policy reflects the Governing Body agreement by creating a separate Governing Body Assurance Framework and Governing Body Issues Log. New Corporate Risk Register and Corporate Issues Log incorporate the former Directorate Risk Registers into consistent formats. 2.2 Gifts, Hospitality and Sponsorship Policy The updated Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy was presented. The updates reflects guidance issued by NHS England in relation to Conflicts of Interest and aligns with the recently approved Conflicts of 2

166 Interest Policy for the CCG. The policy was approved with the addition of a reference to the CCG s existing policy of not accepting sponsorship of meetings by Pharmaceutical Companies. All staff will be communicated to on this item. A copy of the revised policy is attached as Appendix 1 for formal ratification. 2.3 Finance Month 9 Financial Accounts and Year End Preparation The financial statements from the Month 9 submission of draft year-end figures were presented and reviewed. It was noted that the month 9 exercise did not flag up any material issues that would impact on the Year End Accounts process. The year-end plans from the Midlands and Lancashire CSU were presented. 2.4 Finance Annual Review of Accounting Policies The accounting policies for the CCG which are included in Note 1 of the CCG s financial statements were presented and reviewed. It was agreed that the CFO would review and remove statements that were not applicable to Shropshire CCG. 2.5 Finance Procurement Waivers October to December 2017 Three waivers were presented with a total value of 95,700 for the period of October to December After discussions, the Audit Committee ratified the CFO s action to waive procurement activities in these cases. 2.6 Finance Aged Debt Write-off The write-off of aged debt with a total value of some 248K from 4 invoices was approved on the basis that the debts were not recoverable. 245K related to an invoice from 2015 for the provision of a falls prevention service. A complex set of historical circumstances led to this invoice being raised and the agreement to write it off was part of a wider agreement with the Local Authority to settle this legacy issue. 2.7 Finance Review of Non Purchase Orders A paper was presented to the Audit Committee analysing invoices where no purchase order was present. This was in response to concerns raised previously about the number of non PO invoices. The majority of such invoices related to Non Contract Activity, Complex Care and SLA/Contracts with only 11% being in a category where it would have been expected that a PO would be raised. Training will be provided to all relevant staff to ensure that the normal PO processes are followed. It was recommended by the Audit Committee that the CFO would investigate whether there was merit in issuing POs for Care Home placements within Complex Care. 2.7 Internal Audit Progress Report Internal Audit work is on track against the agreed plan for the year. A report was presented on outstanding Internal Audit actions. There is 1 overdue recommendation and 5 deferred recommendations. Given the importance of CHC the Audit Committee requested that the 3 deferred actions in this area are monitored closely to ensure that they do not slip any further. 3

167 The current view is that the Head of Internal Audit annual opinion for the CCG will be Limited Assurance, the same as last Year. 2.8 Internal Audit Review Financial Systems The review of Financial Systems was given Limited Assurance due to a number of issues that were identified. Key issues were: The SLA between the CCG and CSU for 2017/18 is not in place The significant number/value of invoices being held in dispute The ISFE limits are not aligned with the Scheme of Delegation The level of aged debts should be reviewed A number of actions have been agreed to address the recommendations from Internal Audit and progress on completing these will be monitored. It was noted that a couple of the recommendations and agreed resultant actions were the same as those found in the previous review of Financial Systems and it was disappointing that the same issues had arisen again. 2.9 Internal Audit Review Conflicts of Interest Management The review of Conflicts of Interest Management was given Significant Assurance. A number of minor issues were identified and actions to address the recommendations are already complete or in progress External Audit The external Audit fees for 2017/18 will be 41,800 plus an additional 5,000 to cover further work on coding and outturn as a result of the 5M of unmitigated risk identified in November. The External Audit plan was presented to the Audit Committee with submission of Audited Accounts to NHS England due on 29 th May Updated Anti-Fraud Bribery and Corruption Policy An updated policy was presented to reflect the abolishment of NHS Protect and the formation of NHS Counter Fraud Authority and to align with NHS Standards for Commissioners and latest best practice. This was approved by the Audit Committee Sanctions and Redress Policy A new policy was presented and approved by the Audit Committee, detailing how the CCG will seek to apply sanctions and redress against individuals who have committed acts of fraud, bribery or corruption against it. 4

168 Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure Document Title: CCG document ref: Author/originator: Date of approval: Approving Committee: Responsible Director: Category: (delete as appropriate) Sub Category: Declaration of Gifts, Hospitality and Sponsorship Anti- Bribery Policy and Procedure Gifts,Hosp an Spon Policy Final v3 January 2018.docx Caine Black Deputy Head Counter Fraud Services/ Sam Tilley, Director of Corporate Affairs 31 January 2018 Audit Committee and Governing Body Claire Skidmore Chief Finance Officer Finance Counter Fraud Date policy due for review: January 2021 Target audience: This policy applies to all CCG employees, contractors, agents, lay and clinical members, volunteers or others performing any role on behalf of NHS Shropshire CCG.

169 VERSION CONTROL Document location This document is only valid on the day it was printed. The current version of this document will be found at Revision History Date of this revision: 31 st January 2018 Date of next revision: January 2021 Version Date Author Change Description 1 December September January 2018 Caine Black Caine Black/Alison Smith Caine Tilley Black/Sam Original Policy Amended to reflect new statutory guidance published by NHS England on 28 th June 2016 updating guidance to CCG on conflicts of interest, gifts, hospitality and sponsorship. Amended to reflect revised value limits included in the national guidance (February 2017) Approvals This document requires the following approvals: Name/Committee Title (if individual) Audit Committee Distribution This document has been distributed to: Name and job title/shropshare/staff newsletter Date of Issue CCG website/shropshare/staff newsletter CCG website/shropshare/staff newsletter/ccg Membership/CSU CCG website/staff newsletter/ccg Membership/CSU February 2015 October 2016 February 2018 Version Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 2

170 Contents Page 1. Introduction 4 2. Scope 5 3. Policy Statement 5 4. Bribery Act Penalties for failing to comply with the Act 6 6. Anti-Bribery Procedures 7 7. Gifts 8 8. Hospitality 8 9. Sponsorship Declaration of Private Interest Staff Responsibilities Monitoring and Review Conclusion Policy Appendices 13 Appendix 1 Seven Nolan Principles of Public Life Appendix 2 Declaration of Gifts, Hospitality and Sponsorship Guidance and Form Appendix 3 Register of Gifts, Hospitality and Sponsorship Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 3

171 1 Introduction 1.1 NHS Shropshire Clinical Commissioning Group is committed to the anti-bribery procedures as laid out in this policy. 1.2 This document sets out NHS Shropshire Clinical Commissioning Group s policy and procedure for CCG employees, Governing Body and Committee members and contractors to declare gifts, hospitality, commercial sponsorship to ensure the requirements of the Bribery Act 2010 dealing with the requirements of the Bribery Act This document should be read in conjunction with the CCG s Conflicts of Interest Policy. 1.3 The Bribery Act 2010 came into force on 1 st July This Act replaces the previous criminal laws of bribery and corruption. This Act makes it a criminal offence, not just for individuals to engage in acts of bribery and corruption, as explained later, but also for commercial organisations (which includes NHS bodies) to fail to prevent bribery by not having in place a range of predetermined processes, as outlined in Section 6 below. In the event that an offence of bribery is committed by a member of the CCG, Governing Body or Committee/sub committee member or an employee, in the course of their role or employment, then the appointing/employing organisation can be prosecuted for failing to have adequate preventative measures in place. 1.4 Bribery is broadly defined as requesting, agreeing to receive or accept (either directly or through any other party), a financial or other advantage in connection with the improper performance of a relevant function, that expected to be reformed impartially and in good faith, irrespective of whether the recipient of the bribe is the same as the person who is to perform, or has performed, the relevant function. The act of bribery can be committed in the United Kingdom or abroad. 1.5 Bribery does not have to involve cash or an actual payment exchanging hands and can take many forms such as a gift, lavish treatment during a business trip or tickets to an event. 1.6 Organisations which fail to take appropriate steps to avoid (or at least minimise) the risk of bribery taking place will face large fines and this could include the imprisonment of the individuals involved and those who have turned a blind eye to the problem. 1.7 NHS Shropshire Clinical Commissioning Group is committed to the prevention, deterrence and detection of bribery and has a zero-tolerance towards those responsible for bribery and corruption. NHS Shropshire Clinical Commissioning Group aims to maintain complete anti-bribery compliance as part of its NHS business activities and will ensure that the prescribed preventative measures are embedded in its daily activities. This will include such measures as ensuring that reference to the Shropshire Clinical Commissioning Group s Anti-Bribery approach is made in its legal contracts, both internally across the NHS and externally with other contractors. 1.8 The Bribery Act does create an offence of bribing a foreign public official, but this is not summarised as it is unlikely to impact upon the provision of local healthcare services. Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 4

172 1.9 The ultimate aim of the policy is to protect NHS Shropshire Clinical Commissioning Group and its employees and ensure it meets the obligations placed on it by the Bribery Act Scope 2.1 This policy applies to all CCG members, CCG Governing Body and committee/subcommittee members and employees of NHS Shropshire Clinical Commissioning Group and should also be used by interim, agency staff, contractors, volunteers or others performing any role on behalf of NHS Shropshire Clinical Commissioning Group. 2.2 NHS Shropshire Clinical Commissioning Group expects that all those acting on its behalf will act honestly and with integrity at all times. 2.3 This policy is also intended to contribute to maintaining the highest standards of business conduct and ensure compliance with the 7 principles of public life drawn up by the Nolan Committee (see Appendix 1). 2.4 This policy should be considered alongside the CCG s other organisational policies: NHS Shropshire CCG Constitution NHS Shropshire CCG Standing Orders, Scheme of Reservation and Delegation of Powers and Prime Financial Polices Policy and Guidance for Joint Working with the Pharmaceutical Industry (including rebate schemes) & Commercial Sponsorship of Meetings/Training Events Raising Concerns at Work Policy Other relevant HR policies 3 Policy Statement 3.1 NHS Shropshire Clinical Commissioning Group is absolutely committed to maintaining an honest, open culture within the Clinical Commissioning Group, so as to best fulfil the objectives of the NHS Shropshire Clinical Commissioning Group. 3.2 NHS Shropshire Clinical Commissioning Group is, therefore, also committed to the elimination of any form of bribery or corruption within the Clinical Commissioning Group. The CCG is also committed to the rigorous investigations of any such allegations and to taking appropriate sanctions against those individuals when bribery or corruption is identified, including possible criminal prosecution. This would also include undertaking steps to recover any assets lost as a result of bribery or corruption. 3.3 It is the responsibility of each CCG member, CCG Governing Body and committee/subcommittee member and employee to report any reasonable suspicions to the nominated Local Counter Fraud Specialist for Shropshire Clinical Commissioning Group. No individual will suffer any detrimental treatment as a result of reporting reasonably held non malicious suspicions. Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 5

173 4 Bribery Act This Act makes it a criminal offence to: offer, promise or give a bribe to another person (Section 1) request, agree to receive, or accept a bribe (Section 2) (A simple example would include a candidate for a job offering the interviewer tickets to an event in order to secure the position. Under the Bribery Act 2010, two offences would be committed; one by the person offering the bribe and one by the person receiving the bribe.) failure to prevent bribery by persons working on behalf of a commercial organisation (a corporate offence) - (Section 7) (Two simple examples would be: a) Where an act of bribery has occurred, for a director, manager or officer of an organisation ignoring an act or acts of bribery within the organisation. Under the Bribery Act 2010, the corporate offence would have been committed. b) Where an act of bribery has occurred, it was subsequently established that the organisation employing the individual failed to have adequate procedures in place to identify and prevent the act of bribery by its employee. Again, under the Bribery Act 2010, the corporate offence would have been committed.) 4.2 However, an organisation will have a defence against prosecution if it can show that they have adequate procedures in place to prevent bribery see Section The Department of Health lawyers have advised that the Bribery Act 2010 applies to all NHS organisations including, Clinical Commissioning Groups for the purpose of the Act are deemed to be commercial organisations. 4.4 Under the Bribery Act 2010, the term a trade or profession is also considered to be a commercial organisation. This means that independent healthcare contractors working in association with any NHS organisations are also subject to and personally liable under the Act. 4.5 A comprehensive version of the Bribery Act 2010 can be accessed via:- 5 Penalties for failing to comply with the Act 5.1 The penalties for breaches of the Bribery Act 2010 are potentially very severe. There is no upper limit on the level of fines that can be imposed. An individual convicted of an offence will face a prison sentence of up to 10 years. If a bribery offence by a staff member is proved to have been committed with the consent or connivance of an Director, manager or other similar person, that person (as well Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 6

174 as the commercial organisation) is also guilty of the offence and liable to be prosecuted and fined or imprisoned accordingly. The penalties if found guilty of an offence under sections 1, 2 or 7 are as follows: Upon conviction in a magistrates court, to imprisonment for a maximum term of 12 months, or to a fine not exceeding 5,000, or to both. Upon conviction in a crown court, to imprisonment for a maximum term of ten years, or to an unlimited fine, or both. NHS Shropshire Clinical Commissioning Group, if convicted under sections 1 or 2 will also face the same level of fines and, if guilty of an offence under section 7, is liable to an unlimited fine. 6 Anti-Bribery Procedures 6.1 An organisation will have a defence against prosecution if it can show that they have the following adequate procedures in place to prevent bribery. 6.2 The Secretary of State has outlined six principles that are expected from commercial organisations to address the risk of bribery occurring within its business activities. These six principles if adopted amount to a defence from prosecution. The six principles are: Proportionality NHS Shropshire Clinical Commissioning Group must have procedures in place to prevent bribery by persons associated with it. These are proportionate to the bribery risks faced by the organisation and to the nature, scale and complexity of the organisation s activities. They are also clear, practical, accessible, effectively implemented and enforced. Top Level Commitment NHS Shropshire Clinical Commissioning Group s Accountable Officer and its Directors should demonstrate that they are committed to preventing bribery by persons associated with the Clinical Commissioning Group. They will foster a culture within the organisation in which bribery is never acceptable. Risk Assessment There are periodic and documented assessments undertaken of the nature and extent of the Clinical Commissioning Group s exposure to potential external and internal risk of bribery on its behalf by persons associated with it is periodically assessed. This includes financial risks but also other risks such as reputational damage. Due Diligence NHS Shropshire Clinical Commissioning Group takes a proportionate and risk based approach, in respect of persons who perform or will perform services for or on its behalf, in order to mitigate identified bribery risks. Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 7

175 7 Gifts Communication (including training) NHS Shropshire Clinical Commissioning Group seeks to ensure that its bribery prevention policies and procedures are embedded and understood throughout the organisation through internal and external communication, including training that is proportionate to the risks it faces. Monitoring and Review NHS Shropshire Clinical Commissioning Group will monitor and review that its procedures designed to prevent bribery by persons associated with the Clinical Commissioning Group and make improvements to minimise the risk where necessary. 7.1 A gift is defined as any item of cash or goods, or any service, which is provided for personal benefit, free of charge or at less than its commercial value. 7.2 Transparency is so important these days and therefore those acting on behalf of NHS Shropshire Clinical Commissioning Group should never put themselves in a position where there could be any suspicion that their business decisions could have been influenced by accepting hospitality from others. If in doubt about the wisdom of accepting a gift or hospitality offered, it is recommended that advice is sought beforehand and a record is made in the register, of the offer or acceptance of hospitality. 7.2 All gifts of any nature (cash, goods, services) offered to CCG staff, Governing Body members, committee members and individuals with GP member practices by suppliers or contractors linked currently or prospectively to the CCG s business, must be declined, whatever their value (subject to this, low cost branded promotional aids may be accepted and not declared where they are under the value of a common industry standard of 6). The person to whom the gifts were offered should also declare the offer (even if it is declined) on a declaration form and give to the Director of Corporate Affairs who has designated responsibility for maintaining the register of gifts, hospitality and sponsorship onto which this will be recorded. 7.3 Gifts offered from other sources other than suppliers or contractors (eg conferences, events, patients, families and service users) should also be declined if accepting them might give rise to perceptions of bias or favouritism and a declaration made. The only exceptions to the presumption to decline gifts relates to items of modest financial value (i.e. less than 50) such as diaries, calendars, stationary and other gifts acquired from meetings, events and conferences. Gifts of this nature do not need to be declared to the Director of Corporate Affairs or added to the register of gifts, hospitality and sponsorship. 7.4 Gifts valued at over 50 should be treated with caution and only be accepted on behalf of an organisation (i.e. to an organisation s charitable funds), not in a personal capacity. These should be declared by staff; Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 8

176 7.5 A common sense approach should be applied to the valuing of gifts (using an actual amount, if known, or an estimate that a reasonable person would make as to its value); Multiple gifts from the same source over a 12 month period should be treated in the same way as single gifts over 50 where the cumulative value exceeds Any personal gift of cash or cash equivalents (e.g. vouchers, tokens, offers of remuneration to attend meetings whilst in a capacity working for or representing the CCG) must always be declined, whatever their value and whatever their source, and the offer which has been declined must be declared to the Director of Corporate Affairs. 7.7 Both acceptance of gifts and where gifts are declined must be formally declared on the appropriate form (see Appendix 2 for guidance and declaration form) and submitted to the Director of Corporate Affairs for inclusion in the register. 8 Hospitality 8.1 When accepting hospitality, individuals must be able to demonstrate that the acceptance or provision of hospitality would benefit the NHS or CCG. 8.2 Modest hospitality provided in normal and reasonable circumstances is acceptable, although it should be on a similar scale to that which the CCG might offer in similar circumstances (e.g. tea, coffee, light refreshments at meetings). Hospitality of this nature does not need to be declared to the Director of Corporate Affairs nor recorded on the register, unless it is offered by suppliers or contractors linked (currently or prospectively) to the CCGs business in which case all such offers (whether accepted or not accepted) should be declared and recorded on the register. 8.3 Where offers of hospitality go beyond modest or of a type that the CCG itself might offer, they should be politely declined. A non exhaustive list includes: Meals and Refreshments: Under a value of 25 may be accepted and need not be declared; Of a value between 25 and 75 may be accepted and must be declared; Over a value of 75 should be refused unless (in exceptional circumstances) senior approval is given. A clear reason should be recorded on an organisation s register(s) of interest as to why it was permissible to accept; A common sense approach should be applied to the valuing of meals and refreshments (using an actual amount, if known, or an estimate that a reasonable person would make as to its value). Travel and Accommodation: Modest offers to pay some or all of the travel and accommodation costs related to attendance at events may be accepted and must be declared; Offers which go beyond modest, or are of a type that the CCG itself might not usually offer, need approval by senior staff (e.g. the CCG s Director of Corporate Affairs or equivalent), should only be accepted in exceptional circumstances, and must be declared. A clear reason should be recorded on Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 9

177 an organisation s register(s) of interest as to why it was permissible to accept travel and accommodation of this type; A non-exhaustive list of examples includes: - Offers of business class or first class travel and accommodation (including domestic travel); and - Offers of foreign travel and accommodation. 8.4 There may be some limited and exceptional circumstances where accepting the types of hospitality referred to in this paragraph may be contemplated. Express prior approval should be sought from a Director or in the case of the Accountable Officer, the Chair before accepting such offers, and the reasons for acceptance should be declared and recorded in the CCGs register of gifts, hospitality and sponsorship. Particular caution should be exercised where hospitality is offered by suppliers or contractors linked (currently or prospectively) to the CCGs business. Offers of this nature can be accepted if they are modest and reasonable but advice should always be sought from the Director of Corporate Affairs as there may be particular sensitivities for example if a contract retender is imminent. 8.6 Declarations of hospitality must be formally declared on the appropriate form (see Appendix 2 for guidance and declaration form) and submitted to the Director of Corporate Affairs for inclusion in the register. 9 Commercial Sponsorship 9.1 CCG staff, Board and committee members, GP member practices may be offered commercial sponsorship for courses, conferences, post/project funding, meetings and publications in connection with the activities which they carry out for and on behalf of the CCG. All such offers (whether accepted or declined) must be declared so that they can be included in the register of gifts, hospitality and sponsorship. 9.2 Shropshire Clinical Commissioning Group employees may only accept commercial sponsorship for attendance at relevant conferences and courses, post/project funding, meetings and publications if they have obtained permission in advance from a senior manager. The manager should be satisfied that acceptance will not compromise purchasing decisions in any way. 9.2 Commercial sponsorship of regular or one-off in-house events such as meetings, conferences and training events should only be accepted if the lead manager concerned is satisfied that acceptance will not compromise future decisions relating to the future use of the commercial sponsors products or services by Shropshire Clinical Commissioning Group. Sponsors should not have any influence over the content of an event, meeting, seminar, publication to training event. The CCG should not endorse individual companies or their products. It should be made clear that the fact of sponsorship does not mean that the CCG endorses a company s products or services. During dealings with sponsors there should be no breach of patient or individual confidentiality or data protection legislation. Furthermore no information should be supplied to a company for their commercial gain unless there is clear benefit to the NHS. As a general rule that information which is not in the public domain should not normally be supplied. 9.3 Declarations of sponsorship must be formally declared on the appropriate form (see Appendix 2 for guidance and declaration form) and submitted to the Director Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 10

178 of Corporate Affairs for inclusion in the register which will be published on the CCG website. 10 Declaration of Private Interests 10.1 The CCG has a separate policy that governs Conflicts of Interest and this policy can be found on the CCG s website.. It is the responsibility of CCG members, CCG Governing Body and committee/subcommittee members and employees of Shropshire Clinical Commissioning Group (Including interim, agency staff, contractors, volunteers or others performing any role on behalf of Shropshire Clinical Commissioning Group) to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. This primary responsibility applies to ALL Clinical Commissioning Group staff, Governing Body and Committee members i.e. those who commit NHS resources directly (by ordering goods/services) or those who do so indirectly (by the prescribing of medicines). The declaration and management of conflicts of interest are detailed in the Conflicts of Interest Policy NHS Shropshire Clinical Commissioning Group must be made aware of all cases where an employee, or his or her close relative or associate, has a position of authority/influence including a significant financial interest in a business (including private sector, public sector or voluntary sector organisation) or in any other activity or pursuit, which may compete for an NHS contract to supply either goods or services to NHS Shropshire Clinical Commissioning Group All CCG members, CCG Governing Body and committee/subcommittee members and employees of NHS Shropshire Clinical Commissioning Group (Including interim, agency staff, contractors, volunteers or others performing any role on behalf of Shropshire Clinical Commissioning Group) should declare such interests to the NHS Shropshire Clinical Commissioning Group, either on starting or on acquisition of the interest, in order that it may be known to and in no way promoted to the detriment of either the NHS Shropshire Clinical Commissioning Group or the patients whom it serves Declarations of private interests must be formally declared on the appropriate form which can be found as an appendix to the Conflicts of Interest Policy and is available on the CCG s website. When the declaration is made it will be added to a publicly held register of interests which can also be found on the CCG website: 11 Responsibilities 11.1 All Shropshire Clinical Commissioning Group employees and others acting on behalf of the Clinical Commissioning Group, must apply the following principles: Not accepting gifts, hospitality or benefits of any kind from a third party which might be perceived as compromising their personal judgement or integrity; Not using their official position to further their private interests or those of others; Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 11

179 Declare any private interests relating to their public bodies; Base all procurement decisions and negotiations of contracts solely on achieving best value for money for the tax payer; Refer to their line manager or the Chair when faced with a situation for which there is no adequate guidance; If in any doubt, seek advice from the Director of Corporate Affairs 11.2 Shropshire Clinical Commissioning Group Anti-Bribery Policy requires that all Gifts, Hospitality, Sponsorship and the Declaration of Interests are recorded in registers which are maintained by the Shropshire Clinical Commissioning Group Director of Corporate Affairs. The Director of Corporate Affairs will be provided with details of what gift / hospitality / sponsorship have been received, or in the case of a declaration of an outside interest, the nature of the interest. The Director of Corporate Affairs will provide details to the Shropshire Clinical Commissioning Group Audit Committee of any declarations made The prevention, detection and reporting of bribery and other forms of corruption is the responsibility of all those working or acting for the Shropshire Clinical Commissioning Group or under its control. All CCG members, CCG Governing Body and committee/subcommittee members and employees of Shropshire Clinical Commissioning Group are required to adhere to the Bribery Act 2010 and report their suspicions or concerns to or through the following means: The Shropshire CCG Chief Finance Officer The nominated Local Counter Fraud Specialist Through the Shropshire Clinical Commissioning Group - Whistleblowing Policy The NHS Protect Fraud & Corruption Reporting Line Number Online via NHS Protect website All reports of bribery or corruption will be investigated in accordance with the Shropshire Clinical Commissioning Group Anti-Fraud, Bribery and Corruption Response Policy 11.5 As well as the possibility of civil action and/or criminal prosecution, CCG members, CCG Governing Body and committee/subcommittee members and employees of Shropshire Clinical Commissioning Group who breach this policy may face disciplinary action in accordance with the Shropshire Clinical Commissioning Group Disciplinary Policy, which could result in dismissal for gross misconduct. 12 Monitoring and Review 12.1 The Director of Corporate Affairs for NHS Shropshire Clinical Commissioning Group is appointed as the named officer to oversee the implementation of Shropshire Clinical Commissioning Groups responsibilities under the Bribery Act Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 12

180 12.2 The Director of Corporate Affairs will receive and review all declarations of Gifts, Hospitality, Sponsorship and the Declaration of Interests, to determine if there is a need to seek an explanation about this declaration from the member or employee concerned The Director of Corporate Affairs will report to the Shropshire Clinical Commissioning Group Audit Committee all instances of the receipt of any Gifts, Hospitality, Sponsorship has been declared In the event that the Director of Corporate Affairs has an immediate concern about the appropriateness of any declaration, this should be brought to the attention of the Shropshire Chief Finance Officer or Conflicts of Interest Guardian as soon as practicable. 13 Conclusion 13.1 All CCG members, CCG Governing Body and committee/subcommittee members and employees of Shropshire Clinical Commissioning Group employees of Shropshire Clinical Commissioning Group, have a duty to follow the Public Service Values and ensure in particular that they maintain the standards of honesty and accountability All CCG members, CCG Governing Body and committee/subcommittee members and employees of Shropshire Clinical Commissioning Group should at all times comply with Shropshire Clinical Commissioning Group s internal control systems and procedures and report any reasonable non malicious suspicions of bribery or corruption. Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 13

181 14 Policy Appendices Appendix 1 The seven Nolan Principles of Public Life (taken from First Report of the Committee on Standards in Public Life (1995)) Selflessness - Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family or their friends. Integrity - Holders of public office should not place themselves under any financial obligation to outside individuals or organisations that might influence them in the performance of their official duties. Objectivity - In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. Accountability - Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. Openness - Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. Honesty - Holders of public office have a duty to declare any private interests relating to their public duties and take steps to resolve any conflicts arising in a way that protects the public interest. Leadership - Holders of public office should promote and support these principles by leadership and example. Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 14

182 Appendix 2: Template Declarations of gifts, hospitality and sponsorship Recipient Position Date Date of Details of Estimated Supplier / Details of Details of the Declined Reason for Other Name of Receipt (if Gift / Value Offeror Previous Offers officer reviewing or Accepting Comments Offer applicable) Hospitality Name and or Acceptance and approving Accepted? or /Sponsors Nature of by this Offeror/ the declaration Declining hip Business Supplier made and date The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the CCG holds. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, professional regulatory or internal disciplinary action may result. I do / do not (delete as applicable) give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons: Decision making staff should be aware that the information provided in this form will be added to the CCG s registers which are held in hardcopy for inspection by the public and published on the CCG s website. Decision making staff must make any third party whose personal data they are providing in this form aware that the personal data will held in hardcopy for inspection by the public and published on the CCG s website and must inform the third party that the CCG s privacy policy is available on the CCG s website. If you are not sure whether you are a decision making member of staff, please speak to your line manager before completing this form. Signed: Date: Signed: Position: Date: (Line Manager or a Senior CCG Manager) Please return to The Director of Corporate Affairs, NHS Shropshire CCG

183 Appendix3: Template: Register of gifts, hospitality and sponsorship Name Position Date of offer Declined or Accepted? Date of Receipt (if applicable) Details of Gift /Hospitality Estimated Value Supplier / Offeror Name and Nature of business Reason for Accepting or Declining Declaration of Gifts, Hospitality and Sponsorship Anti-Bribery Policy and Procedure 2

184 Title of the report: Responsible Director: Prepared by: Input from: Shropshire, Agenda Item Telford GB & Wrekin Sustainability CCG & Transformation Governing Body programme Date of Report: Jan 2018 Updated 11 Jan 2018 STP Programme Update Phil Evans, STP/Future Fit Director Joanne Harding, Head of STP PMO All input identified below Purpose of the report: The purpose of this paper is to provide an update with a high level RAG rated Programme Status Report against the STP Programme Structure, Governance and Delivery Plan. Key issues or points to note: The Dashboard below gives a sense check as to the individual components that make up our system wide STP and our progress towards system wide working Criteria used to demonstrate progress towards system working Accountable care systems are place-based systems which have taken on the collective responsibility for managing performance, resources and the totality of population health. In return, they receive greater freedoms and flexibilities from NHS England and NHS Improvement. (Shropshire STP is still in discussion stage re ACS across system leadership, the criteria below is for information) Effective leadership and relationships Track record of delivery Strong financial management Strong leadership team, with mature relationships across the NHS and local government Effective collective decision-making that does not rely solely on consensus Clinicians involved in the decision-making, including primary care Evidence that leaders share a vision of what they re trying to achieve Evidence of tangible progress towards delivering Next Steps on the Five Year Forward View especially: redesign of UEC system, better access to primary care, improved mental health and cancer services Leading the pack on delivery of constitutional standards, especially A&E and cancer 62 day Ability to carry out decisions that are made, with the right capability to execute on priorities Demonstrated ability to deliver financial balance across the system Where financial balance is not immediately achievable, control totals are being achieved and there is a compelling system-wide plan for returning to balance and/or resolving historic debt System will is ready to take on a shared control total and has effective ways of managing collective risk Coherent and defined population A meaningful geographical footprint that respects patient flows of at least 0.5m Core providers in the area provide ~70%+ of the care for their resident population Is contiguous with STP or if not has clear division of labour with STP and is not simply a breakaway area Where possible, is contiguous with local government boundaries Care redesign System has persuasive plans for integrating providers vertically (primary care, social care & hospitals) and collaborating horizontally (between hospitals), supported by a solid digital plan Widespread involvement of primary care, with GP practices collaborating through incipient networks Commitment to population health approaches, with new care models that draw on the best vanguard learning Includes a vanguard with plans to scale or has demonstrated learning from the best new care models 1

185 Shropshire, Telford & Wrekin Sustainability & Transformation programme STP Director s Update to STP Partnership Board Jan 2018 Phil Evans, STP/Future Fit Director The purpose of this report is to provide the meeting audience and distribution list with a summary of progress in regard to delivery of the STP Programme Development & Delivery. This report will be used at all Board Meetings from 2 nd Weds of each month until the following 2 nd weds of next month RAG rating Key Updates / Issues / risks 1.0 Sharing a Patient Story where available and approved for wider sharing Last Updated: 10/01/ Overall STP Programme Governance 2.1 STP Programme Structure & Reporting STP PMO Contact Phil.Evans1@nhs.net Jo.Harding1@nhs.net STP Programme Structure, Leadership and agreed system priorities are being refreshed. STP PMO Team is now established and are aligned to the programme Delivery Groups and Enabling Groups STP Coordination and communication of programme activities will be facilitated by Office 365 and STP Partner organisations will have full sight and functionality to contribute to system plans via this platform in coming months. Shropshire Council is working with STP Digital PMO Programme Manager to develop a STP System wide website to support overall communication and engagement of wider STP activities. 2.2 STP PMO Finances Last update 15/12/17 JH STP PMO Contact Jo.Harding1@nhs.net The STP PMO is operating within the STP overall budget controls set by STP Partners All partners have now been issued with 17/18 invoices Outstanding payments due from o SCCG o TWCCG o SSSFT Payments received from o SaTH o RJAH o SCom 3.0 Programme Delivery Out of Hospital Transformation 3.1 Telford Neighbourhood Last updated by Awaiting update Community Resilience Louise Mills (Workstream 1) Ruth Emery (Workstream 2 & 3) Updated 13/12/2017 STP PMO Contact Andrea.Webster5@nhs.net Workstream 1 - Community Resilience & Prevention (Neighbourhood working) 518 people have completed Making Every Contact Count training. Attendance has recently focussed on staff from Council Early Help & Support, social care providers and GP practices. MECC/Active Signposting training has been developed for receptionists in consultation with Practice Mangers. 100 staff participated in the pilot. Further training scheduled for January. Safe and Well Visits (Shropshire Fire and Rescue Service) - during the first 3 months of the project 33 referrals were made to My Choice. 2

186 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 The Healthy Telford Blog is now established providing a mechanism to share local stories, news, ideas and best practice. The blog has an average of 1000 visitors each month A network of 36 trained Community Health Champions across Telford and Wrekin, working with each other and their wider communities Social Prescribing Newport Establishment of the Newport & District Community Patient Group to support co-production of the programme A Weekly link worker clinic at Newport Cottage Care. Referrals are slow and more work is required on partner engagement and developing pathways. Clients are presenting with low level mental health issues, anxiety, depression, loneliness & isolation (including carers) Examples of recent social prescribing solutions: (1) Lady whose Partner had to go into care - was becoming increasingly isolated at her own admittance Is considering becoming a Volunteer for Feed the Birds and also hoping to join the new Nordic Walking group in the New Year. Invited to attend Neighbourhood Meeting to help her to mix more with the community (2) Lady supporting Autistic son put in touch with My Choices for access to request support review, informed of different options including shared lives, advocacy and employment and training support, Branches and local mental health drop in (3) Husband and wife (Husband Carer) - Referred to Carers Centre and Thursday CAB session for benefits support and Senior Gym for supervised physical activity and social sessions for wife (4) Local resident (attends cottage care) wanted advice and help to reduce her transport costs to her activities over the week investigated and sourced local quotes and linked her up to a new service who provide a better service for her than taxis (5) Young Person attended with mum signposted to BEAM drop in Hollinswood and other local community groups that can offer her support. Ongoing support of Parent Carer negotiating the education support system. Also funded some training to set up her own community group in Newport Community Development Initiatives in Newport linked to the social prescribing programme Linking with Newport Retirement Living Complexes (Wrekin Housing Trust) engaging residents about projects and also using rooms for training Collaborative working between Newport Rotary and Walking for Health to establish a Bench to Bench Project to enable inactive residents to begin gentle graduated physical activity. Local volunteers are mapping benches and producing paper maps which will be around the community. It is envisaged that led walks will start in the New Year. Nordic Walking group: local resident now qualified as Nordic Walk Leader and leading weekly walks Feed the Birds - In Partnership with Shropshire Wildlife Trust and Community Participation Team. 3 Volunteers trained in Newport who will 3

187 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme be matched to isolated clients in their local areas Last Updated: 10/01/2018 A Pilot programme is being developed with Wrekin Housing Trust Retirement living schemes in Wellington. More physically able residents are volunteering to work across schemes to support isolated residents on other local schemes. 3 Volunteers are being recruited across 2 pilot schemes in Wellington. When this is evaluated it is hoped to expand to the Newport schemes. Central East Telford Citizen s Advice clinics running successfully within Donnington and Charlton Medical Practices Music to movement sessions for the inactive at Donnington surgery. Patients are being signposted from Long Term Conditions reviews attendees. Branches are now linked in A local community focus group has been established with support volunteers are mapping community assets Meeting held with Shawbirch PPG very supportive, GPs interested in developing some ideas & have requested meeting in the new year. Healthy Lifestyles Service The Healthy Lifestyle Service includes a small number of Healthy Lifestyle Advisors. There are just 2 GP surgeries who do not have a dedicated HLA but discussions are in place to address this. In addition to this some GP clinics have increased from 1 half-day session to 2 full days due to the clinics being 100% booked and the GP s being encouraged by the positive outcomes of patients resulting in more referrals. Positive links with Speciality Consultants at Princess Royal Hospital have been developed resulting in an increase in referrals of patients from their clinics Since April the service has delivered brief interventions to 19,911 people (2016/17 outturn position was 19,263); completed 2,082 Health Checks; worked with over 1000 adults to develop personalised healthy lifestyle plans and made 7,617 onward referrals to community based support. The team are now operating at full capacity. 100 adults have participated in creative arts programmes as part of the Building Better Opportunities Programme. A large number of participants experienced poor mental health, issues with physical disability and pain management, substance misuse and rehabilitation, or socially isolated Workstream 2 Neighbourhood Teams Directly bookable slots for GPs to access Early Help and Support Workers has commenced in some GP practices, which is gradually being rolled out to all practices. Estates workshop has taken place with GPs, SSSFT, ShropCom to scope estates provision across the locality and gain an understanding of services delivered and where from, and consider where estates could overlap between health and the local authority to support collaborative working. Two MOUs have been drafted one for the Neighbourhoods (i.e. how the 4

188 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 practices will work together as a neighbourhood), and the second for the operation of the Neighbourhood Teams Service specification for Neighbourhood Teams currently underway, due for completion by the end of November. The CCG is working with the Strategy Unit to develop an evaluation strategy to measure the impact of neighbourhood working, to ensure robust, real measurables are in place for the programme. Work continues to progress with Social Prescribing, including 100 reception staff trained in Making Every Contact Count (MECC) and further training scheduled for January. MDT meetings have commenced in Newport Neighbourhood (includes mental health, community nursing, social care, therapists etc.) to support patients at risk of admission to hospital, and identify ways that patients can be supported who have been identified by a risk stratification tool. First draft of Alliance Agreement for integrated teams has been drafted and is currently being reviewed by stakeholders. Workstream 3 Systematic specialty review Diabetes STP Area won 200k in funding over two years to increase Diabetes Structured Education and achievement of NICE Treatment Targets (TT) and we also developed locally a CCG GP Incentive scheme to improve TT achievement. The following work has been taking place to support patients to be managed more optimally: Additional specialist support and advice via neighbourhood level MDT (support to primary care) with case reviews and consultant clinics individualised practice support (e.g. visits to practices to discuss their results, share best practice and identify training/support needs) incentive scheme to improve all 3 targets. structured patient education (provided by ShropCom) Outcomes: The percentage of patients with diabetes who achieve all three targets (BP, Chol, HbA1c (blood glucose levels)) in Telford & Wrekin has increased. 546 more people have achieved all three target values and are now at reduced risk of diabetes related complications. Ongoing work: Work continues to improve the overall level on this measure whilst also reducing inter-practice variation. Work continues to encourage more patients to take up the structured education, and a press release has been developed to go out in the next two weeks intended to increase awareness of the education on offer New Three Tiered Diabetes Model of Care has been developed, we are working with ShropCom to mobilise a pilot, or demonstrator site, in at least one of the four neighbourhoods, commencing 2nd April 2018.Workstream 1 - Community Resilience & Prevention 3.2 Shropshire Neighbourhood (Out of Hospital Programme) Last Updated by Workstream 1 - Community Resilience & Prevention Working across organisations to connect vulnerable or at risk communities with support to improve health and wellbeing outcomes. Resilient communities developing and making best use of local assets in 5

189 RAG rating Lisa Wicks 13/11/17 STP PMO Contact Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 communities; developing hyper local directories and community connectors on going Social Prescribing demonstrator sight in operation (Oswestry), rolling out to Albrighton, Bishops Castle, and Brown Clee next (early 2018). Early discussions with Shrewsbury based practices for third phase. Awaiting news of national funding Health and Wellbeing Fund Diabetes Prevention working to connect pilot models with the National Diabetes Prevention Programme evaluation on tenders in Jan 2018 Fire Service Safe and Well rolled out across Shropshire and T&W connecting people with lifestyle, loneliness, falls risk and warmth risk to support. Physical Activity developing community postural stability instructor programme delivery to begin early 2018; developing MSK prevention training offer; Falls risk campaign, Let s Talk About the F Word ; improving access to physical activity options in communities; developing Everybody Active Every day. Housing working across health and care to develop a range of options for step up and step down facilities; linking to one public estate and STP estates Mental Health Delivering Health Checks for those with enduring MH conditions, developing sanctuary scheme for to prevent section 136 crisis, connecting low level MH to Social Prescribing and community support such as Shropshire Wild Teams Carers - Delivering all age carers strategy; improving hospital discharge to support carers, improving access to information and advice, carers assessments and support for young carers; improving support for those with dementia and their carers through Dementia Companions pilot in Oswestry and Ludlow from November Workstream 2 Work has commenced within the localities to develop the out of hospital model of care (based on the 9 commissioning clusters). The design work will be overseen by a CCG s design authority as part of the programme governance. Admission avoidance modelling has been undertaken by practice to inform the out of hospital model. The model is based on the following: Rapid Turnaround at the Front Door Community beds and Crisis Resolution Hospital at Home Community Services Non-core enhanced services Outcome based specifications will be developed by locality for each element of the model based on: Maintenance of good health Locally determined practice-level management of cohort conditions Timely, efficient access to cluster-level core services Health crisis prevention through cluster-level case-management Admission avoidance through Integrated locality-level crisis resolution Efficient and effective treatment and stabilisation of acute need A review of MIU, DAART and Community Hospitals has also been undertaken and a case for change developed. Pre-engagement is currently taking place and feedback will be considered by the Clinical Reference Group at the end of November. 6

190 RAG rating 3.3 Powys Neighbourhood Last updated by Andrew Evans STP PMO Contact Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 A health needs assessment for Shropshire has also been commissioned to inform the out of hospital model of care. The Locality Model comprises of five key service components as follows: Primary Care Community Resource Team and Virtual Ward Community Hospital: Health and Social Care Centre (Core Elements: Health & Wellbeing Advice Hub, Health and Wellbeing Day Centre, Intermediate Care Unit (Step up/step Down), End Of Life Unit Community Hospital: Diagnostic and Treatment Centre (Core Elements: Minor Injuries Unit, Diagnostic Unit, Assessment and Treatment Unit, Day Care Unit Acute Hospital Care Unscheduled Care Improvement Plan The vision for unscheduled care in Wales is that people should be supported to remain as independent as possible, that it should be easy to get the right help when needed and that no one should have to wait unnecessarily for the care they need, or to go back to their home. We will achieve this by working with patients and carers as equal partners to provide prudent care. We will put quality and safety first, working with staff to improve the care we deliver by identifying and removing any waste from our work, and openly sharing our outcomes or learning Planned Care Improvement Plan The vision for planned care in Wales is to improve the flow of patients along their healthcare journey by ensuring that their experience of assessment, diagnosis and treatment is based on augmented, safe and reliable systems. In essence this means that we must ensure that people access care at the right level for their needs: right care; right time; right place; right people 4.0 Programme Delivery Acute & Specialist in Hospital Transformation 4.1 Local Maternity Services Transformation Plan NHS England have released guidance for identifying Last update: Baselines and trajectories and the LMS plan is being refined accordingly. Programme Lead Fiona Funding bids are being developed ready for submission to NHS England on Ellis 10/01/ st January 2018 for non-recurrent funding in 2018/19. The amount available has not been confirmed. Reporting against local measures will commence this month. Maternity and Newborn Service Reconfiguration Proposals to re-model Midwife Led Services have been endorsed by both Shropshire CCG and Telford and Wrekin Governing Bodies. A period of consultation is now being planned and is anticipated to commence early in Neonatal and Consultant let unit reviews have commenced. Perinatal Mental Health A funding bid is being finalised in preparation for the expected bidding opportunity during January 2018 for Perinatal Mental Health funding. 7

191 RAG rating 4.2 Muscular Skeletal Services Updates to be provided by Sabrina Brown 15/12/2017 STP PMO Contact Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 Shropshire MSK Programme Board has been established and includes the following work streams: o Physiotherapy o SOOS o Value based commissioning o Rheumatology o Communications o Education, support & Prevention A standard MSK community based physiotherapy service specification has been drafted and approved at the CCG s November Clinical Commissioning Committee meeting. The specification will facilitate consistency in service provision and reporting across the four providers. This is the first stage to a number of service improvement initiatives for physiotherapy. Work is currently underway to model up the enhancement and expansion of conservative management services as an evidence based alternative to surgical procedures. Shropshire Orthopaedic Outreach Service is currently implementing a redesign and expansion of an existing community based specialist MSK service. Additional staff has been recruited and premises identified to serve as hubs in Shrewsbury and the South of the County. Plans are in place to go live during this financial year 17/18. The nationally mandated elective care high impact MSK triage intervention for all orthopedic referrals will be completed via RAS/ SOOS via a phased approach to full implementation MSK VBC: The Value Based Commissioning process is operating well at the Robert Jones & Agnes Hunt provider however a small number of issues are outstanding and are scheduled to be resolved shortly. The policy has been updated and is scheduled for approval at the January CCC meeting. 4.3 Urgent Emergency Care Updates to be provided by Claire Old UEC tracker submitted to NHSE, no questions raised or feedback received. System Winter plan has been included in the submission Confirmation that we have received the 197k from NHSE 4.4 Future Fit / Sustainable Services Programme Updates provided by Phil Evans Last update provided by Pam Schreier 15/12/17 STP PMO Contact pam.schreier1@nhs.net All information has been provided to NHSE and no further requests for additional information are expected. Conversations continue between SaTH, NHSI and the Treasury regarding capital funding ahead of approval to proceed. All public facing consultation documents and the PCBC has been signed off in draft and await NHSE approval. Public facing consultation materials and the website continue to be developed and all necessary translations into Welsh being progressed. The consultation plan and event planner are being developed with public facing, deliberative and third party events being added as information becomes available. Early drafts of this were shared for feedback with the Joint HOSC. As part of the Consultation Institute QA process a further meeting is planned for the new year. The FF Assurance Group and the Clinical Design Group met on 14 December

192 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/ Programme Delivery Enablement of Transformation 5.1 Digital Enablement Group Office 365 pilot implementation for STP team has been priced up. Last updated by Licence costs have been agreed. Rob Gray Implementation costs from the CSU are being reviewed. 12/12/17 Started to nominate owners (sponsors) for each programme and project. Those without owners will be cancelled from the programme STP PMO Contact Design Authority: robgray@nhs.net Piloting project process with End of Life module. Planning to fit in with overall integrated care record. Clinical workshop scheduled to define process requirement Clinical Professional Reference Reinstated regular meetings. Primary aim to nominate clinical lead for every programme and project - agreed by group EoL process to set template. Information Governance Agreed to nominate an IG lead for every project as advisory contact Agreed to send rep to other group meetings to get overview of all workstreams. Agreed to chase Owner for the scope for the data sharing gateway project. Key risks: lack of project managers offered by contributing organisations. Lack of attendance at group meetings 5.2 Strategic Workforce Group Last updated by Heather Pitchford 02/11/17 STP PMO Contact Sara.edwards3@nhs.net Strategic Workforce Group SaTH have agreed to employ the first cohort of apprentices to enable the Agile Workforce Programme to continue at pace. We are receiving some extra support from HEE with this to feed into the national programme First iteration of Mental Health Plan submitted on time, meeting planned 9th Jan with stakeholders to agree strategy for March submission Many requests for plans are coming through with Cancer Plans next on the horizon. Workforce Group discussing strategy for completing these requests on next agenda along with a plan to produce a system wide baseline by March 18 There is a need to revise TOR System Organisational Development workstream Transformational Change through System Leadership application was successful. NHSE are supporting a Team to enhance our neighbourhood Programmes of work. Participants include STP PMO, ShropCom, SCCG, T&WCCG Programme will include out of hospital care for Adults The Kings Fund are supporting STP system wide OD, this includes o Facilitated STP Programme Delivery Refresh session on 22 nd Nov, this has approx. 50 confirmed attendee s o Facilitated System Leaders Session via 1:1 & group session Date 20 th Dec 17 o Future co-designed workshops to support system transformation o A full debrief from the 22 nd Nov session will be available once write up is complete Training & Development Workstream Funding bids have been received by HEE and all allocations made in draft prior to final sign off 9

193 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Final allocation is expected to be 522,600 Last Updated: 10/01/ Strategic Estates Group Last updated by Becky Jones 11/01/18 STP PMO Contact maggie.durrant@nhs.net 5.4 Strategic Back Office Updated provided by Ros Preen 15/12/17 Baseline data validation is ongoing to provide the baseline information for the Workbook and asset mapping. SHAPE data validated, meeting DoFs on 11/01/18 to discuss STP Strategic Estates Workbook. Although information has been requested, information given as to why it s needed and support offered in gathering, the current position is that the Workbook details are not fully reflective of the current position. The Workbook is a living document and as such can be regularly updated. It will therefore be a standing item at the LEF and work will continue to ensure it is up-to-date. However, the submission in March will have to be a current position rather than a complete position. Close work continues with Shropshire County Council on the asset mapping work Shropshire Community Needs Workshop being planned for 27 February Telford & Wrekin Community Needs Workshop planned for 17 April Data mapping progressing well and identifying ways to share data across health and Council to enable programme of mapping to continue and opportunities to be identified Presentation to Voluntary Sector Assembly on 16 Jan to ensure stakeholder engagement Shropshire CC hosting a mapping system to pull together all baseline data to use to plan opportunity projects based on health, housing or employment needs identified through the asset mapping process. Supported by Telford and Wrekin Council New LEF Joint Chair identified as Amanda Alamanos (NHSE) and Tim Smith (Shropshire CC) to give whole system support and linkage Presentation given to Telford CCG PCCC to discuss efficiency and transformation approach and received positive response Strengthening links with other workstreams Agreed that LEF will look at energy efficiencies, linking in with Back Office Group and individual nominated at LEF One Public Estate (OPE) received some funding so hopeful of using some of it to progress the Whitchurch project forwards. Initial project meeting now taken place, really positive progression Key risks Finance and data support still required for Workstream A refocus is required for the new year, facilitated by; The more substantive STP PMO support arrangements starting to have traction both directly for the group but also generally across the work streams, The ability to review the refreshed health provider corporate service data which was submitted to NHS Improvement at the end of November and will enable further benchmarking to be undertaken, and A quick conversation with Midlands and Lancs CSU to explore their support model which is up and running in 4 STP footprints (meeting being scheduled for January) The group acknowledges the contributing/associated work going on in other enabling work streams, principally; Workforce in relation to their focus on looking at options to support collaborative bank and recruitment processes (still in early stages), and 10

194 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 Integrating our public estate through the Estates work stream. It is anticipated that the Digital work stream could at some point bring into its remit a focus on the IM&T back office which will require further support The Back Office working group will meet in January and will be looking for options in the rest of the back office and to expand thinking around the Carter agenda/ model hospital etc taking into account all of the above. 5.5 Communication & Engagement Group Last updated by Pam Schreier 15/12/17 STP PMO Contact pam.schreier1@nhs.net 5.6 STP System Finance Group STP PMO Contact Jo.harding1@nhs.net 5.7 STP Clinical Design Group Last updated by Jharding 15/12/17 STP PMO Contact Jo.harding1@nhs.net The communications and engagement work stream met on 14 December Leads aligned to each work stream provided feedback, where available, on work streams progress. In-depth feedback was provided on the Telford& Wrekin and Shropshire Neighbourhoods activity. Winter communications was discussed in-depth including the draft winter communications and engagement plan, (for which the Programme Director is asked to confirm governance procedure for sign off; the plan for the additional funding secured from NHSE and the links to the A&E Delivery Group and a request for one coordinated message from all providers at times of escalation or adverse weather conditions. PS provided an update on Future Fit activity and potential timescales for consultation. PS reported that further work will be undertaken in the coming weeks to explore the proactive, positive activity in the A&E Delivery Group to identify potential good news stories and interviews for the media. The SRO updated on the work progressing with the Kings Fund and the meeting due to take place on 20 December AW attended from the STP PMO and presented the directors update and advised on the new members of the PMO and their responsibilities. Communications around MLU, the Maternity Review and going forward the Women and Children s element of the Future Fit programme was discussed. DB will invite PS and AH to a meeting/conference call to discuss joined up messaging following SaTH s discussion with its retained agency on 15 December Wider STP Communication & engagement strategy still needs to be developed and work has commenced on this and will be progressed in the new year. Review of governance documents to support work stream. A methodology that tracks system finances needs to be developed and agreed. Financial Modelling resource required to support system modelling of finances. Agreed to review TORs in light of STP focus rather than just FF Agreed view from the group that the group needs to evolve to become and STP Clinical Design Group with wider representation from Clinical Leads with clear tasks to support delivery of system transformation. Focus needs to be on system wide pathway development 6.0 Cross Cutting Work Programmes of work 6.1 GP5YFV STP PMO Contact Sara.edwards3@nhs.net The Shropshire STP GP5YFV Workforce plan has now been reviewed by our DCO NHSE Assurance panel. The panel would like to feedback that the plan is FULLY ASSURED with a score of 63.69% (pass score is 50%). 11

195 RAG rating 6.2 Mental Health Awaiting update Richard Kubilis Frances Sutherland STP PMO Contact 6.3 Transforming Care Programme Manager Di Beasley 6.4 Frailty Updates to be provided by Michael Bennet (1&2) Emma Pyrah (3&4) 01/12/17 Gemma McIver Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 The panel noted that the plan was well structured and clear but lacking in detail in some areas with scope to further develop strategically. Specifically the panel would like to see greater focus on the STP footprint rather than individual CCG s to demonstrate increased connectivity across the whole area; it felt that the plan could be more ambitious with further exploration and commitment to exploit national schemes and funding sources and also HEE funding for training. It is clear that work is still in progress and further transformation schemes will need to be included within the plan to diversify workforce and increase multi-disciplinary working. It is suggested that Shropshire, whilst not feeling the same heat as other STP s, could make the most of the headroom that exists locally to get ahead of the transformation curve as workforce pressures are expected to worsen. The plan will be challenging to deliver and there are material risks for delivery which will need to be checked and mitigated. Mental Health Workforce Planning submission is required fully worked up by end of March 18 First meeting iof this group took place on 9 th Jan where system wide representation attended to contribute to the development of this plan Clinical lead identified as Cathy Riley from SSSFT Update to be provided 5 Work streams within the Frailty Programme of work Frailty Programme Board reinstated first meeting scheduled (Programme Exec lead Fran Beck) Workstream 1 - Prevention & Primary Care STP PMO Contact Andrea.webster5@nhs.net CSU developed Frailty tool to support electronic Frailty Index (efi) completion and risk stratification of frail patients Frailty risk stratification being piloted within identified neighbourhood to target support to high risk patients My Health Record (Frailty card) being developed to capture baseline information of patients and support decision-making to appropriat4 clinical care. Plan to pilot in specific care homes when agreed Workstream 2 - Crisis / admission avoidance Review of Intermediate Care Team (ICT) pathways and processes to support admission avoidance. ICT includes BRC and Carers Support Worker and addition capacity via ibcf monies T&WCCG commissioned Care Home MDT to deliver training, skill development, clinical assessment and admission avoidance from care homes. Recruitment of staff to commence December / January. Rapid Response aligned to specific care homes to support and admission avoidance 12

196 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 ICT daily attendance in ED to support admission avoidance Workstream 3 - Flow through acute hospital Phase 2 of the Frailty Front Door at RSH operational service relaunch on 13 th November 2017 supported by the Acute Frailty Network. Phased increase from 10am-2pm to 9am-5pm Mon-Fri during November as workforce comes on stream. Memorandum of Understanding agreed at A&E Delivery Board setting out all key stakeholder partners commitments and responsibilities in phase 2 of this project from November 17 March 2018 and an additional pump priming funding. Data recording and reporting schedule agreed and formal reporting to the project group to commence from PDSA programme and timeline to be agreed by Weekly frailty leads meeting refocused to concentrate on Frailty Front Door (project lead Emma Pyrah). Patient rep joined the group on Workstream 4 Discharge to Assess Fact Finding Assessment (FFA) and process refreshed and updated documentation implemented. D2A reset session held with stakeholder partners in November 2017 to revisit the original D2A principles from 2015 and confirm they remain fit for purpose. Revised set of underpinning principles and processes to be signed off at the next meeting Shropshire Council have commissioned an additional 20 pathway 3 beds (interim placements for patients requiring complex assessments) which increases capacity for discharge and the ability to identify patient s potential for rehabilitation/enablement. Shropcom are working with Shropshire LA to introduce from December a trusted assessor role for care homes, supported by SPIC. Detailed action plan against the LGA 8 High Impact Changes in development. Concern expressed that the system does not have a formal reporting mechanism for progress on this when it is a mandated requirement which is reported on through NHSE and BCF formal routes. To be discussed at A&E Delivery Group. D2A Task & Finish Group continues to meet monthly 6.5 End of Life Update provided by Cath Molineux 12/12/2017 STP PMO Contact Andrea.webster5@nhs.net Workstream 5 End of Life Below National Workshop planned for 8 th Feb 18 for our STP via NHSE The workshops will demonstrate how effective EoLC can deliver next steps priorities, including urgent and emergency care, cancer, financial sustainability and personalisation and choice. The workshops will support development of local strategy and delivery plan across Shropshire End of Life planning project at discovery stage to prep for mandate creation. Workshop scheduled for Dec 13 th (see notes below) 13

197 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 Ensuring our services provide high quality care that is affordable and sustainable ( Shropshire STP) The SCHT Palliative and EOL Strategy for adults is not about trying harder and doing better for the last few days of life but by doing things differently further upstream. This approach needs to be taken across the whole system, in the pathways for people with long term conditions/comorbidities/cancer and also integrated into the neighbourhood team approach. Systems and practitioners need to work upstream with all patients with any type of long term condition/co-morbidities, so treatment options and decisions have been previously discussed and mapped out. Actual care will be appropriate to preferred care options, already discussed and planned ahead for and reduce very significantly the number of inappropriate high cost interventions being delivered and the number attending A/E because treatment options will be managed proactively and less reactively. Upstream working is recognising as early as possible in any disease trajectory when a person is in at least in the last 12 months of life. This approach reduces the current position where there is a crisis in the last few days and weeks of life and that person will end up in hospital. The STP already sets out the demographics depicting the rise in our older population, those with Long Term conditions and increase in single households and the unsustainability of the current and future demand. Data is required to quantify this; for example: Those attending AE and the nature of emergency admissions and interventions costed and used inappropriately; The types and numbers of high cost LTC interventions where the patient dies within a certain time limit when other care and treatment options could have been used. Those being admitted 3 times a year or more( particularly those patients with severe frailty). What are expected outcomes as result of implementing this approach: Improved patient/family/carer/partner experience Appropriate use of interventions for all LTC/Cancer/Co-morbiditiesdisease trajectories Care and treatment options are planned ahead Increase in number of people who have an advance care plan reflecting their wishes and preferences including where they want to die. Reduce demand on the acute sector Having upstream/planning ahead conversations as an interventionseen as a positive, with symptom management and still get a quality of life What happens if we don t do upstream working? Paying for inappropriate care- wasting limited resources. When appropriate for treatments to continue or when to stop. Making most of restrictive resources. Demand on acute services continues to rise. Current Situation Shropshire does have a system EoL Group but does not yet have an Eol Strategy for Shropshire. The EoL group has been working on smaller issues that arise ie discharge meds for patients coming home from SaTH etc etc. The Community Trust have a strategy and the hospice are just refreshing theirs, it is recognised that a wider system strategy joining together the priorities from each organisation is required. A small group met and developed a list of strategic objectives from the two existing strategies and the Ambitions for Palliative and end of life care (2015/20) to provide local direction for 3-5 years. 14

198 RAG rating Key Updates / Issues / risks Shropshire, Telford & Wrekin Sustainability & Transformation programme Last Updated: 10/01/2018 These are: To ensure equal access to palliative and end of life care. o Systems to identify patients for referral o Access Criteria o Processes for referral o Referral documents o Frailty Ensure access is based on need not condition. o Establish a needs based model that identifies phase of illness and a system for prioritization o Links with non-cancer specialists Establish systems of prognostication to identifying patients in the last year of life. o GSF register o Frailty register o Important conversations Establish the concept of Living Well o Documentation supports / directs the professional to identify patients preferences/goals for living o Culture of care is enablement o Programs for palliative rehabilitation are established Further develop homecare models to support a preference to be cared for and die at home o Hospice to continue to develop the H@H service o H@H is placed on a sustainable financial footing o Integration of H@H with the Hospice Outreach Service Ensure a competent workforce o Identify education needs across services o Robust systems for appraisal and CPD across groups o Establish education programs Establish systems that support advanced and anticipatory care planning and timely access to services. o Identify key worker o Consider joint documentation (patent held?) Work in partnership to ensure that care is coordinated between services. o Commissioning o Services compliment not replicate each other o There is shared documentation where possible (RESPECT, EOL care plan, PPC) Consider compassionate communities voluntary support as an extension to services o Severn Hospice continued roll out of coco o Volunteering is seen as an arm to wider services o Clinical services refer to established volunteer support Key ( based on STP PMO system intelligence) Unknown On track no issues requiring escalation Require Programme Delivery Executive Lead & or SRO input Require STP Partnership Board input 15 Need to engage and receive update from Programme Lead Where this is required, this will be detailed in recommendations and noted for relevant SRO Where this is required, this will be escalated via STP

199 Shropshire, Telford & Wrekin Sustainability & Transformation programme Partnership Board by STP Programme Director 16

200 Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: Responsible Director: Risk Management Policy including revised Governing Body Assurance Framework Sam Tilley, Director of Corporate Affairs Author of the report: Sam Tilley, Director of Corporate Affairs Presenter: Sam Tilley, Director of Corporate Affairs Purpose of the report: To present to the Governing Body the revised CCG Risk Management Policy along with a revised Governing Body Assurance Framework and Issues Log and details of the Corporate Risk Register and Issues Log Key issues or points to note: Following a Governing Body development session in October 2017 regarding improvements to the CCG s risk management arrangements the CCG s Risk Management Policy has been revised. In line with the output of the development session the Governing Body Assurance Framework has also been revised to include a Governing Body Issues Log. In addition to this a Corporate Risk Register and Corporate Issue Log have been developed This approach and the revisions to the Risk Management Policy were supported by the Audit Committee on 31 January 2018 Actions required by Governing Body Members: Governing Body Members are asked: To approve the revisions to the Risk Management Policy To note and approve the addition of a Governing Body Issues Log to support the Governing Body Assurance Framework as the future method for monitoring Governing Body Risks and Issues To note the development of a Corporate Risk Register and Issues Log and to approve this as the future method for monitoring Corporate Risks and Issues via the sub committees of the Governing Body To review the content of the GBAF and Issues Log and highlight any revisions required. 1

201 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required No 2 Health inequalities If yes, please provide details of the effect upon health inequalities No 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement 5 Patient and public engagement If yes, please provide details of the patient and public engagement 6 Risk to financial and clinical sustainability The new Risk Management Policy and associated Risk Registers and Issues Logs enable the CCG to improve their risk management arrangements to support improvements to financial and clinical sustainability No No No Yes 2

202 NHS Shropshire CCG Governing Body Meeting 14 February 2018 Risk Management Policy including revised Governing Body Assurance Framework and Issues Log and Corporate Risk Register and Issues Log Sam Tilley, Director of Corporate Affairs Executive Summary and Actions Required 1. Following a Governing Body development session in October 2017 regarding improvements to the CCG s risk management arrangements the CCG s Risk Management Policy has been revised. In line with the output of the development session the Governing Body Assurance Framework has been revised to include a Governing Body Issues Log. In addition to this a Corporate Risk Register and Corporate Issue Log have been developed 2. Governing Body Members are asked: To approve the revisions to the Risk Management Policy To note and approve the addition of a Governing Body Issues Log to support the Governing Body Assurance Framework as the future method for monitoring Governing Body Risks and Issues To note the development of a Corporate Risk Register and Issues Log and to approve this as the future method for monitoring Corporate Risks and Issues via the sub committees of the Governing Body To review the content of the GBAF and Issues Log and highlight any revisions required. Report 3. In October 2017 CCG Governing Body members attended a Governing Body development session regarding Risk Management facilitated by our internal auditors with a view to reviewing and improving the CCG s Risk management arrangements. 4. As a result of this session it was agreed that: The CCG needed to be able to differentiate between the management of risks (A circumstance that could cause harm to individuals or the organisation) and the management of Issues (a risk which has occurred) The Governing Body Assurance Framework (GBAF) should be reviewed on this basis and a Governing Body Issues Log should be developed to sit alongside the GBAF to capture any risks that had become Issues A Corporate Risk Register should be developed to capture in one place all the risks being managed within Directorates with an associated Corporate Issues Log to capture any directorate risks that had become Issues The Risk Management Policy be updated to reflect this 5. The GBAF (and Issues Log if approved) will be presented to the Governing Body for review on the first month of each Quarter. The Directorate sections of the Corporate Risk Register and Risk Log will be reviewed by the relevant Governing Body Sub Committee s on a quarterly basis and by the Executive Team on a regular basis. Both Sub Committees and the Executive Team will be responsible for recommending escalations of Risks and Issues from the 3

203 Corporate Risk Register and Issues Log to the GBAF and Issues Log for consideration by the Governing Body. 6. The CCG s Risk Management Policy has been updated to reflect these arrangements and to ensure appropriate oversight, review and escalation of Risks and Issues (for ease amendments are noted in yellow) Recommendations 7. Governing Body Members are asked to: To approve the revisions to the Risk Management Policy To note and approve the addition of a Governing Body Issues Log to support the Governing Body Assurance Framework as the future method for monitoring Governing Body Risks and Issues To note the development of a Corporate Risk Register and Issues Log and to approve this as the future method for monitoring Corporate Risks and Issues via the sub committees of the Governing Body To review the content of the GBAF and Issues Log and highlight any revisions required. 4

204 Document title: Risk Management Strategy / Policy CCG document ref: Author / originator: Sam Tilley Date of approval: Approving committee: Audit Committee Responsible director: Director of Corporate Affairs Category: Corporate/General Sub category: Date policy is due for review: Target audience: Policy Equality Impact Assessed Risk management April 2019 All staff This policy does not exclude or impact on any protected characteristics (RISK MANAGEMENT STRATEGY / POLICY)

205 VERSION CONTROL Document Location This document is only valid on the day it was printed. The current version of this document will be found at Revision History Date of this revision: 18 December 2017 Date of next revision: April 2019 Version Date Author Change Description /06/14 BPS 1. Statement of Intent 2. Risk Management Organisational Structure 7.1 CCG Governing Body 7.2 Audit Committee 7.5 Locality Committees 8.7 Commissioning Managers 8.8 Executive Team To reflect post authorisation position /12/17 ST 1. Amend responsibilities throughout to line up with the new Directorate and Committee Structures Amend to reflect introduction of corporate risk registers and Issues Log Approvals This document requires the following approvals: Name / Committee Audit Committee Sam Tilley Title (if individual) Director of Corporate Affairs Distribution This document has been distributed to: 1

206 Name and job title / External organisation / All staff Date of Issue Version CCG website / TBC TBC 1

207 CONTENTS Section 1 Statement of Intent 5 2 Introduction 6 3 Purpose 6 4 Definitions 7 5 Key Aims 7 6 Risk Management Organisational Structure 7 7 Committees/Groups with responsibility for risk CCG Governing Body Audit Committee Quality Committee Clinical Commissioning Committee Finance and Performance Committee Primary Care Commissioning Committee Locality Committees All Committees 9 8 Duties of Key Individuals Accountable Officer All Governing Body Directors Director of Corporate Affairs Chief Finance Officer Director of Nursing and Quality Director of Contracting and Planning Director of Performance and Delivery Director of Primary Care Commissioning Managers Executive Team 11 9 Documentation Linked to Risk Management Risk Assessment Risk Identification Analysis of risks Rating Risk Acceptance of risk Risk Moderation Escalation of Risks Exceptions to the above Risk Register & Issues Log Monitoring of Risks Groups and Committees responsible Governing Body Assurance Framework Communication Strategy review arrangements References 15 Appendices Appendix 1 Guidance on Risk Assessment Appendix 2 Adverse Incidents Involving National Screening Programmes: National Cancer Screening Programme 16 24

208 Risk Management Strategy/Policy Strategy 1. Statement of Intent Shropshire Clinical Commissioning Group (CCG) is committed to ensuring that it has in place structures that will effectively manage risks to a level which is in line with its key aims as set out in the Constitution. Some of these risks are internal and these will be controlled by the internal control system and internal controls. Others are external and arise due to unpredictable changes in the economic, business, political, technological and financial environment. The CCG Governing Body will ensure that it has in place a risk management framework to support the key aims which are to commission high quality, safe and cost effective services and in doing so will use this framework to take all reasonably practicable steps in the management of risks associated with: commissioned services staff and visitors the organisation s reputation the organisational assets Through these risk management processes the CCG Governing Body will proactively seek to identify the risks to its key aims and to identify mitigation processes where it is reasonably practical and desirable to do so. Taking risks is part of everyday living and has many benefits. An organisation cannot be innovative without taking risks. The risk management framework is very much centred on identifying risks, and managing them in a controlled way. Accepting risk should not be seen as a failure to manage the risk. The Governing Body will seek assurance that the risk management framework is working effectively through its own activities and that of its committees. The CCG will follow the principles detailed below: 1) Identification of risk The CCG will identify its significant risks from the following sources The investigation of incidents, claims, and complaints. Concerns raised by stakeholders, patients and staff. Expertise of managers and other lead personnel. Issues raised by CCG committees and groups. External organisation reports and inspections. External and internal audits and surveys. Carrying out risk analyses or assessment work. And any other relevant information. 2) Analysing the risk 5

209 The following factors will be taken into account when the risk is analysed: The full extent of the consequences of the risk. The likelihood of the risk occurring. Any means by which the risk is currently controlled or mitigated. How the CCG will be assured that the risk is being adequately managed. 3) Developing further mitigating controls/accepting the risk Following analysis of the risk, the risk lead, in conjunction with other interested parties, will consider the circumstances identified and decide whether further mitigating controls are necessary. This decision will be based on balancing the level of risk against the benefit of taking the risk. Examples of benefit would include an overall improvement to the services commissioned by the CCG, to improve the sustainability of services or a patient outcome. If the risk outweighs the benefit then further mitigating controls need to be identified. These controls will effectively reduce the risk. Any additional risks introduced as a result of the controls will be taken into account and the additional control will be monitored for successful implementation. 4) Monitoring the Risk The CCG will ensure, through the processes described in the policy below, that all identified significant risks are monitored to ensure: The level of risk that the CCG is exposed to is acceptable to the CCG and its stakeholders. The risk is communicated to all relevant parties. That identified systems of internal control are working effectively, reducing risk to an accepted level identified by its management. Identified assurances have been received. 5) Differentiation of Risks and Issues As well as managing Risk the CCG will also manage Issues. An Issue is defined as a matter that is current and happening now as opposed to a Risk which has not occurred yet. The management of Risks which have occurred and become Issues will be tracked via an Issues Log. Policy 2. Introduction This policy sets out how the CCG will meet the principles detailed above. 3. Purpose The purpose of this Policy is to detail the Risk Management Framework for the CCG, the responsibilities for its implementation, the involvement of the CCG Governing Body, its committees and other relevant committees and the recording and reporting of relevant risks. 6

210 4. Definitions Risk Risk Control Initial Risk Rating Current Risk Rating Target Risk Rating Residual Risk Risk Appetite Assurance Governing Board Assurance Framework Issue A circumstance that could cause harm to individuals or the organisation, expressed as the level of the harm multiplied by the likelihood that the harm will be caused. A measure in place to mitigate the risk, either by reducing the level of harm or the likelihood of occurrence, or both. The consequence, likelihood and rating of the risk if no risk controls were in place. The consequence, likelihood and rating of the risk given the current risk controls in place. The consequence, likelihood and rating of the risk after all actions to introduce further risk controls have been completed, taking into account residual risks. Risks that remain after all desirable risk controls have been implemented. This is likely to be either that these risks are accepted by the CCG or imposed by external influences. Level of exposure to the risk the CCG is willing to accept and therefore considers that it is not desirable or worthwhile to introduce further mitigation measures. Evidence that risk controls are being implemented effectively. Risks which could have a serious effect on the delivery of the CCG s strategic aims. A Risk which has now occurred 5. Key Aims Key Aims A continually improving healthcare and patient experience Create a true membership organisation Financial sustainability Influence and lead the development of the local health economy Grow the leadership for future organisations All risks detailed in Risk Registers will be linked to one or more of these key aims. 6. Risk Management Organisational Structure Figure 1 below shows the organisational structure of the CCG Governing Body and its Committees. Figure Governing Body 3 Locality Committees South, North and Shrewsbury and Atcham Quality Committee Finance and Performance Committee Clinical Commissioning Committee 7 Audit Committee Remuneration Committee Primary Care Commissioning Committee

211 7. Committees/groups with responsibility for risk The Terms of Reference for the established committees and the CCG Governing Body are available through the Director of Corporate Affairs. All committees and work streams should have in their terms of reference the requirement to consider risk and their mitigation and escalate as appropriate. The key responsibilities for the Governing Body and its committees in relation to risk are: 7.1 CCG Governing Body The CCG Governing Body will receive the Governing Body Assurance Framework (GBAF) in the first month of each quarter at its meetings held in public. The Governing Body should: consider the risks on the GBAF and assess how they have been identified, evaluated and managed consider the associated Issues Log assess the effectiveness of the related system of internal control in managing the risks, having regard, in particular, to any significant failings or weaknesses in internal control that have been reported consider whether necessary actions are being taken promptly to remedy any significant failings or weaknesses consider whether the findings indicate a need for more extensive monitoring of the system of internal control The Governing Body will receive reports from the Audit Committee outlining the effectiveness of the internal control, risk management systems and assurances that they have received from committees, managers and internal auditors. 7.2 Audit Committee The Audit committee is responsible for the review of the internal control system and risk management system (for the identification, control and monitoring of all risks, both internal and external) through its review of the work of the Governing Body committees. In particular it will use the GBAF to guide its work. The Committee will review the GBAF entries quarterly and will make recommendations to the Governing Body relating to its findings on the management of the risks associated with the entries and the assurance it has received. The committee will review the components of the Corporate Risk Register on a rolling program. 7.3 Quality Committee The Quality Committee will review risks associated with the quality of commissioned services, performance and targets. The review of these risks will be supported by detailed work carried out within individual work programmes. 7.4 Clinical Commissioning Committee The Clinical Commissioning Committee s role is to develop, review and ensure the viability of clinically and financially sustainable services, overseeing QIPP and 8

212 strategy development and delivery. It is tasked with ensuring effective clinical input into the work of the Governing Body to achieve clinical objectives, mitigate risk and embed principles of clinician led commissioning through the alignment with clinical evidence. 7.5 Finance and Performance Committee The Finance and Performance Committee will review risks associated with the CCG s financial duties, contract performance and delivery of the operational plan 7.6 Primary Care Commissioning Committee The Primary Care Commissioning Committee will review risks associated with its delegated authority from NHS England to exercise primary care functions on its behalf. 7.7 Locality Committees The Locality Committees are tasked with ensuring the involvement of members to work with the Governing Body to support delivery of the CCG s key aims and ensure that appropriate actions are in place to mitigate potential risks associated with delivery of these aims. 7.8 All Committees All committees are responsible for reviewing those aspects of the Governing Body Assurance Framework pertinent to the work of the committee and these should be reviewed at least quarterly by each committee. All Committees should review the relevant section of the Corporate Risk Register and associated Issue Log and make recommendations regarding the escalation of risks to the GBAF. 8. Duties of Key Individuals 8.1 Accountable Officer The Accountable Officer is the individual with accountability for the management of risk and will need to ensure that Directors meet their risk management responsibilities detailed below. 8.2 All Governing Body Directors Directors will ensure that within their directorate they have arrangements for departmental risk assessment to be carried out, and to develop, maintain and monitor Directorate Risk Registers. 8.3 Director of Corporate Affairs (Risk Manager) The Director of Corporate Affairs will ensure that there are arrangements in place to support the application of this policy and to monitor its effectiveness. In particular they will be responsible for ensuring that systems are in place to monitor the GBAF and ensure risks are brought to the attention of the Audit Committee and Executive Team and will assist with the moderation of risk at these levels. 9

213 The Director of Corporate Affairs is the lead risk manager and is responsible for providing support to staff and managers in the application of this policy. They are responsible for the maintenance of the systems supporting good risk management, including the risk registers. 8.4 Chief Finance Officer The Chief Finance Officer, will ensure that there are arrangements in place to identify corporate risks associated with finance, performance and information, the mitigation measures necessary to control the risk and to monitor these measures. 8.5 Director of Nursing and Quality The Director of Nursing and Quality will ensure that there are arrangements in place to identify, mitigate and monitor risks associated with clinical care and treatment within our commissioned services. 8.6 Director of Contracting and Planning The Director of Contracting and Planning will ensure that there are arrangements in place to identify, mitigate and monitor risks associated with contracts, planning and IT. 8.7 Director of Performance and Delivery The Director of Performance and Delivery will ensure that there are arrangements in place to identify, mitigate and monitor risks associated with commissioning and performance. 8.8 Director of Primary Care The Director of Primary Care will ensure that there are arrangements in place to identify, mitigate and monitor risks associated with primary care commissioning and medicines management. 8.9 Commissioning Managers At this level Managers can accept risks with a score of up to 7. Risks with a score of 8 and above should be notified to the responsible Director immediately with an explanation of what further mitigating actions are to be introduced. Risks with scores of 15 or above newly notified to a Director must be raised with the Executive Team at its next meeting and the CCG Governing Body at the next meeting via A Significant Risk Report, or with the Accountable Officer and the Director of Corporate Affairs if the risk poses imminent danger. Similarly where a Risk has become an Issue this should be reported to the Executive Team and a management plan agreed. This should be added to the Issues Log aligned to the Risk Register where the original risk was noted 10

214 8.10 Executive Team The Executive Team and individual members through their involvement in the committees of the Governing Body will be responsible for monitoring risks identified within their scope of work. The Executive Team will determine where risks have escalated and make recommendations regarding whether they should therefore be escalated from the Corporate risk register to the GBAF. Short term risks or issues identified which my sit outside the scope of one Directorate or require a co-ordinated organisational response should be highlighted as soon as possible to the Executive team and a response and lead Director agreed. Updates and progress to mitigate the risk should be reported via the Executive team meetings. 9. Documentation linked to risk management All risks and Issues will be entered onto the Risk Management and Issues Log templates. Staff should use the pro forma risk register entry at Appendix 1. These should be submitted to their line manager, who will check the entry and forward to the relevant Director. Directors should present to the Executive Team any items of risk which become apparent which may have a significant impact on Corporate Objectives for consideration for inclusion in the GBAF. 10. Risk Assessment 10.1 Risk Identification There are many sources from which risks may be identified: Through formal risk assessment required by legislation or other sources e.g. Management of Health and Safety at Work Regulations Analysis or investigation of incidents, claims, complaints and concerns raised by patients and staff As a result of audit findings As a result of national enquiries and investigations As a result of work carried out by CCG committees / groups As a result of external body inspection e.g. CQC, HSE As a result of routine management or business processes Service development, planning or change Risk workshops, e.g. annual review of risks to key aims by the Governing Body Where a risk is identified by any of the above methods it will need to be reported and analysed. Where an individual member of staff identifies a risk it should be reported to their line manager Analysis of risks Rating Risk Following identification of the risk, a lead person must be identified for the risk. This will normally be the line or service manager for the area that the 11

215 Consequen ce risk relates to, or if appropriate a subject expert or lead. The nominated lead person will rate the risk using the chart below Appendix 2 gives further guidance on the circumstances and methodology for carrying out risk assessments according to the ratings on the chart below. Figure 2 Risk Matrix Likelihood Rare Unlikely Possible Likely Almost certain 5 Catastrophic Major Moderate Minor Negligible For grading risk, the scores obtained from the risk matrix are assigned grades as follows. 1-3 Low risk 4-6 Moderate risk 8-12 High risk Extreme risk The lead person will arrange for the risk to be entered on the risk management template. They will carry out an initial analysis of the risk and enter any further mitigating controls that are required onto the action plan within the template. Further guidance on the process of risk assessment is given in appendix 2. Issues will be graded in the same way Acceptance of risk General Principles The general principle is that the benefit of taking the risk outweighs the risk itself. If the risk in its current situation outweighs the benefit this implies that either: The activity that creates the risk should be ceased or: Further mitigating controls to reduce the consequence or likelihood are necessary. Any further mitigating controls will have a burden attached to them, normally financial, but could be a reduction in service or other aspect. The burden must 12

216 be commensurate with the controls to be introduced, and the risk itself, i.e. a large cost for a small gain in risk reduction would not be acceptable. Taking risks is part of everyday living and has many benefits. An organisation cannot be innovative without taking risks. The risk management framework is very much centred on identifying risks, and managing them in a controlled way. Accepting risk should not be seen as a failure to manage the risk. The table below sets out the frequency of risk/issue review depending on risk score Risk score Monitoring by Frequency 1-4 Managers At least annually 5-9 Chief Officers and their management teams Six monthly Executive leadership team Committees Quarterly Quarterly Executive leadership team Committees Governing Body Quarterly or as required Quarterly Quarterly Risk Moderation It is important that all risks identified within the framework described in this policy are rated taking into account the rating chart above, and aligned with the other risks detailed. It is inevitable that there will be a degree of subjectivity when rating risks and the reporter will not necessarily be able to compare the risk reported within the context of other risks. Risk moderation is essential in assuring that the risk management framework is an accurate representation of the CCG risks at all levels. Risk moderation will be carried out in the first instance by the Director of Corporate Affairs. The Director of Corporate Affairs may change the risk rating where necessary and report back to the reporter any further information necessary to complete the assessment. An un-editable audit trail of risk rating changes should be kept, which can be viewed at any time should changes be disputed. The Director of Corporate Affairs will be consulted when the risk is at the strategic level and is to be incorporated with the GBAF. 13

217 The committees responsible for monitoring risk will also play an important role in moderating risk. The Director of Corporate Affairs will consult with these committees with any issues arising from the initial moderation. 14

218 Escalation of Risks The need to escalate risk could be identified via a number of routes and should be notified to the Director of Corporate Affairs for consideration by the Executive Team, Audit Committee and subsequently the Governing Body Exceptions to the above Following escalation to the appropriate level and following risk moderation the designated group or committee reviewing the risk can allocate the risk to a higher or lower level than indicated by the rating if they feel that the risk would be better managed at this level. Examples are: Reduction in level - The risk rating indicates a high residual risk that the CCG does not have the opportunity to control. All risk reduction controls are proven to be effective. Raising the level - A strategic risk on the corporate register that may have a significant effect on the delivery of the key aims. The Governing Body wishes the risk to be included in the GBAF so that it is assured that the risk is being effectively managed as part of its management of the delivery of objectives. 11. Risk Register & Issues Log Risks are recorded on the Directorate Risk Register /Corporate Risk Register /GBAF. Issues are recorded on the Directorate Issues Log/ Corporate Issues Log GB Issues Log 11.1 Monitoring of Risks Each Risk will be assigned a lead officer or Risk Owner. The Risk Owner will ensure that the risk entry is up to date and that : The description accurately reflects the nature of the risk, who is affected and describes the consequence. The controls stated are in place and effective. The current rating is correct. Actions are in progress or are completed and that the due date is correct. Where actions have been completed the controls in place are updated Governing Body Assurance Framework The Governing Body Assurance Framework (GBAF) consists of risks which have the potential to affect the delivery of the CCG s key aims. The majority of these risks are likely to be identified as part of the Governing Body or Governing Body committee management processes. However some risks may be identified at any level of the risk management process that are of sufficient stature to warrant inclusion in the GBAF. The GBAF will be monitored as described in section The purpose of monitoring the GBAF is to seek assurance that the listed mitigation is being effective. 15

219 12. Communication All policies relating to Risk Management are available on the CCG website. Risk management communications will be included in the staff newsletter when appropriate to do so. 14. Strategy review arrangements This strategy/policy will be reviewed bi-annually 15. References Department of Health (2002) Assurance: The Board Agenda Department of Health (2003) Governing the NHS: A guide for NHS Boards Department of Health (2006) Integrated Governance Handbook. A handbook for executives and non-executives in healthcare organisations Health and Safety Executive (HSE) (2010) Leading Health and Safety at Work: Leadership Actions for Directors and Board Members Health and Safety Executive (HSE) Health and Safety at Work Etc Act 1974 Health and Safety Executive (HSE) Management if Health and Safety at Work Regulations 1999 Monitor (2011) Compliance Framework

220 Appendix 1 Guidance on Risk Assessment Risk Assessment Requirements Risk assessments are required to be carried out by a number of sources, these are chiefly: The CCG Risk Management Policy - which requires the risks associated with the delivery of the CCG strategic aims, and therefore its services, to be identified and entered into a corporate register so that, where necessary, the appropriate levels of the management structure can take these into account as part of its decision making and management processes. It requires Directorates to assess risks of all kinds and maintain a register of these risks. Health and Safety Legislation several pieces of legislation require assessment of risk as part of their structure, there is also a general requirement implied in the Health and Safety at Work Act and specified within the Management of Health and Safety at Work Act. Indemnity Schemes NHS Resolution (previously the National Health Service Litigation Authority (NHSLA)) standards require that a risk register is in place, and that it should include both strategic and operational risks. At the higher levels of the standards, as well as the legislative requirements, it specifies that the risks associated with diagnosis and treatment should be identified along with the controls necessary to ensure possible adverse outcomes are either unlikely or the level is reduced. Assessments are also required as part of the control of specific risks, where certain conditions or criteria are met, then levels of pre-determined control are introduced; good examples of this would be Falls Risk Assessment and Individual Patient Handling Risk Assessments. However - as the CCG is a commissioning organisation and does not provide clinical care this guidance is aimed at general areas of risk, rather than specific risks. It will refer to other policies and guidance where appropriate. Definition of Risk to be covered by this Guidance This guidance details the assessment of risk in general; it should therefore apply to the activities of the CCG in general, and should be used to identify any detriment caused to the delivery of the CCG aims, and therefore its services and service users. Detailed requirements Risk Management Strategy/Policy The Risk Management Strategy/Policy defines the level of risks and the authority of managers to accept risk. 17

221 Health and Safety Legislation The Health and Safety at Work (etc) Act 1974 There is an implied requirement for risks to be identified and considered under the general sections 2&3, the employers duties to employees, and any other person affected by the work undertaking. This is not however specific, and could be met in other means. The Management of Health and Safety at Work Regulations were first introduced in These regulations set out the requirements for all employers with regard to risks of all kinds. It is accompanied by a supporting Approved Code of Practice. The key requirement is; Every employer shall make a suitable and sufficient assessment of: (a) (b) the risks to the health and safety of his employees to which they are exposed whilst they are at work; and the risks to the health and safety of persons not in his employment arising out of or in connection with the conduct by him of his undertaking. Within these regulations there are specific provisions to consider the extra risks posed to: women who are pregnant, have recently given birth or are breastfeeding, young persons. This is often termed the General Risk Assessment. Other legislation A number of other regulations are in force, which would require assessments of particular risks, normally using specific methods or criteria. The main regulations are: The Manual Handling Operations requires an assessment of manual handling operations where there is a risk of injury. The Control of Substances Hazardous to Health requires an assessment of the use of hazardous substances as defined. The Display Screen Equipment Regulations requires an analysis of DSE workstations and improvements where there is a risk associated. The Fire Precautions (Workplace) Regulations requires fire risk assessments to be carried out. In all the above there is specific provision for risk assessments to be carried out, in many other pieces of legislation there is also an implied need for assessment. NHS Resolution (previously National Health Service Litigation Authority (NHSLA)) Standards NHS Resolution standard 1.6 requires an organisation-wide risk register. The register must include the source of the risk (including, but not limited to, incident reports, risk assessments and directorate risk registers). 18

222 Standard 3.1 requires appropriate risk assessments regarding the physical security of premises and assets. Standard 3.2 requires risk assessment s for the management of slips, trips and falls involving staff and others (including falls from height). Standard 3.3 requires risk assessments for the management of slips, trips and falls involving patients (including falls from height). Standard 3.4 requires risk assessments for the moving and handling of patients and objects. Standard 3.8 requires risk assessments for the prevention and management of violence and aggression. Standard 3.10 requires risk assessments for the prevention and management of workrelated stress. Clinical risk assessment (relevant to assessment of risk in commissioned services) Although not specifically required by legislation or standards assessing the risks associated with diagnosis and treatment will be a key contributor to patient safety. Care Quality Commission (relevant to assessment of risk in commissioned services) The Health and Social Care Act 2008 (Regulated Activities) Regulations, and the associated CQC outcomes do not specifically require risk assessments to be carried out, but imply it in the requirements. In particular: Regulation 9 states the organisation must ensure the welfare and safety of the service user. Regulation 10 states that service users must be protected against the risk of unsafe care and treatment. Regulation 12 states that staff patients and others are protected against identified risks of acquiring healthcare associated infection. Regulation 13 states that service users must be protected against the risks of unsafe use and management of medicines. Regulation 15 states that service users and others are protected against the risk associated with unsafe or unsuitable premises. Regulation 16 states that organisations must have arrangements to protect service users and others who may be at risk from the use of unsafe equipment. With all of the above the risks referred to must be identified and assessed in order that the regulations are complied with. Risk Assessment Process As detailed above the term risk assessment is used (and misused) in many different ways, it is therefore important to establish its purpose. A risk assessment should seek to reduce the impact of likelihood of loss (be-it injury, money, damage or other). Its purpose should not be: To justify systems after an event or incident. To justify extra expenditure, although there may be implications regarding expenditure. 19

223 To satisfy documentation requirements. By definition it should be an assessment to identify risks, evaluate the risks and controls in operation and to highlight any extra controls and action necessary. If the risk controls and actions needed to be implemented are obvious, then an assessment is unlikely to be needed. Risk Assessment Methods The Health Safety Executive puts forward a simple method of risk assessment in its guidance document 5 steps to Risk Assessment, these are: Step 1 Step 2 Step 3 Step 4 Step 5 Look for the hazards. Decide who might be harmed, and how. Evaluate the risks arising from the hazards and decide whether existing precautions are adequate or more should be done. Record your findings. Review your assessment from time to time and revise. This is a sensible approach for a majority of circumstances, where the risk area is more complex, more detail will be required, e.g. with risks to service objectives. In these cases the following paragraphs give guidance on the processes. Establishing the Context As stated in this policy, risk assessments can be applied to many activities for many purposes. It is therefore essential to establish the scope of the assessment and what is to be achieved be it. For the purposes of this Policy the following are contexts which may be appropriate: An assessment of: the risks associated with organisational objectives or service delivery, risks associated with diagnosis and treatment, general risks to patient and staff safety posed by the range of activities carried, Risks associated with the environment and activities within. Where the assessment is designed to meet a specific purpose, e.g. an individual patient assessment, then the general content of this policy would be applicable, or in some instances a further policy may need to be followed. Relevant policies/codes include: Violence Policy Pregnant Workers Policy Manual Handling Policy Display Screen policy Health and Safety Policy Stress Policy Infection Control Policies 20

224 This is not an exhaustive list, others may equally be relevant. The context will also determine the methods to be chosen and the staff who should be consulted to carry out the assessment. The Management Regulations, in its Approved Code of Practice, states that the assessment should be a systematic general examination of the effect of the undertaking. This is equally applicable in a general assessment of clinical risks. In most cases in healthcare, in order to comply with this, the work activities will need to be broken down into individual tasks or components, and each one scrutinised in turn. Generic Assessment Where areas of work, disciplines or types of work are broadly similar then in order to simplify the process a master or generic assessment can be produced and applied over the whole. This should be modified, however on a local level, to take into account factors such as local environment, different practices, different client or staff groups and any other local variation. Staff Involved Whilst in virtually every situation the responsibility will rest on managers to carry out assessments, the involvement of others is likely to be necessary. Especially where quantitative factors cannot be established, a range of views across staff and staff groups will help to provide objectivity. Staff leading the assessment should have knowledge and skills in the assessment process and knowledge of the work being assessed. Identify Risks Having broken down the work into tasks, the risks should be identified. The definition of a risk would be a foreseeable circumstance which could lead to injury, loss or damage. In considering this it should be identified who is affected. The Management regulations Approved Code of Practice (ACOP) again gives guidance on this aspect insignificant risks can usually be ignored as can risks associated with life in general, unless the work activity compounds the risks. A good example of this is a radiator with a hot surface, a risk associated with life in general, work involved with very young or old people would compound this risk, and it would therefore need to be assessed. The ACOP also states that the level of detail should be proportionate to the risk. This is especially important, due to the fact that long documents, full of trivia, will mask the important details and result in them not being effective. 21

225 In identifying the risks the assessor should consider what actually happens, not what should happen. Policies and training will only have an impact on risk if they are put into practice. Advice in recording risk can be obtained from the Corporate Risk Manager. Analysing Risk Having identified the nature of the risk, the following should be considered: What is currently in place to either mitigate the risk or its effect? Are there any standards, guidance or legislation that should be taken into account. Is there any historical information? (e.g. incidents or complaints). Is there any further information or more detailed work to be completed, (e.g. environmental monitoring). Risk Rating The rating system detailed in the risk management policy should be applied. The purpose of rating is to assist in setting priorities and in determining the level of reporting. It should be noted that in many circumstances the rating will be largely subjective. Any factors that that can be quantified will help to make it less so. The rating should take into account any controls which are in place and are effective. Evaluating Risks The purpose of this is to make the decision whether the situation can remain as it is or whether more should be done. Inevitably this will also involve consulting standards, guidance and legislation if applicable, and will be commensurate to the level of presenting risk. With simple risks this will be a straightforward process, probably involving one person, in a more complex or severe situation it will be the decision of a group or committee. Accepting Risk The Risk Management Policy gives more detail on the level of authority to accept risk, in practice many risks will be accepted, and the level of control would be the monitoring of the risk. Risks are taken in order to achieve a benefit e.g. A frail elderly patient is encouraged to walk unaided, and therefore is at a greater risk of falling, in order to achieve the benefit of greater independence and increased quality of life. The overlying principle in accepting risk should be that the benefit of exposure to the risk outweighs the risk itself. Treating / Controlling Risk There are many different ways of controlling risks; the methods chosen will be dependent on the nature of the risk. The following principles are deemed to be most appropriate, and are from the guidance to the Management of Health and Safety at Work Regulations: 22

226 a) If possible remove the risk completely, e.g. do the work a different way, taking care not to introduce new risks. In some extreme circumstances it may be appropriate to cease the activity completely, but this would only be the case where there was a strong likelihood of extreme circumstances. b) evaluate risks that cannot be avoided by carrying out a risk assessments; c) combat risks at source, rather than taking palliative measures. So, if the steps are slippery, treating or replacing them is better than displaying a warning sign; d) adapt work to the requirements of the individual (consulting those who will be affected when designing workplaces, selecting work and personal protective equipment and drawing up working and safety procedures and methods of production). Aim to alleviate monotonous work and paced working at a predetermined rate, and increase the control individuals have over work they are responsible for; e) take advantage of technological and technical progress, which often offers opportunities for improving working methods and making them safer; f) implement risk prevention measures to form part of a coherent policy and approach. This will progressively reduce those risks that cannot be prevented or avoided altogether, and will take account of the way work is organised, the working conditions, the environment and any relevant social factors. Health and safety policy statements required under section 2(3) of the HSW Act should be prepared and applied by reference to these principles; g) give priority to those measures which protect the whole workplace and everyone who works there, and so give the greatest benefit (i.e. give collective protective measures priority over individual measures); h) ensure that workers, whether employees or self-employed, understand what they must do; i) the existence of a positive health and safety culture should exist within an organisation. That means the avoidance; prevention and reduction of risks at work must be accepted as part of the organisation s approach and attitude to all its activities. This should be recognised at all levels of the organisation, from junior to senior management. Although the above is worded from a Health and Safety viewpoint, it can equally be applied to all types of risk and the organisational risk management culture. Monitoring and Review An important aspect of the assessment should be to identify who is going to monitor the risk and how. Again the level, frequency and detail of the monitoring will be determined by the severity of the presenting risk. Monitoring will take many different forms, it could be: The observance of risk controls. The level of training achieved. Audit, be-it continuous or spot checking. Occurrences or near- misses. Group discussion. Observation by an outside agency or body. Implementation of policy. 23

227 The monitoring body should be assured that the risk is being managed to a satisfactory level, and that the stated controls are being effective in reducing either the potential likelihood or outcome. In addition to this, risk assessments will be reviewed as part of an annual program of safety advisory visits. This review will consist of an assessment of the currency and completeness of required assessments, and an assessment of the effectiveness of the identified risk controls, using national guidance as a benchmark. Communication and Consultation The assessment process should include the involvement of any affected stakeholders in the activity or task that is being assessed. This will include all staff involved, and may include others such as patients and external bodies of organisations. The level of the consultation will depend on the context of the assessment and the level of risk. In many circumstances it will be appropriate to consult with a representative of the stakeholders, rather than them all. In all circumstances, where the assessment indicates it necessary to do so, information on the risks should be given to all affected. Examples of this would include: Giving information to patients about the risks to a particular treatment. Telling staff about the risks that are associated with a particular task. Telling other organisations about a problem encountered in a routine activity. Where the assessment indicates that to control the risk, those involved need particular skills or knowledge, then training should be organised to achieve this. Records Where an assessment is required to meet legislation, they should be available at all times within the related area. In practice this is a sensible measure for all assessments. Where the assessment indicates a higher risk, generally where the rating is Amber or Red, then it should be submitted for inclusion in the Directorate Risk Register, this would also apply to any risk which is Directorate or CCG wide, in which case the Directorate management team should consider the inclusion. The context of the assessment will determine the type of recording undertaken, where the assessment is in pursuit of the Risk Management Policy, the Management of Health and Safety at Work Regulations, the Director of Corporate Affairs should be contacted and will give advice on recording methods. Where the risk is to be included in the Directorate or Governing Body Assurance Framework it will be recorded on the Risk Management Template 24

228 Appendix 2 Adverse Incidents Involving National Screening Programmes: National Cancer Screening Programme Adverse incidents involving any aspect of a national cancer screening programme should be managed with reference to the appropriate NHS Cancer Screening Programme publications for managing incidents in the NHS Cancer screening programmes. 25

229 Governing Body Assurance Framework Version 17.3 updates for Governing Body December 2017 shown in red Risk ID Opened Map to by/ when key Principle Summary title of risk and fuller description of risk Key Controls Summary of existing controls / systems in place to manage the risk Source of Assurance Summary of existing assurances that provide confidence that the existing controls relied upon are operating effectively and that action plans to address weaknesses are implemented. Gaps in Controls/Assurances Summary of gaps in existing controls or assurances at the time the risk is identified or subsequently updated. Assessment of risk level - Low / Medium / High / Extreme Risk /Movement of risk rating Action / Lead Name / Timescale Identify what actions can be taken to fill gaps in controls and assurances and to also assist in achieving the residual target risk rating by the end of the financial year post mitigation Assessment of risk level - Low / Medium / High / Extreme Risk Risk Owner Amend/ Review: name and date Key Principle 1 - Deliver a continually improving Healthcare and Patient Experience Key Principle 2 - Develop a 'true membership' organisation (active engagement and clinically led organisation) Key Principle 3 - Achieve Financial sustainability for future investment Key Principle 4 - Visible leadership of the local health economy through behaviour and action Key Principle 5 - Grow the leaders for tomorrow (Business Continuity) 68/16 AN Previous risk CCG 62/16 Revised April 16 Key 1 Finance Principle 3 There is a risk that the CCG fails to achieve its planned control total for 17/18 specifically: This is most likely if there are movements in areas susceptible to slippage in savings plans or large contracts which may deliver activity in excess of plan Development of a robust plan for 17/18 Comprehensive QIPP Programme in place; signed off by Finance & Performance (F&P) Committee in April 17 and supported by: QIPP Programme Board (meets monthly): QIPP PMO. Full review of QIPP governance, ownership and process. Focus on delivery in F&P Committee with a programme of 'Deep Dives' for 17/18. Buisness case challenge/due diligence on schemes Constitution, Standing Orders, Prime Financial Policies and Scheme of Reservation and Delegation Robust contract challenge mechanisms with major providers Contract reports to F+P Committee and Governing Body of contracts activity and finance -ytd and fot Lead Committee - Finance and Performance Committee Regular reporting of Finance, QIPP, Contracting and Performance position to Finance and Performance Committee and Governing Body Signed Contracts/Budgets for 17/18 Effective Contract challenge process operating Completion of internal audit recommendations from 2015/16 and 16/17 and outstanding audit actions reviewed at Audit Committee. Action Trackers for Contract Management Meetings with Providers Assurance gained through seeing improving internal audit ratings for finance and QIPP Gaps in controls: PMO in early establishment phase Finance team recruitment not yet complete Refresh of budget manager training and associated policies outstanding Gaps in Assurances: Aasurance of planning and delivery of schemes. The Finance & Performance committee require more information to evidence delivery and confidence in forecast Extreme Likelihood 5 x Impact 5 = 25 Budget Manager training planned along with a refresh of financial policicies and procedures to ensure a strong grip on the finance position throughout the CCG PMO process continues to be embedded. Head of PMO in post September 2017; support role commenced 30 October 2017 Permanent Finance Staff roles continue to be persued,. Some not all vacancies filled, interims continue to provide capacity in the team. Recruitment actions resumed January Continue to improve the levels of CCG assurance through internal and external audit reports. Interim turnarund director appointed to support AO/CFO in short term to promote rigour of schemes and support challenge of modelling and reporting Weekly Exec/ Management meetings established in October to drive actions, particularly in relation to delivery of QIPP Likely 4 x Impact 5 = 20 Claire Skidmore Directors and Budget Holders have signed off budgets for 17/18 (March 2017) Regular budget manager meetings in order to identify early deviation from plan and agree mitigating actions Review of Disinvestment Process Additional capacity sourced in Finance and Commissioning NHSE meetings with P. Watson every 4 weeks

230 Risk ID Opened Map to by/ when key Principle Summary title of risk and fuller description of risk Key Controls Summary of existing controls / systems in place to manage the risk Source of Assurance Summary of existing assurances that provide confidence that the existing controls relied upon are operating effectively and that action plans to address weaknesses are implemented. Gaps in Controls/Assurances Summary of gaps in existing controls or assurances at the time the risk is identified or subsequently updated. Assessment of risk level - Low / Medium / High / Extreme Risk /Movement of risk rating Action / Lead Name / Timescale Identify what actions can be taken to fill gaps in controls and assurances and to also assist in achieving the residual target risk rating by the end of the financial year post mitigation Assessment of risk level - Low / Medium / High / Extreme Risk Risk Owner Amend/ Review: name and date 72/16 AS 20/09/16 NEW Key 2. Quality and Safety Principle 1 There is a risk that the CCG fails to commission safe, quality services for its population CQRM meetings with providers Quality and Safety visits Triangulation of information and exception and escalation reporting to Quality Committee National and local reporting Healthwatch CQC QSG NHSE Joint Commissioning Serious Incident Panel in place Governing Body approved WMQRS Formative Review of Quality, Patient Safety and Experience Function,Structure, systems & process and assurance Janauary 2018: Quality Strategy and supporting delivery plan approved at Quality Committee in December and is being prepared for January Governing Body meeting Early Actions include: - Quality Strategy and Delivery Plan drafted for September Quality Committee - Nursing & Quality Directorate structure finalised - Early and evolving revision of quality monitoring and quality assurance processes includes revised dashboard, forward planner for Quality Committee, care homes and primary care has been confirmed and has commenced. Lead Committee - Quality Committee CQRM meetings with providers which feed into the Quality Committee. Minutes of QC meeting and Chairs report presented monthly to QC, Public Governing body Excutive team meetings, reports, escalation Clinical Commissioning Meeting Joint Commissioning Serious Incident Panel reports to Quality Committee WMQRS review of Quality, Patient Safety and Experience Structure, systems & process and assurance July 17 including review of QC lines of accountability, resonsibilty and reporting September 2017: actions reorted in key controls column Gaps in Controls: Reporting to the Quality Committee requires a review on level of detail provided to provide correct level of assurance to the governing body, refer to WMQR of SCCG Quality comittee as aprt of wider review Limited assurance on CCG Quality, Patient Safety and Experience Structure, systems & process and assurance - WMQRS review of Quality, Patient Safety and Experience Structure, systems & process and assurance July 17 includiing review of QC lines of accountability, resonsibilty and reporting January 2018: As per key controls column. Delivery Plan will be monitored bi-monthly at Quality Committee September 2017: Draft Quality Strategy and Delivery Plan to September Quality Committee with achievable milestones included. Possible x Major = High 12 A review on level of detail provided to Quality Committee to provide correct level of assurance to the governing body to be undertaken. Exception reporting and escalation in terms of level of assurance to Governing Body currently being reviewed by Quality Committee through actions set out below A review of the requirements of the Quality Committee carried out with the Chair April 17. Confirmed by the execuitve team and AO, Public Governing Boday and QC to undertake a comprehensive root and branch review of the quality, patient safety and experience team, systems, processes, roles, responsibiliities and accountability to ensure fit for purpose as currently in the NHS IAF Dashboard lowest performing quartile under the better care category. Update at Governing body private board May 17 completed. Also ensure correct fit with contracting, delivery and performance. Review commenced June/July 17 monthly reporting on progress and on receipt of report and action plan implemenation through the DON Healthwatch involvement confirmed as a) seat on NHSE Quality Surveillance Group b) seat at Governing Body Public Meeting c) monthly one to ones with Director of Nursing and Quality' Possible x Moderate = High 9 Dawn Clarke /16 AS 20/09/16 NEW Key Principle 1 3. NHS Constitution There is a risk that the CCG fails to meet its NHS Constitution targets either fully or sustainably A+E Delivery Board in place Planned Care Working Group for Cancer and Referral to Treatment Times (RTT) in place Lead Committee - Finance and Performance Committee A&E Rapid Improvement Plan agreed with NHS England and progress reported monthly Contract and quality monitoring data Provider Contract meetings (including RAP monitoring) CQRM meetings Reporting to Finance and Performance Committee and to Governing Body Gaps in controls: A&E Delivery Board's effectiveness of managing the System A&E Recovery plan. Gaps in Assurances: Likely x Major = Extreme 16 The weekly A&E Delivery Group meeting is being changed from February to include clinical input and focus on actions to deliver improved discharges and reduced stranded patient number. The system is currently being assessed by its new Urgent Care Director and each action plan for recovery will follow this assessment. GP streaming is now in place on both sites but is urgently being reviewedby commissioners to increase its usage at both sites. The sytem also now has a complex discharge action plan to improve the weekly number of complex discharges to the target level of 135. Current performance agianst this peaked at 126 the week before Christmas. SaTH are equally charged with improving the simple discharge position to achieve its weekly target of 968, currently operating at The Urgent Care Director is arranging for external colleagues to come in and develop a system wide demand and capacity plan to ensure we ahve sufficient capacity across the whole system to manage urgent care demand. This is due to take place during Janaury. Possible x Moderate = High 9 Julie Davies /16 AS 20/09/16 NEW Key 4. Transformation principle 1, 3 and 4 There is a risk that the CCG fails to effectively lead transformation of local health services across acute, community and primary care to ensure sustainability for the future. Strategic Transformation Plan (STP) Board and workstreams developed across acute (Future Fit) and 2 neighbourhood working areas SRO leads and support staff identified for workstream delivery Future Fit Programme Board - Board includes all providers. Transformation Dashboard in place STP update standard item on CCC agenda Lead Committee - Clinical Commissioning Committee Standing reporting item on Governing body agenda on development of STP Plans. Gaps in Controls: The CCG recovery plan remains to be fully developed although strong progress is being made with NHS England CCG is now represented in the governance structure of the STP STP plan updated to reflect Shropshire financial position Shropshire Neighbourhoods plan needs further revision if it is to meet Shropshire needs Further work required to strenghten STP governance arrangements Almost certain x Major - Extreme 20 SaTH have achieved RTT in September, October and November. RJAH have resubmitted a recovery trajectory for delivery of the 92% by March The CCG Recovery plan is progressing through the final stages of the NHSE assurance process and is expected to be de-escalated by the Autumn STP revised governance structure agreed by STP partnership Board and includes senior SCCG representation. However, further work is required to set an MoU between partners,, terms of reference and delegated authority arrangements across the whole structure The STP plan now better reflets the financial position of the CCG. The MSK scheme is now a key STP workstream and the CCG CFO is now the finance lead for the STP Shropshire Out of Hospital work is being progressed through 5 agreed work streams that report into a Programme Board. The strategic outline case for out of hospital transformation is being prepared and regular updates will be presented to the Governing Body Possible x Major = High 12 Simon Freeman Gaps in Assurances: Reporting of implementation of STP to Governing Body yet to be determined STP now as standard item on Governing Body agenda STP Chair attended the December Governing Body Meeting

231 Risk ID Opened Map to by/ when key Principle Summary title of risk and fuller description of risk Key Controls Summary of existing controls / systems in place to manage the risk Source of Assurance Summary of existing assurances that provide confidence that the existing controls relied upon are operating effectively and that action plans to address weaknesses are implemented. Gaps in Controls/Assurances Summary of gaps in existing controls or assurances at the time the risk is identified or subsequently updated. Assessment of risk level - Low / Medium / High / Extreme Risk /Movement of risk rating Action / Lead Name / Timescale Identify what actions can be taken to fill gaps in controls and assurances and to also assist in achieving the residual target risk rating by the end of the financial year post mitigation Assessment of risk level - Low / Medium / High / Extreme Risk Risk Owner Amend/ Review: name and date 75/16 AS 20/09/16 NEW Key Principle 1 and 2 5. Communication and Engagement There is a risk that the CCG will fail to effectively engage and communicate with its CCG members, the public, partners and stakeholders and the CCG staff. Communications and Engagement Plan and Lead Committee - Clinical Commissioning Strategy Dedicated comms team to support Future Fit and 360 Stakeholder survey feedback STP Individual Comms and Engagement plans for Equality Delivery System2 reporting significant pieces of work in a standard format Staff newsletter Feedback from Shropshire Healthwatch via GP newsletter formal reporting and feedback into Governing Patient Advisory Group (PAG) in place (advisory body via Healthwatch observer. committee replacing PPECC) 3 Locality Committees and Chairs are Governing Body (GB) Members enabling a clear communications conduit between the membership and GB Appointment of Governing Body GP with a lead for communications and engagement with the membership Strong relationship with Shropshire Healthwatch and other patient groups Gaps in controls: Improve communications to staff and member practices Communication and Engagement arrangements for all QIPP schemes Gaps in Assurances: Likely x Major = Extreme 16 Head of Communication and Engagement post now well established. Two further communications post have been filled to ensure the CCG has enough capapcity to cover the communicaiton and engagement requirements associated with key workstreams and general business. There is a risk regarding the specific engagement capacity of the team and this will be kep under review in the new year. Work is ongoing to review and implement the Communications and Engagement Plan. Two short term communication and engagement posts have been recruited to to support the Future Fit programme Communication and Engagement arrangements for all major 2017/18 QIPP schemes in place using standard template to include Communications and engagement, EQIA,EIA and PIA. Comms and engagement plans in place for a number of QIPP schemes and process of review by PAG instigated. Lay member for Public and Patient Engagment supporting Possible x Major = High 9 Sam Tilley /16 AS 20/09/16 NEW Key Principle 5 6. CCG Workforce Resilience and trust There is a risk that the current financial situation impacts negatively on existing CCG staff resilience and retention levels and prevents successful recruitment in the future. clear staffing structure which meets the needs of the organisation Clear and structured OD plan for the organisation Executive team prioritising key workstreams. Sickness absence information to Executive Team Statutory and Mandatory Training targets achieved Staff newsletter OD Plan in place Lead Committee - All Staff feedback via staff OD group Line management 1:1 with staff Training reports reviewed by Directors Organisational Culture Staff Survey results Staff briefings AO meeting with small groups of staff on a regular basis following feedback from staff identified identified the need for informal executive drop in sessions Gaps in controls: Clear and structured OD plan for the organisation Statutory and Mandatory Training targets not achieved Gaps in assurances: Key workforce KPIs not reported to Board Key workforce KPIS not accurately recorded and stored centrally Staff survey not recently undertaken Likely x Major = Extreme 16 OD group re-instated. OD plan to be developed to meet the needs of the new permanent structure and role of the organisation. Plans to develop internal staff survey and health and well being programme are underway. New format for Staff Briefings implemented and programme of social activities being developed. The CCG has completed the Corporate Global Challenge Health & Wellbeing programme for staff, 84 members of staff participated New Statutory and Mandatory Training System has now been implemented Work currently underway to refine staff absence and statutory and mandatory training achievement information in order for it to be regularly reviewed by the Executive team and then reported to the Governing Body Possible x Major = High 9 Sam Tilley Reviewed sickness/absence and implementing planned interventions with support from human resources 77/16 AS 20/09/16 NEW Key principle 1,2,3 and 5 7. of Provider Workforce There is a risk that providers ability to deliver services and remain financially viable is not sustainable. Primary care: Prime Ministers Challenge Fund project work on creating a sustainable workforce locally. Primary Care Strategy Primary Care Workforce Group (PCWG) led by NHSE with remit to look at sustainable Primary Care Workforce for the future. Secondary care: Contract monitoring via CQRM, A&E Delivery Board, QSG, and external reviews - CQC WMQRS LHE Clinical Sustainability Group Provider has key processes for managing staff shortages to minimise risk Local Workforce Action Board (SLWAB) in place with remit to support the implementation of robust workforce strategies and sustainable workforce and education plans October Update: Health Education England held a workforce summit and agreed to several actions regarding medical workforce planning for SaTH Lead Committees - Quality Committee, Primary Care Committee Primary Care: Individual GP practice visits Reporting to PCC and Governing Body. PCWG reporting into PCC GPFV workforce section assured by NHSE Primary Care workforce survey completed Staffordshire/ Shropshire Primary Care Programme Management Office for GP Forward View oversees delivery of the GPFV plan which includes Primary Care Workforce Secondary Care: Reporting from CQRM to QC and then onto Governing body Regular updates shared by commissioners at North Midlands Quality Surveillance Group (QSG) chaired by NHS England. SWLAB reporting into QC Gaps in controls: Up to date Primary Care Strategy Full analysis of Acute Trusts position and options for business continuity long term workforce planning via Future Fit and STP workforce workstream Gap in Primary Care leadership at governing body Gaps in assurances: GPFV Workforce section assured by NHSE Primary Care workforce survey results into PCC Formal sight of the provider Business Continuity plan and risk assessment LWAB reporting into Quality Committee Reporting of Primary Care development and performance requiring development as per internal audit report Like x catastrophic = Extreme 20 Possible x Major = High Primary Care Strategy development now incorporating GPFV 12 priorities and will incorporate outcomes from: a) Primary Care Needs Assessment agreed by the Primary Care Commissioning Committee and being presented to CCG Board in August 2017 b) Primary Care workforce survey. Through the national survey, this information is collated via our GP practices. A GP workforce audit is underway and will be completed during quarter 2. Audits for other Primary Care Workforce will follow in line with the GPFV PMO timescales - to be defined. Primary Care Workforce is now included in the STP work programme and will be reported to Primary Care Commissioning Committee. New Executive Structure to address gap in Primary Care leadership approved at Governing Body December Substantive Director of Primary Care commenced at the end of May 2017 Internal audit recommendations to be delivered (JT) Complete and reported to Primary Care Committee New quality and performance report being designed to present to Primary Care committee in October 2017 October update: Strategic Primary Care Workforce Plan complted and to be submitted to NHS England in October. Clear milestones and actions agreed. STP workforce delivery group membership - first meeting end of October Dawn Clarke

232 Risk ID Opened Map to by/ when key Principle Summary title of risk and fuller description of risk Key Controls Summary of existing controls / systems in place to manage the risk Source of Assurance Summary of existing assurances that provide confidence that the existing controls relied upon are operating effectively and that action plans to address weaknesses are implemented. Gaps in Controls/Assurances Summary of gaps in existing controls or assurances at the time the risk is identified or subsequently updated. Assessment of risk level - Low / Medium / High / Extreme Risk /Movement of risk rating Action / Lead Name / Timescale Identify what actions can be taken to fill gaps in controls and assurances and to also assist in achieving the residual target risk rating by the end of the financial year post mitigation Assessment of risk level - Low / Medium / High / Extreme Risk Risk Owner Amend/ Review: name and date 61/15 Accounta ble Officer / Chair Key 8. Stakeholder and Patient support and trust principle 1, Failure to maintain stakeholder (including 2,3 and 4 membership) and Patient/Public trust and support leading to negative organisational reputation because of the following reasons-: - Financial performance challenges - Leadership challenges - Organisational culture challenges - NHSE CCG Assurance - 'needs improvement' Financial performance challenges Addressed above. Leadership challenges Substantive AO in place, Substantive Directors in place Clinical Chair in place Governing Body has full complement of GP representatives Key principles in place to support delivery of CCG objectives Organisational development plan across all levels in the organisation Patient Advisory Group in place Lead Committee - Governing Body Financial performance challenges - addressed above. Monitoring delivery of key objectives Organisational culture Staff survey results Staff Briefings / Newsletters GP Newsletters Membership Locality meetings 360 degree stakeholder survey Gaps in controls: Clear organisational development plan across all levels in the organisation Gaps in assurances: programme of proactive engagement with public and membership Like x catastrophic = Extreme / degree stakeholder survey action plan published to the CCG Website Preparation for the 17/18 survey are underway Communication and Engagement arrangements for all major 2017/18 QIPP schemes in place using standard template to include Communications and engagement, EQIA,EIA and PIA. QIPP plans to include CCG staffing implications (QIPP Leads) Process of review by PAG instigated. Lay member for Public and Patient Engagment supporting GP leadership development programme wil commence in 2018 Possible x Major = High 9 Sam Tilley /16 Accounta ble Officer Key 9. Directions principle 1,2,3,4 and There is a risk that the CCG will fail to achieve 5 revocation of NHS England Directions within an agreed time frame. Lead Committee - Governing Body Refer to assurances in risk CCG 68/16 Agreed actions completed as evidenced by action notes Up to date Constitution and Committee TOR and regular meetings and recordings of discussions and decisions Gaps in controls: Absence of a robust organisational development plan to improve organisational culture and delivery Gaps in Assurances: Likely x major = High 16 Work regarding financial recovery continues with twice weekly meetings to focus on delivery of QIPP and associated workstreams Continued dialogue with NHSE regarding progress Possible x Major = High 9 Simon Freeman Capacity and Capability Plan complete and approved by NHSE Regular reporting to Governing Body on Financial Recovery Review of governance arrangements/statutory groups undertaken and constitution amended however further revisions to take place. 78/16 GB Key Principles 1, Impact of Social Care Funding Challenges STP Programme Board in place Lead Committee - Clinical Commissioning Committee Risk of individuals escalating into acute hospital care or not being able to be discharged from acute hospital care thus impacting adversely on the capacity and capability of health services Neighbourhood Plans in Place Approved Better Care Fund Plan Sustainability and Transformation Plan approved by NHS England Health and Wellbeing Board Gaps in controls: Neighbourhood Plans in place Gaps in Assurances: Almost certain x Major - Extreme 20 New Risk National mitigation in place through ibcf ( 6 million) for Shropshire via the Local Authority. BCF plan for the coming 2 year period has been developed and submitted to NHSE Joint working on out of hospital transformation and the BCF plan maintains and enhances social care funding Out of Hospital Paper considered by Governing Body in October 2017.Further updates to be taken to subsequent Governing Body meetings Possible x Major = High 9 Simon Freeman STP approval by NHSE Appointment of Urgent Care Director who commenced in post on 1 December /17 GB Key Principles 1, Impact of sustainability of local Out of Hours provider Risk that the CCG will not be able to commission a sustainable and cost effective out of Hours provider in the future Governing Body meetings Programme of dedicated Shropdoc meetings specifically to address sustainability issues Contract and Quality Review meetings Lead Committee -Governing Body Gaps in controls: Agreed recovery plam and agreed forward commissioning plan Gaps in Assurances: Almost certain x Major - Extreme 20 CCG supporting Shropdoc with the development of a clear recovery plan with timelines. Regular CCG meetings taking place with Shropdoc CCG work ongoing to define future service needs Possible x Major = High 9 Nicky Wilde CCG support in development of a recovery plan with Shropdoc Supporting information for contracts New Risk Note Items in the Key Controls and Source of Assurance columns which are underlined and in italics relate to items which should be in place to achieve control or assurance but are either missing or are not as robust as needed. They will be resolved when the actions included in the action column are complete. Items in red are amendments from the version presented to the April 2017 Governing Body and which have been amended as a result of discussions at Governing Body Committees or lead officer updates

233 y Issues Log January 2018 Issue ID Date Description RAG Management Response RAG status after action Financial Position CCG placed in Legal Directions due to a significant financial deficit New Executive Team appointed. Stringent QIPP plans developed. Regular reporting to NHSE. Regular internal financial reporting. Owner Jan Jan Jan Jan-18 Quality & Safety Triangulation of intelligence from a range of sources has highlighted a range of Quality issues for ongoing management Out of Hours Provision Requirement to assist Shropdoc to maintain services during a period of financial instability Constitutional Targets Failure to meet targets on A&E 4 hour wait and Cancer 62 day RTT Working with providers to ensure patient safety. Ongoing monitoring arragenments in place. Quality Strategy and delivery plan developed to focus action where needed. Utilising NHS quality escalation framework in addition to our own reporting mechansms to identify and manage concerns Reviewing details of service specifications to ensure they are robust and meet patient needs. Regular meetings with Shropdoc. Progress closely linked to the development of 111. Link to risk 79/17 on GBAF. T&W CCG lead commissioner Cancer - Working with Lead Commissioners for Out of County Contracts to improve position A&E - Urget Care Director appointed for system. Working with ECIP to address performance issues. 90 day plan in devleopment and will be presented to CS DC NW/CS JD

234 Consequence Risk Matrix Risk Matrix Likelihood Almost Rare Unlikely Possible Likely certain 5 Catastrophic Major Moderate Minor Negligible For grading risk, the scores obtained from the risk matrix are assigned grades as follows Low risk Moderate risk High risk Extreme risk

235 MINUTES OF SHROPSHIRE CLINICAL COMMISSIONING GROUP (CCG) CLINICAL COMMISSIONING COMMITTEE (CCC) MEETING HELD IN K2, WILLIAM FARR HOUSE 9.00AM ON WEDNESDAY 20 DECEMBER 2017 Agenda Item GB CCG Governing Body Present: Mrs Sarah Porter Mr Meredith Vivian Dr Jessica Sokolov Dr Tim Lyttle Dr Shailendra Allen Mrs Nicky Wilde Dr Finola Lynch Dr Steve James Dr Julie Davies Dr Julian Povey Dr Ed Rysdale Mrs Claire Skidmore Mr Kevin Morris Dr Deborah Shepherd Lay Member for Transformation (Chair) Lay Member for Patient & Public Involvement Deputy Chair, GP Board Member North Locality Chair South Locality Chair Director of Primary Care GP Board Member GP Board Member Director of Performance & Delivery CCG Chair Clinical Board Member, Secondary Care Chief Finance Officer, Deputy Accountable Officer Practice Manager Board Representative Shrewsbury & Atcham Locality Chair In Attendance: Mrs Jenny Stevenson Shrewsbury & Atcham Locality Manager (for agenda item 17/144) Ms Janet Gittins North Locality Manager (for agenda item 17/144) Ms Lisa Wicks Commissioning Redesign Lead (for agenda items 17/148, 17/149 and 17/150) Mrs Faye Harrison Minute Taker Apologies: Ms Dawn Clarke Mrs Gail Fortes-Mayer Director of Nursing, Quality & Patient Safety & Experience Director of Contracting CCC-17/140 Apologies 1.1 Apologies were notes as above. CCC-17/141 Members Declarations of Interest 2.1 Ms Sarah Porter requested that attendees declare any potential conflicts of interest regarding the Committee agenda. The following declarations were noted: Dr Tim Lyttle GP at Bridgwater Medical Practice and Claypit Street Medical Practice Meredith Vivian married to a South Staff Member Dr Shailandra Allen GP at Broseley Medical Practice Dr Ed Rysdale married to a GP at Beeches Dr Jessica Sokolov married to Physiotherapist who works for ShropCom and father is a County Councillor and Governor on the Board at West Midlands Ambulance Service Kevin Morris Partner at a GP Practice and married to an Executive at Telford & Wrekin CCG Dr Julian Povey GP at Pontesbury Medical Practice Dr Finola Lynch GP at Bishops Castle Medical Practice and her husband works for ShropDoc 1

236 CCC-17/142 Minutes of Previous Meeting & Matters Arising 3.1 The minutes of the previous meeting which took place on 15 November 2017, were agreed to be an accurate record with the exception of the fact that Dr Deborah Shepherds name needed to be added to the list of apologies. 3.2 The CCC Action Tracker was discussed and updated as appropriate. CCC-17/143 Governing Body Assurance Framework (GBAF) 4.1 There was no update on the GBAF at the moment. CCC-17/144 Locally Commissioned Services (LCS) and Non-Core Activity Review Interim Report 5.1 Mrs Jenny Stevenson and Mrs Janet Gittins attended the meeting to present the above paper. 5.2 The report was to highlight the key challenges in the review with the full report due to be issued in January. Since July the 3 Locality Managers have been involved in a Task and Finish Group meeting with representatives from Healthwatch, Practice Managers, Clinical Leads and Patient Representatives. 5.3 The objective is to provide Primary Care clear guidance and payment for services from April The full list of services can be found on page 4 of the report. 5.4 There are currently gaps in the Activity Data which is proving a challenge along with inconsistent coding and recording of activity across the providers. There is also inequity in access for patients and inequality in the payments. Despite all these challenges work is currently progressing well. 5.5 The wider piece of work around the Out of Hospital work and Community Services Review is impacting on services such as phlebotomy, wound care and minor injuries and it is the recommendation that they are removed from the review. 5.6 There was a prior review which took place in 2011 although the questions from this were not available. Discussion was held around this, the outcome from it and the best way to use this in moving forward. Members agreed that moving forward the 2011 review and could be dismissed although it should be referred to. The LMC Audit may also need to be included. 5.7 Members agreed that a sub-group from the Clinical Commissioning Committee should be set up to discuss the review in more detail and then an update can be brought to the Committee with the key points from this. It was agreed that members of this group should include a representative from the LMC. 5.8 It was highlighted that some services may not be in place by April and that an interim plan will need to be considered to cover the gap. Delay in services will be associated with funding and further challenge will be in accepting notice periods. 2

237 5.9 It would also need to be considered whether the enhanced services would be beneficial before agreeing funding going forward. The proposal would be going to the LMC in January and if agreed 3 months notice would be required Dr Lyttle felt that phlebotomy needed further discussion as there is significant cost involved and currently multiple staff are providing the same service. Mrs Wilde informed members about the different types of funding; this was discussed at the Task and Finish Group the previous day. It may be useful to break the service up in order to address the inequity and manage the workload efficiently moving forward it needs to be clarified what services are core and non-core; this is something that can be picked up via the sub-group. Communication will need to be improved once the service is defined to move this forward Lengthy discussion was held around the services required, how the inequity is addressed and what the funding will be. Part of the problem currently is around how the service is delivered as there are many inconsistencies throughout the county. It may be beneficial to start again in order to make the service more efficient with greater clarity and regular monitoring. Patient need will also need to be taken into consideration. Future need also needs to be factored in It was hoped that the new templates and recommendations would be ready by the middle of January It was agreed that members of the sub-group would be Deborah Shepherd, Finola Lynch, Steve James, Dawn Clarke (or representative from the Quality Team), Julie Davies and Nicky Wilde. An LMC representative will also be invited. Meredith Vivian also offered to be involved as a patient representative if required. Action: Jenny Stevenson/Janet Gittins to set up a small sub-group to discuss LCS and Non-Core Activity Review and provide update to the January Meeting. CCC-17/145 Acute Kidney Injury in Primary Care 6.1 Dr Julie Davies gave members a brief overview of the paper requesting support from members for SaTH to begin using the AKI alerts with appropriate communications out to Primary Care. Feedback can be given to Secondary Care as required. 6.2 It was discussed and agreed that slight rephrasing within the report was required to formalise the actions and highlight that this won t impact on workload. Extra information around interpreting the blood test would also be beneficial. 6.3 Communication to Primary Care colleagues would be a key element to move this forward with inclusion of details on access to advice. It was agreed that this should be sent out after Christmas. SaTH would be asked to begin the alerts from middle of January. CCC-17/146 Non-Emergency Patient Transport (NEPT) Recharge QIPP 7.1 Dr Julie Davies informed members that the Contract had been checked and that they are now in a position to recharge other commissioners for transport for their patients. It has also been 3

238 checked that reciprocal arrangements have been paid and therefore any on going issues can be resolved. 7.2 The Business Intelligence resource will be utilised to validate the invoices to and the finance function will then invoice the respective commissioners. This will be carried out from January and will include Decembers invoices. 7.3 Site to site transfers both Ambulance and Non-Emergency contract is now being formalised to ensure Secondary Care is paying for this service. 7.4 An issue was raised a while ago by Healthwatch with regards to patients going out of county and not being allowed to have carers with them. It was confirmed that this is not the case and is covered within the policy. This can be confirmed at Quality Committee. CCC-17/147 Suspected Cancer Vague Symptoms Pilot Proposal 8.1 David Whiting attended the meeting to discuss the above paper. He informed members that this was a pathway from the 2015 NICE Guidance. Pilots have been on going across the Country although there is not much evidence available yet. 8.2 Telford & Wrekin began a pilot involving 7 GP Practices a while ago with SaTH funding some Consultant and CNS time. The number of referrals was very low and the pilot was opened up to all practices approximately 4 months ago. SaTH have recently approached Shropshire Practices to become involved to improve uptake. Dr Davies reported that following Executive Team discussion this was not the most appropriate way forward as Shropshire had not be involved in any of the planning. 8.3 Going forward it needed to be understood what the implications of the service would be as well as the financial impact. Shropshire would also need to be involved in the planning of this from the beginning. 8.4 Discussion was held and it transpired that not all practices had received correspondence from SaTH regarding this and those that had found the forms to be confusing. It was felt that better models were available nationally. Clarification to Shropshire practices would be required stating the current position and that it is not supported by the CCG. 8.5 Further discussion was held around the planning of the pilot moving forward and whose involvement would be required. It would be key to streamline the process and align the pathways. Action: Action: Action: Communication to be sent out to Shropshire Practices to highlight that the pilot on Suspected Cancer Vague Symptoms is not being supported by the CCG Meeting to be set up around the planning of the pilot on Suspected Cancer Vague Symptoms David Whiting to contact SaTH and Telford & Wrekin around the Suspected Cancer Vague Symptoms pilot to inform them of agreed recommendations 4

239 CCC-17/148 Out of Hospital Programme Update 9.1 Lisa Wicks attended the meeting to provide an update on the Out of Hospital Programme and gave a summary of the case for change for MiU, DAART and Community Beds with the recommendation that DAART and Community Beds transfers into the wider Out of Hospital Programme with a re-specification of MiU. 9.2 Workshops have been arranged within the 3 Localities and the first one took place for Shrewsbury and Atcham recently. Any feedback would be gratefully received going forward to use for the scheduled workshops in the North and South. Engagement from the GP s is there but that the pace needs to be kept up and the scale of the project highlighted. It would be important to get balance between how services are delivered whilst keeping to the timescale. 9.3 At the workshop pathways were discussed and open discussion was held on the timescales and how the work would be carried out moving forward. There will be different challenges in different parts of the County although it was felt that a clear vision was required to ensure balance and consistency. The needs of the patients and what outcomes are looking at being achieved need to be considered to meet the objective. GP involvement would be highly beneficial from an early stage. 9.4 Discussion was held around the patient journey, the pathway end to end and how this links together. Concern around the timescale was highlighted as Telford & Wrekin is further along that Shropshire. Further discussion will be required about the best way to approach partnership working to move this forward. 9.5 It was felt that GP Engagement would be key to progressing the service along with clarity around what needs to be achieved. It would also be important to highlight that this will be linked into to the enhanced services work which is currently on going. Positive management and clear timescales will also be required with a mindful approach around QIPP timelines. 9.6 Further discussion was held around the risks and concerns moving forward and how these will be best managed. Clear precise communication with GP Practices will be required to allow time for consideration. A planned Comms Strategy may be beneficial and decisions will need to be agreed around how this will be articulated. 11am Claire Skidmore left the meeting 9.7 It was highlighted that the Executives are currently under pressure to make savings and at the moment there are additional costs within the CHC Service which the Out of Hospital links in to and therefore more alignment is required. Total respecification would be required if this does not occur. 9.8 In Summary to achieve what is required another service may need to be decommissioned and decision around this needs to be made. Funding may need to come from the Community Contract. Key decisions will be discussed at the January Governing Body around the ShropCom Contract and depending on the decision reprocurement may be required. Action: Out of Hospital Programme Update and decision around ShropCom Contract to be discussed at the January Governing Body Confidential Section 5

240 CCC-17/149 Five Year Forward View for Mental Health 2017/18 Funding Allocation 10.1 Lisa Wicks attended the meeting to present the paper on Mental Health although she is covering this due to Richard Kubilis being on sick leave. Dr Davies began by giving a brief background to members Physical Health checks would be done as a Local Enhanced Service (LES) and a full specification could be brought back to the next meeting if required detailing all the aspects. The 5 Year View is very specific regarding what the money can be spent on Shropshire Sanctuary is currently looking to increase their opening hours and some Winter Pressure money is being received from NHS England to help with this over the next few months some of the grants for the services may be recommissioned and no impact assessment has been carried out. If the services are removed the Crisis pathway will be affected. Discussion was held around the grant programme and how this works It would be key to identify the risks and look at the longer term contractual arrangements to mitigate the risks It was agreed to develop the recommendations into a full service specification and bring back to a future meeting with IAPT linked in. CCC-17/150 Community Learning Disabilities and Oak House 11.1 Lisa Wicks summarise the work which has been undertaken by Telford and Shropshire around Oak House. Currently Telford are proposing to close Oak House and are making alternative arrangements whereas Shropshire have not engaged with Primary Care or carried out any consultation with NHS England Service Change Guidance regarding this Approval is required to request Telford to halt their process to give Shropshire time to catch up and assess patients accordingly, look at alternative arrangements and engage with Primary Care. Julie Davies will be drafting a letter around this to go to Telford & Wrekin CCG. Action: Dr Julie Davies to draft letter to Telford & Wrekin CCG around Oak House requesting them to halt their process while Shropshire catches up Discussion was held around issues with the T&W process of consultation and engagement. It was felt conversations between both CCG s would be required to move this forward. Joint working with the CCG s and Local Authorities would also be required to realign services. CCC-17/151 Any Other Business 12.1 There were no items of Any Other Business discussed. CCC-17/152 Date of Next Meeting The next meeting of this Committee will take place on Wednesday 17 January, 9.00am in K2, William Farr House. 6

241 Shropshire Clinical Commissioning Group Agenda Item GB CCG Governing Body MINUTES OF THE QUALITY COMMITTEE (QC) HELD IN ROOM B, WILLIAM FARR HOUSE SITE AT 1.00PM ON WEDNESDAY 20 DECEMBER 2017 Present Mr Meredith Vivian (Chair) Ms Dawn Clarke Dr Julie Davies Dr Jessica Sokolov Dr Finola Lynch Mr Keith Timmis Mrs Sara Bailey Mrs Helen Bayley Mrs Sarah Porter Mrs Jane Randall-Smith Dr Ed Rysdale Mrs Sarah Smith SCCG Lay Member (Chair) Director of Nursing, Quality, Safety & Patient Experience Director of GP Member GP Member SCCG Lay Member Lead Nurse for Quality and Patient Safety, SCCG Quality Lead Nurse for Primary Care, Care Homes and TCP SCCG Lay Member (Part meeting only) Shropshire Healthwatch Secondary Care Consultant Personal Assistant, Minute Taker QC (Agenda Item 1) - Apologies No apologies were received. QC (Agenda Item 2) - Members Declaration of Interests Mr Meredith Vivian welcomed members and attendees to the Quality Committee (QC) Meeting. The following declarations of interests were raised: - Mr Vivian raised a declaration of interest in relation to Shrewsbury and Telford Hospitals NHS Trust (SaTH). - Dr Sokolov raised declarations of interests in relation to subjects referring to Shropshire s Community Health Trust Physiotherapy service, advising she was a GP Partner and was related to members employed by the Local Authority and West Midlands Ambulance Service. - Dr Rysdale raised a declaration of interest in relation to anything raised in relation to Beeches Medical Practice, Bayston Hill, Shrewsbury. - Dr Lynch raised a declaration of interest in with regard to anything raised in relation to Shropdoc. QC (Agenda Item 3) Minutes/Actions from Previous Meeting and Action Log held on 29 November 2017 The minutes of the last meeting held on 29 November 2017 were agreed to be a true and accurate record. Action Log from 29 November 2017 Members received an update for each item and noted that all actions had been completed or were on as an agenda item with the exception of: QC Research Governance Mrs Clarke noted that she was the lead for research governance and advised she would bring a research governance policy back to the February meeting. Mr Vivian asked a brief context to be included in the paper around what the CCGs and QC s responsibilities were around research governance. Mrs Clarke advised a complaints lead had been appointed and would be commencing his post in the new year. ACTION: Mrs Clarke to bring a research governance policy/paper back to the February QC meeting. QC Healthwatch Update and Non-Elective Transport Query Dr Sokolov this action was in relation to non-elective transport and carers not being able to accompany a patient and confirmed that if a patient needs a carer then they should be able to have a carer accompany them if necessary. Dr Sokolov advised if there were any issues with this where this was not happening this should be reported to the CCG so that it could be taken up with the Trust. Dr Davies confirmed a carer accompanying a patient was part of the contract and it was therefore agreed that Dr Davies arrange for a letter to be sent to Mrs Randal-Smith confirming this was part of the contract P a g e

242 ACTION: Dr Davies to arrange for a letter to be sent to Mrs Randal-Smith in relation to non-elective transport to confirm that carers accompanying patients was acceptable and part of the contract. QC day cancer waits Mrs Bailey to liaise with Mr Whiting around information received and data analysis Mrs Bailey to provide QC with an update at the next meeting Mrs Bailey informed members that in terms of contract letter that went to SaTH each month the wording has been amended to ensure the CCG received more information around themes and trends coming forward. The expectation was that SaTH will now get the new amended letter each month going forward. Mrs Clarke advised SaTH had also given the CCG an update advising there were some issues with administration and also with radiology. It was agreed Mrs Bailey forward on the detail of this update to Dr Davies so that this could be included in the performance report for the CCG Board meeting. In relation to the recording of RCAs Mrs Bailey informed members she was due to meet with Ms Meryl Flaherty in January 2018 to look at the RCA process and to ensure the provider is clear on what is expected. ACTION: Mrs Bailey to forward on details of SaTH s update to Dr Davies so this could be included in the performance report for the CCG Board meeting. QC Ambulatory Care Visit Mrs Bailey advised the ambulatory care visit had been postponed due to the escalation levels at SaTH and noted she had done a brief visit yesterday to clarify if patients were still presenting through the ambulatory care unit unnecessarily. Mrs Bailey confirmed she had been advised that patients were still presenting through the unit with approximately 1-2 patients with for example potential sepsis symptoms. Mrs Bailey asked how the Committee wanted to proceed with this information. In relation to other pathways and patients being referred to the ambulatory care unit with medical conditions which were deemed unsuitable with things such as high blood pressure and replacement of pegs. Extensive discussion was held as to what was appropriate to be referred into the ambulatory care unit and Dr Sokolov advised that with regard to pegs this should be dealt with by the Clinical Care Co-ordinators (CCC) and at was agreed this issue should be taken up with Shropdoc. Mrs Bailey would forward the relevant detail onto Mrs Nicky Wilde who would pick this up with Shropdoc. Mrs Bailey also raised bloods being taken in the ambulatory care unit and it was noted that bloods could be taken in the urgent care centre. ACTION: Mrs Bailey to forward information to Mrs Nicky Wilde regarding inappropriate referrals to the ambulatory care unit to enable this to be picked up with Shropdoc and CCC. QC Quarterly Safeguarding Reports 3.1 Children s Safeguarding and Looked After Children Level 2 and 3 Training Issues Mrs Clarke noted the issues with level 2 and 3 training issues were escalated to the Strategic Commissioning Board, however noted that training issues across the patch with all areas was concerning. Mrs Clarke advised a bigger discussion was needed on what was essential areas of work and training. Further discussion was held on Looked After Children and contracts and it was noted that wider discussions were needed on this area. The Committee noted there were nearly 100 homes in Shropshire and Mrs Clarke noted Looked After Children was on the risk register. QC Whitchurch Hospital Visit Mrs Bailey advised ECGs and clarification of nurses and whether they have the appropriate skills and training. Feedback from the Community Trust is that the registered nurses there have the core set of skills to do the basic ECGs and interpretation of those but they have not got the advanced skills and interpretation. Further to concerns raised previously with regard to patients presenting with chest pains and the concern of the patients driving to the hospital for assessment. Mrs Bailey was advised they do refer patients back to GP if the nurse feels there is nothing they can see. They do refer back to if they have got pain they ring the GP back for advice. Dr Sokolov advised no patients with chest pain should be sent to a MIU for assessment and concerns were raised about patient safety. It was agreed Mrs Bailey would check with other MIUs to confirm if they were receiving patients presenting with chest pains and it was agreed Mrs Clarke would draft a letter to send out to Practices, to be signed by the clinical leads and liaise with Dr Sokolov and Dr Povey before this was sent out. QC (Agenda Item 4) - Matters Arising There were no matters arising. QC (Agenda Item 5) Quality Strategy and Delivery Plan P a g e

243 Mrs Clarke advised she had ed the updated Quality Strategy and Delivery Plan to members and Mr Vivian noted he had met with Dr Sokolov and Dr Lynch in order to take the work forward. The Committee approved this document. Mrs Clarke noted the Quality Directorate and function was a big role and this would need to be integrated. Mr Vivian would look at the document again with this information in mind. Mrs Randall-Smith welcomed this document and noted that section 2 was particularly good around effective early warning systems. Under section 5 and serious incidents Mrs Randall-Smith suggested adding learning to this section also as this was important. Under section 7 in relation to safety and clinical effectiveness this section was welcomed in relation to embedding this into service redesign. Mrs Clarke raised the delivery plan and objectives. Mrs Clarke advised she would pull key themes out of the document and noted this linked closely with the forward planner for QC meetings. Mrs Clarke noted this document would be going to the CCG Board meeting and it was also being discussed at the Quality team meeting. Mrs Clarke raised the amount of key areas of work coming out of this document and advised work and services would need to be prioritised. The Committee acknowledged work fluctuated. Discussion was held about prioritisation and resources. Mrs Clarke agreed prioritisation needed to be discussed further and to recognise the pressures on individual Directorates. At least risk areas were being identified. Mr Vivian advised the Quality Strategy would need to be a standing item on the QC meeting. QC (Agenda Item 6) Provider Exception Report Mrs Sara Bailey presented this item and the following key points were noted: Mrs Bailey took members through the summary of key issues and it was noted work was continuing in relation to the deep dive analysis of unexpected deaths at South Staffordshire and Shropshire Healthcare NHS Foundation Trust (SSSFT). The review of the cases was being undertaken in collaboration with the Director of Public Health with a first report to the December Quality Committee meeting following discussion with the Trust. The CCG were also linking with Telford & Wrekin CCG and the Care Quality Commission (CQC). Mrs Bailey noted that SaTH had identified as a mortality outlier for fluids and electrolyte disorders by the Imperial College Dr Foster. A review of data identified care homes where there were issues with escalation and treatment plans resulting in transfer to SaTH. The CCG Quality team has offered to assist the care homes and SaTH to understand and rectify the problems identified. Early discussions have been had with Shropshire Partners in Care to support the process. Mrs Bailey advised a response had been received from SaTH and Mrs Helen Bayley would be progressing this work with the nursing homes and would update QC when information was available. In relation to the Child and Adolescent Mental Health Services (CAMHS) provision it had been reported previously that a number of senior professionals across children s services, the CCG and providers have been involved in discussions to address matters of concern within the service. Urgent action had been taken to review the situation further and ensure appropriate mitigating action is taken. A meeting between CCGs and the Director of Children s Services at both Shropshire and Telford & Wrekin Councils have been convened for December to agree a collective strategy. Mrs Randall-Smith advised Healthwatch Shropshire had received very few comments regarding this service since it had changed noting Healthwatch were planning to do a hot topic on this service in February or March Dr Davies raised concerns over CAMHS and their remedial action plan noting the level of risk associated with this service was high. Members acknowledged that meetings had been held with the Trust and issues had been raised however no progress had been made to tackle the issues. Mrs Clarke asked Dr Davies to forward the remedial action plan to her so that she could raise the concerns and issues with Mrs Chris Morris at Telford & Wrekin CCG as the lead commissioner of this service. Mrs Porter left the meeting. Mrs Randall-Smith advised Healthwatch Shropshire had received some comments about podiatry and P a g e Princess House and it was agreed Mrs Randall-Smith forward these comments onto Mrs Bailey. Mr Timmis made an observation in relation to referral processes and DNAs highlighting issues around these had been linked into the Local Maternity Services (LMS). Also with regard to providers ratings which one of them is rated as good is the provider we have concerns about and has high suicide rates and the value for money question with this provider would be a no. Mr Timmis asked for clarification in relation to West Midlands Ambulance Service figures and members went on to discuss the Ambulance Response Programme (ARP) and alternative models. With regard to Shropdoc and Care UK it was noted this was a separate issue to the ARP model and Mrs Bailey updated members on the current position with this. Members agreed that data was needed from the Emergency Department at SATH to clarify the position in relation to ambulances. Mrs Bayley noted that this data had been requested.

244 ACTION: ACTION: Dr Davies to forward the remedial action plan to Mrs Clarke so that any issues and concerns can be raised with Mrs Chris Morris at Telford & Wrekin CCG. Mrs Randall-Smith would forward on the comments regarding Princess House onto Mrs Bailey. QC (Agenda Item 7) SSSFT Serious Incidents Ms Clarke presented this item regarding SSSFT serious incidents and the following information was highlighted: Ms Clarke advised this information was very sensitive and asked members to treat this carefully. It was noted that Mr Paul Cooper, Head of Safeguarding was working very closely with the Trust and CQC on the issues with SSSFT. Mrs Bailey took members through the detail resulting from the deep dive of the Trust noting the themes and key issues that had arisen. There had been 19 reported deaths by suicide in 2016/17 and to date in 2017/18 there had been 18 deaths including a recent homicide/suicide. Members noted the key themes would be explored further with the Trust and contact would be made with the lead commissioner. The issues had also been raised at the Quality Surveillance Group Meeting and Mrs Chris Morris, Telford & Wrekin CCG who is the lead commissioner was also conducting a similar review. Members were informed that a meeting would be held with the Director of Public Health in the New Year to look at the key themes and further deep dive. Mrs Clarke would contact the Director of Nursing at SSSFT and liaise with Mrs Chris Morris at Telford & Wrekin CCG. Further detail on this would come back to the January QC Meeting. Mrs Clarke informed members in relation to maternal and obstetric SIs that NHS Improvement had requested an internal review. The Committee thanked Mrs Bailey for the report and noted all the information. ACTION: Further detail regarding SSSFT and serious incidents would come back to the January QC Meeting. QC (Agenda Item 8) Healthwatch Update Mrs Randall-Smith gave an update on this item and tabled a paper on neurology. The following key areas were highlighted: Mrs Randall-Smith tabled a paper on the hot topic around neurology and advised a good response was received. Most feedback was around Parkinson s and Motor Neurone Disease. Mrs Randall-Smith noted the report had been shared with SaTH and the relevant user groups. Results were mixed, however, access and waiting times came out as a key theme. Dr Davies confirmed the CCG were aware of all the issues raised in the report which was re-assuring and it was noted that if this report was done again in one year, it was anticipated the results would be very different and more positive. Dr Davies highlighted consultant capacity at SaTH was very much at the top of the agenda and a significant improvement should be seen from March 2018 onwards. Mrs Randall-Smith advised the next hot topic was podiatry and one of the key areas with the podiatry service was that patients did not know where to go to get this service even if they paid for it. Mrs Randall- Smith would bring a report back to the next QC meeting on podiatry. Extensive discussion was held around capacity and specialities at SaTH and QC were informed of the success with the ophthalmology service. It was agreed a letter be sent to the department to acknowledge and communicate that the CCG were very impressed by their hard work in getting the ophthalmology service turned around. Mrs Clarke would draft a letter to be sent out. Mrs Clarke raised the issue of junior doctors at SaTH and members noted that intake number of junior doctors at SaTH was low and the difficulty of recruiting more doctors. Work was ongoing with this. Mrs Randall-Smith raised Futurefit and the clinical senate response. ACTION: ACTION: Mrs Randall-Smith would bring a report back on podiatry to the January QC Meeting. It was agreed a letter be sent to the department to acknowledge and communicate that the CCG were very impressed by their hard work in getting the ophthalmology service turned around. Mrs Clarke would draft a letter to be sent out. QC (Agenda Item 9) Quality Forward Planner P a g e

245 Mrs Clarke presented this item and members noted and this information provided. QC (Agenda Item 10) Any Other Business There was no other business. Date of Next Meeting The next would be held on Wednesday 31 st January 2018 in Meeting Room B, William Farr House Site, Mytton Oak Road, Shrewsbury SY3 8XL, pm P a g e

246 Shropshire Clinical Commissioning Group ACTIONS FROM THE QUALITY COMMITTEE WEDNESDAY 20 DECEMBER 2017 Action Required By Whom By When QC QC Research Governance - Mrs Clarke to bring a research governance Mrs Clarke February policy/paper back to the February QC meeting. QC QC Healthwatch Update and Non-Elective Transport Query Dr Davies to arrange for a letter to be sent to Mrs Randal-Smith in relation to non-elective transport to confirm that carers accompanying patients was acceptable and part of the contract. Dr Davies Next meeting QC QC day cancer waits Mrs Bailey to liaise with Mr Whiting around information received and data analysis Mrs Bailey to provide QC with an update at the next meeting Mrs Bailey to forward on details of SaTH s update to Dr Davies so this could be included in the performance report for the CCG Board meeting. Mrs Bailey Next Meeting QC QC Ambulatory Care Visit Mrs Bailey to forward information to Mrs Nicky Wilde regarding inappropriate referrals to the ambulatory care unit to enable this to be picked up with Shropdoc and CCC. Mrs Bailey Next Meeting QC QC Whitchurch Hospital Visit Mrs Clarke would draft a letter to send out to Practices,regarding ECG referrals to be signed by the clinical leads and liaise with Dr Sokolov and Dr Povey before this was sent out. QC (Agenda Item 6) Provider Exception Report - Dr Davies to forward the remedial action plan to Mrs Clarke so that any issues and concerns can be raised with Mrs Chris Morris at Telford & Wrekin CCG. Dawn Clarke Dr Davies Next meeting Next Meeting Mrs Randall-Smith would forward on the comments regarding Princess House onto Mrs Bailey. Mrs Randall-Smith QC QC (Agenda Item 7) SSSFT Serious Incidents - Further detail regarding SSSFT and serious incidents would come back to the January QC Meeting. Mrs Clarke/ Mrs Bailey Next Meeting QC QC (Agenda Item 8) Healthwatch Update - Mrs Randall-Smith would bring a report back on podiatry to the January QC Meeting. Mrs Randall-Smith Next Meeting It was agreed a letter be sent to the department to acknowledge and communicate that the CCG were very impressed by their hard work in getting the ophthalmology service turned around. Mrs Clarke would draft a letter to be sent out. Mrs Clarke Next Meeting P a g e

247 Agenda Item GB CCG Governing Body Shropshire Clinical Commissioning Group MINUTES OF THE FINANCE & PERFORMANCE COMMITTEE HELD IN MEETING ROOM A, WILLIAM FARR HOUSE, SHREWSBURY, SY3 8XL ON WEDNESDAY 3 JANUARY 2018 AT 1.30PM Present Mr Keith Timmis (Chair) Mr William Hutton Mrs Claire Skidmore Mr Kevin Morris In Attendance Ms Kim Morris Mr Meredith Vivian Mr Charles Millar Mrs Faye Harrison Apologies Mrs Gail Fortes-Mayer Dr Julie Davies Ms Sarah Porter Dr Jessica Sokolov Lay Member Lay Member and Audit Chair Chief Finance Officer GP Board Representative Head of PMO Lay Member Head of Contracting (Part) Personal Assistant/Minute Taker Director of Contracting Director of Performance & Delivery Lay Member Deputy Clinical Chair FPC Apologies 1.1 Apologies were received as listed above. FPC Members Declaration of Interests 2.1 There were no declarations of interest. FPC Minutes of Previous Meeting held on 6 December The minutes from the previous meeting were agreed as being a true and accurate record. FPC Matters Arising/Action Tracker 4.1 The Action Tracker was discussed and updated as appropriate. Please see attached. 4.2 It was discussed that the Terms of Reference for the Finance and Performance Committee would be reviewed by Mr Timmis, Mrs Skidmore, Dr Davies and Mrs Fortes-Mayer with a revised copy to be brought to the March meeting. Action: Mr Timmis to review the Terms of Reference with Directors and bring a revised copy to the March Committee. FPC Work Plan 5.1 The work plan would be reviewed outside of the meeting by Mr Timmis and Mrs Skidmore and a revised copy to be brought to the March Committee. 1

248 Action: Mr Timmis and Mrs Skidmore to review the Committee Workplan and bring revised copy to March meeting FPC QIPP Update 6.1 Ms Kim Morris attended the meeting to talk through the QIPP report with members. She highlighted that a QIPP Finance Lead is currently in post who is providing support in triangulating all the numbers with BI. She also highlighted a slight increase in the Month 8 figures; this is due to the prescribing numbers which were reported but has had no impact on the overall figure. 6.2 It was commented that the figures in this part of the report were confusing. Mrs Skidmore talked through the numbers and gave clarification. There had been a national impact on prescribing budgets this year with an increase in cost to the NCSO category drugs. Advice from Region requested that these were then removed from the reported position. Further discussion was had regarding this. National discussions are also on going. 6.3 There has been a small deterioration in the MSK and VBC numbers along with a bigger change in the CHC number; the risk has been included in the position. All the numbers are being worked though line by line looking at the 18/19 budget as the anticipated delivery has not been achieved. Discussion was held regarding the current budget and how this moves forward to enable delivery. It is hoped that now there is a stable management team in place this will be more achievable. The Committee stated that the CCG needs to improve its approach to QIPP. While more has been achieved this year there remain problems with the way we approach schemes. 6.4 Wording within the report was discussed as it was felt this needed to be clearer on some points and would need to be changed. 2.20pm Charles Millar joined the meeting MONTHLY MONITORING FOR FINANCE & PERFORMANCE FPC Finance Report 7.1 Mrs Skidmore updated members that the position at month 8 as detailed in the report was finalised as being 19.4m with 5m of unmitigated risk (which excludes the 2.9m for NCSO). This position was agreed prior to the Year End deal with SaTH. NHS England advised to stick with the 5m risk as it will allow some head room. 7.2 There are currently some unplanned cost pressures with ShropDoc, HRG4+ and non-recurring expenditure. Discussion was held regarding the figures changing from Month 7 to Month 8 and the reason for this as conflicting messages had been received from NHS England. Winter pressures and activity numbers also have an impact on the figures along with the added complication of national guidance and the Year End deal; however there is a limit to SaTH s capacity and this will require monitoring. 7.3 Mr Timmis summarised that the Year End agreement has been reached which will give them a sum of money however it is not clear what activity will be delivered because the trajectory will be invalidated by the NHSE instruction cancelling planned 2

249 care to deal with winter pressures.. Mrs Skidmore confirmed that monthly activity would continue to be monitored. Further discussion was held around the arrangements currently in place and how the activity figures are monitored. 7.4 Mrs Skidmore highlighted that the Year End agreement that was currently in place would be in relation to this year s position to give stability. 7.5 Non-Purchase orders were discussed and how this position can be improved moving forward as it was felt that training on the system was not enough. There is currently a grey area around invoices and clarity to staff is needed around each category. Mrs Skidmore talked through the process with members and highlighted that the issue was around invoices not having PO numbers when they should do. It was commented that the system was not particularly user friendly which was adding to the issues; there would need to be extensive investigation into the figures and processes. It was agreed that a report would be brought back to the March meeting for further discussion. The Committee is looking for assurance we have effective control over expenditure and that financial forecasts are not at risk because of the level of expenditure that is incurred outside normal financial controls. Action: Non-PO Invoices to be added to March Agenda. 7.6 Mr Hutton raised a query regarding CHC monthly figures and why there had been a sudden increase in the number of patients. It was agreed that a further explanation would be required. Action: Mrs Skidmore to provide further information regarding the increase in monthly figures in CHC FPC Contracting Report 8.1 Mr Charles Millar attended the meeting to discuss the Contracting Report with members. Mr Timmis informed Mr Millar on the earlier conversations around ShropDoc and it was confirmed that this information can be added to the report going forward. 8.2 The data problem with SSSFT was discussed around the 2 week psychosis referral and the differing processes. Mr Millar reported that the reporting process will need to be worked on especially around data quality assurance. There will be an action plan to get into a better position. This will also provide a clearer picture on waiting times within the Mental Health Service. 8.3 Contracts will require sign off before the end of March. Executive discussions will be taking place for the 2018/19 budget. 8.4 Mr Hutton made suggestions around the graphs in the report as the scale range was inconsistent which could be misleading. FPC Performance Report 9.1 Mr Charles Millar also discussed the Performance Report with members and explained that the providers have agreed the trajectories as far as A&E and RTT are concerned but that these will need to be looked at in more detail. 3

250 9.2 RJAH are confident they will achieve performance targets in March however this may have a major impact on SaTH. There has been a mix of inpatient and outpatient activity. 9.3 Mr Vivian enquired around the extent of intervention and whether this was having any real effect. Mr Millar commented that he felt this was having an impact however it was difficult to prove statistically. RTT would not have improved without the ongoing pressure and it would be important to keep it in the spotlight. 9.4 There are some underlying concerns around data quality and it would be important to assess this properly and ensure all data is aligned. FPC Any Other Business 10.1 There were no items of any other business discussed. Meeting closed 3.10pm Date of Next Meeting Wednesday 7 February 2018, 1.30pm, Room A, William Farr House Signed 4

251 Agenda Item GB CCG Governing Body Shropshire Clinical Commissioning Group MINUTES OF THE PRIMARY CARE COMMISSIONING COMMITTEE (PCCC) HELD IN ROOM K2, WILLIAM FARR HOUSE, SHREWSBURY AT 9.00 AM ON WEDNESDAY 3 JANUARY 2018 Present Mr Keith Timmis Mrs Nicky Wilde Mrs Claire Skidmore Mrs Sam Tilley Mrs Dawn Clarke Mr William Hutton Mrs Sarah Porter Mr Meredith Vivian Dr Finola Lynch Dr Steve James In Attendance Dr Julian Povey Dr Shailendra Allen Dr Tim Lyttle Mr Kevin Morris Dr Deborah Shepherd Mr Steve Ellis Mr Phil Morgan Mr Tom Brettell Ms Janet Gittins Mrs Sarah Smith Councillor Madge Shineton Lay Member, Performance (Chair) Director of Primary Care Chief Finance Officer Director of Corporate Affairs Director of Nursing, Quality, Safety & Patient Experience Lay Member Lay Member Lay Member GP Member GP Member CCG Chair & GP Member GP Member, Locality Chair GP Member, Locality Chair Clinical Lead GP Member, Locality Chair Head of Primary Care Primary Care Manager Locality Manager Locality Manager Personal Assistant, Minute Taker Shropshire Council Apologies Councillor Lee Chapman Dr Colin Stanford Dr Ed Rysdale Portfolio for Health, Adult & Social Care, Shropshire Council GP Member Secondary Care Consultant PCCC (Agenda Item 1) - Apologies Mr Timmis welcomed members and attendees to the Primary Care Commissioning Committee. Apologies were received from Councillor Lee Chapman, Dr Colin Stanford and Dr Ed Rysdale. PCCC (Agenda Item 2) - Members Declaration of Interests Declarations of interests were raised by Dr Lyttle, Dr Allen, Dr Povey and Mr Morris in relation to primary care/premises items. Dr Shepherd and Dr James advised they were not aware of any conflicts but noted they were GPs. PCCC (Agenda Item 3) Minutes/Actions of Previous Meeting and Action Log held on 6 December 2017 The minutes of the last meeting held on 6 December 2017 were agreed to be a true and accurate record subject to the following amendment: P a g e

252 Page 8, Primary Care NHS England Update - Under the second bullet point stating In relation to indemnity schemes and the future Mrs Woods advised that stakeholder engagement at a national level had commenced with Medical Defence Unions (MDUs). should read In relation to indemnity schemes and the future Mrs Woods advised that stakeholder engagement at a national level had commenced with Medical Defence Union (MDU). Action Log from 6 December 2017 All completed or on as Agenda Item with the exception of: PCCC Finance Update At the last meeting it was agreed that Mrs Woods would ask for a contact name from the heads of primary care in relation to the presentation entitled the accountable care system primary care development programme and put them in contact with Mrs Wilde to enable the CCG to get some support from the national team to look at how to explore at scale based on rural population. Mrs Wilde agreed to liaise with Mrs Woods to gain this information. ACTION: Mrs Wilde agreed to liaise with Mrs Woods to obtain the contact name from the heads of primary care in relation to the presentation entitled the accountable care system primary care development programme to enable the CCG to get some support from the national team and to look at how to explore at scale based on rural population. PCCC Primary Care Workforce Plan At the last meeting it was agreed Mrs Woods would forward on the information regarding a letter that was sent out to STP in relation to the funding allocation for education and primary care investment to Mrs Wilde. Mrs Wilde agreed to liaise with Mrs Woods to gain this information. ACTION: Mrs Wilde to liaise with Mrs Woods to obtain the information regarding a letter that was sent out to STP in relation to the funding allocation for education and primary care investment. PCCC Primary Care Workforce Plan Further to the discussion at the last meeting where it had been agreed that a further discussion would be held in relation to locum cover and engagement with locums. Mrs Wilde confirmed that this discussion was still to take place. The PCCC noted this item regarding locum cover would be taken to the Primary Care Working Group agenda for further discussion. ACTION: Mrs Wilde and Mr Ellis to put the item regarding locum cover and engagement to the next Primary Care Working Group meeting for further discussion. PCCC Primary Care Committee Risk Register Verbal report on the enhanced services and non-core review mid-review- Mrs Wilde confirmed there had been lots of work done with this since the last meeting and noted a meeting was taking place with the Local Medical Committee (LMC) on 9 February where they would be updated on the progress of this work. On 12 January this work would be discussed at the sub-group of the Clinical Commissioning Committee where the new potential service specifications and costings would be looked at with a view to taking this work to the CCC in February. PCCC Options Appraisal - Whitchurch Premises It was previously agreed that an outline business case (OBC) would come back to the January PCCC meeting. Mrs Wilde noted the OBC would now come back to the February PCCC meeting. Mr Timmis noted he and Dr Lyttle had had a conversation regarding the conflict of interests in relation to this item to ensure this item was being dealt with appropriately in accordance with the conflicts of interest guidance. It was noted Dr Lyttle would be able to offer his viewpoint from the Practice perspective. ACTION: The outline business case for Whitchurch Premises would come back to the February PCCC meeting P a g e

253 PCCC Primary NHS England Update It was noted at the last meeting that the PCCC would receive an enclosure for the NHS Update rather than a verbal report going forward. Unfortunately an enclosure had not been received for this meeting, however, this was the plan going forward. ACTION: Mrs Woods advised the PCCC would receive written reports at future meetings for the NHS England Update. PCCC Primary NHS England Update At the last meeting it was agreed Mrs Woods would bring an update regarding the ongoing national work with General Practice and outcomes dataset and high level indicators data back to a future PCCC meeting. Mrs Wilde confirmed this work would link in with ongoing work around the performance report and it was agreed a joint performance report to include General Practice outcomes dataset and high level indicators would come back to the February PCCC meeting. ACTION: Mrs Wilde confirmed a joint performance report to include General Practice outcomes dataset and high level indicators would come back to the February PCCC meeting. PCCC Primary NHS England Update It was previously noted that Mrs Alamanos would provide Ruth Bolderstone s contact details which would be included in the GP newsletter sent out to GPs in relation to reporting any issues with CAPITA and the service. Mr Ellis confirmed this information was included in the newsletters sent out to GPs, however, Mr Timmis advised the CCG would need to keep updated with the issues with CAPITA. PCCC (Agenda Item 4) - Matters Arising There were no matters arising. PCCC (Agenda Item 5) PCCC Cycle of Work Mr Timmis noted the PCCC Cycle of Work was on the agenda for information purposes and advised this would remain on the agenda to give members an insight of what reports were due to the PCCC meeting. It was noted the PCCC Cycle of Work would be updated to reflect current work pressures. Discussion was held in relation to the PCCC Terms of Reference (TOR). Mr Timmis advised he would be meeting with Mrs Wilde to go through the PCCC Terms of Reference with a view to bringing a revised TOR back to the March PCCC for approval. ACTION: It was agreed a revised PCCC Terms of Reference be brought back to the March PCCC meeting for approval. PCCC (Agenda Item 6) GP Forward View Progress Report Mr Steve Ellis presented this item and the following key points were noted: Clinical pharmacist scheme and Darwin Health bid Mr Ellis advised this application had been unsuccessful due to technical reasons and information regarding NHS England criteria. Darwin Health would be re-submitting this application this month. Workforce The international recruitment bid was currently being amended and the workforce group were currently working on this in order to re-submit this bid. Non-doctor clinical post Data was currently being collated from Practices. Responses had been received from 30 out of the 43 Practices. The deadline was this Friday (5 January 2018). Mr Ellis was liaising with NHS England in relation to figures. The Committee noted the workforce target set by NHS England which was noted as an allocated recruitment target of 32 non-doctor clinical posts. Mrs Wilde advised the CCG would be liaising with Practices to look at workforce confirming access and workforce were going to be the key pieces of work this calendar year. It was also noted this work would need to be closely aligned with the Sustainability and Transformation Plan (STP) in terms of resources and Mrs Clarke reported she was a member of the STP Board noting the importance of primary care input into this meeting. Mrs Wilde confirmed the STP Board had received the CCG workforce plan and Mrs Woods was representing primary care across the system on that group P a g e

254 Access A workshop with Practices was due to be held on 6 February 2018 to discuss the GP Access Fund and the way forward with collating information and Mr Vivian raised concern over capacity with arranging such events. Plans are underway to hold a joint patient and engagement event with Telford & Wrekin CCG (provisionally set for 1 March). Finances available from NHS England Mr Ellis confirmed that some detail was available regarding finances and Mr Ellis was liaising with NHS England with regard to weighted patient numbers as there appeared to be different calculations to the normal weighted formula being uses. Discussion was held over winter access monies and extended access and Mr Ellis advised he had been liaising with Shropdoc about them providing this service and noted he would also be meeting with Mrs Woods for an update. Members noted the CCG had requested the use of NHS England s service level agreement (SLA) which they held for Shropdoc for current extended access model. Mrs Wilde reported she had asked Mrs Woods to forward the SLA to her and would be chasing this up. Concerns were raised over unrealistic time constraints and the timetables for which funding bids had to in to NHS England by and Mrs Wilde noted the CCG did their best to complete all bids within the set timescale and confirmed that ideally she would like to introduce another step in the bid process (to include a signing off process), but timescales do not allow this to happen. Members acknowledged the tight turn-around times and noted a better system was needed with regard to having information available in advance and also the CCG needed to be more robust with NHS England with regard to capacity and turn-around times. Mrs Wilde agreed to provide an update on winter monies once the primary care team had spoken to Shropdoc this week in relation to the increase in the coverage of the scheme from 47% up to 100%. The paragraph in the paper would be amended to reflect discussions with Shropdoc and an update would be sent to Practices by the end of the week. Mrs Wilde would also update on this at the next PCCC meeting. Further discussion was held about the outstanding data sharing agreements which were still to be signed. Discussion was held over the finance section of the workstream report and Mr Phil Morgan confirmed he was working on this with Mr Roger Eades. Mrs Wilde recommended that the finance information although submitting it regionally should also come to the PCCC so the Committee were aware of the current status. Mr Timmis also noted health inequalities and proposed that it would be useful for the PCCC to see information regarding morbidity and mortality rates and to look at the impact on patients. Mr Timmis advised as a general note for all reports the PCCC would benefit from seeing the background data for any subject which would enhance the reports. The PCCC noted all the information and recommendations and approved the report subject to having further information regarding finance and where possible detail regarding the impact on patients. ACTION: Mrs Wilde to provide an update on winter monies once the primary care team had spoken to Shropdoc this week in relation to the increase in the coverage of the scheme from 47% up to 100%. The paragraph in the paper would be amended to reflect discussions with Shropdoc and an update sent to Practices by the end of the week. Mrs Wilde would also update on this at the next PCCC meeting. PCCC (Agenda Item 7) Finance Update Mrs Skidmore presented this item for information and the following points were noted: Mrs Skidmore advised the financial position had not moved significantly from the month 7 reported positions. The outstanding action around any potential underspend and what the PCCC agreed to use the 47,000 underspend against was discussed. Mrs Skidmore noted she had spoken with Mrs Wilde and it had been confirmed this was the amount available but did not want to authorise it for spend just yet in case anything else came through in the next couple of months. Mrs Wilde noted she was comfortable to release this money in March and would need to look at how to use this money practically for Practices for example on access but reported she was concerned about timescales. Members noted the amount of funding per Practice would be small and it was suggested the money be disseminated under the GPFV work and noted the possibility a letter being sent to P a g e

255 Practices advising this was an additional payment to help ease the pressures over the next month. Mrs Wilde also noted she would like to retain some monies back and round the figure down to 40,000 which would be split between the Practices. The PCCC agreed with this option in principle and supported this idea. Mrs Wilde and Mrs Skidmore would look at a suitable date for this money to be released. It was agreed the wording that would be used in the letter sent out to Practices be clarified to ensure it is used for GMS with the final sign off for this proposal at the next PCCC meeting. A cut-off date which the money was to be used by would be set and an update on this would be brought back to the next meeting. Dr Allen raised conflicts of issues with the GPs involved and it was noted that if this was voted on GPs they wouldn t have vote. Dr Povey raised General Practice finances and seniority payments. Mrs Skidmore advised the figures for this would be better defined as the longer term finance model was constructed. Further discussion was held with regard to the figures in the finance report and tables and members noted it would be good to see information in the report which described what the tables represented. Mr Timmis thanked Mrs Wilde and Mrs Skidmore for all their work done on the primary care budgets and for providing a clear position. Discussion was held over the PMS practices and spend and premium monies and the change over into GMS and how the PMS premium was going to be re-invested into primary care ( 70,000 or 80,000). Members noted this funding was included in the budget lines however, this was not specific. It was agreed Mrs Skidmore clarify the position re PMS premium monies and re-investment of these monies in future finance reports for the PCCC. ACTION: Mrs Wilde and Mrs Skidmore would look at a suitable date for this money to be released. It was agreed the wording that would be used in the letter sent out to Practices be clarified to ensure it is used for GMS with the final sign off for this proposal at the next PCCC meeting. A cut-off date which the money was to be used by would be set and an update on this would be brought back to the next meeting. ACTION: It was agreed Mrs Skidmore clarify the position re PMS premium monies and re-investment of these monies in future finance reports for the PCCC. PCCC (Agenda Item 8) Primary Care Working Group (PCWG) - Update Mr Steve Ellis presented this item and the following key points were noted: It was noted the Primary Care Working Group met on 20 December and the following areas were discussed: - GPFV the update on this as given earlier in meeting. - Clinical pharmacists - Sean Mackey had asked Practices if they wanted to take bids forward and the CCG were supportive of this. - Mandatory training matrix and who the responsibility lay with - It was noted the mandatory training was the employer s responsibility (Practice responsibility) with CCG support. - LCS review - work was ongoing with this. - Easter period and cover with Practices and pressures points was discussed. Mr Ellis informed members a new cycle of dates had been agreed for the Primary Care Working Group. The meeting would now be held on a Tuesday with the next meeting due on 16 January The Committee went on to discuss whether the PCWG was still relevant and needed. It was proposed the PCCC re-consider the PCWG functions and the nature of this group in terms of timing of work and reports for the PCCC meetings. Members agreed it would be useful to look at this and it was agreed to explore this further at the next meeting. Mr Ellis agreed to forward the PCWG TOR to Mr Timmis with a view to linking this more closely with the PCCC TOR. Mrs Clarke raised mandatory training and safeguarding training and requested the safeguarding leads be involved in this work P a g e

256 ACTION: Members agreed it would be useful to look at the functions of the PCWG and it was agreed to explore this further at the next meeting. Mr Ellis agreed to forward the PCWG TOR to Mr Timmis with a view to linking this more closely with the PCCC TOR. PCCC (Agenda Item 9) Quarterly Assurance for NHSE Mrs Wilde presented this item and the following points were raised: The PCCC were asked to agree the content of the report and to recommend this be sent to Dr Simon Freeman, CCG Accountable Officer and Mr William Hutton, Audit Committee Chair for sign off prior to submission to NHS England. The next quarterly assurance report was due in April 2018 and Mrs Wilde confirmed she was would be meeting with internal audit next week. Discussion was held as to whether the quarterly assurance report should be posted on the CCG website additional to the PCCC agenda and papers. Mrs Tilley advised she would upload the document onto the CCG website should this be required. The Committee noted all the information and approved the report. PCCC (Agenda Item 10) Primary Care Estates Update Mr Timmis asked any GP members who were partners at a Practice to sit in the audience for this item due to conflict of interests. Mr Ellis presented this item and the following key points were noted: Mr Ellis advised this item was presented in the part 2 of the December PCCC meeting and the amendments noted at that meeting had been made. Discussion over rurality was held and Mr Ellis noted all of Shropshire came out as rural apart from Shrewsbury. Mrs Wilde proposed Public Health could help the CCG with this work and take this information to the next level to make it meaningful. Councillor Madge Shineton noted that Shropshire Council had a vast amount of information and data available that the CCG could use and suggested the CCG contact Mr Tom Dodds, information analyst and Professor Rod Thomson from Public Health at the Council. Mrs Skidmore proposed the CCG linked this work through the Local Estates Forum as the Shape Toolkit was a big database which held a lot of this information regarding rurality data. This link was already in place, however Mr Ellis confirmed he would be liaising with the Council about this. Mrs Clarke asked about page 2 the monitoring form, under point 1and additional staffing section. Mrs Clarke suggested the answer in this section should be yes as this work would have huge implications. Mr Timmis raised the section regarding leasing commencing issues noted on page 6 and asked how lease commencing was defined. Mrs Wilde informed members of the issues with GP Practices and leases and noted that Practices would be asked whether they would be prepared to hold the lease before the business case stage. It was noted GPs would need to let the CCG know by outline business case stage. It was agreed Mr Ellis would amend the paragraph to clarify this point and to make it clearer that a decision would need to be made by the Practice at the very latest by outline business case stage as to whether they were taking on a lease. Subject to the above amendments the PCCC approved the report. ACTION: It was agreed Mr Ellis would amend the paragraph to clarify this point and to make it clearer that a decision would need to be made by the Practice at the very latest by outline business case stage as to whether they were taking on a lease. PCCC (Agenda Item 11) NHS England Update It was noted that Mrs Woods was due to attend to present on this item, but unfortunately Mrs Woods was not present at the meeting to present this item and no report had been received. Mrs Wilde raised MOU and referred to previous conversations held at the PCCC meeting with regard to the relationship and responsibilities between the CCG and NHS England. As part of the MOU document there was some reporting that NHS England agreed to provide and it was noted that whilst the PCWG were beginning to get some information through from P a g e

257 NHS England about partnership changes, more information was needed. Concerns over who was responsible for what areas of work and were also noted and the Practices were unsure of which work NHS England were responsible for and what the CCG were responsible for. It was proposed the PCCC ask Mrs Woods to include the update relating to MOU as part of her general update for PCCC. Mrs Skidmore suggested looking at the MOU to see if this document was meeting the needs for the CCG and to see if the CCG was getting sufficient support from NHS England. It was agreed Mrs Wilde would look at this and suggest to Mrs Woods the update on MOU be provided alongside the general NHS England update. Mr Timmis also requested if Mrs Woods could send the NHS England update that would have been provided for this meeting to Mrs Wilde to enable this report to be shared with the Committee. Mrs Wilde agreed to follow this up. ACTION: It was proposed the PCCC ask Mrs Woods to include the update relating to MOU as part of her general update for PCCC. Mrs Wilde would look at the MOU work and suggest to Mrs Woods the update on MOU be provided alongside the general NHS England update. Mrs Wilde would also request from Mrs Woods the NHS England update which would have been provided for this meeting to enable this report to be shared with the Committee. PCCC (Agenda Item 12) Any Other Business There was no further business. Questions from the Public Councillor Madge Shineton noted she had raised this issue at the last PCCC meeting with regard to patient notes and no digital connection between hospitals in relation to getting access to patient notes. Dr Povey advised this issue could be raised through the contracting route and advised Councillor Shineton to raise this with Mrs Gail Fortes-Mayer. Councillor Shineton asked for contact details of who to forward this information onto. Mr Tom Brettell advised he had been working with Councillor Shineton and Cleobury Mortimer Medical Practice on this issue and noted work was ongoing with this. Mr Timmis and Dr Povey thanked Councillor Shineton for her comments and closed the meeting by thanking all attendees and members for their attendance. Date of Next Meeting The next meeting is due to be held on Wednesday 7 February 2018, 9.00 am, in Meeting Room K2, William Farr House, Mytton Oak Road, Shrewsbury SY3 8XL P a g e

258 Agenda Item GB CCG Governing Body System A&E Delivery (SAED) Board Meeting Aldridge room, Halesfield, Telford Date of Meeting: 28 November 2017 Time of Meeting: Attendees: Simon Freeman David Evans Julie Davies Graham Shepherd Nicky Jacques Tanya Miles Jo Leahy Sally-Anne Osborne Colin Ovington Sarah Dillon Sarah Draper Jenny Sears-Brown Linda Duncan 2.00pm pm Accountable Officer, Shropshire CCG Accountable Officer, Telford and Wrekin CCG Director of Performance & Delivery, Shropshire CCG Chair, Shropshire Patient Group Chief Officer, Shropshire Partners in Care Deputy Director of Adult Social Care, Shropshire Council Chair, Telford & Wrekin CCG Deputy Director of Operations, Shropshire Community Health Trust A&E Recovery Lead, SaTH Associate Director of Adult Social Care, Telford & Wrekin Council Delivery & Improvement Lead, NHSI Local Operations Manager, West Midlands Ambulance Service Notes 1. Apologies Apologies were received from Simon Wright, Jan Ditheridge, Steve Gregory, Andy Begley, Dawn Clarke and Fran Beck. 2. Minutes of Previous Meeting Jenny Sears-Brown advised that, although listed as an attendee, she had not been present at the October meeting and her apologies had also been noted. Pippa Wall had attended the meeting on her behalf. With this amendment to the attendance list, the minutes of the previous meeting (31 October 2017) were agreed. Matters Arising Matters arising from the previous minutes are included as agenda items 3. Feedback from Urgent Care Escalation Meeting Julie Davies advised that the Urgent Care Escalation meeting held on the 15 th November 2017 felt better than previous although there was still concern that overall system capacity was insufficient to meet demand over the winter period. During the discussion the following was noted:- Time patient declared medically fit for discharge need to measure if a material delay then do something about it, this has been requested from John Cliffe with hopefully an update to A&E Delivery Group meeting tomorrow Neurology rehabilitation is costing millions of pounds across the region. The trust is working Page 1 of 6

259 to increase the workforce, and more urgent discussions are needed. The trust has been asked to put forward what is required. Discussed pull-out of hospital, community services and review of community beds and this was going to A&E Delivery Group meeting tomorrow. This was requested to be enacted by the 1 st December and had been passed to Dawn Clarke to look at as soon as possible There were 11 community beds this morning and only 3 reserved. David Evans reported that the CCG had received a call to request spot purchase of beds but available capacity is not being utilised. Simon Freeman advised that there was a set of criteria to look at with defined specification for patients to use these beds and there were no patients in SaTH who met the criteria there were 7 last night. Sally-Anne Osborne added that there were 5 when finished with 1 taken up at 3am. Simon Freeman advised that Shropshire was not good at hospital at home; would normally be better balance between virtual and physical beds. There is massive CHC spend in Shropshire, other services not commissioned so are going into CHC Complex discharges are increasing, don t have the volume of patients to discharge therefore causing the blockage There are problems with adult handovers Impact of 111. It was felt that to undertake the national switch in December would be problematic and if carried out after Easter would mitigate problems. Simon Freeman advised a telecommunications issue with 111 Welsh patients registered with an English practice can t access 111 therefore an alternative out-of-hours number would be required. David Evans reported that the Welsh 111 system will go live on the 1 st April 2018 therefore the reasoning behind stopping the ShropDoc number mid-april 2018 would assist and added that Telford and Wrekin CCG Governance Board agreed to the mid- April ShropDoc number switch off this morning. Simon added that this issue would be discussed at the Shropshire CCG Board tomorrow. Graham Shepherd queried why still waiting for ShropDoc and 111 data as he thought it had been agreed at the May meeting what data was needed and where it was coming from. Julie Davies advised that there had been a significant step change since April and we don t accept we are trying to understand the change, 93% of the over-performance we are seeing in the ambulance contract we think is coming from 111, also there have been no increase in admissions, Simon Freeman added that this will be protocol driven Jo Leahy reported that she had visited Dudley call centre, also ShropDoc the week before although in Dudley she had sat with the most experienced call handlers Jo to ask Jane about this. Graham Shepherd advised that the visits were unannounced but were not comparable as not like-for-like. 4. Current Performance Against Trajectory/Key Actions The attached presentation was given outlining current performance: SAED November.pptx Julie Davies reported that performance was not good. Last week s dashboard had not yet been received and MAU activity was included in last week. Julie Davies reported that we had got used to a level of performance of 70% and not yet seen factored-in MAU data last week was particularly bad with a 30% increase in ambulance Page 2 of 6

260 Page 3 of 6 conveyances further information requested but not yet received. Need to understand what happened last week; there was an ambulance meeting this morning. Jenny Sears-Brown reported that on Monday there was exceptional activity across the region with 4000 incidents. Efforts are being made to, efforts being made to understand the cause, looking at HALOs now in situ, need to challenge crews to see if the patient could be taken elsewhere, also looked at same-day discharge with no diagnostic intervention and this will be sent to Colin Ovington. David Evans suggesting stripping out bloods as this could be carried out elsewhere and Jo Leahy added that if requested blood results could be obtained quickly. There had been lots of ambulance feedback that between 5pm and midnight was the busiest and Julie Davies added that there could be a decision to admit overnight then the decision is reversed the volume of arrivals needs to match the decision-maker; also the GP referrals patients coming in late in the evening might explain the 30% increase. Jo Leahy suggested that these patients should be coming in during early afternoon depending on what time they are visited by the GP. High Level Indicators key changes Julie Davies reported that non-admitted should be up in the 90s but still struggling; 18 patients at PRH and 14 at RSH, stranded patients over is a real problem. David Evans advised that a further Escalation Meeting is scheduled for the 21 st December and David queried before discharges and what action is being taken to get to the target. Julie Davies reported that DTOC had been good in September with possible 5% for October. MFFD trying to concentrate on time rather than number and Simple Discharges need to be moving towards 900. There was a need to keep the good performance going. Graham Shepherd queried over 12-hour breaches and Julie reported 1 in October which is the only one had for some time. 5. GP Streaming The following was noted: Colin Ovington reported that having a Shropdoc team in ED had been tried with a maximum of 32 patients in a 12 hour period Jo Leahy advised that she and Joe Allen had visited SaTH and felt that the model is wrong, GPs need to carry out the streaming David Evans reported that he had challenged at the HSJ summit and that was not mandated Simon Freeman quoted the Luton model and what proportion they go through streaming. In RSH the missing factor was access to diagnostics agreement needed on what is the possible maximum number of patients and what is stopping that number being reached Jo Leahy advised a maximum of 5 per hour which is 120 per day is the problem a lack of patients Minors could be dealt with in general practice and should be telling patients that next time to go to their GP. Yesterday patients were being pushed through and numbers have been requested. 30 patients were treated and some were pushed back to other departments based on the illness category; also a staff competency issue Graham Shepherd reported that previously lucky to get 25 patients per day on weekdays and 60ish at weekends; data was looked at over past 2 weeks and there were only 3 patients who had been incorrectly streamed. Simon Freeman added that this equated to 300 per patient with a million and a half investment Julie Davies advised the need to discuss the best use of this resource and diagnostics is key therefore will need to look at this. Jo Leahy advised that GP streaming is with Shropdoc, if using EMIS could use TQEST for diagnostics Simon Freeman suggested would be useful to know the number of patients going through and Colin Ovington added that it was also about the criteria used. David Evans reported

261 469 patients yesterday with 65 through the urgent care centres and suggested asking Luton what their criteria is Simon Freeman advised that with 60 patients short per day across both sites this was still expensive. Colin Ovington advised there should be at least 100 and it was suggested to ask Claire Old when she comes into post on Friday (1 st December) to see Colin to assist in getting the information; Colin added there may need to be a contractual discussion David Evans queried whether every patient coming to Luton A&E would go through streaming. Simon Freeman advised in Leicester all patients would come in by ambulance, there would be no foot-fall cost of triage has to be cheaper Page 4 of 6 Bed availability looking a gathering a range of data sets and can now tell if kept in A&E control then doing well with up to 100% on some days; delays are caused when we have to rely on other Organisations or parts of other Organisations - up to 50% of patients will have a decision to admit within 3 hours and will then require a bed. Julie Davies reported that today needed 200 discharges only 49 in total in PRH. Jo Leahy advised that the work she and Alastair were doing may help what intervention is most at risk of holding patients up. Red day means nothing happens and red-to-green doesn t tell you what is stopping it happening therefore unsure red-to-green informs what to do to get it right but tells you what the team has done correctly. David Evans felt that acceptance of the level of risk that needs to change and Simon Freeman added that would normally have senior people on calls but this week are struggling - a simple discharge may need drugs but don t require further treatment which gives the impression that they could walk straight home, however this may not be correct as they may need transport or a possible wait for drugs etc. There was a need for an on-line pharmacy system as the pharmacy seems to be the bigger delay. Julie Davies suggested that Claire Old could look at what is stopping discharge and going in to look at what patients are waiting for. Also to look forward at complex patients in preparation for the following weeks discharge; need not do everything in parallel, carry out discharge and planning in coordination, almost applying principles for cancer to discharge suggest Claire focus on this with her ECIP experience. ACTION: Claire Old to be asked to focus on discharge planning using her ECIP experience Handover Delays The following was noted: Julie Davies advised that this works well, however problem was getting patients into beds; needed to be tracked, HALO is very specific. Jenny Sears-Brown added there is a HALO report daily Colin Ovington reported received assurance trying to get nurses on every shift. Nonadmitted breaches should be 90% and do get mid to high 90s by streaming minors Simon Freeman advised that on the call today, Pauline Phillips asked Simon Wright if there was an option to take down planned care to free beds Julie Davies suggested a re-think on what the top 5 actions are to get to performance. Simon Freeman asked what the right target was as seems quite high and the number of non-admitted patients where the pathway is clearly wrong unsure whether 95 is correct. If patient goes to CDU then is no longer on the clock Colin Ovington advised the need to work on non-admitted breaches and identify the top 5 actions; although this won t be achieved without unclogging MAU Colin Ovington advised of the Clinical leadership issue 1 consultant joining but 3 more possible; however if these are recruited would still be over-recruiting. Also have a good nurse who had been given a position in Stoke and was about to leave the team, however

262 have now created new role within the team and will now remain. Simon Freeman queried whether we can track the current Shropshire resident consultant to carry out extra shifts; however David Evans suggested that this wouldn t solve the senior decision-maker problems as beds needed to be freed-up. Colin Ovington advised the need to look at the whole thing rather than in silos and how to get the best out of the system 6. Improving Flow through A&E Julie Davies requested whether this can be split before midday. Colin Ovington advised he will look at how easy that would be to achieve. Colin Ovington reported that he had spent time with David Ashcroft from NHS I with regard to how to challenge at the front door. 7. Complex Discharges Julie Davies reported that there was a meeting tomorrow, after which it was hoped to have better monitoring arrangements then Julie can share with the SAED next month. There was concern that if FFAs not getting through then were not completed in a timely manner. Julie advised that 165 patients were needed across the system and concern about Powys as they were not represented on today s call. Today there were 17 patients on the medically fit list with 13 of them Powys patients. 2 delays in Community Hospital with 1 Powys patient need to mutually escalate the concerns. 8. Discharge to Asses Julie Davies reported that a Trust Assessor had been appointed for care homes and an update will come to the next meeting once they have been in post for a month. It was important to build on relationships to support discharges and important in December to get the foundation right. Julie added that there would now be a move away from the title of Trust Assessor to Independent Care Assessor. ACTION: Update to future meeting - agenda 9. Ambulance Handover Directive The following was noted: Colin Ovington reported that the letter set out how the country is expected to handle ambulance handovers, there shouldn t be delays in handing over patients however, during the past 2 days alone this was not working Is the emergency portal the correct portal a patient has to be processed and admitted into ED, however if the patient is for gynaecology then should be taken to the gynaecology department and moves the queue to somewhere else conversations are ongoing Simon Freeman was concerned with recommendation 15 CCG being responsible for overseeing daily schedule of GP visits from all surgeries to ensure large numbers of ambulances do not arrive together this is not feasible, of GP direct admissions 99.9% are relevant Julie Davies advised this is about demand a patient not been able to manage overnight but won t present until mid to late morning. Also about managing the clinical risk when a GP thinks the patient needs to be admitted then would want this to happen straight away Colin Ovington reported that there was still more to be worked through last week in one day there were 17 patients on trolleys and part of the document is about the number of trolleys in use (ambulance and hospital trolleys); Colin added that he did not have Simon Page 5 of 6

263 Wright s view on this as yet 10. Any Other Business There was no further business and the meeting closed 11. Date and Time of Next Meeting: Julie Davies reported today s meeting agenda stated that the December SAED meeting date was yet to be confirmed; the meeting usually takes place on the 4 th Tuesday of each month, however this would not be possible for December. Also a meeting would need to be held before the next Urgent Care Escalation meeting scheduled for the 21 st December. Following a brief discussion, the 19 th December was suggested and agreed for the next SAED, to be held in Telford at 3pm to follow the Telford and Wrekin CCG GP Practice Forum. (Aldridge room, Halesfield booked) Page 6 of 6

264 A&E Delivery Board Current Performance 28 th November 2017 Version 0.4

265 Current Performance

266 Indicator Movement from previous value High Level Indicators key changes Target Latest Value Previous Value Non admitted % 95% 86.9% 84.8% A&E Attendances vs plan 0% -0.2% +2.0% Emergency Admissions 0% -6.7% +0.9% Discharges before 12 30% 15.75% 14.5% Stranded patients < DTOC SaTH 3.5% 2.4% 3.1% DTOC Shrop Comm 3.5% 8.0% 6.0% MFFD Simple Discharge Complex Discharge

267 Patient Streaming GP Streaming has been in operation since 28 th October 472 patients have been seen in the PRH GP Streaming service since it started on 28 th October to 23 rd November averaging 17 patients per 12 hour day (range 8 to 32) Operational and clinical teams have been working together to increase the number of patients being referred to the service, but without any real impact Tow issues are criteria for identifying relevant patients and the second is competency of the staff delivering GP streaming for minor injury care The Practice Development Nurse from PRH is spending time at RSH to see how GP streaming is conducted and to bring learning back to enhance practices at PRH

268 Improving flow through A&E

269 Ambulance handover pilot started on the 9 th October has continued in place for 12 hours at peak times Patient Handover Delays NHSI have advised on the fit to sit initiative (23/11/17) and amendments have been made to the ambulance handover to make better use of the information including gaining the NEWS/MEWS or PEWS which will indicate who is more able to sit National letter to address ambulance handovers received on 15 th November, WMAS response to SaTH received 22 nd November to advise that they will handing over patients and not waiting beyond 15 minutes from 1 st December HALO appointments to a weekend rota started 17 th November until the end of March Top 3 actions Who What are the three key actions we need to achieve next month? What is the expected impact on the related key indicator/s? Has it had the corresponding impact on reducing A&E breaches and improving 4hr performance? Sep Oct Nov Dec 2018 Mark Docherty Colin Ovington Improve the handover process for patients conveyed to hospital. Eliminate the number of over 1 hour ambulance patient handovers. Improves 4 hour waiting time targets by reducing delays at the start of the patient pathway. Across both sites, November 2017 there were an average of 6 over 1 hour delays each day. 4 Achieved <1 (average per day across both sites) Mark Docherty Colin Ovington Improve the handover process for patients conveyed to hospital. Reduce the number of patients waiting over 30 minutes to be handed over from ambulance crews to ED team. Improves 4 hour waiting time targets by reducing delays at the start of the patient pathway. In November, more than 30% of patient handovers exceeded 30 minutes 25 Achieved <10% Mark Docherty Colin Ovington Improve data recording of patient handover More accurate data helps identify areas for improvement Recording the patient handover is poor, and needs to be improved 81% at PRH and 77% at RSH. The Regional target is 95% >97%

270 Non admitted breaches ENP recruitment process under way with only one of the new recruits who will join the team in January, an additional advert is to be put out as other ENP s have approached the Matron about joining the team CDU identified on the AEC at PRH, however the area has been used continuously for six escalation beds which is preventing the CDU functionality A capital bid has been placed with NHSI to build a dedicated CDU Non-admitted breaches are 85.82% YTD for Non admitted minors 93.5% YTD and non admitted majors 52.52%YTD Non admitted majors are predominantly patients waiting on-going care who would be admitted to CDU, and blocked from doing so by inpatient beds Top 3 actions Who What are the three key actions we need to achieve next month? What is the expected impact on the related key indicator/s? Has it had the corresponding impact on reducing A&E breaches and improving 4hr performance? Sep Oct Nov Dec 2018 Colin Ovington Implement Streaming at PRH Patients signposted to relevant services Reduce demand in line with contractual plan Relieve pressure on ED services and team 95% of avoidable non-admitted patients to be discharged within 4 hours 91 Achieved achieved Colin Ovington Redesign ED process based on analysis of daily breach data and assessment of daily shift logs focusing on identified areas that are amenable to transformation. Develop a CDU at PRH to ensure patients with less than 24 hours have an appropriate environment for that care to be delivered Reduce internal delay in ED 95% of avoidable non-admitted breaches to be discharged within 4 hours 91 Achieved achieved Mark Doherty Minimise the number of patients conveyed to hospital who are subsequently discharged with no further treatment Minimise ambulance handover delays Eliminate the number of over 1 hour ambulance patient handovers. Reduce the number of patients waiting over 30 minutes to be handed over from ambulance crews to ED team <2% RSH <5% PRH

271

272

273 Clinical leadership / Engagement issues Consultant team remains 5 substantive and 4 locum Clinical team modelling of the workforce to be undertaken in the next three weeks Top 3 actions Who What are the three key actions we need to achieve next month? What is the expected impact on the related key indicator/s? Has it had the corresponding impact on reducing A&E breaches and improving 4hr performance? Sep Oct Nov Dec 2018 Deirdre Fowler Matron of the day removed and refocusing role of matron to support staff to implement Criteria Led Discharge in both USC and SC Discussed at subspecialty operations meetings and governance meetings Establish the process for KPIs 1. Reduce ALOS and bed occupancy, 2. Increasing the number of discharges outside core hours 3. To provide safer discharge and assurance around CLD 1. Process too early to measure 2. This will only start to impact in October 3. Audit of readmission rates will be analysed in October Dr Edwin Borman Medical clinical lead identified to support the embedding of safer R2G and Criteria Led Discharge Medical Director training session on patient flow Leadership programme in place to develop behaviours and values aligned to the trust strategy Reduce LOS Increase pre 10 discharges Smoother pathway for patients Beds available to admit patients earlier in the day should help improve the admitted patient performance Achieved Achieved Carol McInnes Management of frail patients is in pilot phase focused on MDT effective working. Specific KPI s have been designed into this project and monitored from the 4 th September 2017 Reduce the number of stranded patients. Reduced LoS for patients who fit the criteria on the frailty pathway Beds available to admit patients earlier in the day should help improve the admitted patient performance Achieved Achieved

274 Three additional ENPs were recruited only one will now be joining the team in January 2018 Workforce plans Additional recruitment is underway for more ENP and paramedics to join the team three more ENP s have approached us about vacancies New role being created at PRH as a lead nurse/specialist in majors and resuscitation Top 3 actions Who What are the three key actions we need to achieve next month? What is the expected impact on the related key indicator/s? Has it had the corresponding impact on reducing A&E breaches and improving 4hr performance? Sep Oct Nov Dec 2018 Colin Ovington Recruitment of Emergency department Consultants Learn from the Leicester experience in international recruitment Improve the number of consultants in the workforce which increases the senior decision making capacity Improve the decision making time line and the review period particular reference to the admitted patients Achieved Achieved Colin Ovington Recruitment of ACP to fill gaps at junior and middle grade - training model and test the market place for experienced ACP s Increase in senior non-medical decision making Improve the decision making time line and the review period particular reference to the admitted patients Achieved Achieved Ceri Adamson Rework the nurse staffing model to ensure that the base establishment is aligned to service including the numbers of ENPs and future proofing the alignment Improving the skill mix, increases shift coordination and decision making for minors stream of patents Improve the decision making time line and the review period particular reference to the minors and non-admitted patients 91 Achieved Achieved

275 Improving flow In and Out of Hospital

276 Embedding SAFER/ R2G A detailed work programme has been put in place across SaTH to ensure that the internal flow of patients into and out of the trust is working more efficiently with leadership from Executive Directors and programme oversight by the CEO SAFER - Board Rounds; - Ward Rounds; - 4pm Huddles. Red to Green is being refocused Rollout Respiratory Value Stream (VMI Learning) Bed Reconfiguration - detailed planning work is underway to increase bed numbers on some wards at both hospitals which should substantially reduce the need for boarding and patients sleeping in the A&E s., although this is more problematic at RSH Increasing Weekend Discharges, Criteria-led Discharge Front Door Specialty In-reach 7 Day Working Ring fencing Assessment Areas (AMU/SAU/AEC) Frailty Unit (STP and SAED priority) Project 15 SaTH2 Home Discharge Liaison Model Top 2 actions Who Deirdre Fowler What are the three key actions we need to achieve next month? Implement Criteria led decision making for all key decisions that otherwise lead to delays waiting for doctors What is the expected impact on the related key indicator/s? Reduce ALOS and bed occupancy, and increasing the number of discharges before midday; freeing beds for emergency admissions Deirdre Fowler Achieve 30% of discharges before midday Will impact positively on Bed availability during the day and early afternoon Has it had the corresponding impact on reducing A&E breaches and improving 4hr performance? Improvement in the number of patients who need admitting to hospital doing so within 4 hours (12 patients per day) Admitted Breaches will reduce by 500 per month Sep Oct Nov Dec Achieved % Achieved 15% Achieved % Achieved 14.5% % 25% 30%

277 Internal Flow Daily graph demonstrates discharges from the trust which requires further work to improve performance of discharge processes earlier in the day to achieve the expected level of 30% discharges before 12pm early indicators are demonstrating 20% before midday for November

278 Admitted breaches Definite and demonstrable variation in performance which is reliant upon senior clinical decision making Performance slightly improved at PRH and relative static at RSH A fit to sit model has been put in place in the majors areas to help reduce blocking of a trolley area meaning that we have a place to assess patients at the time of arrival in majors. NHSI were invited in to give advise on the application of the F2S model and a number of amendments to the ambulance handover have been put in place as a result Top 3 actions Who What are the three key actions we need to achieve next month? What is the expected impact on the related key indicator/s? Has it had the corresponding impact on reducing A&E breaches and improving 4hr performance? Sep Oct Nov Dec 2018 Carol McInnes Ensure one bed available on all key wards (to be identified) for admissions at all times Bed occupancy to be 93% on a routine basis and 85% leading into a public holiday Reducing trend in the breach analysis that records unavailability of an AMU or specialty bed Improvement the number of patients who need admitting to hospital doing so within 4 hours Achieved Achieved Colin Ovington Reduce complexity of admission processes to minimise delay Reduce time spent on admission process within the emergency department Improvement the number of patients who need admitting to hospital doing so within 4 hours Achieved Achieved Colin Ovington Reduce the number of specialty patients being sent via the ED as an admission portal for acute services Reduce the inappropriate demand for ED clinical time, allowing true emergencies to be managed according to clinical plan and within 4 hours Improvement the number of patients who need admitting to hospital doing so within 4 hours Achieved Achieved

279

280