Governing Body Part One

Transcription

1 Governing Body Part One Agenda Item 3.1 Minutes of the Part One Meeting held at 2.30pm on Thursday 25 th January 2018 in the Forest Hills Golf Club, Mile End Road, Coleford, GL16 7QD Present: Dr Andy Seymour (Chair) AS Clinical Chair Mary Hutton MH Accountable Officer Alan Elkin AE Lay Member Patient and Public Engagement and Vice Chair Dr Caroline Bennett CBe GP Liaison Lead North Cotswolds Locality Cath Leech CL Chief Finance Officer Colin Greaves CG Lay Member - Governance Ellen Rule ER Director of Transformation and Service Redesign Helen Goodey HG Director of Locality Engagement and Primary Care Dr Jeremy Welch JW GP Liaison Lead Tewkesbury Locality Joanna Davies JD Lay Member Patient and Public Engagement Julie Clatworthy JC Registered Nurse Dr Lawrence Fielder LF GP Liaison Lead Forest Locality Dr Lesley Jordan LJ Secondary Care Doctor Margaret Willcox MWi Director of Adult Social Care, GCC Marion Andrews-Evans MAE Executive Nurse and Quality Lead Mark Walkingshaw MW Director of Commissioning Implementation and Deputy Accountable Officer Peter Marriner PM Lay Member - Business Dr Sheena Yerburgh SY GP Liaison Lead Stroud and Berkeley Vale Dr Will Haynes WH GP Liaison Lead Gloucester Locality In attendance: Becky Parish BP Associate Director of Engagement and Experience Caroline Smith CS Senior Manager, Engagement and Inclusion Christina Gradowski CGw Associate Director of Corporate Governance Mary Coupe MC Safeguarding Administrator Ryan Brunsdon RB Board Administrator There were 41 members of the public present. Page 1 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

2 1 Welcome AS welcomed everyone to part one of the Governing Body meeting. He stated that this was a meeting held in public and not a public meeting. Questions from the public had been sent to the respective NHS organisations in advance of the meeting and would be answered as part of the meeting. Apologies were received from: Alan Gwynn (AG), Hein Le Roux (HLR), Sarah Scott (SS) and Kim Forey (KF). 1.3 The meeting was confirmed as quorate. 2 Declarations of Interest 2.1 LF declared an interest as a Forest of Dean GP. 2.2 WH and AS both declared interests as GPs from Gloucester City. The Governing Body noted the potential implications of decisions made with regard to the Forest of Dean and the impact on Gloucester City locality. 3 Health and Wellbeing for the Future: Community Hospitals in the Forest of Dean Outcome of Consultation 3.1 AS introduced the Health and Wellbeing for the Future: Community Hospitals in the Forest of Dean Outcome of the Consultation. A joint consultation was undertaken by NHS Gloucestershire Clinical Commissioning Group (GCCG) and Gloucestershire Care Services NHS Trust (GCS) on the preferred option for a new community hospital in the Forest of Dean. The outcome of the consultation report had been carefully considered by both organisations which included taking into consideration the feedback from the Gloucestershire Health and Care Overview and Scrutiny Committee (HCOSC) following its meeting held in public on 9 th January In line with national guidance, while recognising that NHS bodies were not bound by the views expressed by those who took the opportunity to respond to the consultation, both GCCG and GCS were committed to ensuring that the views of HCOSC and the public were fully considered and taken into account as part of the decision making process. Page 2 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

3 3.2 AS acknowledged that the presentation made within the seminar on the Community Hospitals in the Forest of Dean comprehensively covered the outcome and the response to the consultation, including the detailed recommendations. It was also noted that the CCG Governing Body had observed and listened to the discussion and debate held by the GCS Board, which would be taken into consideration in the Governing Body s deliberations on the consultation outcome and recommendations. 3.3 AS identified that there were a number of questions that had been sent to the two respective NHS organisations in advance of the meeting. It was noted that the GCS Board had discussed and responded to the majority of the questions as they primarily related to GCS. However there were a number of questions that related to the CCG and would be answered during the course of the meeting. The questions and answers would be made available to the public via each organisation s website. 3.4 AS presented the first public question that had been submitted. It read as follows: As a retired professional statistician, I was appalled by the comments made by the individual who "analysed" the survey results for the Forest Hospitals consultation at the meeting in Shire Hall last Tuesday. Firstly, she failed to point out that the difference between the responses to the "easy read" and "full" versions of the questionnaire were so large that either they were asking different questions, or they were answered by different populations. It ought to be possible to test whether the "full" versions were disproportionately completed by health professionals, which would point to the second option. Next, she claimed that "less than 400 responses would have been adequate" to get a representative cross section of the Forest population. This would be true, if (a) a 10% confidence interval was adequate (but the difference between pro/anti response was much less than 10%) and (b) the sample used was truly random. However the "analyst" clearly did not have the necessary skills or training to understand either point, which suggests that her statistical Page 3 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

4 knowledge is completely inadequate to the task she had been given. Thirdly, and much more seriously, she said that "obviously anyone who agreed with the proposal wouldn't have bothered to fill in the questionnaire". This indicates a significant bias in her thinking, as well as proving that she does not believe that the sample completing the questionnaires was in any way random. I suspect that the problems illustrated here provide sufficient evidence to justify a judicial review of the validity of the consultation, if the proposal to sell off both hospital sites is accepted AS read out the response to this question which was: The questions asked in the Main Survey and Easy Read Survey are similar, but not exactly the same. Advice was sought from 2gether NHS Foundation Trust in the development of the Easy Read Survey. Easy read, as a format, was created to help people with learning disabilities understand information easily. Easy read uses pictures to support the meaning of text. Easy read is often also preferred by readers without learning disabilities, as it gives the essential information on a topic without a lot of background information. It can be especially helpful for people who are not fluent in English. During this consultation we also targeted the Easy Read Survey to the younger population. In this case, 56% of respondents who answered the question in the Easy Read survey which asked whether they considered themselves to have a disability, indicated that they did not have a disability. Responses to the Main Survey by health or care professionals. There were 3344 responses to the combined surveys. There were 2990 responses to the main survey people responded to the question in the main survey, which Page 4 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

5 asked whether they were health or care professionals or a community partner or a member of the public (1237 people did not answer this question). 279 (16%) respondents indicated that they were health or care professionals (84%) indicated that they were community partner/members of the public (84%) Of the 279 health or care staff, 204 (73%) supported the proposal, 55 (20%) did not support the proposal and 20 (7%) did not know. Sample Size The consultation team used a sample size calculator, which asks the following questions: What margin of error can you accept? 5% is a common choice for a margin of error. 5% was selected in this case. What confidence level do you need? Typical choices are 90%, 95%, or 99%. 95% was selected in this case. Response distribution or Percentage = 50% (always select 50%) Population size: 85,385 in this case. The sample size calculator recommended a sample size of: This is the minimum recommended size for this activity. The figures quoted at the meeting of HCOSC used the 5% margin of error and a 95% confidence level on a population size of 85,385. As an example to test the sample size calculator we selected 3% for margin of error and a confidence level of 99%, which gave a recommended sample size of This consultation achieved almost twice this amount of responses. Confidence interval Our sample size with a confidence level of 95% gives us a confidence interval between 1 and 2%. (1.66%) Page 5 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

6 Our sample size with a confidence level of 99% gives us a confidence interval of just over 2% (2.19%). Our sample size with confidence level of 95% and a confidence interval of 10% tells us we need a sample size of 96. Respondents Previous feedback to consultations locally and nationally suggests that the most motivated individuals participate in consultations. We are grateful to the many people who took the time to provide their feedback during this consultation. 3.5 ER outlined the principle aspects from the Case for Change document that informed the development and consideration of options for the future delivery of community hospital services. This resulted in the identification of a preferred option that was presented for public consultation. 3.6 ER gave due regard to the consultation feedback stating that population demographic information would be updated to take into account new information that had been received regarding the planned additional housing developments. However she considered this would not change the fundamental premise for the case for change. It was noted that the projected population figures would be updated to reflect changes in demography (Section 3, Forest of Dean profile, Case for Change). 3.7 ER highlighted some of the key challenges facing the Forest of Dean in terms of current service provision and key issues including, workforce pressures within primary care, poor estate infrastructure and GCS and 2gether (mental health services) increasingly moving towards integrated service provision. ER considered that significant progress had been made with developing primary care infrastructure with planned developments in place for the Cinderford area. 3.8 ER stated that the case for change document described the national and local strategic background covering the policy context and public feedback as well as emerging models of care and noted that the Sustainable Transformation Partnership (STP) was the vehicle through which improvements to local services would be steered. 3.9 ER commented that the diversity and range of opinions and feedback offered by respondents to the consultation was invaluable. Page 6 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

7 It was added that the feedback strongly prioritised the number of patient beds as a key issue in the consultation. This meant that further thought needed to be given to the work around urgent care, outpatients and community services ER advised that there would be increased collaboration between GP practices to provide a range of services in new ways on a larger scale. It was felt that practices will work more effectively with integrated community teams, community mental health teams, the voluntary sector and district councils AS asked the Governing Body to consider endorsing the Recommendations for the Next Steps following the public consultation, which had been clearly set out in the joint seminar held prior to the Governing Body meeting: The ten recommendations were: 1. Case for change; 2. Bed modelling; 3. Travel and access; 4. Planning for demographic growth; 5. Heritage and legacy; 6. Detailed service planning; 7. NHS Financial Framework; 8. Alternative options; 9. Impact assessment; and 10.Criteria and approach for appraising location and site. AS asked governing body members if there were any questions and points for clarification regarding these recommendations JC suggested that within the documents it was not sufficiently clear about the range of choices patients had with regard to alternative home and community base services and beds. This was illustrated by the number of concerns raised regarding the proposed number of beds. JC requested assurance that the new bed modelling methodology took into consideration all points made within the consultation. MH assured Governing Body members that all issues raised regarding the numbers of bed were being taken into consideration and work was being undertaken regarding the models of care for Gloucestershire. She stated that the development of new models of care would be shared widely through an open process with the public. MH commented that that there was work underway to review the End of Life Care (EoL) model by consulting with local Page 7 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

8 providers in the Forest of Dean, on an improved service offer to local patients MH explained that there were a number of factors that influenced the work on bed modelling including the review of EoL care, the rapid response service and the development of a complex care model. The complex care model was a collaborative project with GCS that would provide more proactive services, due to go live during 2018/19. It was noted that the Rapid Response Service was also seeing a significant increase in patients. Additionally a significant programme of work had commenced on nursing homes with GPs and therapists providing coordinated support to patients. MH considered that these community developments would have a significant impact on the number of beds required in the Forest of Dean WH commented that the bed modelling work would need to take into account out of area patients that were cared for in the Forest of Dean beds, for example Gloucester patients. He stated that it was important to ensure that there was continuity of care for patients who may be transferred between different sites, and collaboration between different healthcare professionals. It was also felt that transport was a key issue that also needed to be addressed. WH noted that the recommendations for the Forest of Dean had implications for the County as a whole. He stated that he was supportive of the direction of travel and the additional work required around beds and transport CG highlighted the issues regarding heritage and legacy. He queried how the heritage of the Dilke Memorial and Lydney and District hospitals would be maintained, should the Governing Body approve the preferred option for a new community hospital in the Forest of Dean. ER acknowledged that one of the existing sites could be recommended as the location for a new Community Hospital. She advised that there was a strong commitment from the CCG and GCS to respect the heritage and legacy of both sites and this would be undertaken in partnership with local people and the League of Friends JD questioned how the panel would be comprised and requested assurances that appropriate steps would be taken to ensure that the Panel was fully representative of the demographic profile of the Forest of Dean. ER explained that an independent organisation, Page 8 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

9 experienced in this kind of work would be commissioned to help establish the Panel. The organisation would ensure appropriate representation from healthcare professionals, organisations and the local community. ER informed the meeting that the Panel would meet in public and the presentation of options would be made in public. It was expected that the decision making process for the location of a new hospital would take a significant period of time to complete and a wide range of presentations would need to be made LF requested assurance that the investment within healthcare matched the needs of the population of the Forest of Dean. He noted the high level of need within the area, with significant prevalence of chronic diseases, high level of suicide rates which was symptomatic of social deprivation and an increasing aging population. MH confirmed that a Reference Group had been established within the Forest of Dean tasked with working to understand, along with Public Health (PH), the needs of the Forest of Dean and the demographic changes that anticipated expected. MH advised that a risk stratification tool had been purchased, which helped recognise inequality issues and future investment needs of the local population. ER added that there had been significant healthcare investment in the Forest of Dean including the rapid response service, extended access with additional GP appointments available, social prescribing and pulmonary rehabilitation developments as well as support to patients with diabetes to get active HG commented that the GPs within the Forest of Dean were working closer together as part of a cluster, and felt that the GPs should be closely involved in the design and development of hospital services JC asked for assurances that appropriate impact assessments, based on public health equality monitoring had been carried out on the consultation proposals. ER confirmed that this was to be taken into account and that there was a statutory requirement to do so. It was noted that further impact assessments would be undertaken as required JD queried whether the Unions had been consulted regarding the development of a new community hospital. MH confirmed that Tina Ricketts, HR Director of GCS had engaged and consulted with Page 9 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

10 Union representatives on the proposals and outcome of the consultation WH considered that it was important that the CCG and GCS worked closely with local NHS partners and people to ensure that the good quality services are developed and delivered within the new community hospital. MH advised that a One Gloucestershire plan for urgent care and centres of excellence was being developed. This plan would enable clinicians, managers and members of the public to work together to ensure that peoples lived experiences were fully reflected within planned service developments. MH commented that further information could be found on the CCG s website CG considered that the proposal for a new hospital should include consideration to cross border issues e.g. residents in Chepstow who may use Forest of Dean services. ER confirmed that the CCG was working with the Aneurin Bevan Health Board and consultation events had been held for Chepstow residents. ER stated that the plans for the new developments at Beechly took into consideration the local population needs RESOLUTION: Following a full discussion, the Governing Body voted on the three proposals and: 1) Unanimously confirmed it was satisfied that there was no new or material information which had come to light through the consultation that would bring into question the case for change 2) Unanimously endorsed the recommendations set out in the response to the issues identified through the public consultation; and 3) Unanimously approved the preferred option for a new community hospital in the Forest of Dean which would replace The Dilke Memorial Hospital and Lydney and District Hospital. AS confirmed the next steps as follows Undertake work to establish the Panel. Undertake appropriate work to address issues identified from the outcome of the consultation including bed modelling, Page 10 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

11 service developments and transport. The meeting was suspended at 3:07pm. Date and Time of next meeting: Part Two of the Governing Body Meeting reconvened at 3:25pm Minutes Approved by Gloucestershire Clinical Commissioning Group Governing Body: Signed (Chair): Date: Page 11 of 11 Draft Minutes from Governing Body Meeting, Part One 25 th January 2018

12 Governing Body Part Two Agenda Item 3.2 Minutes of the Part Two Meeting held at 3.25pm on Thursday 25 th January 2018 in the Forest Hills Golf Club, Mile End Road, Coleford, GL16 7QD Present: Dr Andy Seymour (Chair) AS Clinical Chair Mary Hutton MH Accountable Officer Alan Elkin AE Lay Member Patient and Public Engagement and Vice Chair Dr Caroline Bennett CBe GP Liaison Lead North Cotswolds Locality Cath Leech CL Chief Finance Officer Colin Greaves CG Lay Member - Governance Ellen Rule ER Director of Transformation and Service Redesign Helen Goodey HG Director of Locality Engagement and Primary Care Dr Jeremy Welch JW GP Liaison Lead Tewkesbury Locality Joanna Davies JD Lay Member Patient and Public Engagement Julie Clatworthy JC Registered Nurse Dr Lawrence Fielder LF GP Liaison Lead Forest Locality Dr Lesley Jordan LJ Secondary Care Doctor Margaret Willcox MWi Director of Adult Social Care, GCC Marion Andrews-Evans MAE Executive Nurse and Quality Lead Mark Walkingshaw MW Director of Commissioning Implementation and Deputy Accountable Officer Peter Marriner PM Lay Member - Business Dr Sheena Yerburgh SY GP Liaison Lead Stroud and Berkeley Vale Dr Will Haynes WH GP Liaison Lead Gloucester Locality In attendance: Becky Parish BP Associate Director of Engagement and Experience Christina Gradowski CGw Associate Director of Corporate Governance Ryan Brunsdon RB Board Administrator Helen Ford (Agenda Item 10) HF Lead Commissioner, Children s Health and Maternity There were 2 members of the public present. Page 1 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

13 1 Apologies for Absence 1.1 Apologies were received from: Alan Gwynn (AG), Hein Le Roux (HLR), Sarah Scott (SS) and Kim Forey (KF). 1.2 The meeting was confirmed as quorate. 2 Declarations of Interest 2.1 WH declared that he was a member of Gloucestershire Health Access Centre (GHAC). 3 Minutes of the Meeting held on 30 th November The minutes of the meeting held on Thursday 30 th November 2017 were approved as an accurate record, subject to the following minor amendment: The addition of JC within the attendance. 4 Matters Arising 4.1 5/10/2017 Agenda item 8.21, No Cheaper Stock Option Drugs (NCSO) MAE provided a verbal update regarding NCSO and informed the Governing Body that changes were being uploaded weekly to G-Care. MAE reported that the position was improving. AS suggested that the Governing Body was routinely updated on this issue through the performance report. Item Closed /11/2017 Agenda Item 8.20, Parkinson Nursing performance ER advised that the Parkinson s Nursing Team at Gloucestershire Hospitals NHS Foundation Trust (GHFT) gave a presentation at the Clinical Programme Board which identified that the Community Team were facing significant staffing pressures. The hospital team proposed the reconfiguring of services alongside the community team, which the Clinical Programme Board collectively thought would be beneficial. Item Closed. 5 Public Questions 5.1 There were no questions received from the public for part two of the Governing Body meeting. Page 2 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

14 6 Clinical Chairs Update Report 6.1 AS presented the Clinical Chair s report which highlighted key issues arising during October and November AS highlighted that the improved access clusters pilots, of which there were four, continued to develop. The pilots delivered improved access to primary care appointments until 8pm at night during weekdays, with further provision on Saturdays and Sundays. It was noted that during November 2017, there were an additional 396 appointments provided. HG advised that a fifth pilot had gone live. She expected the whole County to deliver improved access by the end of March AS noted that the Primary Care Workforce Strategy was due for the March Governing Body Meeting. HG suggested that the strategy should be circulated before the March Governing Body meeting so it could presented to NHSE England (NHSE). AE added that the PCCC Committee held on 25 th January 2018 had formally recommended the Strategy for approval to the Governing Body. 6.4 It was decided that the Primary Care Workforce Strategy was to be circulated to the Governing Body following the meeting, and any additional comments were to be made by close of play on Friday 2 nd February Post Meeting Note: The Primary Care Workforce Strategy was sent to the Governing Body electronically following the meeting for any comments to be made by close of play Friday 2 nd February 2018 in which none were received, which resulted in the Workforce Strategy being signed off ready to be presented to NHSE before the March Governing Body date. 6.5 AS advised that the tender process for the ten year contract to deliver an Alternative Provider Medical Service (APMS) Primary Care Medical List and an Urgent Primary Care Centre had concluded and the CCG awarded the contract to Gloucester GP Consortium Ltd. The Primary Care team were working with Gloucester GP Consortium Ltd to mobilise the service in readiness for 5 th May RESOLUTION: The Governing Body noted the Clinical Chair s report. Page 3 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

15 7 Accountable Officers Update Report 7.1 MH presented the Accountable Officers Update Report which provided a summary of key updates and issues that arose during December 2017 and January MH informed that a celebration event had been planned for the 29 th January at the University of Gloucestershire which brought together over 35 local organisations who were successful in achieving accreditation of the National Workplace Wellbeing Charter in 2017 and suggested that Governing Body Members may wish to attend. 7.3 MH advised that 130,000 had been secured from Health Education England (HEE) to progress the work that looked to develop the skills and confidence of staff and provide coaching conversations with patients and service users. 7.4 MH highlighted that work had been progressing with the National Diabetes Prevention Programme and the Gloucestershire Sustainable Transformation Partnership (STP) had secured 112,000 from South West Avon Gloucestershire (SWAG) Cancer Alliance to support the implementation of the National Optimal Lung Cancer Pathway. 7.5 MH mentioned that Gloucestershire had approximately 33 Clinical Pharmacists (CPs),of which fifteen Whole Time Equivalent (WTE) held their Independent Prescriber qualification (IP); recruitment continued in order to fill service gaps arising through maternity cover as well as continued growth in clinical pharmacists requirements. 7.6 MH detailed the 2017 staff survey results and acknowledged that there were broadly positive results, but noted that there was room for improvement and that a series of actions were underway. 7.7 MH highlighted the Integrating Health and Care update found at part nine of the report which provided a brief summary of some of the key issues within Older Peoples Integrated Commissioning. This included the Complex Care at Home Project and the South Cotswolds Frailty Service MH noted the benefits of the South Cotswolds Frailty Service and added that workshops had taken place to define the pathway for people with dementia and to assist with dementia Clinical Page 4 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

16 Programme Groups (CPG s). 7.8 MH felt that the Housing with Care Strategy, as part of the Better Care Fund, had progressed extremely well and was moving the County to best practice regarding housing. 7.9 MH emphasised that there were national issues regarding domiciliary care, as found at item eleven of the report and added that the Institute of Public Care (IPC) had been commissioned to develop a market position statement for Gloucestershire CCG and Gloucester County Council. The IPC work would provide a market overview document and commissioning intentions for both bedbased and community-based domiciliary care MH identified that the since the launch of the regional Proud To Care (PTC) South West campaign in July 2017, a PTC Gloucestershire initiative had been put in place. MWi advised that since the launch of the Gloucestershire initiative, there had been approximately 100 vacancies advertised on the portal JC commended the work on the Optimal Lung Cancer Pathway MWi predicted that the CCG would be one of the only organisations who had invested over a third of the Better Care Funding within an acute environment. It was anticipated that an update on the evaluation of the Better Care Fund would be completed by the end of March RESOLUTION: The Governing Body noted the Accountable Officers Update Report. 8 Performance Report 8.1 MW presented the performance framework report which provided an overview of Gloucestershire CCG performance, including finance against organisational objectives and national performance measures for the period to the end of month nine, and some information on January performance where data was available and covered the following domains: Leadership Better Care Sustainability Better Health Page 5 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

17 8.2 MW highlighted that the CCG Performance Overview was presented on page three of the report, and it showed that: Better Health, Leadership and Sustainability were rated as Good and Better Care was amber rated as Requires Improvement. 8.3 MW advised that performance against the key national performance standards within the County had shown strong evidence of improvement but acknowledged that there was still further work that needed to be completed to recover performance against a number of national standards. 8.4 MAE provided an update on the Better Health indicators and Patient Experience measures MAE specifically highlighted that the CCG performance for women smokers at the time of delivery, out of the number of maternities was 5.4%, with the national average noted to be at 12% MAE suggested that the work regarding the falls programme and frailty work had influenced a lower than average performance for falls. The CCG performance was noted at 1,744 with the national performance of 1, HG queried whether the recruitment of the Clinical Pharmacists had been a factor in the reduction of the number of falls. MAE advised that the patient audit of the South Cotswolds Frailty Project suggested that there was a link between de-prescribing and a clear reduction in the number of falls and hospital admissions MAE reported that the CCG performance in relation to the number of deaths which took place in hospital was lower than the national average, but advised that the aim was to further improve this performance MAE presented the response rates for the Friends and Family Tests (FFT) and identified that in October 2017 GHFT reported an above average response rate for both the Inpatient and A&E FFT but unfortunately, results shown that GHFT continued to perform below national average. MAE noted that there was a correlation between the response rates of FFT and improved waiting times. 8.5 MW provided an update on the Better Care domain and reported that the Healthcare System was facing the anticipated challenges Page 6 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

18 due to winter pressures but acknowledged enormous the efforts made by frontline staff MW commended the partnership working that had taken place across the system which was having a significant impact on ED performance including during weekends and thanked MWi for the help received from social care colleagues MW referenced the strong system-wide winter plan and noted that the key initiatives of the winter plan were summarised on page thirteen of the report. It was added that there was a high focus on maintaining patient flow across the healthcare system and additional resources were included within the winter plan which helped establish a Discharge Task Force MAE advised that there was a reduction in antimicrobial prescribing MW presented a graph for Delayed Transfers of Care (DTOC) as found on page sixteen of the report, and highlighted that performance in November was 2.2%. The CCG was working closely with GHFT to offer support to work towards maintaining staying below the nationally agreed target of 3.5% for the remainder of 2017/18. MWi noted that this was the sixth best performance for DTOC within the Country MW highlighted the good progress regarding planned care as found on page seventeen of the report and noted that there had been full delivery of the national diagnostics standard. 8.6 ER provided an update regarding cancer performance, and acknowledged that there was a time lag in data reporting, and data presented was up to November ER reported that there was a concerted effort regarding pathway improvement to support a sustainable recovery and that there had been improvements. It was felt that recovery by April 2018 was achievable ER appreciated the work undertaken by HLR regarding the cancer Two Week Wait (2WW) forms and the effort to have these forms go live before the anticipated timeline. It was added that the forms were undergoing testing within the Commissioning Support Unit (CSU). 8.7 MW reviewed the leadership domains as found on page 35 of the report, and specifically highlighted the governance arrangements Page 7 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

19 that had been put in place by the CCG, staff engagement and patient and public participation. 8.8 CL gave an overview of the sustainability domain and reported that the CCG was forecasted to achieve a planned in year position which led to a cumulative surplus of 17,249k CL identified the risk regarding prescribing which related to the No Cheaper Stock Obtainable (NCSO) and noted that there was a national pricing issue CL noted the position regarding the out of county contracts and identified that the majority of the contracts remained in a similar position. It was added that there was small decrease with Oxford University NHSFT and small increases within University Hospital Bristol NHSFT and University College London Hospital CL presented the savings plan which was based on year one of the Sustainability and Transformation Plan (STP) solutions which used opportunities identified through benchmarking. Slippage had been identified in programme areas and additional savings had been identified which was noted to be approximately 3million. 8.9 JC acknowledged Gloucestershire Care Services (GCS) performance issues, in particular Adult Speech and Language, MSKCAT and discharges from community hospitals, and requested assurance that a strong action plan was in place to ensure national targets were being met. WH provided clarity regarding the issues around MSKCAT, and added that the majority of the population were transferred from GCS to GHFT and during this process, new patients being looked after by GHFT caused a backlog of those being transferred. WH confirmed that new staff had been employed and the backlog had been cleared MAE expressed concern regarding the number of band six vacancies within Community services. JC also expressed concern regarding the number of band five nurses left un-supported due to the number of band six vacancies CL reported that there had been 4million of prescribing savings made against a target of 5million. HG suggested that if there was not a national pricing issue regarding prescribing, savings would have been around 6million. Page 8 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

20 8.12 AS highlighted the South Central Comparison as at November 2017, found at page 33 of the report and felt that progress was moving in the right direction AS noted that he had expressed his thanks and gratitude through the A&E Delivery Board to system partners for the hard work regarding the improved performance RESOLUTION: The Governing Body: Noted the performance against local and national targets and the actions taken to remedy the current performance position; Noted the financial position as at month nine; Noted the risks identified in the Sustainability section; and Noted the progress on the savings schemes. 9 Sustainability and Transformation Partnership 9.1 MH introduced the STP progress update which provided the Governing Body with a high level STP progress update. The update was taken as read. 9.2 MH identified that the STP plan was in the implementation phase and there was an increased level of trust and collaborative working across the system. 9.3 MH presented the summary of progress against the constitution standards which showed that the STP commitments that had been identified had been delivered. 9.4 MH highlighted the key areas of progress and acknowledged that the One Place Programme Director and project team had been appointed and had made significant progress. 9.5 MH presented the high-level phases of the One Place Programme and noted that the current phase was the High Level Design phase. It was noted that the CCG was moving towards the production of the financial case and draft business case, and looked to move into the assurance process with NHSE. 9.6 RESOLUTION: The Governing Body noted the Sustainability and Transformation Partnership progress update. Page 9 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

21 10 Future in Mind 10.1 AS introduced HF to the Governing Body meeting who provided an update on the Gloucestershire s Future in Mind, A five year Transformation Plan to Improve Children s Mental Health. It was advised that this was the second annual update to the Plan. The Future in Mind Plan was taken as read HF acknowledged that the main feedback that was provided was around increasing the availability of early interventions and added that work had been undertaken to provide colleagues with additional information and training HF advised that work had been completed with staff within the Voluntary and Community Sectors which increased access to face to face counselling and a successful pilot of online counselling, which was since seeking procurement HF reported that there had been a successful and positive evaluation of joining Mental Health (MH) services with schools and added that this project had now been launched with fifteen Secondary Schools within Gloucester City HF noted that support was been looked at for Foster Carers to support Children in care which provided a more supported placement. It was added that work was being undertaken alongside NHSE to support young people within the justice system to support their mental health needs HF highlighted that the Crisis Support was being developed JC commended the Future in Mind update but noted the increase within the face to face counselling and highlighted the issue regarding self-harm and queried whether long term, the increase within face to face counselling would lower self-harm rates. HF suggested that there had been an increase in counselling since pathways had been included within G-Care and added that the voluntary sector identified that those who put themselves forward for counselling were more likely to engage with the services HF advised that 50% of young people who were recommended for counselling were recommended through a GP Practice. Page 10 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

22 10.9 HF acknowledged that Public Health (PH) were leading a review of the self-harm pathway, and the CCG was working alongside PH regarding acute requirements. HF reported that there were high admission rates for self-harm CG queried when the contract expired in relation to the Teens in Crisis (TIC+) service. HF informed the Governing Body that there were two agreements with the TIC+ service and these were a grant agreement which ends March 2019 and a contract for the online counselling pilot which ends 1 st July CG highlighted that there were capacity issues and queried how the TIC+ service was coping with the increase in demand. HF advised that the organisation had an accredited course which provided staff with additional skills in training children and young people which helped meet the demand HF advised that that work regarding maternity services was being undertaken which looked at providing extra support for parents who experienced Adverse Childhood Experiences (ACES). AS highlighted that ACES was included within the Health and Wellbeing Board remit and noted that minutes from this Board were available to the public using the Mod.Gov app. MH requested that minutes from the Health and Wellbeing Board were included within the CCG Governing Body papers AS requested that a presentation on ACES was brought as an agenda item to a future Governing Body meeting RESOLUTION: The Governing Body noted the Future in Mind Plan. 11 West of England Academic Health Science Network Report 11.1 MH introduced the report from the West of England Academic Health Science Network (WEASHN) which was funded by NHSE and the West of England healthcare organisations, which helped deliver measurable gains in health and wellbeing by accelerating innovation and improvement MH advised that the CCG was working with the WEASHN to develop a Diabetes Digital Coach testbed which had been tested on over seven hundred people, and very positive feedback had been Page 11 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

23 received. It was added that work on the Emergency Department Safety Checklist had progressed 11.3 MH confirmed that the WEASHN business plan for 2018/19 was being developed and they had engaged with STPs and West of England organisations to check which projects would be more beneficial. It was noted that there was shift towards delivering a national innovation agenda JC informed the Governing Body that WEASHN had allocated more funding towards Genomic Medicines Centre work MH suggested that the CCG Governing Body provided thanks to Deborah Evans who was retiring from the end of March 2018 for all the hard work that had been provided RESOLUTION: The Governing Body noted the West of England Academic Health Science Network Report 12 Assurance Framework 12.1 CL presented the assurance framework paper which provided details of the assurances regarding the significant risks to the achievement of the CCG s objectives CL identified that there was one new risk included onto the assurance framework, which as noted as risk L5, regarding the APMS contract for a Primary Care registered list at Eastgate House and Matson Lane, and the Urgent Primary Care Centre. CL confirmed that this risk had already been mitigated since the paper had been written and submitted to the Governing Body CL noted that two high red risk remained on the assurance framework and they had remained unchanged. These referred to Specialised Commissioning and the implementation of TrakCare CG highlighted that Risk L3 regarding Primary Care was incorrect within the Progress with Actions column and that responsibility for approval fell to the Primary Care Commissioning Committee, not the Governing Body RESOLUTION: The Governing Body noted the paper and the attached Assurance Framework. Page 12 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

24 13 Integrated Governance and Quality Committee Minutes 13.1 JC advised members that IGQC were receiving regular updates on the decrease in student nurse recruitment since the removal of student bursaries. It was advised that there was also an increased focus on healthcare acquired infections and reported that a Urinary Tract Infections (UTI) pathway group had been formed JC reported that there was a measles outbreak, but this along with influenza, had been monitored closely RESOLUTION: The Governing Body noted the minutes from IGQC held on 19 th October Primary Care Commissioning Committee Minutes 14.1 AE felt that the PCCC meetings needed to be rescheduled to ensure that Governing Body meetings received minutes of these meeting in a more timely way. AS advised that this was being looked into AE informed members that the PCCC self-assessment identified that a regular update of what the Committee had achieved and work it was undertaking would be beneficial to the Governing Body RESOLUTION: The Governing Body noted the minutes from PCCC held on 5 th October Audit Committee Minutes 15.1 There were no comments made regarding the Audit Committee minutes RESOLUTION: The Governing Body noted the minutes from Audit Committee held on 12 th September Section 75 Agreement Between GCC and the CCG 16.1 CL introduced the Section 75 (S75) agreement between the CCG and Gloucestershire County Council (GCC) which proposed to exercise the option to extend the S75 Agreement for a further two years from the period of 1 st April 2018 to 31 st March Page 13 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

25 16.2 CG noticed that there was a discrepancy within financial figures, as they differed within the paper and the cover sheet, and requested clarity to which figure was correct. The figures were noted as million and 143,378 million. CL agreed to clarify what the correct figure was. Post meeting note: It was clarified that the correct financial figure was 143,378 million RESOLUTION: On the caveat that the Governing Body were informed of the correct total, the Governing Body: Approved the extension of the Agreement for the period 1 st April 2018 to 31 st March 2019; and Approved the further extension of the Agreement for the period 1 st April 2019 to March Any Other Business 17.1 MWi informed the Governing Body that a joint enquiry into the funding of Social Care had been announced and the deadline for written submissions was the 7 th March WH suggested that it would be relevant for all localities that on an annual basis, GPs were informed of any planning proposals for the future, to help ensure communication between the CCG and the GP practices BP agreed to send the Governing Body details of the Gloucestershire 2050 event. The meeting was closed at 4:36pm. Date and Time of next meeting: Thursday 29 th March 2018, at 2pm in the Board Room at Sanger House. Minutes Approved by Gloucestershire Clinical Commissioning Group Governing Body: Signed (Chair): Date: Page 14 of 14 Gloucestershire CCG Governing Body Minutes Part Two January 2018

26 Agenda Item 4 Governing Body Matters Arising March 2018 Item Description Response Action with 25/01/2018 Primary Care Item /01/2018 Item /01/2018 Item 10.3 Workforce Strategy Health and Wellbeing Board Minutes Future in mind Plan It was agreed that the primary care workforce strategy was circulated to members following the meeting for comment. Comments were to be made by close of play on Friday 2 February MH requested that minutes from the Health and Wellbeing Board were included within the CCG Governing Body papers moving forwards. AS requested that a presentation on ACES was brought to a future Governing Body meeting. Due Date Status HG 2 Feb 2018 CGi 29 March 2018 CGi 24 May 2018 For confirmation Complete on agenda For Information 25/01/2018 Item /01/2018 Item 17.3 PCCC Selfassessment Gloucestershire 2050 event AE informed members that the PCCC selfassessment identified that a regular update of what the committee had achieved and work it was undertaking would be beneficial to the Governing Body. BP agreed to send the Governing Body details of the Gloucestershire 2050 event. CGi 24 May 2018 BP 29 March 2018 For confirmation For confirmation Page 1 of 1

27 Agenda Items 7 & 8 Governing Body Meeting date Thursday 29 March 2018 Title Executive Summary Key Issues Conflicts of Interest Risk Issues: Original Risk Financial Impact Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Patient and Public Involvement Recommendation Author Designation Clinical Chair s Report & Accountable Officer s Report This report provides a summary of key issues and updates arising during February and March 2018 for the Clinical Chair and Accountable Officer. Key issues addressed within the report include: Improved Access Cluster Pilots Planning for Integrated Locality Boards pilots CQC inspections Workplace Wellbeing Charter Macmillan next steps Cancer Rehabilitation - Advancing Healthcare Awards 2018 Patient and Transport Community Offers Meetings attended None. None. None. None. None. None. None. None. This report is presented for information and Governing Body members are requested to note the contents. Mary Hutton Gloucestershire CCG Accountable Officer Page 1 of 27

28 Agenda Item 7 Governing Body Thursday 29 March 2018 Clinical Chairs Report 1. New GP Clinical Advisor for Diabetes 1.1 The CCG has been awarded funding from NHS England to recruit a GP Clinical Advisor for Diabetes. This role will focus on ensuring patients with Type 2 Diabetes receive an equitable service across the county and work to improve the three treatment targets, which are: Blood pressure Cholesterol Blood glucose levels (HbA1c) 1.2 The CCG is currently advertising for this role with a potential start date of April Improved access cluster pilots 2.1 There are now five Improved Access cluster pilots in the county. The pilots deliver access to primary care appointments until 8pm at night during weekdays, with further provision on Saturdays and Sundays; encompassing innovative models of delivery. For the period until 21 January these pilots provided an additional local 701 appointments to their patients. As well as delivering their core provision, the pilots continue to recruit other members of staff to expand the primary care workforce including paramedics, physiotherapists, mental health nurses and advanced nurse practitioners. 2.2 The remaining clusters have all finalised their delivery plans to go live by the end of March. 2.3 All Improved Access pilots will run until March 2019 in order to inform the long-term commissioning strategy for Improved Access. Page 2 of 27

29 3. Primary care 3.1 Gloucestershire s Primary Care Workforce Strategy was received positively by members of the Primary Care Commissioning Committee meeting in January. It will be presented to Governing Body on 29 March Delivery of the interventions within the strategy will be crucial to ensuring the significant workforce growth required to meet the Office of National Statistics (ONS) population projections and associated consultation growth. 3.2 In my last three Chair reports, I updated on the 35 practices participating in the Productive General Practice programme. Since my last report, we secured an additional module for 12 of these practices from the national team which ran during February and as a CCG we will fund this programme for a further six practices. 3.3 We were also successful in gaining funding from NHS England for Practice Manager (PM) Development; specifically for working at scale, change management and/or quality improvement. We have secured additional expert coaching resource with training running on 15 th and 22 nd March In readiness for the commencement of our ten year APMS contract with GPPC, we have been working with staff from Matson Lane, Councillors, Gloucestershire County Council and Elim Housing on a new partnership project. This will see a part time partnership worker supporting Taylor House and other Matson residents working from the Phoenix Centre adjacent to the surgery. The yearlong project has been co-produced with Taylor House residents with activities focussed around the Five Ways to Wellbeing. 4. Online consultations 4.1 We are working with colleagues across the CCG and the CSU to support the development of our plans for online consultations and ensuring the alignment of our proposals with the future direction of 111 Online. This includes consideration of all online routes to improve patient access, ease patient confusion and ensure a clinically appropriate and consistent response, while also considering the best solution to support and streamline rather than increase GP workload. 4.2 A Procurement Plan has been submitted to NHSE. In the interim we will Page 3 of 27

30 continue to support the three existing practices who have already implemented online consultations and are extending this pilot to three additional practices in order to gain further feedback to support development of a robust implementation strategy and support preparation for future 111 online integration. 5. Planning for Integrated Locality Board (ILB) pilots 5.1 Building on our place based work with our STP partners we are making final plans for the introduction of three Integrated Locality Board pilots in the Forest of Dean, Stroud and Berkeley Vale and Cheltenham. 5.2 It is expected that the ILBs will promote the development of virtual patientcentred teams able to work across organisational boundaries and focusing on better care coordination and joined-up service delivery as a means of reducing the three gaps of health and wellbeing, care and quality, and funding and efficiency. This will include using local intelligence and risk stratification to ensure proactive and timely support to those at risk and prioritisation of resource to support the shift from acute to community based care. 5.3 ILBs are intended to be practical forums, focused on delivery, able to work in an agile way to respond to the needs of their communities. With partners we are participating in an ILB workshop to be held at Gloucestershire Care Services headquarters on 15 March. 6. Care Quality Commission (CQC) inspections 6.1 As at end February 2018, 16 Gloucestershire practices had received visits during 2017/18 and had received their CQC published inspection report. One practice, Walnut Tree, was rated outstanding. Twelve practices were rated good. Two practices were rated requires improvement, one of which (Stow Surgery) has subsequently received a good rating. One practice, Locking Hill, received an inadequate rating but following support from the CCG, a subsequent visit by CQC in January rated the practice good. 7. Primary Care Premises update Page 4 of 27

31 7.1 Additional Improvement Grant Funding - In January 2018, NHS England requested CCGs put forward proposals for Improvement Grant Funding as it had identified an underspend in 2017/18. The CCG applied for a funding allocation of circa 285k for 11 projects to improve primary care premises across the county. Initial feedback from NHS England was very positive and we are waiting for final approval and will begin working with our practices to ensure these projects are brought to fruition. 7.2 Churchdown Surgery (Gloucester) Churchdown Surgery has led its own development of a new build state of the art premises that will be operational from 26 th March Cinderford The two practices currently based in Cinderford Health Centre, i.e. Dockham Road Surgery and Forest Health Care are working together with a third party developer, to deliver a new build state of the art premises, for the population of Cinderford. On 25 th January 2018 the CCG approved the business case presented to it by the practices including the additional recurring costs. The process for delivering the new premises is ongoing with a planned opening date of November This is an exciting development for one of the more deprived areas of Gloucestershire. 8. Meetings 29 January 2018 Practice visit to Cam and Uley Surgery 30 January 2018 Sally Pearson s retirement at Sandford Education Centre 31 January 2018 Health and Social Care celebration event at the House of Lords 1 February 2018 STP Clinical Leads Network meeting, London 5 February 2018 Public Health and Prevention Function peer review interview, Shire Hall 8 February 2018 Governing Body Away Day, National Star College, Ullenwood 13 February 2018 Practice Visit, Church Street Surgery, Tewkesbury Page 5 of 27

32 15 February 2018 CCG Staff Event at Sanger House 22 February 2018 Leadership Gloucestershire, Shire Hall 5 March 2018 West of England AHSN Business Plan meeting, Sanger House 6 March 2018 Health and Care Scrutiny Committee, Shire Hall 6 March 2018 Chairs meeting, Shire Hall 8 March 2018 LMC Main, Gloucester Farmers Club 12 March 2018 Quarterly update meeting with Sean Elyan 13 March 2018 STP Clinical Reference Group, Sanger House 15 March 2018 Integrated Locality Board workshop 27 March 2018 LMC Negotiators, Westgate House Page 6 of 27

33 Agenda Item 8 Governing Body Thursday 29 March 2018 Accountable Officer s Report 1. Introduction 1.1 This report provides a summary of key issues that have arisen over the past two month since the last report was made to the Governing Body 25 January Workplace Health and Wellbeing Thirty-four organisations from across Gloucestershire attended an event on the 29 th January to celebrate their success in achieving the Workplace Wellbeing Charter Award. The event provided local organisations from both the private and statutory sector an opportunity to showcase some of their work that supported the health and wellbeing of their staff. The Workplace Wellbeing Charter is a workplace health, safety and wellbeing initiative which help organisations work towards achieving high standards to support the wellbeing and quality of life of their staff. The process of gaining accreditation covers several areas, including interviews with staff and an audit against eight standards: leadership, absence management, health and safety, mental health, smoking, physical activity, healthy eating and alcohol. Evidence shows that workplace health initiatives can deliver a wide range of benefits to both employers and staff, such as reduced absenteeism and more open and communicative organisational cultures. At the celebration event, local organisations shared their experiences and outlined how they were supporting the health and wellbeing of their workforce and improving their quality of life. Speakers included David Owen, Chief Executive of GFirst LEP, Sarah Scott, Director of Public Health Gloucestershire and John Russell Director of Gloucestershire Healthy Lifestyle Service. Page 7 of 27

34 2.4 The CCG commissioned the delivery of the Workplace Wellbeing Charter in partnership with Gloucestershire County Council, the Local Enterprise Partnership and Active Gloucestershire. 3. Daily Mile 3.1 Gloucestershire CCG have been working in partnership with Gloucestershire County Council (GCC) and Active Gloucestershire to build on the success of last year s Daily Mile initiative. The Daily Mile is a primary school initiative that encourages children to walk, jog or run a mile every day at school with the aim to improve children s health and wellbeing by being active. Last year over 52 schools took part in the daily mile with a reach of over 10,000 children. A recent audit of schools talking part in the 2017 campaign showed that 71% of schools (37 out of 52) who took part are continuing to do the daily mile. The second 12-week daily mile campaign will be delivered throughout the Spring Term. 4. Somerset, Wiltshire, Avon and Gloucestershire (SWAG) Alliance Cancer Transformation Funding 4.1 SWAG cancer partners have been invited to begin drawing on the Cancer Transformation Funds (CTF) for 2017/2018. The funds are held by Bristol CCG on behalf of the SWAG Alliance. We are expecting to receive Gloucestershire s allocation at the beginning of March 2018, which will support Gloucestershire Community Trust (GCS) and Gloucestershire Hospitals Trust (GHFT) to support the delivery of the Early Diagnosis and Living Well and Beyond Cancer (LWBC) programmes. 4.2 We are pleased to announce that in February 2018 we received approval from the Cancer Alliance on Early Diagnosis Optimal Lung Cancer Pathway and Early Diagnosis Straight To Test (STT) Endoscopy Plans on a Page The Optimal Lung Cancer Pathway project concentrates on a roll out of the chest x-ray reporting tool and the implementation of the chest x-ray hot reporting and provision of CTs within 7 days, following an abnormal chest x-ray scan. The straight to test (STT) endoscopy project is offering one-year funding for STT endoscopy nurses. The nurses will be carrying out patients fitness assessment for a two week wait straight to test Page 8 of 27

35 colonoscopy pathway, that we are hoping to launch in June Macmillan next steps Cancer Rehabilitation - Advancing Healthcare Awards We are delighted to announce that the Macmillan next steps cancer rehabilitation (MNSCR) programme, based at GCS, has been shortlisted for the national Advancing Healthcare Awards 2018 in the category for leadership and innovation in cancer rehabilitation. This provides the opportunity to recognise the invaluable work that MNSCR do to support Gloucestershire cancer patients recovery. By improving patients quality of life following diagnosis and treatment. The awards will be presented in London at the end of April Musculoskeletal (MSK) Self-Management and Self-Referral to Physiotherapy Services 6.1 Many MSK conditions are self-limiting and therefore, with time, and the right support, patients will get better without medical intervention. The MSK Clinical Programme Group is therefore working to ensure patients have access to good quality information which gives them the confidence and knowledge to self-manage their condition (without seeing a GP). GHFT and GCS have excellent MSK self-management information on their internet sites and newly designed posters and business cards are also now promoting these resources. 6.2 When initial self-management has not been successful or when additional support is needed, patients are able to refer themselves into physiotherapy services. The physiotherapists at GHT and GCS offer specialist assessment and treatment for a wide range of problems and work with people to promote their own health and wellbeing. They both have referral forms on their websites, which patients can send electronically or print off to send by post. Patients can also call the department(s) to request a form. Referrals into physiotherapy are triaged and patients are seen according to need with urgent cases being seen within 2 weeks. 6.3 Over the next few months we will be actively promoting the patient resources and physiotherapy services to patients directly and via GP practices. Page 9 of 27

36 7. Social prescribing & cultural commissioning 7.1 Our work to develop a comprehensive social prescribing offer is continuing to make good progress. We are working closely with both statutory and the voluntary and community social enterprise (VCSE) partners in a coherent commissioning approach, which spans both a primary care based universal offer, and a targeted offer for selfmanagement of long term conditions. 7.2 The Community Wellbeing Service is now at the end of Q2 and the mobilisation phase for all providers is nearing completion. 7.3 Our social prescribing approach has been identified as a national exemplar, and we have been asked by NHS England and Public Health England to share our learning in order to support the national approach to scaling up and replicating social prescribing across the country. 7.4 The cultural commissioning programme which is integrated within the wider social prescribing framework continues to receive national recognition for targeted arts on prescription activity within clinical pathway re-design. 7.5 Community Wellbeing Service (CWS) For the first quarter during which the service has been running nearly 900 referrals into the service were received. Mental health and wellbeing was the most common reason for referral at 62%, closely followed by social isolation at 57%. For 75% of individuals there were at least two reasons for referral. A separate category for loneliness will be added to the list of referral reasons. 7.6 Social prescribing Pseudonymisation Data Project The development phase of the community wellbeing element of this project is due for completion in March, with all community wellbeing providers now on track to provide high quality data from their operational systems from 1 April In addition to a performance dashboard, the data project will enable us to track NHS activity of patients referred for universal social prescribing. We hope to extend this to patients referred to targeted social prescribing plus interventions in due course. Page 10 of 27

37 7.7 Commissioning of Phase Two Arts on Prescription in Clinical Pathways Phase two of the grant programme is underway, in partnership with Create Gloucestershire and the voluntary and community social enterprise arts & culture sector. Phase two includes the development of a quality standards framework; the development of a local consortium of arts on prescription providers, and a series of test and learn arts on prescription interventions for patients as follows: - Children with long term conditions and mental health needs (to include diabetes type 1, epilepsy and tier 3 obesity) - Adults with chronic obstructive pulmonary disease (COPD) - Adults with chronic pain - Adults with anxiety & depression. 7.8 Gloucestershire as a Regional & National Exemplar We were invited by Public Health England to present workshop for commissioners at a SW regional event in February We had a positive site visit from NHS England (NHSE) in February, where NHSE officers spoke with patients, clinicians, providers and commissioners from the CCG and county council. We are one of five national learning sites for social prescribing We have been invited to present our work at University College London in March, on the themes of arts as a mechanism for behaviour change & self-management of long term conditions We have also been invited to join a task group of The All Party Parliamentary Group for Arts, Health & Wellbeing, to contribute to the implementation of the recommendations made in the 2017 publication Creative Health: The Arts for Health & Wellbeing Safeguarding Training for Clinical Pharmacists 8.1 On 18 th January the GCCG Safeguarding team facilitated a bespoke training session with an external trainer delivering both adult and child safeguarding training to address the needs of the clinical pharmacist working within general practice. The session was well attended with 40 attendees, which included representatives from other statutory organisations ensuring a multi-agency learning event. Page 11 of 27

38 9. Control of Infection 9.1 Flu Vaccination We are very pleased to report that the provisional figures for flu vaccination uptake demonstrate the following improvements: 1. Frontline staff: All three of the hospital trusts exceeded the Commissioning for Quality and Innovation (CQUIN) target of an uptake of 70% amongst frontline staff, and are well placed to achieve the higher target of 75% in place for the 2018/19 season. 2. School immunisation: This is the first year of a new contract under Gloucestershire Community Trust (GCS) and the new expanded team came together well and achieved an uptake of 63% of eligible school children, which is a significant improvement on the previous flu season. 3. The flu vaccination uptake amongst at risk groups has increased, with the exception of two areas. The percentage of 65+ year olds is at 74.3%. A survey of care homes by the CCG demonstrated an 80% uptake amongst residents Learning from this most recent flu season has identified areas to target next year. This includes flu vaccination uptake of care home workers and carers/visitors. To support this work being undertaken, we are looking to include within our contracting arrangements with care homes, the requirement to report flu vaccination uptake of care home staff and residents. Promotional material for carers and visitors is planned to encourage these groups of people to protect residents by having a flu vaccination, and not visiting when they have respiratory infections. 9.2 Measles In September 2017 Gloucestershire has an outbreak of measles with Stroud being the most affected area. A Stroud engagement group was formed to promote Measles, Mumps And Rubella (MMR) vaccination uptake. During the outbreak in September 2017 it was found young adults, whose parents had not consented to them receiving the MMR vaccination in childhood, when presented with the information selected to have a MMR. It was therefore decided to deliver a promotional programme for MMR focusing on young adults aged years across Gloucestershire starting in March 2018 and continuing over the year. Colleges and Universities were also identified as key target areas. The NHS Information Bus will be used to deliver interactive activities to engage young adults. This gives an opportunity to provide Page 12 of 27

39 information and answer questions gether NHS Foundation Trust CQC Inspection 10.1 The CQC inspection team recently visited several 2gether clinical settings. Although the inspection report is awaited, initial feedback from the inspectors has been positive with a small number of recommendations. The Trust will receive an inspection under the CQC domain of Well Led later in March Contracts Update (2018/19) 11.1 The contracts team is working across the CCG s contract portfolio to ensure that the refreshed NHS Technical Guidance is embedded in our contracts for 2018/19 and that 2018/19 contracts are agreed before the national deadline. The requirements and processes required for new legislative requirements such as the General Data Protection Rights (GDPR) are being reviewed. New contract management approaches have been introduced for some of our large contracts and further reviews of the contract management process are being undertaken to ensure that the CCG receives assurance on performance and quality while freeing capacity to focus on collaborative system change. 12. Patient Transport 12.1 The CCG is improving the way that patients are assessed for, and book, NHS non-emergency patient transport. We have commissioned the Commissioning Support Unit (CSU) Patient Transport Advice Centre (PTAC) to assess patients against the DoH Eligibility Criteria and make bookings for eligible patients directly onto the Arriva Transport Solutions Ltd. system. This is a change from the current arrangements where patients are required to call Arriva, sometimes having a long wait for calls to be answered. The service will commence on 3 April PTAC has successfully provided this service for Somerset CCG patients for over 13 years and receives excellent patient feedback. PTAC is run by NHS staff; it will provide a more patient focused service and ensure that only patients who are eligible receive NHS funded transport. This will ensure best use of local resources. Patients who are found not to meet the eligibility criteria will be signposted to alternative means of transport e.g. public transport or community transport. Gloucestershire County Council (GCC) will be providing up Page 13 of 27

40 to date information to PTAC to support this. PTAC will also signpost patients on benefits or low Income to the Healthcare Travel Costs Scheme, which allows qualifying patients to claim reimbursement for their travel costs to hospital appointments Patients will receive a booking confirmation letter (or ) from PTAC and patients can ring them direct to cancel or amend a booking. We will be letting recent/existing transport users know about the new arrangements via Arriva and new patients will be able to hear about the service through their GP surgery, outpatient clinics or via CCG/Healthwatch/Health Provider websites. Transitionary arrangements will be in place with Arriva while we undertake the communications exercise with patients. 13. Advice and Guidance (A&G) 13.1 Improving GP access to specialist opinion, advice and guidance is a key element of the CCG s approach to elective care demand management A core part of this approach is the provision of Advice and Guidance (A&G) through the Electronic Referral Service (ers) platform. During 2017/18 an additional 4 specialties have been added (Urology, Gynaecology, Gastroenterology, and Pain Management), taking the total number of specialties available to 12 with further specialities to be added in the coming months. Uptake of A&G in Gloucestershire is strong and growing with utilisation set to increase by over 50% by the end of this year In quarter 3 an average of 600 requests for advice per month were responded to by GHFT providing valuable specialist support to GPs to inform clinical decision making. The scale of A&G utilisation in Gloucestershire compared to other CCG areas is significant, for example, nearly 10% of all dermatology, 8% of all nephrology, and 5% of all paediatric A&G requests in England are made by Gloucestershire GPs. There are planned developments in 2018/19 that will ensure that the CCG continues to be a national leader in this area. 14. Appointment Slot Issues (ASI s) 14.1 Gloucestershire Hospitals NHS Foundation Trust (GHFT) has extended polling ranges for outpatient services on ers in order to eliminate Appointment Slot Issues (ASIs) and the associated difficulties Page 14 of 27

41 that this causes. The benefit of this change is now being felt with the ASI rate at GHFT reducing from a peak of 73% in July 2017 to just 5.9% in January ers Paper Switch Off 15.1 As part of changes to the NHS Standard Contract from 1 October 2018 it will be a requirement that 100% of GP referrals to consultant led outpatient appointments be completed using NHS Electronic Referral System (ers). Currently around 75% of referrals made by Gloucestershire GP practices are made through ers Locally it has been agreed that paper switch off will take place on the 4 June From this date referrals made by letter, fax or will be returned to the GP practice to be submitted via ers. A programme of regular communication with GP practices will run up until the paper switch off date, which will include access to training, benefits of the paper switch off, and frequently asked questions, to ensure the switch off occurs smoothly. Adopting full use of ers is a key element in the move to a paperless NHS and has the support of NHS England and NHS Improvement The benefits of using ers are immediate for patients being referred through the service and for trusts. Patients have more choice and control over their healthcare and trusts benefit through reducing did not attend (DNA) rates and improving administrative efficiencies. 16. Procurement Update 16.1 NHS Gloucestershire s new e-procurement system (In-Tend) went live on Thursday 1 February This system is used widely by CCGs, Commissioning Support Units and other UK public sector organisations. All future procurement processes, including competitive quotations and tenders, will be conducted through this system. This will enable us to streamline our procurement processes and timescales whilst fully complying with the European Union s Public Contracts Regulations Tender for the Provision of Community Urology Services On 2 February 2018, national and European advertisements were placed for the provision of community urology services. These services are currently provided by GP Care under a short term Page 15 of 27

42 contractual arrangement which terminates on 30 September The CCG anticipates awarding a new contract to commence on 1 October 2018 for an initial period of 3-years, with an option to extend the service contract. The annual service value is circa 750, Tender for the Provision of a Peer Support and Befriending Service Following a competitive tender process, a 3-year contract for provision of a peer support and befriending service has been awarded to Creative Sustainability Community Interest Company. The contract which is valued at 142,000 for the initial contract period is due to commence on 1 May Winter update 17.1 The urgent care system continues to perform strongly despite adverse weather and some significant peaks in demand. Partners continue to work closely to ensure patients are moving through agreed pathways without unnecessary delays and able to access the services they need. During the recent adverse weather we were supported by the fire service, who ensured key staff were able to get to their place of work and dialysis patients were able to attend dialysis centres Acute colleagues have introduced a number of new streamlined assessment pathways for patients. Colleagues from primary care continue to work as part of the Emergency Department Team in Gloucester and the streaming of patients to alternative care settings. The ambulance service and NHS 111 worked closely to support effective clinical triage. Colleagues from GCS and GCC supported discharges, placements and support to get people home safely and quickly. The commitment from all system partners to work in partnership over the winter has played a vital role in delivering improved performance at the busiest time of the year Stay Well This Winter campaign The second phase of the winter campaign Stay Well This Winter ran for 28 days from 2 February to 12 March. This is funded by NHS England, and activity includes: o Adverts in local weekly media titles (print and online) o Promotion of ASAP healthcare choices video through targeted advertising on Facebook o Ongoing social media (Facebook and Twitter) Page 16 of 27

43 The ASAP video reached 34,398 people people clicked on the link through to the landing page (i.e. the ASAP website). The video has currently been viewed 55,000 times since its launch in November. As at 2 February, app downloads stood at 16, Four further Facebook adverts will run over the four weeks from 12 February on with messages advising people to seek early advice from a pharmacist, catch it, bin it, kill it (flu) and self-care for symptoms of norovirus. 18. HR Update 18.1 The first Manager s Workshop took place on 31 January 2018 and was well attended by managers who found it very useful. The workshops are held on a quarterly basis are interactive and cover topical policies and issues including: o Capability policy and process o Managing sickness absence o Flexible working, understanding policy and application o Secondments internal and external secondments o Appraisal conversations and process o Effective team meetings o Disability Confident Employer top 10 myths This is a rolling programme which takes into account feedback and topical concerns received from the previous workshop. The next workshop will take place on 16 May Staff Appraisals The CCG s internal auditors PwC undertook an appraisal audit in February this year. They reported to the Audit Committee on 13 March that significant improvement had been made, with 94% of staff receiving an appraisal within 12 months and a programme of training in place. There are some further improvements to be made with regard to data reporting and further training that will be addressed this year. All teams, particularly directorate personal assistants worked very hard to ensure that appraisals and reviews had been undertaken and relevant paperwork was filed on the new personal files Staff event being part of our future vision Our staff engagement event took place on Thursday 15 February and was attended by more than 120 staff. There was a wide ranging Page 17 of 27

44 programme focusing on the CCG s future vision and direction. An overview of integrated care systems was given along with an exercised delivered by Jo Davies, Lay Member on the CCG visions and values. Thereafter a series of rolling workshops were delivered covering the STP workstreams (i.e. clinical programmes, enabling active communities, reducing clinical variation, urgent care and workforce, IT / finance). Staff feedback was very positive and plans are underway to hold the next staff engagement event in October Disability Confident Employer..On Our Journey In October 2017, the CCG received confirmation that we had been approved as Disability Confident Committed. This means that the CCG has one year, from October 2017 to October 2018 to work towards being a Disability Confident Employer. We have set up a Disability Confident Employer Task and Finish Group whose remit is to work towards obtaining accreditation by October The task group is focusing on ensuring our recruitment processes are inclusive and accessible communicating and promoting vacancies to potential applicants who are disabled offering interviews to people with disabilities anticipating and providing reasonable adjustments as required supporting any existing employee who acquires a disability or long term health condition, enabling them to stay in work developing pages for the website and intranet to raise awareness that the CCG is working towards being disability confident organising lunch and learn sessions and disability confident employer workshop s undertaking at least one activity that will make a difference to someone who is disabled such as a work placement or work trial The task and finish group has representatives from across the CCG and Gloucestershire County Council as well as from groups that work with people with disabilities such as Forward. Both GCC and Forward are helping us to deliver a Disability Confident Manager s workshop scheduled for July Community Offer - Mental Health Initiatives 19.1 Time to Change Hub Page 18 of 27

45 Gloucestershire is already involved in the Time to Change campaign, which is a growing movement of people aiming to change attitudes towards mental health and reduce stigma across a number of our work areas. Gloucestershire have recently been working with partners to develop a bid to become a Time to Change Hub, which is a partnership of local organisations and people who are committed to ending mental health stigma and discrimination. Although this bid was unsuccessful, there remain opportunities for Gloucestershire to become an organic hub where access to Time to Change support and non-financial resources would be available. This will also allow us to strengthen our existing partnerships across health, social care and the third sector, in aligning and maximising our combined activity There were 4 elements to the bid: (1) Tackling stigma primary care, patient participation groups (2) Tackling stigma statutory health and care workers (3) Engaging with media, social media and film (4) Engaging with wider group of people with lived experiences Community Offer - Mental Health - Crisis Care All qualified clinicians in Mental Health Acute Response Service (MHARS) have received training to equip them with the necessary skills to work in a crisis with Children and Young People (CYPS). Performance monitoring of commissioned response times have been undertaken including: Triage face to face assessment within 1 hour when required Full mental health assessment within 4 hours when required Mental Health Matters 12 months pilot providing 24/7 helpline for service users known to 2gether NHSFT that frequently call MHARS for telephone support. Street triage scheme which is having a positive impact on reducing the use of s136 by the Police. Alexandra Wellbeing House and The Cavern (Wellbeing Café) continue to receive positive feedback from people who use them and are providing timely alternatives to prevent crisis. Page 19 of 27

46 21. Community Offer - Hospital to Home Service (H2H) 21.1 The Hospital to Home service provides a supported discharge service delivered by a selection of home care providers. Patients, from acute and community hospitals are discharged home, allowing for 4 visits by 2 carers for a period of 48 / 72 hours. The carers carry out an initial assessment at home to ascertain whether someone needs: Any service or support at all, information & signposting Straight forward home-care Short term intervention/reablement for up to 4 weeks This service commenced in May 2017 and has been steadily growing as dedicated discharge teams have been recruited to each locality. By Provider Active Archive Total Radis Crossroad By Locality Cheltenham Cotswolds Forest Gloucester Stroud Tewkesbury Total H2H Cases Reabled 48.0% % Continued reablement 4.8% % POC required after 28 days 5.0% % Did not require the service 9.2% % Positive Outcomes 195 Readmitted to hospital or died 33.0% The statistics for this service show, of the 195 positive outcomes: 71.% benefited from the short term service with no ongoing needs Page 20 of 27

47 7.2% needed longer than the 4 weeks 7.5% required a package of care 13.7% did not require the service, but benefited from being supported home. This service has released a significant number of bed days. However further work is underway to understand the findings and improve the service It is anticipated that H2H will become the default for new identified care needs from hospital. This will release reablement to provide therapy led support and step up services to avoid hospital admission. Eight workshops have been arranged and are open to any adult/parent carer to attend one in each district, a Black and Minority Ethnic (BME) focussed workshop and a parent carer workshop has also been arranged. Further workshops have been organised including: Two workshops for young carers (including young adult carers 18-25), using a graphics artist A workshop for key Voluntary, Community and Social Enterprise organisations Specialist workshops, including carers of people with mental health issues, learning disabilities and dementia There are also two online surveys which have been designed in association with the Carers Alliance, who also gave ideas for how best to run the workshops, and Gloucestershire Young Carers. 22. Community Offer - Engagement with Carers Across Gloucestershire 22.1 A carer is anyone of any age who on an unpaid basis looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without the carer s support. The 2011 Census recorded 62,644 people in Gloucestershire who reported that they are a carer. This was equivalent to 10.5% of the population. The same census also reports 3,692 young carers (under 18) in Gloucestershire. A substantial engagement programme is being implemented by the CCG and Gloucestershire County Council to help us shape future Page 21 of 27

48 support and services for carers. Our engagement includes: 8 workshops open to any adult/parent carer to attend one in each district, a BME focussed workshop and a parent carer workshop 2 workshops for young carers (including young adult carers 18-25), using a graphics artist 1 workshop for key Voluntary, Community and Social Enterprise organisations Specialist workshops, including carers of people with mental health issues, learning disabilities and dementia. There are also two online surveys which have been designed in association with the Carers Alliance, who also gave ideas for how best to run the workshops, and Gloucestershire Young Carers 22.2 It is nationally recognised that the economic value of unpaid carers to the UK economy is 132 billion every year (this figure has risen from 68 billion in 2001) and the Office for National Statistics calculates that it would cost 56.9bn to replace unpaid carers with paid workers. Early identification of carers is crucial to ensuring that they access support at the earliest opportunity and therefore maintain their own health and wellbeing, as well as continue in their caring role. Our GP Practice workforce can help with this early identification and signposting to information and advice. We are requesting a primary care audit of all 80 general practices in Gloucestershire to establish the number of people registered with their GP as a carer. We will then undertake a review if they have had an annual health check in the last 12 months. With the results of this audit, we can help produce best practice guidance. 23. Community Offer - Children s Commissioning Update 23.1 The children s commissioning team have been working to deliver several programmes: The Future in Mind programme has included the launch of the school pilot in the G15 Gloucester City Schools, delivered by members of GCCG, GHLL, educational psychology and 2gether Trust. Mental health champions for each school have been nominated and we will meet and work throughout the year to progress this project. Page 22 of 27

49 The early intervention programme includes a partnership with Teens in Crisis to provide face to face counselling for young people. Engagement feedback shows 85% of young people reporting that the counselling has helped them significantly. The perinatal mental health community support work continues to grow, with Home-Start scoping the existing perinatal support already in the county and working towards growing home-start throughout Gloucestershire via a bid to the Big Lottery. We are awarding a grant to produce a social media campaign aimed at supporting dads through the perinatal period The integrated personal commissioning (IPC) programme for children in care with mental health needs has developed to the stage of recruiting young people via the social work teams to receive personal health budgets. We are now developing a sustainability plan alongside the wider CCG IPC work to continue the personalised care agenda. We are progressing through a bid a WellChild nurse. WellChild Nurses provide essential care and practical support to children with exceptional health needs and their families. They play a crucial role in enabling children to leave hospital and be cared for at home. WellChild funds each nurse for a period of three years to be employed and managed by the local healthcare trust. We continue to work with Education and Social Care in GCC on the SEND agenda to improve outcomes for children with additional needs. 24. Community Offer - Better Births Maternity Transformation Gloucestershire 24.1 In February 2016, Better Births set out the Five Year Forward View for NHS maternity services in England. The report identified the need for transformation in the provision of maternity services to achieve safer and more personalised care to improve outcomes and reduce inequalities by It puts women and their families at the centre of their care Better Births recognised that its vision could only be delivered through transformation that is locally led, with support at national and regional levels The report recommended that providers and commissioners should operate as local maternity systems, with the aim of ensuring that women, babies and families are able to access the services they need Page 23 of 27

50 and choose, in the community, as close to home as possible In Gloucestershire we have established our Local Maternity System (LMS) bringing together providers, commissioners and all stakeholders involved in providing care to women accessing maternity services. Together we have developed a local transformation plan to drive forward the recommendations from the Better Births report and the national ambition to reduce stillbirths, neonatal and maternal deaths by This high level local plan sets out the vision for maternity services in Gloucestershire and includes a detailed action plan of how we will transform services, working closely with women, their families. Seven workstreams have been established led by clinicians to take forward our local priorities for improvement: 24.5 Progress against out transformation plan is monitored by the LMS with oversight and scrutiny from the STP, regional and national Maternity Transformation Programme Board. The work-streams have excellent multi-professional engagement and each have generated a significant number of quality improvement projects which have been supported with funding from Better Births to deliver improvements in care. GHFT Quality Improvement Academy will be providing training and support to staff undertaking projects Engaging women, their families and local communities in co-designing maternity services in Gloucestershire is key to the successful implementation of the Better Births recommendations. Work is underway to develop a Maternity Voices Partnership (MVP), led by recent users of our maternity service and a website to engage women to influence and share in the decision-making of the Local Maternity System. We are currently agreeing a logo and communications strategy to launch this important aspect of the Better Births plan. A bid to secure Page 24 of 27

51 further funding has been submitted to the South West Clinical Network to support the development of the MVP. Funding was received from NHS England to support the better births programme locally and a project team have been appointed. Further funding has also been secured for 2018/ Community Offer - Continuing Health Care - Internal Audit Update 25.1 Over the last three years PWC, the CCG s internal auditors have undertaken several audits of continuing healthcare (CHC) and funded nursing care (FNC). This activity was following on from an initial review as part of the 2015/16 internal audit programme which rated the service as High Risk. This year s review has identified that there are no high risks. Other risks have reduced over the last year. This improved performance is due to significant and sustained improvements from within the service. One low risk remains and is subject to a focused piece of ongoing work. Our current overall risk rating is LOW PWC noted the following areas of good practice during their review: Management have implemented a restructuring programme which has five teams focusing on specific tasks, one being a review team with the aim of clearing the backlog of overdue reviews. Clinical Team lead meets monthly with the clinical manager to update the trajectory and review progress, which has now reduced from more than a 1000 cases to less than 400. The GCC Brokerage team have been seconded to the CHC team to streamline services. Accurate rate card function and financial forecasting now fully functioning Next Steps to mitigate and reduce the risk further: Develop a joint training programme with system partners to improve the 28 day CHC pathway Quarterly audit of the Fast track pathway to ensure access criteria meets the national Framework Fast Track project to streamline the services for people with a rapidly deteriorating condition. Page 25 of 27

52 Mary s meetings Meetings 26 Jan Chief Executive Meeting, Police Headquarters 29 Jan Workplace Awards Ceremony 30 Jan Gloucestershire Strategic Forum (GSF) 31Jan National Leads of all ALBs, London 01 Feb STP and Clinical Leads Development Day 05 Feb STP Delivery Board 06 Feb Gloucestershire FSM Meeting, London 07 Feb Joint Commissioning Partnership Executive (JCPE) 07 Feb Public Health & Prevention Function Peer Review Feedback 08 Feb Governing Body Away Day 12 Feb Aspiring Chief Executive s Programme, London 13 Feb Church Street Practice Visit, Tewkesbury 14 Feb EAC Commissioning Group 15 Feb STP CEO Meeting 15 Feb Integrated Governance & Quality Committee (IGQC) 15 Feb CCG Staff Event 27 Feb Gloucestershire Strategic Forum (GSF) 27 Feb STP Advisory Group 01 Mar STP Delivery Board 01 Mar New Models of Care Board (NMOCB) 13 Mar CCG Audit Committee 15 Mar STP CEO Meeting Page 26 of 27

53 21 Mar South West STP Board/South West Chief Executives Forum, Taunton 26 Mar GCS/CCG Strategic Board 27 Mar Gloucestershire Strategic Forum (GSF) 29 Mar Primary Care Commissioning Committee (PCCC) Page 27 of 27

54 Governing Body Agenda Item 9 Governing Body Thursday 29 March 2018 Title Executive Summary Key Issues Risk Issues: Original Risk Residual Risk Management Conflicts of Interest Financial Impact of Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Performance Report This performance framework report provides an overview of Gloucestershire CCG performance, including finance against organisational objectives and national performance measures for the period to the end of month 11, and some information on March where data available. These are set out in the executive summary within the report and cover the domains: Leadership Better Care Sustainability Better Health All risks are identified within the relevant sections of this report. None declared. This report gives detail on the financial position to the end of February. These are set out in the main body of the report. Not applicable. There are no direct health and equality implications contained within this report. There are no direct sustainability implications contained within this report. Page 1 of 2

55 Patient and Public Involvement Recommendation Author & Designation Sponsoring Director (if not author) These are set out in the main body of the report. The Governing Body is asked to: Note the performance against local and national targets and the actions taken to remedy the current performance position. Note the financial position as at month 11. Note the risks identified in the Sustainability section. Note progress on the savings schemes. Sarah Hammond, Head of Information and Performance; Andrew Beard, Deputy CFO. Cath Leech Chief Finance Officer Page 2 of 2

56 CCG Monthly Performance Report March

57 Contents This document is a highlight report which is presented to give the CCG Governing Body an overview of current CCG and provider performance across a range of national priorities and local standards. Whilst inevitably this report focuses on areas of concern it should be noted that Gloucestershire is currently achieving the majority of the local and national performance standards. 1.0 Scorecard 2.0 Executive Summary 2.1 Leadership 2.2 Better Care 2.3 Sustainability 2.4 Better Health 5.0 Sustainability 5.1 Resource Limit 5.2 Acute Contracts 5.3 Prescribing 5.4 Primary Care 3.0 Better Care 3.1 Constitution updates reported by exception. 4.0 Leadership 4.1 Measurement 5.5 CHC 5.6 Savings Plan 5.7 Rightcare 5.8 Savings forecast delivery 5.9 Risks & Mitigations 5.10 Cash drawdown 5.11 BPPC performance 2

58 1.0 Scorecard: CCG Performance Overview Better Health Better Care Good Requires Improvement CCG Improvement and Assessment Framework Leadership Good Sustainability Good 3

59 2.1 Executive Summary Leadership This domain assesses the quality of the CCG s leadership, the quality of its plans, how the CCG works with its partners, and the governance arrangements that the CCG has in place to ensure it acts with probity, for example in managing conflicts of interest Staff engagement : Robust culture and Leadership Sustainability (OD Plan) Probity and Corporate Governance: Full governance compliance Effectiveness of working relationships in the local system: Effectiveness of working relationships in the local system Quality of CCG leadership: Review of the effectiveness of culture, leadership sustainability and an oversight of quality assurance. NHSE have rated the CCG as amber for this category in Q1, and we are awaiting Q2 results which are due imminently. 4

60 2.2 Executive Summary Better Care This domain focuses on care redesign, performance of constitutional standards, and outcomes, including in important clinical areas. Overall Rating Planned Care Unscheduled Care Cancer Mental Health Learning disability Maternity 5

61 2.3 Executive Summary - Sustainability This domain looks at how the CCG is remaining in financial balance, and is securing good value for patients and the public from the money it spends Rating Year to date surplus variance to plan (%) Forecast surplus to plan (%variance) Forecast running costs in comparison to running cost allocation (%) Forecast savings delivery in comparison to plan (%) Year to date BPPC performance in comparison to 95% target (%) Cash drawdown in line with planned profile (%) Forecast capital spend in comparison to plan (%) 6

62 2.4 Executive Summary Better Health (1 of 2) These indicators show the latest position and are updated quarterly This section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve. Current CCG Performance Period National Glos CCG What is Good? Smoking: Maternal smoking at delivery: The percentage of women who were smokers at the time of delivery, out of the number of maternities Q2 17/18 11% 6.3% Low is Good Child Obesity: Number of children in Year 6 (aged years) classified as overweight or obese in the National Child Measurement Programme (NCMP) attending participating state maintained schools in England as a proportion of all children measured. 13/14 to 15/ % 31.8% Low is Good Diabetes: Three (HbA1c, cholesterol and blood pressure) for adults and one (HbA1c) for children: The percentage of diabetes patients that have achieved all 3 of the NICE-recommended treatment targets Falls: Age-sex standardised rate of emergency hospital admissions for injuries due to falls in persons aged 65+ per 100,000 population 2016/ % 36.4% High is Good Q1 17/18 1,961 1,686 Low is Good Personalisation and choice: Indicators relating to utilisation of NHS e-referral service to enable choice at first routine elective referral. 10/ % 33.2% High is Good 7

63 2.4 Executive Summary Better Health (2 of 2) This section looks at how the CCG is contributing towards improving the health and wellbeing of its population, and bending the demand curve. Current CCG Performance Period National Glos CCG What is Good? Personal health budgets Per 100k population Q2 17/ Percentage of deaths which take place in hospital Q2 16/ People with a long-term condition feeling supported to manage their condition(s). Q3 16/ High is Good 47.1% 41.4% Low is Good 64.3% 67.8% High is Good Health inequalities: Inequality in avoidable emergency admissions for chronic ambulatory care sensitive conditions Q3 16/ Low is Good Health inequalities: Inequality in avoidable emergency admissions for urgent care sensitive conditions Q1 17/ Low is Good Appropriate prescribing: Antibiotics and prescribing of broad spectrum antibiotics in primary care 09/ N/A Carers: Quality of life of carers 03/ N/A 8

64 3.0 Better Care: Unscheduled Care (CCG / SWASFT) 4 Hour A&E Feb 18 4 Hour A&E YEAR TO DATE Category 1 Ambulance Jan 18 Category 1 Ambulance YEAR TO DATE * 88.5% 86.7% 9.2 mins 9.8 mins Delayed Transfers of Care (DToC) 3% Planned Care (CCG) RTT Incomplete <18 weeks Dec 17 RTT Incomplete <18 weeks YEAR TO DATE National Reporting Suspended Diagnostics >6 weeks Jan 18 Diagnostics >6 weeks YEAR TO DATE 0.7% 2.9% Cancer Dashboard (YEAR TO DATE) (CCG) 2 Week Waits 2 Week Waits Breast 31 Day Waits 31 Day Waits Surgery 31 Day Waits Drugs 31 Day Waits Radiotherapy 62 Day GP Referral 62 Day Screening 62 Day Upgrade 81% 88.3% 96% 93.8% 99.1% 99.1% 73.6% 92% 87.8% * YTD calculated on data from November 17 onwards due to introduction of new methodology 9

65 3.1 System Overview Unscheduled Care: Pre Hospital Ambulance Cat 1 Out of Hours Attendances 111 Call Volume 111 Disposition 10

66 3.1 System Overview Unscheduled Care: In Hospital A&E 4 hr Performance GHFT AVG LOS GCS AVG LOS Delayed Transfers of Care 11

67 3.1 Unscheduled Care 4 hour A&E Top Line Messages: ED Performance for February was 88.5%, which while below the national target, still exceeded the local STF target set of 80%. This follows on from our performance in November, where we met the national standard at 95.3%. This was the first time the trust achieved the target since June Year to date performance is 86.7%. It should also be noted that GHFT was ranked 15th best performing Trust for 4hr waits in January and 18th best in February. Improved ED performance delivered through; Strong leadership within the ED department Maintained flow through GRH and CGH Effective partnership working ensuring system flow Significantly improved collaborative working between operational colleagues from across the system Increased use of ambulatory and assessment pathway Given the improved performance A&E Delivery Board has decided to review both the 4-hour improvement plan and the 10% plan. Focus will be given to areas offering the most substantive and incremental benefit for 2018/19, supporting continuous improvement and achievement of the 4-hour standard. New ways of working and service structure will be pursued which ensure a range of alternatives, both pre-hospital and at the front door, are in place to safely divert activity and enable ED to focus on supporting the most in need. 12

68 3.1 Unscheduled Care 4 hour A&E Key Actions (1 of 2) Key Actions: As part of the Winter plan, trauma has been moved to GRH and all elective orthopaedic activity will take place at CGH with enhancements to Medical provision Live Development of a Surgical Assessment Unit at GRH to include direct admits from GP s and direct referrals from ED General Practitioner admissions direct to Acute Care Unit Partially Live Creation of a winter pressures ward or patients that are medically fit -Live Introduction of Virtual Ward Model for Gloucester and Cheltenham localities Additional Discharge to Assess Nursing Home beds - Live Primary Care Streaming within ED - Live Increase in Domiciliary Care capacity Integrated Frailty model with enhanced Older persons assessment liaison (OPAL) service - Live Enhanced Community team to pull patients and affect shorter stays in hospital. Introduction of Troponin T 1 hour testing -Live Increase in Trusted Assessor, Care Navigator and social worker capacity - Live Full implementation of Mental Health Acute Response Service - Live 13

69 3.1 Unscheduled Care 4 hour A&E Key Actions (2 of 2) Implementation of recommendations from Emergency Department rota review Extension of opening hours for Ambulatory Emergency Care -Live Implementation of an additional Winter Discharge Team Live Winter pressures initiatives within Primary Care including additional capacity and earlier home visiting -Live Weekly cross provider Multidisciplinary Team meetings to support patient flow - Live Introduction of new Escalation Framework within Gloucestershire aligned to National OPEL guidance -Live Extended Criteria led Discharge - Live Extended therapies/pharmacy opening hours - Live Roll out of revised approach to red/green and SAFER* patient flow initiatives Live *The five elements of the SAFER patient flow bundle are: S Senior review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions. A All patients will have an expected discharge date and clinical criteria for discharge. This is set assuming ideal recovery and assuming no unnecessary waiting. F Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards that routinely receive patients from assessment units will ensure the first patient arrives on the ward by 10 am. E Early discharge. 33% of patients will be discharged from base inpatient wards before midday. R Review. A systematic multi-disciplinary team review of patients with extended lengths of stay (>7 days stranded patients ) with a clear home first mindset. 14

70 3.2 Unscheduled Care Category 1 Ambulance Top Line Messages: Ambulance performance has recently changed after a national trial which was rolled out in November This is now measured by the mean time it takes to respond to a Category 1 (most serious) incident. The new national target is the average time of all category 1 responses to be less than 7 minutes. As a result, year to date results will only be calculated from that point forward, due to slight changes in the methodology used to calculate performance. January 2018 Category 1 performance for SWAST is 9.2 minutes against target of 7 minutes, with year to date at 9.8 minutes. Performance for Gloucestershire was 10 minutes and year to date is 10.3 minutes Key Actions- A SWAST staffing rota review is underway to match resources with the peaks in demand. Increase in the number of Dual Crewed Ambulances to reduce delays in transporting patients. Increase in the number of clinicians working within the Clinical hub. The aim is to increase the hear and treat rate through the application of additional clinical expertise. Work is underway between commissioners and SWAST to improve sharing of information and therefore improve the response to care homes. Additional winter non-paramedic crewed vehicles funded to support category 3 and 4 calls, enabling paramedic crews to focus on category 1 and 2 calls. This will also support a regular flow of HCP requested conveyances. 15

71 3.21 Unscheduled Care Delayed Transfers of Care Top Line Messages: GHFT DTOC performance in January was 3%, which continues to meet the target. 2G performance has also fallen to 2.7% for January. The CCG is working closely with the Trust to offer support to work towards maintaining the nationally agreed target of 3.5% for the remainder of 2017/18 Key Actions- Emergency Care Improvement Plan (ECIP) and SAFER navigation meetings being held to discuss medically fit list and the introduction of weekly senior partnership meetings. Senior partnership sign off of Delayed Transfers of care (DTOC ), to enable understanding of actions for acute and community Navigation meetings will feed into senior partnership meetings to escalation any recurrent issues identified which are disrupting the pathway. A Top 12 list of operational standards across the pathway is being developed for all partners the standards will encompass how long should each step of the pathway should take. These standards have been developed and are currently under discussion. winter task force has been implemented to support improved patient flow. A key focus is reducing DToC and addressing the needs of stranded patients. Monitoring will be via a CANDO framework A winter pressures ward at a nursing home is live 16

72 3.3 System Overview Planned Care: Referral Trends Diagnostics Due to the implementation of the patient administration system, TrakCare, in early December 2016, GHFT routine reporting of RTT performance, outpatient/inpatient waiting lists and accurate activity data is not available. A recovery plan is being developed with GHFT to recover routine reporting, as and when available this data will be reflected within this report. 17

73 3.4 Planned Care Diagnostics >6 weeks Top Line Messages: CCG Diagnostic performance improved from 1.1% in December to 0.7% with 61 breaches in January. GHT Performance also showed an improvement in performance, from 0.7% in December to 0.5% based on 38 greater than 6 week waits. The main areas of poor performance for the CCG were in: Cystoscopy (35.7%) Urodynamics (21.4%) Echocardiography (3.0%) Sleep Studies (2.8%). Audiology: Recovery plans have been received by the CCG and a formal response has been provided. Recruitment of additional audiologists has been undertaken and staff have started employment (6 FTE have joined the service as at the end of September). Endoscopy: Waiting list clinics have been initiated, & these have undertaken urgent 2ww appointments and surveillance patients. GHFT have begun subcontracting to alternative providers to support recovery. There is modelling being undertaken to better understand the implications on diagnostic performance. 18

74 3.5 System Overview Cancer: YTD Jan WW (GP Ref d) 2WW (Breast) 31 day 31 day subsequent treatm t: Surgery 19

75 3.5 System Overview Cancer: YTD Jan day subsequent treatm t: Drugs 31 day subsequent treatm t: Radiotherapy 20

76 3.5 System Overview Cancer: YTD Jan day: GP referral 62 day: Screening 62 day: Consultant Upgrade 21

77 3.6 Cancer 2 week waits Top Line Messages: CCG Performance against the 2-week wait target improved from 81.7% in December to 86.5% in January There were 222 breaches of which the main areas of concern are: Gynaecology (26 breaches) Head & Neck (21 breaches) Lower Gastro intestinal (86 breaches ) Skin (21 breaches ) Upper Gastro intestinal (36 breaches ) Urology (14 breaches) An action plan has been received by the CCG to outline performance recovery and is currently being reviewed. Backlogs in skin and lower GI have been addressed throughout November and December such that performance is expected to improve in line with the trajectory. Patient choice breaches continue to be an issue but should improve with the roll out of the new 2ww referral form, which is currently being tested with GP systems. 22

78 3.7 Cancer 62 days Top Line Messages: CCG Performance against the 62-day wait target is 69.6% in January with 48 breaches of which: 6 in Head & Neck 8 in Lower GI 6 in Lung 2 in Other 1 in Sarcoma 20 in Urology 104 Day Breaches There were 17 over 104 day breaches reported at the end of January. The number of patients in this category is tracked weekly by the Trust, the CCG have requested weekly updates to be shared. Urology remains the speciality of most concern with ongoing discussions between GHNHSFT and GCCG regarding recovery actions. The key actions have focused upon creating capacity at GHNHSFT & have plans to expand the current multidisciplinary and diagnostic clinics which will shorten patient pathways. Updated GHFT cancer action plan in place with revised trajectories with 62 day performance to be back to target by Q1 18/19 23

79 3.7 Cancer Key Actions 2 Week Cancer & 62 day Confirmation of National Cancer Recovery funds received October Support previously confirmed for additional MRI capacity for urology. Further funding will now support CT capacity for a number of pathways and additional administrative capacity for colorectal. An in-depth Critical Friend visit held with representatives from NHS Improvement and Intensive Support Team (IST), to undertake a thorough review of cancer services management processes. Findings assured the Trust had a good grip on patient management processes, whilst acknowledging the current significant performance challenges. 2 week wait Booking: New 2WW leaflet and GP checklist agreed with patient group and LMC to optimise use of appointment slots. Individual Cancer site actions Lung Straight to test Lung pathway project o 2ww consultant triage o Lung cancer clinics o Chest X-ray to CT Business case for additional Endobronchial Ultrasound (EBUS) Head & Neck One stop clinic with same day scanning Oral & Maxillofacial Surgery clinic takes place alongside dermatology clinic. Biopsies can be undertaken same day, where indicated and resource available, or booked to next available clinic Colorectal Joint GHFT/CCG project Upper GI Additional E Provision of alternative provider lists to increase Oesophago- gastro-dudenoscopy (OGD) capacity US scope to reduce referrals to Birmingham. Appointment of new consultant who will attend Hereford MDT - will reduce shared breaches 24

80 3.7 Cancer Key Actions 2 Week Cancer & 62 day Urology Additional ad hoc Trans Rectal Ultrasound (TRUS) Biopsy capacity to clear back logs o Backlog cleared. Waiting time reduced from in excess of 9 months to 2 weeks subject to completion of the patient s MRI scan. o Ongoing provision of ad hoc TRUS capacity in accordance with need. o Additional theatre capacity and equipment at/for Cirencester to increase template biopsy capacity Additional theatre capacity and equipment secured and in-situ at Cirencester. o The number of Consultants trained to undertake this specialist procedure has also increased from 2 to 4. o Backlog cleared. Redesign of Consultant Job Plans to facilitate cross-cover of theatre sessions Transfer of procedures to a non-theatre setting (Uro-lift pilot & Flexible Cystoscopy with Botox). Revised Prostate Cancer Pathway (MRI Capacity) Gynae Additional scan slots for Post menopausal bleed patients O&G consultant dedicated to 2ww clinic Creation of one-stop clinics for PMB patients Removal of direct access hysteroscopy clinics from choose and book and prioritise slots for Ca pathway patients Skin One stop dermatology super clinic pilot started in November with increased capacity and shorter diagnostics and treatment pathway. 2ww backlog now fully cleared as a result. 25

81 3.8 System Overview: Mental Health - IAPT Access Recovery Referral to Treatment - 6 wks Referral to Treatment - 18 wks 26

82 3.8 Mental Health - IAPT Top Line Messages: IAPT Access performance in January was 1.18% against a national monthly target of 1.25%. Cumulative year to date performance is 11.28% against a target of 12.5% IAPT Recovery was below target at 46% for January, with YTD at 51%. 2Gether NHSFT have an on-going programme of work that will help ensure better understand of the variances in reporting of data. It was agreed that 2G would resubmit their IAPT dataset for December and January to align their reporting methodology with all other trusts in the southern region. This change in methodology will positively impact the reporting of our IAPT Access rates and 6 & 18 week waiting times. Full impacts of these changes are still being monitored by the Trust. A member of the national IAPT Team is supporting 2G. They have also had an on-site visit from the NHSE Intensive Support team. 2G have created an improvement plan for access and recovery which has been shared with the CCG, which includes an internal productive review and the providing of an E-provision via an external company to improve access rates. 27

83 3.8 System Overview: Mental Health Children & Young People 2017/18 April May June/Q1 July August Children and young people who enter a treatment programme to have a care coordinator - (Level 3 Services) Target : 98% 95% accepted referrals receiving initial appointment within 4 weeks (excludes YOS, substance misuse, inpatient and crisis/home treatment and complex engagement) (CYPS) - Target 95% Level 2 and 3 Referral to treatment within 8 weeks, excludes LD, YOS, inpatient and crisis/home treatment) (CYPS) - Target 80% Level 2 and 3 Referral to treatment within 10 weeks (excludes LD, YOS, inpatient and crisis/home treatment) (CYPS) - Target 95% Children and Young People's Mental Health (CYPS) September /Q2 October November December /Q3 99% 99% 100% 100% 99% 99% 99% 98% 99% 99% 99% 98% 98% 94% 93% 79% 98% 98% 91% January February March/Q4 28

84 3.9 Continuing Health Care - CHC Assessments completed in 28 days Top Line Messages: NHS Continuing Healthcare (CHC) means a package of ongoing care that is arranged and funded solely by the NHS where the individual has been found to have a primary health need. Such care is provided to an individual aged 18 or over, to meet needs that have arisen as a result of disability, accident or illness. The time that elapses between the Checklist (or, where no Checklist is used, other notification of potential eligibility) being received by the CCG and the funding decision being made should, in most cases, not exceed 28 days. The 28 day referral time starts from the date the CCG receives any type of recorded decision that full consideration for NHS CHC is required i.e. a positive checklist or other notification of potential eligibility and ends at the point the CCG makes the decision. Some of the ongoing reasons identified as causing delays are: Accessing Social workers to constitute a Multidisciplinary team. Engaging community nursing teams to complete nursing assessments. Backlogs, in particular areas, learning disability. Key Actions: The CCG invested into the CHC service restructured the team Improved data collection and monitoring to ensure that delays are kept to a minimum and the reasons for delays are identified Improved working arrangements with our Local Authority and our community partners to reduce any CHC process delays 29

85 3.9 Continuing Health Care - CHC Assessments completed in a non acute setting Top Line Messages: It is preferable for eligibility for NHS Continuing Healthcare to be considered after discharge from hospital when the person s long-term needs are clearer, and for NHS-funded services to be provided in the interim. This pathway was developed between CHC along with Adult Social Care to support both organisations with flow into D2A beds and align the CHC National Framework around patients not being assessed whilst in an acute setting. The new Discharge to Assess pathway commenced on the 9th May 2016 and now only in exceptional circumstances does a CHC checklist and full assessment take place in an acute hospital setting within Gloucestershire. This pathway for CHC and Adult Social Care is working well, with those individuals identified as requiring a full assessment for NHS Continuing Healthcare now taking place in a more appropriate setting and within the 28 day timeframe. 30

86 3.10 Gloucestershire Care Services Performance RTT:- 5 of the 8 monitored services are underperforming (% treated within 8 Weeks target 95%). Adult Speech and Language Therapy has dropped to 58.5% in January. Performance was 95.9% in October and fell by over 20% to 75% in November and December before dropping a further 16.5% to January. Occupational Health performance has fallen slightly to 78.8% for January from the December position of 83.2%. Adult Physiotherapy performance has declined in January after recent improvements and is now 78.8%. MSKCAT performance continues to be low but Januarys achievement of 46% is a notable increase on Decembers performance of 38.5%. Podiatry and Diabetes Nursing performance have both dipped below target in January at 85.9% and 93% respectively. Bone Health is the only service meeting the monthly target. Only Diabetes Nursing and Bone Health are meeting the YTD target. Community Hospitals Both weekend and weekday discharges have improved in January with weekend discharge performance now being above target at 4.4 per day. Weekday discharges are 8.8 against a target of 11 for weekdays. Monthly DToC rate (% of DToC days) has again improved and in January is recorded as 1.7% from the December position of 2.9% and is maintained below the NHS England target of 3.5%. Occupancy increased in January to 96.3% from the January position of 95.9%. Length of stay Community Hospitals LOS is 26.3 days for January, an increase of 1.7 days from December and an increase can be seen for both direct and transferred patients. YTD LOS is 27 days. District Nursing:- District nursing is now on the GCS risk register. The main risk perceived by the CCG is with end of life care. The Band 6 district nurse staff group has a high vacancy rate and nurses continue to leave the service in favour of more attractive roles in areas such as complex care at home, pull model and frailty nursing. The nurses who are leaving tend to be more experienced staff members and backfill is being provided by newly qualified band 5 nurses. Overall the skill and experience of this staff group is declining. Rising demand is also being put on the service and this, combined with the shift in staff type, is putting the service under increasing pressure. Commissioners are working closely with GCS regarding the above via Clinical Programme Groups and usual contract levers such as Performance, Finance and Information meetings and Clinical Quality Review Groups. 31

87 3.11 Performance Patient Experience GHT Inpatients Response Rate % Recommend % Not Oct-17 Nov-17 Dec-17 Provider Nat Ave Provider Nat Ave Provider Nat Ave 26.80% 25.10% 26.90% 25.50% 25.40% 22.10% 91% 96% 91% 96% 92% 96% 4% 2% 4% 2% 4% 2% GHT A&E GCS 2g Response Rate % Recommend % Not Response Rate % Recommend % Not Response Rate % Recommend % Not FFT Top Line Messages 19.00% 12.70% 18.40% 12.90% 19.40% 11.60% 81% 87% 87% 87% 86% 85% 10% 7% 8% 7% 8% 8% 95% 95% 94% 96% 93% 96% 2% 2% 2% 1% 3% 2% 86% 86% 85% 88% 83% 88% 7% 5% 7% 5% 10% 4% PROMS In December 2017 GHNHSFT reports an above average response rate for both the Inpatient and A&E FFT. Unfortunately, results show that GHNHSFT continue to perform below national average for Inpatients, but continued improvement in A&E achieving above national average results. GHNHSFT has a strategic objective to improve their FFT score to 93% within 12 months. The trust are also exploring how they can bring the FFT together with their wider surveys and secure a new provider for all. Both GCS and 2G have seen a further drop in the %recommend results in December NHS England has taken the decision to discontinue the mandatory varicose vein and groin hernia procedure national PROM collections. NHS England will continue with hip and knee surgery PROM collections. February 2018: Final 2016/17 data for Varicose Vein and Groin Hernia surgery published by NHS Digital May 2018: Final 2017/18 data for Varicose Vein and Groin Hernia surgery published by NHS Digital. 32

88 3.12 Performance South Central Comparison Jan

89 4.0 Leadership Indicator Component Measure Narrative Staff and member practice engagement OD Plan Staff Survey Turnover Vacancies Sickness PDP/Training Turnover Rate: The January 2018 HR report shows an increase in turnover rates over the last 12months, which now stand at 13% Compliance rates for core mandatory / statutory training have increased since the beginning of the year to January at 81% to 87%. The Corporate Governance team has managed to resolve most of the issues relating to the validation of data from the Skills for Health system. Staff in Post, Starters and Leavers:. Since the last report staffing levels have increased from 267 for December 2017 to 272 WTE which equates 329 headcount. In January there were with 7 new starter and 4 leavers for that month. Over the last 12 months reporting in headcount of 42 leavers and 83 starters. Sickness Absence; Long term absence has increased from 1.75% to 2.1%, in January 4 members of staff were on long term absence. Short term absence has decreased slightly from 2.39% to 1.31%, 48 staff have been off sick on short term sickness in January. Sickness by Reason: For January 2018 there was a high level of sickness absence due to cough and colds, 22.25%. Practice engagement: There are now five Improved Access cluster pilots in the county. For the period until 21 st January these pilots provided an additional local 701 appointments to their patients. We have secured funding for; Practice Manager Development, for a further module for 12 of the 35 Practices who participated in the Productive General Practice Programme and as a CCG are funding a further 6 Practices through this programme. Regular individual practice visits continue. 34

90 4.0 Leadership Indicator Summary and headline evidence/ examples 1. Probity and Governance 2. Staff Engagement 3. Workforce Race Equality 4. Effective Working Relationships The CCG has put in place strong clinical and non clinical leadership across all areas of the STP, recent developments include investment in GP Provider leads to support local delivery and GP cluster working. STP governance structures include CCG staff in senior leadership roles in all areas of the programme alongside provider leadership roles. STP work Programmes progressing with outcomes being seen in a number of areas, including cancer, MSK and eye health. Governance structure for the STP has been in place for some time with new chair coming into post recently. The HR and OD plan aligns to that of the STP and is overseen by the HR/OD group who meet quarterly. There is positive work being undertaken for OD across the system, this includes the development of joint apprenticeship scheme for information analysts. The CCG effectively engages with staff members with a Joint Staff Consultative Committee and an annual staff survey. The 2017 survey demonstrated that staff feel engaged in the work of the organisation with 79% recommending it as a place to work. A robust action plan has been developed in response to the detailed survey results. In addition, staff engagement is aligned to the STP through the Partnership Forum and the Associate Director of Corporate Governance leads on HR and OD internally, and attends associated STP working groups to represent the CCG. Plans linked to overall STP workforce development. WRES data forms part of the CCG s annual Equality and Engagement report, reported to the IGQC. Feedback has been used to inform changes to recruitment processes and the staff survey. Provider organisations are also required to submit copies of their annual WRES reports to the CCG and subsequent action plans to enable specific issues to be addressed. The CCG Governing Body has recently signed up to the Insight Programme: our next participant (April 2018) is from a BME community. An action plan to address findings from the degree survey is in place and is owned by the Clinical Chair and Accountable Officer. 74 of the CCG s stakeholders completed the 2017 survey, and the 2018 stakeholder list was reviewed in line with the actions plan to ensure an appropriate range of responses. CCG is also undertaking consultations at present regarding Community Hospitals in the Forest of Dean and Funded Patient Transport with good engagement taking place. 5. Compliance with statutory guidance on patient and public participation The CCG is committed to embedding involvement in all areas of its commissioning activity and is able to provide clear evidence of progress against the 10 key actions including through the annual report, feedback website pages, communication engagement strategies and plans, consultation report, AGM and equality impact assessments. STP engagement, first stage complete, Forest of Dean initial consultation completed and preparation underway for One Place Business case consultation and next stage for the FoD. 35

91 4.0 Leadership Indicator: Summary and headline evidence/ examples 6.1 Leadership STP five year plan, developed from the FYFV signed off by all partners. CCG operational & financial plans developed from the STP plan, start point April STP work programme developing using the agreed governance structure. The CCG has 80 practices grouped into 7 localities with a strong relationship between the locality and the CCG through Locality Executive Groups and the Primary Care team. Specific examples of good practice include several primary care events and an annual rolling programme of GP Practice visits and varied communication methods such as What s New This Week and G Care. CCG OD plan focus on staff development and includes strong emphasis on formal appraisal including PDPs. Staff training co-ordinated across includes financial training at all levels including Governing Body and all budget holders. 6.2 Quality of Leadership 6.3 Leadership Governance 6.4 Transformational Leadership There is a clear governance structure in place which enables a focus on quality, performance delivery including contracts and finance within the IGQC, Audit Committee, Governing Body business meetings and the formal bi monthly Governing Body. Information is reported to each Committee with a focus on key area of risk as well as the overall performance position. The Governing Body is well sighted on financial and performance issues with regular informal and formal reporting. Meetings are well documented to evidence the level of discussion and challenge. Governing Body members expertise range from governance, clinical, financial and patient experience enabling a strong challenge. The Governing Body has a clear constitution, policies, set roles and responsibilities which enable them to effectively challenge. A recent review has been undertaken of the risk management process. Each committee carries out a self assessment annually to inform future development. Corporate governance team recently strengthened. This can be further evidenced by policies, committee structure and monthly reporting to the GB on financial risk including those within providers and contracts. External advice taken where required. Clean external audit reports since inception. Internal audit annually cover transactional areas as well as developmental areas and are reported to Audit Committee. The STP has a clear governance structure supported by a MOU which has been agreed by all partners. The Governing Body receives bi-monthly STP reports which provide updates on key achievements, performance and areas of focus. Providers also report on STP achievements to their respective boards. For example, partners are involved in progressing the One Place programme to develop the urgent care system to improve the patient experience. A dedicated team has been put in place to drive this project. 36

92 4.13 Performance Quality Premium Overview 37

93 5.0 Sustainability - Month 11 Income and Expenditure YTD surplus FOV surplus YTD Running costs FOV Running costs In year B/even B/even B/even B/even Cumulative ( 15,812k) ( 17,249k) ( 537k) ( 448k) Savings Programme YTD Savings BPPC 19,760k % YTD Savings Cash drawdown 83.0% FOT Savings 21,975k FOT capital % FOT Savings 87.4% Other Metrics TBC% 100% 190k Cash FOT BPPC drawdown Capital 99.8% 91.5% 70k 38

94 5.0 Sustainability Executive Summary Position FOV surplus YTD Running costs FOV Running costs YT FOV surplus YTD Running costs OV Running costs Combined STP Combined STP Gloucestershire CCG is forecasting to achieve it s planned in year position of breakeven before any further adjustments. NHS England have 2,874k now u/s 17,243k u/s 172k u/s TBC 2,874k authorised u/s the CCG to release the 0.5% remaining System Risk reserve TBC 3,705k to the CCG s financial position. In addition, NHSE has also notified the CCG that the Category M savings held by NHS England are also to be returned YTD QIPP to CCGs with the FOT expectation QIPP that there will be an improvement in each CCG s position ; the amount for Gloucestershire is 0.793m and this is currently being validated. The total of the two adjustments is 4.498m, the in year position will then change to a surplus of 9,510k 25,154k 4.498m and the cumulative surplus would become m. Very little flexibility now remains with Cash the CCG to offset any additional pressures as all recurrent and BPPC drawdown FOT capital Capital non-recurrent reserves have been utilised to cover recognised pressures. As much of the in-year TBC% mitigation is non recurrent in 100% 190k nature, the consequence will be an additional 190k pressure in 2018/19; new savings are being identified to bridge the funding gap. Discussions are ongoing with providers regarding the 2018/19 financial year and the first draft 2018/19 financial and operational plans were submitted on 8 th March. 39

95 5.1 Sustainability Resource Limit The CCG s allocation as at 28 th February 2018 is 860.2m. There were 4 adjustments received in January, which were all non-recurrent (see below). NHS England advise that approved Winter Resilience funding ( 1,210k under Tranche 2) will be paid to the CCG once regional teams have validated that schemes has been implemented and delivered the planned additional capacity. This is currently scheduled for mid March. YTD QIPP FOT QIPP 000 Description 9,510k 25,154k 58 Diabetes Transformation Fund (standard quarterly instalment) BPPC Cash drawdown 46 GPFV Resilience Funding FOT capital Capital (90) Additional month 11 IR Changes (i.e. transfers to Spec Comm) 107 Online Consultations 121 Total Change in month 40

96 5.2 Sustainability Acute Contracts (1 of 3) Acute NHS Contracts Key Indicates a favourable movement in the month Indicates an adverse movement in the month Gloucestershire Hospitals NHS Trust (GHNHSFT) A block contract arrangement has been agreed with the Trust, hence the CCG continues to report a breakeven position for the 2017/18 forecast outturn. Current operational information issued by the Trust continues to show that outpatient and elective activity is under planned levels, whilst non-elective and A & E attendances are above the plan. Discussions around contract levels for 2018/19 are ongoing. Great Western Hospitals NHS Trust (GWH) The position remains static this month with continued overspends in the majority of contract areas within: Elective inpatients for trauma & orthopaedics (T&O), ophthalmology, cardiology and podiatry Non-elective inpatients in T&O, general medicine, cardiology and obstetrics Day case in podiatry, cardiology and ophthalmology Non PbR underspends in critical care however these do not offset the pressures elsewhere in the contract. The provider has agreed to the CCG s offer of a block settlement value in 2017/18 and this is reflected in the report. Trend Year end Forecast

97 5.2 Sustainability Acute Contracts (2 of 3) Acute NHS Contracts Trend Year end Forecast 000 Oxford University Hospital NHSFT Underspends continue within the contract position in the following areas which has seen an increase in the forecast under-performance in the month: Elective cardiology and T&O Non elective general surgery, nephrology & neurosurgery Day case in general surgery, gynaecology and hepatology Non PbR in Rehabilitation bed days Marginally offset by increased costs in critical care activity University Hospital Bristol NHSFT There has been an adverse movement of 80k which mainly relate to costs increases in high tech homecare drugs. As in previous months, there is under-performance in day cases which has been offset by overspends in non-elective and high cost drug activity. University College London Hospital The position this month has been maintained and is currently as previously forecast with overspends in: Elective urology, colorectal surgery, T & O and paediatric endocrinology Non elective activity in urology Worcester Acute Hospital NHST The contract continues to show signs of over performance within the areas of: Elective T &O and cardiology Non elective maternity, general medicine & sepsis Day case T&O and cardiology Increased drug costs (350.0)

98 5.2 Sustainability Acute Contracts (3 of 3) Acute NHS Contracts Trend Year end Forecast 000 North Bristol NHS Trust The forecast position has reduced from that shown in with prior months and the Trust has been challenged on this position. There are underspends in the following areas: Elective inpatient for plastic surgery Non elective inpatients for general surgery, nephrology and neurosurgery which is partially offset by overspends in geriatric medicine and T & O Adult critical care activity Winfield The position this month has reduced significantly with under-performance in the majority of contract areas with a slight overspend within pain management. The provider continues to forecast an increase in activity in the remaining two months of the financial year end based on increased capacity and consultant availability. Royal United Hospital Performance has remained consistent with last month with performance being above plan within the following : Elective cardiology, general surgery, obstetrics, respiratory medicine and T&O Non elective rheumatology and T&O (605.1) (947.0) Non Contract Activity/Overseas visitors The over-spending position has deteriorated within NCAs due, in part, to some high cost invoices from Betsi Cadwaladr University LHB and Aneurin Bevan LHB which had not previously been anticipated

99 5.3 Sustainability Prescribing Primary Care YTD Prescribing Trend Year end surplus FOV surplus YTD Running costs FOV Running costs Combined STP Forecast 000 The current forecast outturn position is for a 2m overspend to budget due to the ongoing No Cheaper Stock Obtainable (NCSO) drugs issue and the additional charge levied by NHSE for in year Cat M price reductions. The estimated cost pressure for the period April to February is approximately 3.1m. This position is fully included within the CCG s overall financial position and whilst still a significant cost pressure, it does appear to be reducing significantly in value in the last quarter of the year. The 2017/18 savings programme continues to perform extremely well and is currently on target to deliver over 4m within 17/18. The largest single growth area is NOAC s which has seen almost 1m more in the first three quarters of 17/18 than the previous financial year. Annual Spend on NOAC s is likely to be 5.7m assuming current growth rates continue There has been a YTD reduction in items prescribed for April to December of 0.8% compared to 16/17. This equates to an actual reduction of items prescribed of over 80,000. 2,000 44

100 5.3 Sustainability Prescribing Locality Prescribing : Prescribing data Apr 17 to Dec 17 Locality YTD % Growth In Cost of Prescribing YTD % Growth In volume of Prescribing Cheltenham -1.2 % -0.2 % Forest of Dean 0.7 % 0.7 % Gloucester City -0.5 % -0.7 % North Cotswold -3.8 % -1.5 % South Cotswold -1.0 % -1.3 % Stroud and Berkeley Vale -0.8 % -1.5 % Tewkesbury, Newent & Staunton -3.4 % -3.8 % Total -1.0 % -0.8 %

101 5.3 Sustainability Prescribing Impact of NCSO & CAT M on YTD Growth (Apr-Dec17)

102 5.4 Sustainability Mental Health Mental Health Trend Year end Forecast 000 Mental Health Services This area includes costs associated with patients with a learning difficulties and is characterised by low volumes of patients with each attracting a high cost and, therefore, fluctuations from the average are noticeable. The current budget is predicated on last year s trends which, to date, have not been replicated in 2017/18 thus leading to an overspend. This is based on the current number of patients currently in placements. Staff have been appointed to engage patients in day care which should facilitate a quicker discharge. The improvement in the month relates to a decrease in the charge from Gloucestershire County Council relating to fixed short tem patients. Placements can be for a fixed short period or an ongoing basis and such ongoing costs will have a consequent knock-on effect within 2018/19 budget planning

103 5.5 Sustainability Primary Care Primary Care Trend Year end Forecast 000 Delegated Co-Commissioning The forecast is a breakeven position against a budget of m. Demographic growth in patient list sizes by practices has outstripped planned levels Claims for sickness and maternity cover have increased again this month. 0 Other Primary Care The Local Enhanced Services continues to show an underspend predominantly within schemes for anti coagulation, leg ulcer services and urgent care The primary eye care contract continues to underspend against plan. Some minor slippage in the implementation of cluster schemes in the early months of the financial year has been experienced within the primary care transformation fund however all schemes are now on track. Reassessment of staffing costs (91.7) 48

104 5.6 Sustainability Continuing Health Care Continuing Health Care/Funded Nursing Care Trend Year end YTD surplus FOV surplus YTD Running costs FOV Running costs Combined STP Forecast 000 The reconciliation of patient numbers and package costs between systems across the CCG and Gloucestershire County Council (GCC) has now been incorporated into the monthly business as usual procedure. Ongoing dialogue between organisations ensures that any variances are followed up on a regular basis and any reimbursement is actively pursued. There currently remains a difference of 375k between the two organisation s systems and discussions are ongoing to clear these items on a case-by-case basis. The CCG s overall financial position includes an assessed clearance of a proportion of these differences. This area predominantly includes costs based on client level information from GCC and independent providers which includes amounts for domiciliary care, nursing home placements, those in receipt of funded nursing care and personal health budgets. The current overspend represents a slight deterioration during the month. The reported position includes backdated costs for a case which has been recently approved under a Section 256 arrangement with GCC. In addition, some new personal health budgets have recently been approved which is included within the adverse movement

105 5.7 Sustainability Savings Plan 2017/18 savings plan is based on Year 1 of Sustainability and Transformation Plan (STP) solutions which used opportunities identified through benchmarking included national RightCare comparisons The forecast for savings plans has been included in the financial forecast Slippage and additional savings have been identified to cover any programme shortfalls. Savings plans for 2018/19 are progressing well and build on the current year s programme, the planned programmes under the STP and further opportunities from benchmarking. The CCG is currently working on RightCare Delivery Plans as part of its savings programme for 2018/19 with 37.5% of the programme aligned to RightCare. 50

106 5.9 Sustainability Savings forecast delivery 51

107 5.10 Sustainability Risks & Mitigations Risks Volatility in prescribing (including NCSO) Impact on 17/18 GHFT activity of Trakcare implementation which will have a further effect on RTT backlog impacting on future years Delivery of other constitutional standards Growth & demand pressures True impact of transfers of activity from Specialised Commissioning Transforming Care transfers from Specialist Commissioning Slippage in delivery of saving solutions Mitigations Slippage on developments retain centrally Identify new savings schemes Urgent care reset plan Apply minimal contingency No controllable expenditure to be committed if no identified funding source Developments - release subject to business case sign off. 52

108 5.11 Sustainability Cash drawdown 900,000 Proportion of Cash Limit Utilised Actual and Forecast 800, , ,000 ' , , ,000 Cash Forecast Cash Limit Cash used YTD 200, ,000 0 April May June July August September October November December January February March At the end of February 769m had been drawn down (91.5%) of the maximum cash drawdown available of 840m. The cash balance at 28 th February 2018 was 8.1m. 53

109 5.12 Sustainability BPPC performance 100% 99% 98% 97% 96% 95% 94% 93% %age Performance by value Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar NHS 100.0% 99.9% 99.8% 100.0% 99.8% 100.0% 100.0% 100.0% 99.9% 100.0% 100.0% Non NHS 98.8% 99.6% 100.0% 97.8% 99.4% 97.9% 100.0% 99.0% 96.8% 99.0% 99.8% Target Performance 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 54

110 If you require more information than the data provided in the Monthly Performance Report or Accompanying Scorecard please contact: Information & Performance Department - GLCCG.InformationTeam@nhs.net 55

111 Governing Body Agenda Item 10 Meeting Date Thursday 29 th March 2018 Report Title Sustainability & Transformation Partnership (STP) Progress Update Executive Summary A high level STP progress update is attached for the Governing Body. Key Issues STP Programme update outlining key achievements in Quarter 4 and high level 18/19 plans Risk Issues: Original Risk (CxL) The main risks currently inherent in the development of the STP are still present. Residual Risk (CxL) Management of N/A Conflicts of Interest Financial Impact The STP is a key part of ensuring that we Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Patient and Public Involvement Recommendation Author Designation Sponsoring Director (if not author) maintain financial balance as a health community The STP includes a commitment to ensure compliance with NHS Constitution Standards and meet national requirements. The STP includes a clear commitment to reduce health inequalities. The STP includes a commitment to ensure equality, value diversity. The STP supports sustainable development. Patient and public representatives are engaged through various stakeholder events. This report is provided for information and CCG Members are invited to note the contents. Emily Beardshall STP Deputy Programme Director Ellen Rule STP Programme Director Page 1 of 1

112 Gloucestershire s Sustainability & Transformation Partnership Update to Gloucestershire Clinical Commissioning Group Governing Body March 2018 #glosstp

113 #glosstp

114 Our 2017/18 Focus 2017/ / / / /21 Significant transformation plan now in implementation phase Increased level of trust across the system adopting a distributed leadership model Driving delivery on current plans to achieve: Improved quality outcomes Population health approach (Place Based) More efficient services through improved pathways with an increased focus on prevention and self-care Real signs of positive change #glosstp

115 Progress on Delivery Programmes Enabling Active Communities Clinical Programme Approach One Place, One Budget, One System Reducing Clinical Variation Second Daily Mile initiative planned Community Well-being service established 803 referrals onto the National Diabetes Prevention Programme 156 patients referred to Stop B4 the Op service since Oct 17 MSK programme at a crucial phase in implementation Improved Cancer pathways including implementation of straight to test in colorectal MyCOPD online tool approved for roll-out in March Widening of Community Dementia offering being planned for 18/19 One place clinical model evolving rapidly Centres of Excellence programme progressing Integrated Locality Board pilots to be established from April 18 Continued increase in elective activity in T&O following elective/nonelective inpatient split Achievement of 4m of medicine optimisation savings in 17/18 30 Clinical pharmacists support GP practices across Gloucestershire Development & distribution of the pain countywide joint formulary #glosstp

116 Progress on Enabling Programmes Workforce Strategy Primary Care Strategy IT Strategy Estates Strategy Improvement Academy & OD New roles within primary care including mental health workers & frailty nurses Commenced training of Nursing Associates Launched Proud to Care Extended access progressing with go live in South East Gloucester and North East Gloucester during Quarter 4 Further Productive General Practice modules delivered Joining up your information programme in test phase Wi-Fi availability in GP practices has started roll-out 2 programmes taken through to completion 4 programmes now signed off for completion in 2018/19 Submitted refreshed capital case for GHNHSFT Next wave of QSIR training planned Building leadership network plans Alignment of training across organisations Strategy refreshed #glosstp

117 Priorities for the next 3-6 months: Full roll-out of Joining Up your Information programme Implementation of electronic referrals by June 2018 Continued progression on transforming and streamlining cancer pathways Develop a county-wide model for community dementia service Extended access in primary care in all clusters Rapid progression of the capacity modelling for Urgent & Emergency Care and Centres of Excellence programme Develop the case for test & learn projects within Urgent Care pathway work Deliver next phase programme for cultural commissioning, including new pilots for children with long term conditions Finalise the functional specification for Online Consultations in conjunction with ongoing GP & Practice Manager engagement across practices & patient engagement Continue to deliver against clinical programmes objectives, examples include go live with countywide MSK triage business case, delivery of respiratory integration, complete business case for stroke rehab, develop case for online diabetes management tool and develop further community eye care pathways. Underpin progress with a full staff, public and patient engagement programme #glosstp

118 Our 2018/19 Plans 2017/ / / / /21 Rapid progress on implementation across the clinical and enabling programmes building on progress made to date to achieve Improved quality outcomes Population health approach (Place Based) More efficient services through improved pathways with an increased focus on prevention and self-care Progression of urgent & emergency care and Centres of Excellence Programme Further focus on mental health and integrated commissioning hubs Follow through on commitments made in refresh of workforce and reducing clinical unwarranted variation strategies Review, revise & refresh STP processes to ensure that they are best placed to support the progress towards integrated care Delivery of STP solutions to meet system-wide financial challenge #glosstp

119 Agenda Item 11 Governing Body Meeting Date Thursday 29 th March 2018 Report Title Quality Report Executive Summary This report provides assurance to the Governing Body that quality and patient safety issues are given the appropriate priority. Key Issues The Quality Report provides an overview of activity undertaken within the CCG to monitor and improve quality of commissioned services.. The report highlights areas of strong performance and areas which may require increased surveillance. Risk Issues: Failure to secure quality, safe services for the Original Risk (CxL) population of Gloucestershire Residual Risk (CxL) Management of Not applicable Conflicts of Interest Financial Impact Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Patient and Public Involvement Recommendation Author Designation Sponsoring Director (if not author) There is no financial impact Compliance with the NHS Constitution, NHS Outcomes Framework and recommendations from NICE and CQC. A focus on the delivery of equitable services for the residents of Gloucestershire and which will reflect the diversity of the population served. There are no direct health and equality implications contained within this report. There are no direct sustainability implications contained within this report. There is no impact The Governing Body is asked to note the contents of this report. Marion Andrews-Evans Executive Nurse and Quality Lead Not applicable Page 1 of 7

120 Agenda Item 11 Governing Body Thursday 29 th March Introduction Quality Report The Governing Body Quality Report is produced to provide assurance of the quality monitoring and support work being undertaken by GCCG with providers in county. Formal assurance of the quality of NHS services is by way of the Governance and Quality Committee, minutes of which are received by the Governing Body. This report provides succinct detail on activity undertaken and areas of strong performance or concern. 2 Summary Serious Incidents & Never Events A Serious Incident is defined by the National Patient Safety Agency (NPSA) as an incident that occurred in relation to NHS-funded services and care. These are often referred to as STEIS incidents after the reporting system. The Strategic Executive Information System (STEIS) allows us to break down the numbers being reported into categories/ Each reported incident is reviewed by the Quality Lead for that specific provider. This allows for identification of any potential themes or trends and can inform more in-depth discussions at the relevant Clinical Quality Review Group. Full details, split by category are provided to Quality and Governance Committee. Gloucestershire Hospitals NHF FT Q4 16/17 Q1 17/18 Q2 17/18 Never Event Q3 17/18 Serious Incidents Incorrect lens inserted during surgery 2.4 Gloucestershire Care Service NHS Trust Q4 16/17 Q1 17/18 Q2 17/18 Never Event Q3 17/18 Page 2 of 7

121 Serious Incidents Incorrect tooth extraction gether NHS FT Q4 16/17 Q1 17/18 Q2 17/18 Never Event Q3 17/18 Serious Incidents Patient Advice and Liaison Service (PALS) Activity Type Quarter 3 16/17 Quarter 4 16/17 Advice or Information Comment 7 7 Quarter 1 17/18 48 (16 PC) 2 (1 PC) Quarter2 17/18 45 (15PC) 2 7 Quarter 3 17/18 58 (PC16) Compliment Concern (17 PC) (17PC) (PC15) Complaint (1 PC) 10 (2 PC) 5 about GCCG Complaint about provider (7 PC) 18 (3 PC) 21 (PC4) NHSE complaint responses copied to GCCG PALS Other (4 PC) 15 (1 PC) 8 Page 3 of 7

122 Clinical Variation (Gluten Free) Total contacts GP medical service complaints in brackets 4 Infection Control 4.1 Seasonal Flu GCCG is very pleased to report that the provisional figures for flu vaccination uptake demonstrate the following improvements: 1. Frontline staff: All three of the Hospital Trusts exceeded the CQUIN target of an uptake in 70% amongst frontline staff and look well placed to achieve the higher target of 75% in place for the 2018/19 season. 2. School immunisation: This is the first year of a new contract under GCS and the new expanded team came together well and achieved an uptake of 63% which is an improvement on the last flu season. 3. In all but two areas the flu vaccination uptake amongst at risk groups has increased. The percentage of 65+ year olds is at 74.3%. A survey of care homes by the CCG demonstrated an 80% uptake amongst residents Learning from this most recent flu season has identified areas to target next year. This includes flu vaccination uptake of care home workers and carers/visitors. To support this work is being undertaken to include in contracting arrangements with care homes the requirement to report on flu vaccination uptake of care home staff and residents. Promotional material for carers and visitors is planned to encourage these groups of people to protect residents by having a flu vaccination and not visiting when they have respiratory infections. Measles Last year (September 2017) we had a measles outbreak in Gloucestershire with Stroud as the most affected area. A Stroud Engagement group was formed to promote MMR uptake. During the outbreak in September 2017 it was found young adults, with parents who had refused for them to have the MMR when they were children, when presented with the information selected to have a MMR. Therefore it was decided to deliver a promotional programme for MMR focusing on young adults aged years across Gloucestershire starting in March 2018 and continuing over the year. Colleges and Universities were identified as key target areas. An event has been designed for delivery from the NHS Information Bus which includes interactive activities to engage young adults. This gives an opportunity to provide information and answer questions. Page 4 of 7

123 4.4 Escherichia coli (E.coli) Infections The Quality Premium for 17/19 aims to reduce E.coli Gram Negative Bloodstream Infections (GNBSIs) by 10% and reduce inappropriate antibiotic prescribing for Urinary Tract Infections as well as sustain the decrease. The target for the year is 257 (or less) cases. At the end of December 2017 in Gloucestershire the number of cases recorded is 215. This is above the projected trajectory required to meet the target by 20 cases. Of the cases reported to end of December 2017 (215) these were apportioned as follows; 169 cases (79%) allocated to Primary Care, 46 cases to Hospitals (21%). 4.5 C. Difficile Infections (CDI) The target for GCCG is 157 cases of CDI over 12 months. Between 1 April 2017 and 31 December cases with 72% (105 cases) reported with community onset and 28% (41 cases) with a hospital onset. Viewed proportionally we are 40 cases over our target. Between 1 April 2017 and 31 December CDI related deaths have been reported. All have been reviewed. Countywide there is an upward trend in cases. A short life working group has been established and met for the first time on 12 October The purpose of the group is to develop an action plan to reduce the incidence of CDI in Gloucestershire. At the first two meetings local data and practice was reviewed. The third meeting is on 6 March 2018 and work is now focused on developing the action plan. 5 CQC 5.1 Gloucestershire Care Services CQC Inspection The GCS CQC inspection took place as planned. In particular they focussed on End of Life Care, which was expected, MIIU s and Trust leadership. The CQC have undertaken an additional inspection of Dental services and have indicated that the report should be with the provider by Easter g NHS Foundation Trust CQC inspection team recently visited several 2g clinical settings. Although the inspection report is awaited, initial feedback from the inspectors has been positive with a small number of recommendations. 2g will receive an inspection under the CQC domain of Well Led later in March. 5.3 Gloucestershire Hospitals NHS Foundation Trust Following last year s inspection of the Trust where it was identified to have areas that require improvement, a Quality Improvement Plan (QIP) was developed. The implementation of the plan was overseen by the NHSE/I Quality Improvement Group. At Page 5 of 7

124 the end of last year it was agreed that responsibility for monitoring the delivery of the action plan would transfer to the CCG. The CCG has now received an updated improvement plan from the Trust and progress is being monitored through the Clinical Quality Review Group. The current areas of concern that are focused around the urgent care pathway are specifically the recognition of the deteriorating patient, the use of the ED checklist and patient experience. In addition some of the other areas being actioned relate to the management of patients on the cancer waiting list and some aspects of infection control. Primary Care CQC Inspections 5.4 Locking Hill Stroud The CQC inspection of 9 th May 2017 rated the practice as Inadequate and placed it into Special Measures. The CCG has been actively engaged with the practice since this time to support improvement. The practice was re-inspected in January and the report of this inspection was published on 8 th March This report rates the practice as Good in all domains. 6 Quality Team Activity 6.1 Safeguarding On 18 th January the GCCG Safeguarding team facilitated a bespoke training session with an external trainer delivering both adult and child safeguarding training to address the needs of the clinical pharmacist working within general practice. The session was well supported with 40 attendees which included representatives from other statutory organisations ensuring a multi-agency learning event 6.2 PALS visit to Patient Transport Advice Centre The PALS team recently arranged to visit the Patient Transport Advice Centre (PTAC) in Bridgwater. From April 3 rd 2018 all pre-booked Patient transport will go through the Centre. The team based at PTAC will take the Patient through a list of questions to establish whether they are eligible and meet the criteria to access Arriva services. The team have been up and running the Somerset area for 10 years now and it has proved to be really successful. Part of the service they offer is to find the Patient another alternative, should they not meet the criteria. This could be Community Transport, Volunteer Services, the best bus routes, so it a more holistic approach. They use a scoring system of: automatically qualifies this is escalated to a Supervisor who will look at the details and decide eligibility - Over 21 they do not qualify and an alternative is offered Page 6 of 7

125 There will be Patients who have been accessing transport even though they are not eligible, and the team have been briefed to handle those calls. Page 7 of 7

126 Agenda Item 12 Governing Body Meeting Date 29 th March 2017 Report Title Executive Summary CCG Proposed Annual Budget This paper outlines the proposed 2018/19 budget for the CCG that supports the organisation s operational plan and the Gloucestershire STP. The proposed budget includes proposed contract values with the CCG s providers, however, there remains a significant gap between the CCG s proposed contract with GHFT and the GHFT contract proposal. Other, smaller differences remain on a range of contracts with work underway to resolve these differences. The proposed budget is predicated on a savings programme of 18.6m. Careful financial control and monitoring will need to be maintained during the year across all budget areas in order to deliver the planned system changes and to ensure that the in year breakeven control total is achieved. The CCG has a cumulative surplus brought forward from 2017/18 which exceeds the 1% requirement. An update to the budget position will be presented at the May Governing Body meeting to reflect contract agreements. Key Issues In reaching the draft budget the CCG is proposing to utilise the 0.5% national contingency reserve. A number of contract agreements remain outstanding, the major one is GHFT. 1

127 The CCG is no longer required to hold a 0.5% system risk reserve or headroom and this is reflected in the draft budget. The CCG s current savings requirement totals 18.6m; plans and risk ratings having been developed for schemes. Risk Issues: Original Risk (CxL) Residual Risk (CxL) The key risk within the plan is the non achievement of the planned control total, key risks are: Lack of agreement on the GHFT contract The impact of the Trakcare recovery at GHFT, including RTT delivery In-year contract over-performance within acute contracts; Under delivery of savings plans, particularly those reliant on a whole systems solutions. Prescribing costs being higher than that planned, either due to the introduction of new drugs, increased growth or price increases on Category M items The potential for increasing continuing health care cases The impact of LD transfers under the Transforming Care agenda Primary care expenditure exceeding the budget set System risk relating to potential nonavailability of STF funding should providers fail to meet control totals 4 x 5 = 20 4 x 5 = 20 Management of Conflicts of Interest No specific conflicts of interest other than those declared at the board meeting 2

128 Financial Impact Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Patient and Public Involvement Recommendation Author & Designation Sponsoring Director (if not author) The CCG has a statutory duty to achieve financial balance. The CCG is planning for a breakeven financial position in year. Not Applicable. There are no direct health and equality implications contained within this report. The assessed impact on health inequalities is contained within individual programmes for the year. Not Applicable. The are no direct sustainability implications contained within this report Not applicable The Governing Body is asked to: Approve the proposed 2018/19 budget Approve the 2018/19 Financial Management Policy Note the inherent risks within the plan Andrew Beard, Deputy Chief Finance Officer Cath Leech, Chief Finance Officer 3

129 Agenda Item 12 Gloucestershire CCG 2018/19 Proposed Budget 1.0 Introduction This paper presents the 2018/19 proposed budget to the Governing Body for approval. The financial plans are consistent with and support the Gloucestershire Sustainability and Transformation Plan. The budget represents year two of the operational plan and builds on performance in 2017/18. The CCG is forecast to achieve its financial plan in 2017/18, within this position there have been a number of pressures and these have been included in the budget for 2018/ CCG Business Rules The CCG is required to set a budget which includes the financial planning parameters required by NHS England. These are as follows: a cumulative surplus equivalent to at least 1% of allocations (excluding primary care) a minimum contingency reserve of 0.5% amounting to 4.3m (inclusive of 0.4m Delegated Primary Care) there is no longer a requirement to hold a non-recurrent (headroom) reserve of 1.0%. Drawdown in line with the NHS England business rules. The CCG has, in a previous year, built up a surplus greater than 1% of its allocation, NHSE have notified that the CCG is able to draw down 0.3m over each of the following two years. The CCG is requesting further drawdown in year to take forward a number of transformational schemes to underpin an accelerated rate of transformation but this is not yet approved. This is expected to be included in the 4

130 final contract update. These parameters are applied to the primary care allocation as well as the programme allocation with the exception of the surplus requirement 2018/19 m Programme Budget: Planned in year position Breakeven Contingency reserve 0.5% Draw down Primary Care Budget Contingency reserve 0.5% The CCG s proposed budget meets the above requirements. 3.0 Tariff 2018/19 The 2018/19 tariff is the second year of a two year national tariff. The tariff is based on the following: - inflation uplifts of 2.1% - cash releasing efficiency savings (CRES) of -2% - Clinical Negligence Scheme for Trusts (CNST) within specific published national tariffs. - HRG4+ phase 3 currency for national prices - tariff based on 2014/15 reference costs The structure of the tariff introduced in 2017/18 is such that there were significant changes in funding flows within contracts and between specialist and non specialist commissioners. NHSE sought to ensure that these are cost neutral through calculating the potential impact on a commissioner and its contracts and then adjusting the commissioner allocation accordingly. Adjustments in 2017/18 have been reflected in the 2018/19 allocation. 4.0 System Risk 5

131 Each STP area has a control total which is built up of the individual organisational control totals. For Gloucestershire these are: - the CCG - Gloucestershire Hospitals NHSFT - Gloucestershire Care Services NHST - 2Gether NHS FT All organisations will be accountable for delivery of their own organisational control total and the system control total; this is to ensure that perverse finance incentives do not get in the way of transformation. GHFT and NHS Improvement are still in discussion on the control total for 2018/19, the current GHFT control total as set has not been agreed. Control Total m Gloucestershire CCG Gloucestershire Hospitals GHFT and NHSI still NHSFT in discussion Gloucestershire Care Services NHST 2Gether NHS FT The national planning guidance for 2018/19 does not require each organisation to hold a system risk reserve /19 Draft Budget The proposed 2018/19 budget is shown in Appendix 1. The budget shows a planned in year breakeven position for 2018/19 and includes the planned savings (Appendix 2). The CCG is currently still negotiating a number of contracts with providers, the budget includes anticipated contract amounts for each of these. Of the contracts outstanding, the Gloucestershire Hospitals NHSFT (GHFT) is the most significant. The draft budget includes a contract envelope reflecting the CCG s view on the contract value, however, there 6

132 is currently a gap between contract proposals and this represents a significant risk to the CCG s financial plan. The proposals are fully inclusive of recurrent plans for the use of the 30% non-elective threshold monies, readmission credits and resilience funds. They also include investment to support the CCG s commitment to parity of esteem in mental health related services. Savings plans and risk sharing against delivery of savings plans have been allocated across headings within the plan and these are currently the subject of discussions with providers. There remains some further outstanding work to finalise some of the detail around schemes. 6.0 Resources The CCG s allocations were been published for the period 2016/17 to 2020/21; the first three years representing firm allocations with the subsequent ones being indicative only. These allocations have now been updated for the increase in NHS funding announced in the autumn. The allocations for 2018/19 is as follows: Programme allocation (Used to commission health care services) /19 m Primary care services allocation Running Cost Allocation Total The CCG received an initial 1.99% uplift in its programme allocation plus an additional 6.3m from the Autumn funding announcement. Prior to the allocation of the Autumn funding, the CCG was -1.67% away from its target allocation. The allocation changes included in the budget are: 7

133 The recurrent funding transfers between specialist commissioning and CCGs to ensure consistency of commissioning across England The recurrent funding adjustment for HRG4+ Recurrent changes associated with GP Access Fund Non recurrent uplifts relating to the national paramedic rebanding exercise and costs of the Health and Social care Network (HSCN) It has been confirmed that no financial flows will change in 2018/19 relating to the commissioning responsibility of English patients registered with Welsh GP practices. It is not currently known when these changes will take place. 7.0 Expenditure The CCG is planning to spend, prior to savings plans, 848.7m on commissioning health care services in 2018/19 including primary care (of 81.5m). This accounts for over 98.4% of our expenditure as a clinical commissioning group, the remaining amount is spent on running costs. The services that we commission include: Non specialist acute care in hospitals; Services in the community; Medicines prescribed in general practice; Primary care services; and Continuing healthcare for patients with longer term needs Placements for individuals with complex needs Services are provided by both NHS organisations and providers from other sectors, such as private companies and voluntary organisations. 8.0 Investments Investments include the full year effect of 2017/18 investments, activity and demand driven investments from the previous year and those prioritised as part of the strategic plan through the 8

134 CCG s Prioritisation Committee. Where an investment relates to a proposal which is still in development, the funding will be held in reserves and released against an approved business case. Other investments include: funding for forecast elective and non-elective demand, including demographic growth, within contracts in line with population growth trends by specialty; funding for resilience across the health community is currently being reviewed on an individual scheme basis with providers in the A & E delivery Board and will be finalised in April. (2017/18 values included at Appendix 3 for information) investments to fund new NICE technology appraisals (TAs); investment in mental health services in line with parity of esteem, this includes IAPT, eating disorder services, early intervention and Future in Mind. Investment in primary care in line with both the GP Five Year Forward View and the anticipated 2018/19 contract offer Increased investment in the ongoing costs of GP practice buildings following the completion of approved premises developments. The cost of transfers of LD patients under the Transforming Care agenda Implementation of agreed changes to the learning disabilities provision within the county, particularly relating to assessment and treatment beds. Investments in digital including NHS111 online, increased network costs and cyber security. 9.0 Better Care Fund and Partnership Funds The Better Care Fund for 2018/19 has been nationally mandated to increase by inflation of 708k (1.9%) to a value of 37,995k from 37,287k in 2017/18 (both excluding Disabled 9

135 Facilities Grant element of the fund). The proposals will be reviewed by Joint Commissioning Partnership Executive and Joint Commissioning Partnership Board in forthcoming months and is fully covered by existing Section 75 arrangements between GCC and the CCG. A draft schedule representing the proposed partnership funding between the organisations is provided at Appendix Primary Care Budgets The allocation for Gloucestershire s primary care budgets is m. The budgets in 2018/19 have been built up from the budgets and expenditure profile in 2017/18 and have been reported to the Primary Care Co-Commissioning Committee (PCCC). The GP contract for 2018/19 has recently been released and the implications are currently being worked through which includes cost increases to both the global sum element of the contract itself and an increase in payments for Quality and Outcomes Framework (QoF). The CCG has worked closely with NHS England colleagues to ensure that appropriate assumptions were made in arriving at the budget setting proposals and the initial assessment is that the current budget is compliant with the contract requirements Running Costs The CCG s running cost envelope is m; this includes a small decrease of 5k on the 2017/18 running costs plus a non-recurrent allocation of 10k for HSCN and additional property costs ( 26k). The running cost budgets are fully committed and it is important to note that any recurrent changes will need to be carefully managed to ensure that the running cost allocation is not exceeded. 10

136 12.0 Savings Requirements The CCG s budget assumes delivery of a savings programme of 18.6m. A breakdown of schemes across the main headings is shown at Appendix 5. Savings plans have been discussed with the STP Delivery Board and in contract discussions. Most schemes are fully worked up at this point, any slippage to delivery of savings plans represents a risk to the CCG s overall financial position. The savings programmes fall into four main areas: - Urgent care initiatives that are being progressed and include the full year impact of existing schemes together with new projects. These schemes focus on treating patients in the most appropriate setting for their condition and with the most appropriate member of staff. - Planned care is focussed on the development of more effective pathways for specific areas are being progressed through the Clinical Programme Groups and the planned care board These schemes include the implementation of changed pathways and models of delivery in both inpatients and outpatients with changes such as telephone appointments and one stop services - Prescribing savings of 5m include a focus on improved prescribing with better outcomes and more cost effective prescribing, including procurement savings, combined with a reduction in waste. - Transactional savings have been identified as part of an overall detailed review of the CCG s budgets Reserves The CCG has set aside the following specific programme reserves: - national contingency reserve of 0.5% ( 4,312k) - specific investments, where an approved business case or 11

137 contract variation has yet to be signed off, are held in reserves until approval Risk Management The proposed 2018/19 budget is reliant upon realisation of savings schemes and the control of expenditure in year. Key risks and mitigating actions are shown in Appendix 6. In addition to this, the CCG Financial Management Framework has been reviewed and is attached at Appendix 7. In order to manage in year financial risks the following actions will need to be agreed: - Developments funded within the Annual Operating Plan which are not unavoidably committed will be retained within reserves. Release of developments will be subject to a business case sign off. - No controllable expenditure will be committed if there is no identified funding source - Underspends will be removed from budgets periodically throughout the year on a non-recurrent basis in year following discussion with the relevant Director. - The first call on any budgets released whether recurrently or non recurrently will need to be the reinstatement of a CCG contingency reserve 15.0 Capital The CCG has previously bid for capital funding which is being reviewed by NHS England. These funds cover:- Category 2018/19 ( 000) Local Digital Roadmap 3,000 Practice Network/Hardware 1,450 Refresh 12

138 CCG Network/Hardware Refresh 70 Practice Minor Improvement 250 Grants CCG IT Infrastructure TBC The above schemes exclude capital bids made against the Primary Care Transformation Fund (including for completion of existing practice build schemes and wifi implications) and Transforming Care Partnerships (relating to Learning Disabilities) Recommendation The Governing Body is asked to Approve the proposed 2018/19 budgets Approve the 2018/19 Financial Management Policy Note the inherent risks within the plan Appendices Appendix /19 Budget proposals Appendix /19 Allocation of savings applied to budgets Appendix /19 Resilience Funding Appendix /19 Partnership Budgets Appendix /19 Savings Plans Appendix 6 Risk Management Appendix 7 Financial Management Framework 13

139 Appendix /19 Budget Primary Care Admin/Prog (net of Savings) Co- Commissioning TOTAL CCG Resources '000 '000 '000 Programme Allocation 767, ,233 Primary Care Co-Commissioning 81,511 81,511 Running Costs Allocation 13,589 13, ,822 81, ,333 Expenditure Programme Acute 380, ,436 Community 82,619 82,619 Mental Health 83,401 83,401 Primary Care 123,071 81, ,180 CHC 43,715 43,715 Other 47,296 47,296 Reserves Specific investment proposals 2,785 2,785 National Contingency 3, ,312 Corporate (Running Costs) 13,589 13,589 Total Expenditure 780,822 81, ,333 SURPLUS 0 0

140 Gloucestershire CCG APPENDIX /19 Application of Savings (Programme Budgets only) Gross Budget Excl savings Transformational Savings Applied to Budgets Transactional Savings Applied to budgets Net Expenditure Programme Acute 391,238 (10,139) (662) 380,436 Community 82,981 (363) 82,619 Mental Health 83,401 83,401 Primary Care including prescribing 128,071 (5,000) 123,071 CHC 44,302 (87) (500) 43,715 Other 49,147 (400) (1,451) 47,296 Reserves Specific investment proposals 2,785 2,785 National Contingency 3,910 3,910 Savings (18,602) 15,627 2,975 Corporate 13,589 13,589 Total Expenditure 780, ,822

141 Gloucestershire CCG 2017/18 Resilience Funding APPENDIX 3 Breakdown of budgeted resilience funding allocated in 2017/18 was: Organisation Scheme GHFT ED consultants Emergency Nurse Practitioners Weekend discharge Onward Care Team Streaming 90.0 Primary care in ED ,776.0 GCC/care homes/dom care Brokerage First responder 50.0 Hospital to home 50.0 IV therapy 43.0 Nursing home beds ,081.4 GCS IDT (incl ex-oct) 1,344.0 Voluntary sector ,444.0 Other PSV/rapid response vehicle Minor Ailment scheme 82.4 Urgent repeat medicines 96.2 Primary Care capacity High intensity user 40.0 NHS111 DoS 7.0 Maternity triage Alamac 90.0 Winter leaflet drop 30.0 Contingency ,252.6 Total 5,554.0

142 Gloucestershire CCG APPENDIX /19 Draft Partnership Budgets with Gloucestershire County Council 2018/19 Draft Budget Total Budget CCG GCC Child & Adolescent Mental Health Services 5, ,281 Adult Mental Health Servoces 49,806 4,940 54,746 Occupational Therapy 3,030 3,030 Community Equipment Services 3,359 1,463 4,822 Continuing Health Care and Funded Nursing Care 27,258 27,258 Better Care Fund Programme (BCF) 22,203 15,792 37,995 BCF (substitution funding) 2, ,514 Improved Better care Fund (ibcf) 2,941 8,420 11,361 s256 agreements 7,699 14,948 22,647 Public Health Commissioning 11,436 11,436 s76 Social Care agreements Total 121,410 61, ,644

143 Gloucestershire CCG APPENDIX 5 Urgent Care 2018/19 Savings Plans Transformational schemes Category Scheme Description Total '000 Ambulatory Emergency Care (AEC) Complex Care at Home (Virtual Ward) GP Streaming Older People Advice & Liaison Service (OPAL) Regular Attenders/ South Cots Frailty 3,240 CPGs & Planned Care Medicines Optimisation Prevention & Self Care Cancer Transformation Circulatory Clinical Thresholds Diabetes Fitness for Surgery Outpatient Efficiency & Productivity Primary Care initiation - Insulin Physical Activity - Weight Management & Obesity: Falls Prevention Self-Management Programme Inc. Expert Patient, Patient Activation Respiratory Tract Infections (RTI) in Children Social Prescribing - Community Wellbeing Service 5,270 5, Community & Other Community Stroke Rehabilitation Beds/ Dementia/ Management of Complex Patients Pathway/ Out of County Contracts 1,466 Other Secondary Care - Biologics & Biosimilars 250 Total 15,627

144 Category Urgent Care CPGs & Planned Care Medicines Optimisation Continuing Health Care (CHC) Transactional schemes Scheme Description Commissioning Policy for Continuous Glucose Monitoring in Children and Young People Aged up to 19 Years/ Contract Equity (MSK Contractual & Finance Changes)/ Diabetes - Education Programme (Prevention Savings)/ Outpatient Procedures (Previously Daycases)/ Stroke (Atrial Fibrillation) 2017/18 Total '000 1,025 Other 1,451 Total 2,975 GRAND TOTAL 18,

145 Risk Further changes to the CCG's allocation as a result of transfers between commissioning organisations may not be cost neutral Assumed allocations may not materialise Gloucestershire CCG 2018/19 Risk Management APPENDIX 6 Mitigating Action Work with the Area Team and local providers to ensure that adjustments are cost neutral and transacted on the correct basis. Ongoing liaison with NHSE and other relevant parties to ensure that all issues are known together with a phased approach to the release of expenditure commitments to mitigate the risk of a reduced allocation. Expenditure on Primary Care Co-commissioning may not be contained within the budget due to pressures within primary care Non achievement of the required level of savings through slippage in implementation or benefits not being realised as anticipated: Close monitoring and forecasting to enable early warning of financial issues arising. Regular contact with NHSE and other relevant parties. Close review of resources allocated to each project to ensure sufficient to ensure robust implementation and delivery, enhanced monitoring of the project to ensure timely warning of slippage or benefit realisation differing to the forecast project. Development of robust exit strategies for projects to ensure that these can be stopped at short notice if they do not deliver against agreed objectives Overperformance on acute contracts Strengthening the contract management & monitoring processes, particularly including that in relation to out of county contracts Potential loss of control over service priorities or cost changes where the CCG is an associate commissioner to a contract Plans to improve practice engagement to ensure that pathways followed are the most appropriate for the presenting condition. Establish stronger working relationships with other commissioners to ensure early warning of pressures within other contracts Increased growth in prescribing Increases in continuing health care and placements Costs of nationally approved NICE developments in excess of that provided for (both in cost and take-up) Population growth above planning assumptions Monthly enhanced monitoring in place. Prescribing working group set up to implement savings plans. Monthly monitoring of trends. Joint plan to manage process improvement in year including further utilisation of Caretrack software and alignment with GCC systems. Increased profile of NICE horizon scanning and close liaison with contract management. Continuing work to benchmark services to identify areas to review to ensure value for money from all services Mitigating Actions Covering all risks: Non release of development funds unless key to delivering service change or contactually committed, until planned financial targets are forecast to be delivered with a reasonable degree of confidence. Utilisation of contingency and activity reserves Increased financial management awareness throughout the organisation and member practices

146 Gloucestershire CCG Appendix 7 Financial Management Framework 1. Purpose The Clinical Commissioning Group is accountable for the effective, efficient and economical use of public funds allocated to the organisation and the safeguarding of public resources. There is an expectation that reporting on how funds are being spent will be reliable and transparent. The policy framework sets out key principles, especially around the management of financial risk including the management of cash. 2. Principles: Effective financial management is guided by the following fundamental principles: Value for money Public funds are managed with prudence and probity, resources are safeguarded and are used effectively, efficiently and economically to achieve the organisation s objectives. Accountability: There are clear accountabilities for financial management, which provide assurance regarding the effective use of public funds and the results achieved. Transparency: The Governing Body and NHS England are provided with relevant, reliable and timely financial and related non-financial information and reports so they can be well informed of the use and management of the CCG s financial resources. Governing Body financial reports are published on the CCG s web site Risk management: Effective and efficient systems of internal control are in place, and controls are proportionate to the risks they aim to mitigate, yet support innovation and results for the CCG. Appendix 1 clarifies the guidance for: Compliance with clearly defined systems for controlling spend The responsibilities of budget managers Provision of financial advice and support Page 1 of 10

147 Processes and systems Financial Risk Management Policy The organisation will set a balanced annual financial plan based on national guidance on resource availability. The level of surplus within the plan will be within guidance issued by NHS England. The organisation will create a contingency reserve of at least 0.5% of its recurrent resource limit. All financial plans will include an assessment of financial risk and actions for managing and responding to the risk. Developments funded within the Annual Operating Plan which are not unavoidably committed will be retained centrally and only released by the Accountable Officer and / or Chief Finance Officer once achievement of the organisation s control total is forecast to be delivered with confidence. Release of developments will be subject to a business case sign off. The holding of these amounts centrally is to provide flexibility in order to protect the control total, and ultimately the CCG s statutory breakeven duty. All project plans include outcomes with robust, measurable KPIs, timely monitoring mechanisms and exit plans to ensure that projects which are not delivering agreed outcomes can be stopped at short notice. Options for risk sharing arrangements within the Health Economy or with other agencies must be considered and evaluated as appropriate. Approval for risk sharing will be by the Chief Finance Officer. Recurring commitments will be funded from recurring resources and there will be no avoidable over commitment of recurring funds. Business cases must clearly indicate the recurrent/non-recurrent elements of each proposal and must be developed with the assistance of the Finance and Information Department. When making a non-recurring commitment in areas with potential recurrent expenditure, consideration will be given to the implications of the cessation of funding either by clear exit strategies or how commitment may be funded. Authorisation from the Chief Finance Officer must be obtained. The use of reserves will be minimised and consistent with prudent financial management. The need for and level of contingency reserves will be reviewed annually. Access to and release of general and earmarked reserves will be authorised by the Accountable Officer and the Chief Finance Officer. Page 2 of 10

148 Robust monitoring and control mechanisms will be maintained. Where potential overspends are identified, corrective action plans to address the issue will be required. Any organisational recovery plans will be subject to rigorous review by the Audit Committee and the Governing Body; being clearly identified on the risk register, which will be scrutinised by the Integrated Governance and Quality Committee. Both the recurring and non-recurring development programmes will be proactively managed to secure maximum flexibility. This may mean phasing planned developments throughout the year and exercising the option not to proceed or to defer schemes if unavoidable expenditure is incurred. Underspends will be removed from budgets periodically throughout the year on a nonrecurrent basis in year following discussion with the relevant Director. A review of the recurrent level of budget requirement will take place during the annual budget setting period. Budget holder skills will be reviewed and appropriate development and training agreed and arranged. Identified recurrent deficits will be funded from growth or savings in future years. The financial risk management policy will be reviewed annually by the Governing Body. Cash Management Policy Cash plans, to ensure compliance with statutory duty to remain within the CCG s maximum cash drawdown, must form part of the budget proposals, monthly monitoring to the Governing Body and the medium term resource strategy. Working balances will be maintained at the minimum levels consistent with prudent financial management and within resource accounting guidelines. Budget Managers must ensure that invoices are processed promptly and always within 30 days. Those for non NHS suppliers should be processed within 10 days. All invoices in dispute should be placed on hold within the Oracle financial management system. Budget holders and managers must ensure that they have a nominated deputy set up as an authorised signatory for invoices to cover any absences and not delay payments. They must ensure that diversion of invoices within the Oracle system is activated prior to any period of planned absence. Monies due should be invoiced promptly. Page 3 of 10

149 Budget managers must discuss cash requirements, if exceptional or out of the ordinary, with their management accountant. Any cash shortfall should be identified at the planning stage and discussed with Chief Finance Officer. Should a cash shortfall arise at year end, there will need to be a slowing down of payments. Detailed options will need to be discussed and agreed with the Chief Finance Officer. Options for managing cash shortfalls are: - Reducing creditor payments (this will obviously impact performance against the Public Sector Prompt Payment target) - Actively chasing all outstanding debt - Agreement with external parties for the CCG to receive pre-payments - Increase drawdown from NHSE, if known within required timescales and the issue is short term in nature. Conversely, options for managing excess cash are: - Reduction of Creditors - Delay income collections - Making Pre-payments. These are only permitted in exceptional circumstances and must be agreed by the Chief Finance Officer. - Reduced drawdown from NHSE (although the implications for future financial years must be considered). Cash management options must not impact adversely on the CCGs financial position or increase financial risk. Page 4 of 10

150 Appendix Compliance with Clearly Defined Systems for Controlling Spend Budgetary control is maintained by: clear definitions of budgetary responsibility both in terms of delegating budgets to specific managers and clearly setting out their responsibilities both in Prime Financial Policies, Standing Orders, the detailed scheme of delegation and in this document. Accountability of budget managers to the relevant Director where overspends arise compliance with specified control arrangement as in Prime Financial Policies, documented financial management arrangements and this document. auditing compliance via internal audit. 2.0 Responsibilities of Budget Managers The nature of financial responsibility for budgets will vary depending on the budget. All managers who have delegated responsibility must have a good understanding of the budget and be able to monitor and forecast spend. The authority and ability to incur and control expenditure varies as follows: Responsibility for controlling the budget including authority to incur costs, authorise spend and exercise virements. Authority to approve spends and exercise virement Responsibility for monitoring and forecasting spend realistically and accurately. Responsibility to ensure that they have the skills to manage the budget effectively and to seek further training where required If managers are in any doubt about the extent of their responsibilities they should seek guidance from their line manager or a member of the finance team. Prime Financial Policies make explicit the requirement that budget holders, at every level, must not exceed the limits of the budget delegated to them i.e. must not overspend against their budget. Any overspending by the CCG as a whole constitutes a breach of its statutory duty to remain within its allocated resources. Page 5 of 10

151 Therefore, any individual overspending against a delegated budget contributes to the CCG failing to achieve its statutory duty. 2.1 Prime Financial Policies The policies and procedures which govern the CCG s financial transactions are set out in its Prime Financial Policies and scheme of delegation and other policies and procedure. Budget managers must be familiar with and adhere to the policies contained within them. The authority to transfer or vire funds to another budget head is also delegated within prescribed limits (see Table 1). The responsibilities of budget holders as set out in Prime Financial Policies are repeated below together with practical comments (in italics) on their implications. a) Any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the Governing Body. (Budget managers must not incur expenditure without being clear that budgetary provision exists to meet the expenditure). b) The amount provided in the approved budget is not used in whole or any part for any purpose other than that specifically authorised subject to the rules of virement. (Expenditure/invoices for items other than those expressly covered by the budget cannot be charged to a budget head. If in any doubt, advice should be obtained from a finance contact). c) No permanent employees are appointed without the approval of the Accountable Officer other than those provided for in the budgeted establishment as approved by the Board. 2.2 Authority and Transfer of Budgetary provision (Virement) Budget managers are able to transfer between budget heads within the prescribed limits as approved by the Board replicated below in Table 1 with the exception that There shall be no virement between Patient Services and Administration. There shall be no virement between capital and revenue without the agreement of the Chief Finance Officer. Opportunities for this are limited and governed by strict financial rules. Budget Holders wishing to incur capital expenditure shall contact the Chief Finance Officer. Virement under these arrangements only applies to established budget heads. Budget managers are not authorised to create new budgets. Proposals for spending in new areas should be submitted to Accountable Officer and Chief Finance Officer. Page 6 of 10

152 Virement from general reserves should only be actioned following the agreement of the Accountable Officer and Chief Finance Officer, and from earmarked reserves following the agreement of the Chief Finance Officer. Where virement is proposed between budget heads under control of different managers it must be approved by both. Table 1 Virement Limits Budget Holder Admin 000 Patient Services 000 Chief Finance Officer Admin Patient Services Accountable Officer Admin Patient Services Virement Nonrecurring >50 >100 Recurring >50 >100 Additionally budget managers, with assistance from the finance staff are required to: Monitor the performance of the budget and have a good understanding of the reasons for variances at any point in time. Regularly forecast the year-end position on the budget. If budget begins to overspend take prompt corrective action. Where expenditure is outside the manager s direct control any overspending should be reported to the Chief Finance Officer. 3.0 Provision of Financial Advice and Support Budget managers receive support and advice from the finance team. Finance staff should: be able to quickly investigate queries on expenditure raised by budget managers. Page 7 of 10

153 provide regular monitoring information to budget managers be clear what financial systems are in place for accounting for and monitoring income/expenditure and advise budget managers on their development and use. make proposals on behalf of the budget manager for changes in budget structure to the Deputy Chief Finance Officer explain technical changes in budgets arising from NHS England. explain how budgets are financed and follow up on any outstanding cash and resource limit adjustments. seek guidance from other finance staff and Chief Finance Officer as necessary. ensure that the interaction between financial management teams, financial services teams and budget managers is understood and works to facilitate timely support and advice. 4.0 Processes and Systems 4.1 Reporting Systems A comprehensive financial and reporting system is in place. Individual budget managers should: expect to receive monthly details of expenditure against budgets within 10 working days from the end of each month and identify problems or issues arising. ensure they meet regularly with their finance contact and follow up issues which arise. Actions must be agreed and recorded. Make a monthly assessment of outstanding commitments (accruals) and forecast outturn on their budget. be clear what financial information relating to budgets for which they are responsible is being included in financial reporting to line managers and onwards. identify any deficiencies in financial monitoring and reporting and draw these to the attention of the Chief Finance Officer who will work with finance staff to rectify any such deficiencies. Identify any issues which could impact on projected cash flows, Page 8 of 10

154 4.2 Budgets Annual Budget Setting Budgets are reviewed annually and approved by the Board. All budget managers should review the adequacy of their budgets as part of the annual process and raise concerns with their Finance contact. Managers wishing to restructure budgets (i.e., differently or more details) should make requests by 30 th November. Any unused funds revert to the Accountable Officer. Any requests to carry forward deferred income budget should be addressed to the Chief Finance Officer by the end of December. The decision to carry forward unused budget is at the discretion of the Chief Finance Officer, taking account of the overall CCG financial position for the current and following financial year and within Resource Accounting guidelines. Formal budgets should be issued to budget holders by the end of March or as soon as a balanced Annual Operating Plan has been signed off by the Governing Body and NHS England In-year Change There are two routes for changes. As indicated previously budget managers can request/authorise virement. All virements are actioned by the Finance Department on receipt of a properly authorised virement request form. Budget changes can also be imposed as a result of financial difficulties. All such changes will be notified to the budget manager by the Chief Finance Officer. 4.3 Expenditure Incurring Expenditure Arrangements for ordering and processing of invoices are set out in Prime Financial Policies. It is the responsibility of the budget manager to ensure invoices are properly and promptly authorised and coded to enable payment within 30 days. This will enable accurate cash flow monitoring. Invoices for non NHS organisations should be processed to achieve payment within 10 working days Invoice Disputes Page 9 of 10

155 All disputes on invoices must be notified promptly to the Creditor payments provider and to the relevant Management Accountant Receipting of Goods Delivery of goods should be confirmed in writing (by wherever possible) to the Procurement Team. It is the responsibility of budget managers to ensure that goods received are booked in promptly Classification of Expenditure Expenditure should always be coded to the correct subjective (account) code for the type of expenditure incurred. If budget managers wish more detailed or different expenditure reports they should discuss their requirements with the Finance Department. 4.4 Year End Financial Management Detailed instructions for managing the closure of the year will be issued by the Finance Team and must be followed by all members of staff. 4.5 Income Invoice requests must be raised promptly by budget managers and within the financial year to which they relate. Page 10 of 10

156 Governing Body Agenda Item 13 Meeting Date Thursday 29 th March 2018 Report Title An Open Culture: Engagement Equality Experience Annual Report: 2017 Executive Summary The report highlights the work NHS Gloucestershire CCG has undertaken towards meeting its general Public Sector Equality Duty, through engagement with patients, carers, staff and communities The Public Sector Equality Duty came into force in April It requires the CCG, in the exercise of its functions, to have due regard to the need to: Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act; Advance equality of opportunity between people who share a protected characteristic and those who do not; Foster good relations between people who share a protected characteristic and those who do not. Key Issues The report will be available via the CCG website. It covers: An Open Culture : an introduction to our strategies; Legal requirements relating to engagement, experience and equality; A profile of the population of Gloucestershire; Innovative practice that demonstrates our commitment to engagement and equality (web links to case studies will be presented on the day); Page 1 of 4

157 Risk Issues: Original Risk (CxL) Residual Risk (CxL) Management of Conflicts of Interest Equality information regarding our workforce. None Financial Impact Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Patient and Public Involvement The CCG is required to publish an annual report, under the specific equality duty of the Equality Act This report highlights the CCG s approach to work in partnership to reduce health inequalities in the county. This report highlights the CCG s approach to ensuring that equality issues inform the commissioning of health services for the people of Gloucestershire. Recommendation Paper for approval Author Becky Parish and Caroline Smith Designation Associate Director, Patient Engagement & Experience; Senior Manager, Engagement & Inclusion Sponsoring Director (if not author) Marion Andrews-Evans, Executive Nurse and Quality Lead Page 2 of 4

158 Governing Body Agenda Item 13 Thursday 29 th March 2018 An Open Culture: Engagement Equality Experience Annual Report: Introduction 1.1 NHS Gloucestershire Clinical Commissioning Group (CCG) is publishing this report as required under the specific equality duty of the Equality Act As in previous years, we have chosen to combine our progress report on equalities work with examples of innovative practice in engaging and involving our local patients, carers, staff and communities. 1.2 The Public Sector Equality Duty came into force in April It requires the CCG, in the exercise of its functions, to have due regard to the need to: Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act; Advance equality of opportunity between people who share a protected characteristic 1 and those who do not; Foster good relations between people who share a protected characteristic and those who do not This report covers: An Open Culture : an introduction to our strategies Legal requirements relating to engagement, experience and equality A profile of the population of Gloucestershire Innovative practice that demonstrates our commitment to engagement and equality (web links to case studies) Equality information regarding our workforce 1 There are nine protected characteristics as outlined in the Equality Act 2010: age; disability; gender reassignment; marriage and civil partnership; pregnancy and maternity; race; religion or belief; sex and sexual orientation. Page 3 of 4

159 2 Recommendation(s) 2.1 This paper is for information and approval. 3 Appendices Appendix 1: Gloucestershire Health Profile 2017 Page 4 of 4

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162 An Open Culture: Engagement Equality - Experience Annual Report 2017 Content Foreword 1. Introduction 1 2. Promoting equality and valuing diversity: An Open Culture 3. A Strategy for Engagement and Experience Our Open Culture Legal Requirements 3 5. Profile of Gloucestershire 4 6. Innovative Engagement 9 7. Workforce Equality 10 Appendices: Appendix 1: Gloucestershire Health Profile 2017

163 Foreword On behalf of our Governing Body colleagues I am delighted to present NHS Gloucestershire Clinical Commissioning Group s (GCCG) annual Engagement, Equality and Experience Report, 2017: Our Open Culture. This report sets out our continued progress against our equality objectives and highlights the future direction of our work to promote equality and reduce health inequalities. It also gives some examples of how GCCG is working hard to ensure that the healthcare experiences and views of the people of Gloucestershire inform our commissioning priorities, service design and delivery. The report is published on-line and contains web-links to a range of resources which support or promote the CCG s engagement, equality and experience activities. Case studies and Real life stories are used to illustrate examples of engagement activity from the last twelve months. During 2017, our ambition has been to continue to: support our staff to understand the importance of engaging our diverse communities in the planning and delivery of local services; ensure equity of access to local health services for all our residents, support personalisation of care, diversity and fairness ; and provide a working environment where are staff can thrive and feel valued. Going forward into 2018, we aim to strengthen our partnership working in relation to equality and engagement, working together to develop closer links with our communities of interest. I would also like to take this opportunity to welcome Peter Marriner, my colleague on the CCG Governing Body, who has recently taken the lead for equality. During the coming weeks, Peter and I will lead a refresh of both our engagement and equality strategies, developing new action plans to take this work forward for the next three years. Alan Elkin Chair, Primary Care Commissioning Committee and Lay Member for Public and Patient Engagement/Involvement, GCCG Governing Body

164 1. Introduction 1.1. NHS Gloucestershire Clinical Commissioning Group (CCG) is publishing this report as required under the specific equality duty of the Equality Act We have again chosen to combine our progress report on equalities work with examples of innovative practice in engaging and involving our local patients, carers, staff and communities The Public Sector Equality Duty 1 came into force in April It requires the CCG, in the exercise of its functions, to have due regard to the need to: Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act; Advance equality of opportunity between people who share a protected characteristic and those who do not; Foster good relations between people who share a protected characteristic and those who do not. 1.3 Reducing health inequalities is a key factor in all our decision-making, with particular regard to the nine protected characteristics as outlined in the Equality Act 2010: age; disability; gender reassignment; marriage and civil partnership; pregnancy and maternity; race; religion or belief; sex and sexual orientation. Our aim is to include equalities considerations as an integral part of commissioning business and not as an after-thought This report covers: An Open Culture : an introduction to our strategies; Legal requirements relating to engagement, experience and equality; A profile of the population of Gloucestershire; Innovative and established practice that demonstrates our commitment to engagement and equality (web links to case studies); Equality information regarding our workforce. 1 Source: 1

165 2. Promoting equality and valuing diversity: An Open Culture 2.1. This strategy sets out how we will ensure that promoting equality and valuing diversity is embedded in the planning, commissioning and delivery of local health services. We are keen to build upon the work that has already been undertaken since GCCG was established in GCCG has adopted the following Equality Objectives: To develop a fresh strategy and action plan for promoting equality, diversity, human rights, inclusion and reduction in health inequalities including the implementation of the revised Equality Delivery System (EDS2). To increase awareness of the importance of promoting equality/ reducing health inequalities agenda within the CCG and across member practices. To improve quality of, and accessibility to, the demographic profile of Gloucestershire by protected characteristics and identify variations in health needs to enable staff to undertake meaningful equality impact analysis on the work as it develops. Support staff to put equality/reduction in health inequalities at the heart of the commissioning cycle The full Strategy and action plan is currently being refreshed. However, the existing documentation can be found on the CCG website at: 3. A Strategy for Engagement and Experience (incorporating Primary Medical Care from 1/4/2015) Our Open Culture 3.1. We want to ensure that quiet voices are heard and that we are recognised as commissioners on the ground. The Strategy for Engagement and Experience, approved by GCCG in September 2014, describes how using a simple Framework, underpinned by three enabling principles and three methods of delivery, we achieve this. 2

166 3.2. Our Open Culture Framework promotes Equality and working in Partnership and the desire to enable Anyone and Everyone to have a voice. To achieve this we provide Information and good Communication, focus on Experience feedback and undertake good Engagement and Consultation The Strategy s aim is to ensure that the CCG: achieves the essential conditions and culture within the organisation to make effective engagement a reality and to ensure that the individual s experience of care is a driver for quality and service improvement The Strategy is available on the CCG website at: Work to update the Strategy is currently underway. 4. Legal Requirements 4.1. Equality: Our strategy recognises our commitment to, and legal obligations under, the Equality Act 2010 and Public Sector Equality Duty; Health and Social Care Act 2012; Human Rights Act 1998 and the FREDA principles; Convention on the Rights of the Child; NHS Constitution and NHS Workforce Equality Standard. Further information on current legislation can be found at: Engagement and Experience: There are several must dos in the field of engagement, equality and experience. These are set out in national legislation and guidance. The key requirements and mechanisms we must work with are described within three key pieces of legislation: Health and Social Care Act 2012, The Equality Act 2010 and The NHS Constitution Details of these requirements, which ensure the CCG meets these legal responsibilities, can be found on the GCCG website: 3

167 5. Profile of Gloucestershire 5.1 We use a range of data and information when we develop policies, set strategies, design, review and deliver our services. We believe that it is important to understand the composition of our local population by protected characteristics 2 so that we can: engage effectively with different communities to understand their varying health and self-care support needs; commission services to meet their health and self-care needs in an appropriate manner; ensure equity of access to health services and support; assess the likely impact of our decisions on a diverse range of communities; and work with these communities to minimise any adverse impact and maximise any positive impact. 5.2 Understanding Gloucestershire - A Joint Strategic Needs Assessment 2017, aims to provide a common understanding of the County and its communities for use by decision makers and commissioners of services. It looks at need in the community and how we expect it to change in the future. The JNSA, together with a wealth of information about our county can be found at: Gloucestershire-JSNA Public Health England also provides an annual Health Profile for each county. A copy of the profile for 2017 is included in Appendix An overview of our county population, by each of the protected characteristics is given below. Further detail can also be found on the Inform Gloucestershire website: 2 There are nine protected characteristics, as set out in the Equality Act Further information is available at: 4

168 5.4 Current Population: Age In 2016 the resident population of Gloucestershire was estimated to be 623,129 people, of which: 22.6% are aged % are aged % are aged 65 and over. Gloucestershire has a lower proportion of 0-19 year olds and year olds when compared to the national average. In contrast the proportion of people aged 65+ exceeds the national average. Projections suggest this trend will continue, with the number of people aged 65+ projected to increase by 85,000 or 72.2% between 2012 and There is considerable variation at district level: At 25.0% Gloucester has the highest representation of children and young people and exceeds the county and national average. At 58.9% Cheltenham has the highest proportion of people aged 20-64, exceeding the county and national average. Cotswold, the Forest of Dean, Stroud and Tewkesbury all have an overrepresentation of people aged 65+ when compared to the county and national average. At 25.2% Cotswold has the largest proportion of people aged 65 and over. 5.5 Current Population: Disability According to the 2011 Census 16.7% of Gloucestershire residents reported having a long term limiting health problem; this was below the national average. Forest of Dean had the highest proportion of residents reporting a long term limiting health problem at 19.6% of the total population, and was the only district that exceeded the national average. Cheltenham had the lowest proportion of residents reporting a long term limiting health problem. Given the ageing population the number of people with a limiting long term health problem is likely to increase in the future. 5

169 Dementia is one of the major causes of disability in older people. Estimates suggest there are 9,042 people aged 65+ living with dementia in Gloucestershire. Learning disability is one of the most common forms of disability in the UK. Estimates suggest there are 11,434 people aged 18+ living with a learning disability in Gloucestershire. Sensory impairment: In 2012/13 approximately 1.0% of the 18+ population reported blindness or severe visual impairments. During the same period 4.0% of the adult population reported deafness or severe hearing impairments. 5.6 Current Population: Gender Reassignment There are no official estimates of gender reassignment at either national or local level. However, in a study funded by the Home Office, the Gender Identity Research and Education Society (GIRES) estimate that between 0.6% and 1% of the UK's adult population are experiencing some degree of gender variance. For Gloucestershire, this equates to between 3,000 and 5,100 adults. GIRES also reported in 2011 that approximately 100 children and adolescents are referred annually to the UK s specialised gender identity service, compared with 1500 adults. 5.7 Current population: Marriage and Civil Partnership The 2011 Census recorded that among residents of Gloucestershire: 30.5% were single and had never married, or registered a same-sex civil partnership 50.2% were married 0.3% were in a registered same-sex civil partnership 2.3% were separated but still legally married or still legally in a same sex civil partnership 9.5% were divorced or had formerly been in a same sex civil partnership which was now legally dissolved 7.2% were widowed or a surviving partner from a same sex civil partnership 6

170 At that time, Gloucestershire had a lower proportion of people who were single or separated when compared to the national average. In contrast the proportion of people who were married, divorced or widowed exceeded the national average. 5.8 Current Population: Pregnancy and Maternity There were 6,697 live births in Gloucestershire in Gloucester and Cheltenham continued to account for the largest numbers of births in Gloucestershire, representing 26.8% and 18.6%. Births to mothers aged accounted for 32.4% of total births in Gloucestershire, followed by births to those aged (29.3% of total births). This reflects the national trend for England. 5.9 Current Population: Race Gloucestershire is characterised by a comparatively small Black and Minority Ethnic population (England average of 14.6%): The 2011 census showed that overall, 4.6% of the population were from Black and Minority Ethnic (BME) backgrounds; this figure increased to 8.4% when the Irish, Gypsy or Irish Traveller and other White categories were included. There is a wide variation at district level in the proportion of the population who are not White British. At the time of the 2011 Census, Gloucester and Cheltenham had the highest proportions at 15.4% and 11.7% respectively, whilst the Forest of Dean had the lowest proportion at 3.3%. At the end of the first quarter of 2016, there were 124 asylum seekers and their dependents living in Gloucestershire Current Population: Religion According to the 2011 Census, 63.5% of residents in Gloucestershire are Christian, making it the most common religion. This is followed by no religion which accounts for 26.7% of the total population. 7

171 Gloucestershire has a higher proportion of people who are Christian, have no religion or have not stated a religion than the national average. In contrast it has a lower proportion of people who follow a religion other than Christianity, which reflects the ethnic composition of the county Current Population: Sex The overall gender split in Gloucestershire is slightly skewed towards females, with males making up 49.0% of the population and females accounting for 51.0%. This situation is also reflected at district, regional and national level. As age increases gender differences become more noticeable, with females outnumbering males by an increasing margin. In 2015, 53.0% of people in Gloucestershire aged are female, while for people aged 85+ the difference is even more marked with females accounting for 65.2% of this age group. This is due to the fact that women in Gloucestershire have a longer life expectancy than men; 83.7 years compared with 80.1 years. Figures for Gloucestershire also show that men have a shorter healthy life expectancy than women; 63.9 years compared with 66.9 years Current Population: Sexual Orientation There is no definitive data on sexual orientation at a local or national level. A number of studies have attempted to provide estimates for the proportion of people who may identify as lesbian, gay or bisexual (LGB), generating a range of different results. A recent estimate from the 2015 ONS Annual Population Survey (APS) suggests that nationally 1.7% of the population is LGB; if this figure was applied to Gloucestershire it would mean that there are approximately 8,600 LGB people in the county. 8

172 6. Innovative Engagement 6.1 The CCG is committed to effective engagement with our local communities to help us ensure that we provide equity of access and fair treatment, continuing to improve the quality of our services and achieve better health outcomes for everyone. 6.2 We have developed case studies to illustrate examples of activity undertaken in the last twelve months, which demonstrate how patient experience and engagement inform our commissioning priorities and decisions. It is our intention to continue to gather and publish such case studies, as well as Real Life Stories. These can be found at Examples of innovative local practice We have collated examples of our engagement activity under the following headings: Information and Communication Patient Experience Engagement and Consultation Primary care Examples of our engagement activity are accessible via the hyperlinks above on the web-based version of this document. 9

173 7. Workforce Equality 7.1 We respect and value the diversity of our workforce and are committed to: making best use of the range of talent and experience available within our workforce and potential workforce; supporting our workforce through learning and development, recruitment and succession planning; ensuring that our legal obligations are fulfilled. 7.2 Workforce data As a relatively new organisation we do not yet have any significant equality and diversity trend information available regarding our workforce. However, we collect this information year on year to enable us assess our progress, investigate any disparities in outcomes for our different employee groups, and identify where we may need to act. More detailed information about our work force and recruitment activity from 1 January 2017 to 31 December 2017 is available in our on-line equality information An overview of this information is presented below (source: Electronic Staff Records as at 31 December 2017): The CCG has full time equivalent (FTE) employees. 53% of our staff work full time while 46% work part time 74% of our workforce are female 2% of our workforce describe themselves as having a disability; 13% of our staff have not declared whether or not they have a disability 8% of our workforce declared that they are from ethnic minority groups; 9% of our staff have not specified their ethnicity 61% of our workforce are aged under 50 73% per cent of our workforce declared a religion or belief 80% of our workforce declared they are heterosexual; 1% per cent of our workforce declared that they are lesbian, gay or bisexual; 19% did not specify their sexual orientation 10

174 No staff have identified themselves as transgender We do not monitor our staff on their marital or a civil partnership status, but may consider doing so in the future 7.2 We have collated benchmarking data about our workforce to comply with the Workforce Race Equality Standard (WRES). This can be found on our website at Our annual staff survey helps us to monitor equality issues, identify areas for action and evaluate support mechanisms available to our staff. Over time, it will also help us to fill some of the gaps in data that are required as part of WRES reporting. 11

175 Gloucestershire County This profile was published on 4th July 2017 Health Profile 2017 Health in summary The health of people in Gloucestershire is generally better than the England average. Gloucestershire is one of the 20% least deprived counties/unitary authorities in England, however about 14% (15,300) of children live in low income families. Life expectancy for both men and women is higher than the England average. N Tewkesbury Stow-on-the-Wold Cheltenham Health inequalities Life expectancy is 7.7 years lower for men and 5.4 years lower for women in the most deprived areas of Gloucestershire than in the least deprived areas. Gloucester Northleach Child health In Year 6, 17.7% (1,000) of children are classified as obese, better than the average for England. The rate of alcohol-specific hospital stays among those under 18 is 43*. This represents 53 stays per year. Levels of teenage pregnancy, GCSE attainment, breastfeeding initiation and smoking at time of delivery are better than the England average. Stroud Cirencester Nailsworth Fairford Tetbury 10 miles Adult health The rate of alcohol-related harm hospital stays is 640*. This represents 3,980 stays per year. The rate of self-harm hospital stays is 254*, worse than the average for England. This represents 1,527 stays per year. The rate of smoking related deaths is 248*, better than the average for England. This represents 949 deaths per year. Estimated levels of adult smoking and physical activity are better than the England average. Rates of sexually transmitted infections and TB are better than average. Rates of statutory homelessness, violent crime, long term unemployment, early deaths from cardiovascular diseases and early deaths from cancer are better than average. Contains National Statistics data Crown copyright and database right 2017 Contains OS data Crown copyright and database right 2017 This profile gives a picture of people s health in Gloucestershire. It is designed to help local government and health services understand their community s needs, so that they can work together to improve people s health and reduce health inequalities. Visit for more profiles, more information and interactive maps and tools. Local priorities The priorities for Gloucestershire are reducing obesity, reducing the harm caused by alcohol, improving mental health, improving health and wellbeing into older age, and tackling health inequalities. For more information see on Twitter * rate per 100,000 population Crown Copyright Gloucestershire - 4 July 2017

176 Population: summary characteristics Age profile Males Age Females % of total population Gloucestershire (population in thousands) Gloucestershire 2015 (Male) Gloucestershire 2015 (Female) Males Females Persons Population (2015): Projected population (2020): % people from an ethnic minority group: 4.7% 3.7% 4.2% Dependency ratio (dependants / working population) x % England (population in thousands) Population (2015): 27,029 27,757 54,786 Projected population (2020): 28,157 28,706 56,862 % people from an ethnic minority group: 13.1% 13.4% 13.2% Dependency ratio (dependants / working population) x % The age profile and table present demographic information for the residents of the area and England. They include a 2014-based population projection (to 2020), the percentage of people from an ethnic minority group (Annual Population Survey, October 2014 to September 2015) and the dependency ratio. The dependency ratio estimates the number of dependants in an area by comparing the number of people considered less likely to be working (children aged under 16 and those of state pension age or above) with the working age population. A high ratio suggests the area might want to commission a greater level of services for older or younger people than those areas with a low ratio. England 2015 Gloucestershire 2020 estimate Deprivation: a national view The map shows differences in deprivation in this area based on national comparisons, using national quintiles (fifths) of the Index of Multiple Deprivation 2015 (IMD 2015), shown by lower super output area. The darkest coloured areas are some of the most deprived neighbourhoods in England. This chart shows the percentage of the population who live in areas at each level of deprivation. 100 Contains OS data Crown copyright and database rights 2017 N Lines represent electoral wards (2016) % Residents England Gloucestershire Most deprived quintile Least deprived quintile Crown Copyright Gloucestershire - 4 July 2017

177 Life expectancy: inequalities in this local authority The charts show life expectancy for men and women in this local authority for The local authority is divided into local deciles (tenths) by deprivation (IMD 2015), from the most deprived decile on the left of the chart to the least deprived decile on the right. The steepness of the slope represents the inequality in life expectancy that is related to deprivation in this local area. If there was no inequality in life expectancy the line would be horizontal. Life expectancy gap for men: 7.7 years 95 Life expectancy gap for women: 5.4 years 95 Life expectancy at birth (years) Life expectancy at birth (years) Most deprived Inequality slope for men Least deprived Life expectancy for men 65 Most deprived Inequality slope for women Least deprived Life expectancy for women Health inequalities: changes over time These charts provide a comparison of the changes in death rates in people under 75 (early deaths) between this area and England. Early deaths from all causes also show the differences between the most and least deprived local quintile in this area. Data from onwards have been revised to use IMD 2015 to define local deprivation quintiles (fifths), all prior time points use IMD In doing this, areas are grouped into deprivation quintiles using the Index of Multiple Deprivation which most closely aligns with time period of the data. This provides a more accurate way of discriminating changes between similarly deprived areas over time Early deaths from all causes: men IMD 2010 IMD Early deaths from all causes: women IMD 2010 IMD Age-standardised rate per 100,000 population Age-standardised rate per 100,000 population Years 250 Early deaths from heart disease and stroke Years Early deaths from cancer Age-standardised rate per 100,000 population Age-standardised rate per 100,000 population Years Years Data points are the midpoints of three year averages of annual rates, for example 2005 represents the period 2004 to Where data are missing for local least or most deprived, the value could not be calculated as the number of cases is too small. England average Local average Local least deprived Local most deprived Local inequality Crown Copyright Gloucestershire - 4 July 2017

178 E Health summary for Gloucestershire The chart below shows how the health of people in this area compares with the rest of England. This area s result for each indicator is shown as a circle. The average rate for England is shown by the black line, which is always at the centre of the chart. The range of results for all local areas in England is shown as a grey bar. A red circle means that this area is significantly worse than England for that indicator; however, a green circle may still indicate an important public health problem. Significantly worse than England average Not significantly different from England average Significantly better than England average Not compared Domain Indicator Period England worst Local count Regional average Local value 25th percentile Eng value Eng worst England average 75th percentile England range England best Eng best 1 Deprivation score (IMD 2015) 2015 n/a Our communities 2 Children in low income families (under 16s) , Statutory homelessness 2015/ ~ GCSEs achieved 2015/16 3, Violent crime (violence offences) 2015/16 6, Long term unemployment ^ ^ Children's and young people's health Adults' health and lifestyle Disease and poor health Life expectancy and causes of death 7 Smoking status at time of delivery 2015/ $ Breastfeeding initiation 2014/15 4, Obese children (Year 6) 2015/16 1, Admission episodes for alcohol-specific conditions (under 18s) 2013/14-15/ Under 18 conceptions Smoking prevalence in adults 2016 n/a Percentage of physically active adults 2015 n/a Excess weight in adults n/a Cancer diagnosed at early stage , Hospital stays for self-harm 2015/16 1, Hospital stays for alcohol-related harm 2015/16 3, , Recorded diabetes 2014/15 31, Incidence of TB New sexually transmitted infections (STI) , , Hip fractures in people aged 65 and over 2015/ Life expectancy at birth (Male) n/a Life expectancy at birth (Female) n/a Infant mortality Killed and seriously injured on roads Suicide rate Smoking related deaths , Under 75 mortality rate: cardiovascular , Under 75 mortality rate: cancer , Excess winter deaths Aug Jul , Indicator notes 1 Index of Multiple Deprivation (IMD) % children (under 16) in low income families 3 Eligible homeless people not in priority need, crude rate per 1,000 households 4 5 A*-C including English & Maths, % pupils at end of key stage 4 resident in local authority 5 Recorded violence against the person crimes, crude rate per 1,000 population 6 Crude rate per 1,000 population aged % of women who smoke at time of delivery 8 % of all mothers who breastfeed their babies in the first 48hrs after delivery 9 % school children in Year 6 (age 10-11) 10 Persons under 18 admitted to hospital due to alcohol-specific conditions, crude rate per 100,000 population 11 Under-18 conception rate per 1,000 females aged 15 to 17 (crude rate) 12 Current smokers (aged 18 and over), Annual Population Survey 13 % adults (aged 16 and over) achieving at least 150 mins physical activity per week, Active People Survey 14 % adults (aged 16 and over) classified as overweight or obese, Active People Survey 15 Experimental statistics - % of cancers diagnosed at stage 1 or 2 16 Directly age sex standardised rate per 100,000 population 17 Admissions involving an alcohol-related primary diagnosis or an alcohol-related external cause (narrow definition), directly age standardised rate per 100,000 population 18 % people (aged 17 and over) on GP registers with a recorded diagnosis of diabetes 19 Crude rate per 100,000 population 20 All new diagnoses (excluding chlamydia under age 25), crude rate per 100,000 population aged 15 to Directly age-sex standardised rate of emergency admissions, per 100,000 population aged 65 and over 22, 23 The average number of years a person would expect to live based on contemporary mortality rates 24 Rate of deaths in infants aged under 1 year per 1,000 live births 25 Rate per 100,000 population 26 Directly age standardised mortality rate from suicide and injury of undetermined intent per 100,000 population (aged 10 and over) 27 Directly age standardised rate per 100,000 population aged 35 and over 28 Directly age standardised rate per 100,000 population aged under Directly age standardised rate per 100,000 population aged under Ratio of excess winter deaths (observed winter deaths minus expected deaths based on non-winter deaths) to average non-winter deaths (three years) Indicator has had methodological changes so is not directly comparable with previously released values. "Regional" refers to the former government regions. ^20 Value based on an average of monthly counts $ 1 There is a data quality issue with this value ~ 0 Aggregated from all known lower geography values If 25% or more of areas have no data then the England range is not displayed. Please send any enquiries to healthprofiles@phe.gov.uk You may re-use this information (not including logos) free of charge in any format or medium, under the terms of the Open Government Licence. To view this licence, visit Crown Copyright Gloucestershire - 4 July 2017

179 Agenda Item 14 Governing Body Meeting Date Thursday 29 March 2018 Title Executive Summary Key Issues Governing Body Assurance Framework The Governing Body Assurance Framework (GBAF) details the key high level risks to the achievement of the CCG s strategic objectives. The GBAF identifies the key controls and assurances of those controls. The key new risk that have been included on the current Assurance Framework are as follows: Management Conflicts of Interest Risk Issues: Original Risk Residual Risk Financial Impact of T15 Specialised Commissioning There is a risk around the current lack of knowledge of NHSE strategy for specialised services and current lack of engagement with NHSE in relation to specialised services. This risk is rated as RED (16) None identified The absence of a fit for purpose Governing Body Assurance Framework could result in risks not being identified, acted upon and reported and gaps in control / assurances not being identified and addressed. 12 (3x4) 4 (1x4) Not applicable Legal Issues Not applicable (including NHS Constitution) Impact on Health None Inequalities Impact on Equality None Page 1 of 8

180 and Diversity Impact on Sustainable Development Patient and Public Involvement Recommendation Author Designation Sponsoring Director (if not author) None Not applicable The committee is requested to note this paper and the attached GBAF. Christina Gradowski Associate Director of Corporate Governance Cath Leech Chief Finance Officer Page 2 of 8

181 Agenda Item 14 Governing Body Meeting Thursday 29 th March 2018 Governing Body Assurance Framework (GBAF) 1. Introduction 1.1 It is essential for the CCG to have an effective and efficient assurance framework in place to give sufficient, continuous and reliable assurance to the CCG on the delivery of organisational objectives. The Assurance Framework provides a mechanism to identify, manage and mitigate major risks to the delivery of the organisation s objectives. The Assurance Framework is underpinned by a corporate risk register comprising significant risks taken from directorate risk registers. Only those risks identified as significant, major risks and scoring 12 or more on the risk matrix, are included on the GBAF. 1.2 In accordance with the CCG s Risk Management policy the GBAF was considered by the Integrated Governance and Quality Committee (IGQC) at its meeting on 15 February 2018, prior to submission to the Governing Body meeting on 29 March The IGQC noted progress that had been made on improving risk reporting, with a newly formatted directorate risk registers, corporate risk register and assurance framework. 1.3 Following on from the feedback received by IGQC, the Corporate Governance Team has offered further training in risk management in order to improve risk identification and management. Following on from the training delivered to the Transformation and Commissioning Implementation directorates, training has now been delivered to Finance and Primary Care Directorates. The Quality directorate will receive training in May and a Risk Management workshop focusing on risk appetite and organisational risk culture will be delivered in June this year. The CCG s internal auditors BDO will deliver the training with the support of the Associate Director of Corporate Governance. Page 3 of 8

182 1.4 A schedule of lunch and learn seminars organised by the Governance Team will also include risk management along with conflicts of interest workshop type training. 2. The Assurance Framework 2.1 The Assurance Framework is based upon the six summary objectives outlined in the 5 Year Plan for 2014/ The document outlines the principal high-level risks, controls and assurances that are provided to the Governing Body regarding the achievement of each summary objective. Details of the action plans to address the risks, gaps in controls or gaps in assurance are also provided. 2.3 Progress regarding the achievement of each objective is monitored separately through the performance management process. 2.4 All Directorates have submitted their own directorate risk registers containing their risks. Those risks that have been indicated as significant and substantial risks have been included on the Corporate Risk Register (CRR). The risks contained within the CRR have been reviewed and those high level risk rated 12 and above were included on the GBAF. 3. IGQC The Integrated Governance and Quality Committee approved the closure of the following risks at its meeting held on 15 February 2018 L4 College Yard. Original risk: There is a risk that if the Application to merge College Yard and Highnam surgery and Cheltenham Road surgery from April 2018, together with an application to close College Yard does not go ahead there is a risk of the contract for College Yard and Highnam being handed back to GCCG. This risk is recommended for closure having met its target risk rating (4). A recommendation was made to Primary Care Commissioning Page 4 of 8

183 Committee for the merger and closure of College Yard on 5 October 2017 and this was approved. CCG assurances were given to PCCC regarding vulnerable patients and to practices who may be impacted by the closure. Quality Impact Assessment Completed. GccG exploring with partners a re-development at Quayside and Blackfriars. T13 Specialised Commissioning There is a risk around specialised services for children and young people with mental health problems. This risk had emerged due to specialised commissioning transferring to NHS England which resulted in the fragmentation of pathways. There is a recommendation to close this risk due to a new risk around specialised services which will encompass this risk (ref T15 New Risk). Q18 Non-compliant NICE guidelines There is a risk that areas of commissioned services which are noncompliant with NICE guidelines could be subject to challenge. Recommend closure of this risk as the CCG has robust processes in place for highlighting areas of non-compliance. F23 New Tariff 2017/18 The proposed allocation change relating to the new tariff for 2017/18 may not be cost neutral for Gloucestershire. The actions have been updated and the risk reduced from 12 (Amber) to 8 (Amber) in December 2017, to 4 (Yellow) in January Therefore there is a recommendation to close this risk. The committee agreed to include the following new risks T15 Specialised Commissioning There is a risk around the current lack of knowledge of NHSE strategy for specialised services and current lack of engagement with NHSE in relation to specialised services. Due to mixed messages from NHSE regarding specialised commissioning and lack of CCG links with specialised commissioning; resulting in uncertainty. This risk is rated as 16 RED, in accordance with the risk rating for T13. This is included Page 5 of 8

184 on the Governing Body Assurance Framework and Corporate Risk Register. L6 Future viability of GDoC There is a potential risk to the future viability of GDoC. Due to: Choice+ ceasing on with the potential loss of other contracts (other contracts could be won). This will result in the CCG s inability to commission Improved Access pilots from all clusters by and patients unable to access a National requirement for urgent and routine appointments between 6.30pm and 8pm and at weekends. This risk is rated as 8 Amber and included on the corporate risk register. Risks on GBAF 2.5 Highest risks RED o F24 Implementation of Trakcare remains unchanged at 16 (RED), risk has been updated with additional actions included. o F20 Shared care record project. This risk has been reviewed and updated, the risk has been increased from 12 (Amber) to 16 (Red). Amber risks o L3 APMS procurement updated actions and dates risk rating remains the same 12 (Amber) o K2 Impact on discharges the risk was rated at 12 (Amber) and remains unchanged. This risk has not been updated for this report. o K7 Implementation of Trakcare risk to maternity data has been updated and remains unchanged at 12 (Amber) o T12 Insufficient clinical capacity this risk has been reviewed and updated, there is clarification that the risk is now insufficient clinical capacity. Actions have been updated. The risk rating remains unchanged at 12 (Amber). o C3 Procurement risk of legal challenge. This risk has been re-articulated with clearer details on the impact of the risk. The risk rating has been reviewed and is unchanged at 12 (Amber) Page 6 of 8

185 o C27 Non-emergency patient transport actions and assurances have been updated, risk remains unchanged at 12 (Amber) since the last report. o C5 Discharge, risk has been reviewed, actions updated and remains unchanged at 12 (Amber) down from an original risk rating of 16 (Red) o C6 A&E target 4 hour wait, remains unchanged since the last report in December at 12 (Amber). The original risk was 16. o C15 Constitution targets, cancer. Risk has been reviewed, actions and assurances updated. Risk remains at 12 (Amber) o C8 including C28 Risk of failure to reduce demand and prevent unnecessary acute attendances, actions have been updated the risk remains unchanged at 12 (Amber) o C36 Inability to report on constitutional standards, remains unchanged at 12 (Amber) o C35 Risk that the transfer in providers of the OOH service from SWAST to CareUK leads to an inability to deliver an effective service during transition. The actions had been updated and risk reduced from 16 (RED) to 12 (Amber) in the December 2017 report. This risk remains unchanged. o T10 Risk that delayed implementation of STP Solutions and/or failure of projects to deliver anticipated benefits, actions have been updated and this risk remains unchanged since the last report in Dec 17at 12 (Amber). o L5 Risk that the APMS contract for a Primary Care registered list at Eastgate House and Matson Lane and the Urgent Primary Care Centre are handed back. This was a new risk added in December The risk actions and assurances have been updated. The risk rating remains unchanged at 12 Amber. o F11 and F16 risk of failure to deliver financial targets, the risks have been reviewed and actions updated; this risk continues to be rated 12 (Amber). o F26 Local Digital Roadmap - Resources may not be available to deliver the programme, actions have been updated and the risk remains unchanged at 12 (Amber) o F27 Risk of Cyber Attack actions have been updated and risk remains unchanged at 12 (Amber) Page 7 of 8

186 o Q19 Health needs of children in care, risk has been rearticulated, actions updated, the risk remains unchanged at 12 (Amber) o Q20 Mortality review risks reviewed, the risk has been rearticulated and actions updated and the risk remains unchanged at 12 (amber) Risks on GBAF 4. Appendix Appendix 1: Governing Body Assurance Framework Page 8 of 8

187 Agenda Item 9, GBAF Governing Body Assurance Framework Risk details Risk Description Controls Strategic Objective Objective 1: Develop strong, high quality, clinically effective and innovative services. Gaps in Controls Assurance Gaps in Assurance Previous risk rating LxS Current risk rating LxS Trend Progress with actions Date added 22/09/2014 Directorate T12 Transformation Executive Sponsor Ellen Rule Lead Manager Kathryn Hall Lead Committee IGQC Review date 31/03/2018 Insufficient clinical capacity and leadership across the system Leading to: Leading to a lack of delivery required within the CPG. Cinical programme approach, locality structure and meetings. Terms of reference for CPG, Use of CPG Board. None Governing Body / performance reports None 3x4=12 3x4= /17 CPG programme agreed. 2.a Terms of Reference developed with clinicians included and expectation of attendance at meetings. CPG Minutes monitored for attendance of clinicians. 2.b Job roles for CPG members that have been drafted and shared with Clinical leads via Governing Body. 3.Clinical Programmes Board established as part of the STP, Terms of Reference Agreed. Clinical capacity risk escalated from CPGs to the board. 4. Development session with CPG clinical leads and Governing Body members held on 2nd March 2017 to develop roles and identify development. 5. Clinical change management leads recruited to support respiratory integration to start 1st February Date added Directorate T10 incl F12 Transformation Executive Sponsor Ellen Rule Lead Manager Haydn Jones Lead Committee IGQC Review date Risk that delayed implementation of QIPP Projects and/or failure of projects to deliver anticipated benefits Due to: Resulting in: under-delivery on planned care QIPP savings target. Therefore transformation projects may not deliver the expected outcomes. Robust project management planning and reporting to the PMO. None Performance reports to Governing Body None 3x4=12 3x4=12 1. KPIs developed and uploaded to new Verto performance management system. 2. Ongoing. 3. QIPP Portal developed & being used by project managers to inform and report on QIPP scheme progress. 4.Triangulation of information data and finance for year to date position and improved QIPP scheme forecasts. 5.Regular monthly meetings with service leads for scheme reviews. 6. Regular discussion regarding delivery with Core Team with a focus on escalatation of risk and issues. Date added Directorate K2 Integration Executive Sponsor Kim Forey Lead Manager Donna Miles Lead Committee IGQC Review date Date added Directorate F24 Finance / Comm Implementation Executive Sponsor Cath Leech / Mark Walkingshaw Lead Manager Sarah Hammond Lead Committee IGQC Review date Risk of delayed discharges Due to: Delay with sourcing independent sector domicillary care Resulting in: Implementation of Trakcare within the main acute provider has reporting issues for clinical correspondence, national performance reporting and contractual management due to: implementation issues Resulting in: increased clinical risk GCC CPAC / Brokerage for LA funded service users Development of a remedial action plan supported by CCG/CSU staff to mitigate risks of adverse clinical communication and incomplete reporting None Performance reports to Governing Body None None Reports to the Governing Body None 3x4=12 3x4=12 4x4=16 4x4=16 Demand and capacity monitored to understand underlying issues of dom care new contracting arrangements. Rural framework currently has 35 providers across 4 zones. The Urban providers (Human Support Group in Gloucester and Comfort Call in Cheltenham) - both have struggled to pick up new packages of care or deliver H2H services. Alternative providers have been delivered H2H since May 2017 (Radis - Countywide, Crossroads - FoD in-reach). Pressures in the dom care market are continuing with demand outstripping capacity, however, this is an improving position despite a recent large provider failure. Requests from acute hospitals remain at high levels - due to these requests being prioritised this blocks available capacity to meet the wider system needs across the county. IBCF funding confirmed to increase H2H offer across acute and community hospitals. Work underway in Q3 to support extended operating hours of Brokerage and interface with Rapid Response for night sitting 1. Remedial action plan in place for performance reporting, fortnightly assurance calls in place to manage progress with NHSI/NHSE/GHFT/GCCG. Update reports provided. GHFT have approached an external supplier to assist in identification of anomalies. GHFT have recently submitted a proposal to NHSE for the funding of additional validators. Funding has been agreed with the CCG in 2017/ Ongoing communication with regular face to face meetings GHFT/GCCG 3. Confirmation of arrangements in place for management of operational and clinical risks including operational risk review process. The CCG has agreed a block contract type arrangement with GHFT in 2017/18 and are looking to repeat such an arrangement in 2018/ A comprehendive set of recommendations were published via the NHSD report; being worked on via GHFT SmartCare Board 5. A recovery plan is being put in place and will be available by the end of February 2018 which will determine the overarching plan for full recovery. Date added Directorate T 15- Transformation Executive Sponsor Ellen Rule Lead Manager Kathryn Hall Lead Committee Risk around the current lack of knowledge of NHSE strategy for specialised services and current lack of engagement with NHSE in relation to specialised services. Due to mixed messages from NHSE regarding specialised commissioning and lack of CCG links with specialised commissioning: Resulting in: uncertainty Due to specialised commissioning transferring to NHS England CCG Specialised commissioning lead to monitor situation. None Assurance from NHSE and Area Team None 4x3+12 4x4=16 NEW New Risk - new role in PMO to have specialised commissioning liaison incorporated. Page 1 of 5

188 Agenda Item 9, GBAF Risk details Risk Description Controls Gaps in Controls Assurance Gaps in Assurance Previous risk rating Current risk rating Trend Progress with actions Review date Objective 3: Transform services to meet the future needs of the population, through the most effective use of resources; ensuring the reduction of harm, waste and variation. Date added Directorate C3 Commissioning Implementation Executive Sponsor Mark Walkingshaw Lead Manager David Porter Lead Committee IGQC Review date Date added Directorate C27 Commissioning Implementation Executive Sponsor Mark Walkingshaw Lead Manager Gill Brigland Lead Committee IGQC Review date Date added Directorate C5 Commissioning Implementation Executive Sponsor Mark Walkingshaw Lead Manager Maria Meatherall Lead Committee IGQC Review date Increased risk of CCG receiving legal challenge. Due to: competitive tendering following the introduction of the EU Remedies Act, the National Health Service (Procurement, Patient Choice and Competition) (No 2) Regulations 1 April 2013 and the Public Procurement (The Public Contracts Regulations 2015). Resulting in: Could result in any contract that has been negotiated / signed being 'set-aside' by the courts and / or a fine being levied against the CCG which may be equivilent to the loss of profits for the challenging organisation. Risk to KPI delivery and Patient experience. Due to: due to operational issues and financial sustainability of the Non-Emergency Patient Transport contract: Resulting in: Poor patient experience Risk that system partners will be unable to effectively deliver a timely and coordinated approach to patient flow and discharge ensuring a reduction of patients who remain in the acute trust when medically stable and with a LOS greater than 14 days. Due to: Resulting in: Ensure that EU procurement process is followed for all procurement exercises (above and below) the EU threshold in accordance with DoH, Cabinet Office and Government Procurement Service Guidelines. Continued risk which applies to all procurement process but particularly those which exceed the Light Touch Regime threshold ( 615, total aggregated contract value) Risk to be managed consistently across Gloucestershire, Swindon, Wiltshire and BaNES CCGs. A&EDB, Onward Care Task & Finish Group, Urgent Care Strategy Group None None None Project reports to Core Executive Team and Governing Body Monthly Contract Board Meetings and ad hoc meetings with ATSL and other commissioners. Ad hoc performance reports to Governing Body and HCOSC Performance Reports and dashboards, critical milestones reviewed, regular programme stocktake. None None None 4x3=12 4x3=12 4x3=12 4x3=12 4x4=16 4x3=12 Revised Procurement Strategy was approved by the July 2016 Governing Body. Further amendments to this documents to be discussed and agreed at November 17 Governing Body meeting Revised Procurement Strategy was approved by the July 2016 Governing Body. Further amendments to this document to be discussed / approved at Core Executive Team meeting of 9 January and subsequently the Governing Body meeting of 25 January Monthly Contract Board Meetings and ad hoc meetings with ATSL and other commissioners. Contract funding agreed for 2017/18 and discussions underway re potential to extend contract for 6 months (from Nov 18) to allow time for development of a revised service specification, procurement and mobilisation (avoiding winter implementation of new service). Improvements have been maintained in Contact Centre performance and a pilot to improve the way that dialysis transport is delivered has been rolled out in Gloucestershire. GCCG is undertaking a NEPT eligibility review together with 11 other SW CCGs. Winter planning underway to ensure that availaiblity of transport does not impeded patient flow. 1. Monthly Task & Finish group meetings revised to provide more in depth analysis and challenge. Discussions and development underway of CQUIN 8. Further forensic analysis of MSFD list completed and presented at CCG. 3 month Care Sourcer pilot underway. 2. Acute trust on-line tool capture of patient complexity now operational on 6 exemplar wards; R/G codes to reflect DTOC codes alighted to top 10 Operational Standards. 3. Dom care provision seeing an improvement, 2 new providers to Gloucestershire each month; H2H service operational since May with 4 providers; Proud to Care 5 yr Strategy launched July 17 with yr1 focus on dom care; ongoing work to stabilise and embed services following provider failure and to improve referral process into community based support. 4. Working with Care Home Select for transition of services for end Sept 17; redesign of referral and tracking process for people in D2A beds to support CHC and social work. 5. H2H Trusted Assessor pilots for FoD and GRH in place; ibcf funding confirmed to extend roles, expressions of interest out to providers. 6. Embed and further roll-out of red/green approach - 6 wards currently reporting; meeting to review and relaunch internal professional standards taken place; therapies and pharmacy standards and target agreed; Peer Review of Board Rounds with ECIP and matrons planned September. 7. Develop and implement the Pull / Enhanced Community Discharge Model for Gloucester and Cheltenham; recruitment ongoing to deliver service; commence first PDSA cycle. 8. 2nd Care Nav post in place in acute, 3rd post to be offered; further development of roles ongoing as well as work around capture of benefits and cost avoidance activity. GFRS Care Nav post to commence. ibcf funding agreed to extend Care Nav roles - recruitment process to commence. 9. Confirmed Windsor St beds no longer required; Wheatridge - work ongoing; meetings with OSJT to reinvigorate use of reablement beds; planned review of Winchcombe Unit and reablement flats. 10. Ongoing acivity includes D&C planning, development of H2H service, simplification of referral processes, support to board rounds, increased Care Navigators support. ibcf schemes to support received agreement - recruitment to commence. 11. Daily navigation meetings pilot commenced with ward managers; Partnership Operational Standards workstream to identify and reduce DTOC and MFFD patient delays planned with programme manager CCG, GCH, social care and GHT leads identified; undertaking work to critically review the 40 patient target and evaluation of whether system can reasonably support; PDSA cycles of change planned; draft communication plan for top 10 standards; to set baseline and agree MFFD reduction target Downgrade of current risk + update of narrative / actions Date added May 13. Updated inline with UC strategy June `14. updated again Sep Directorate Non-delivery of the Constitution standard for maximum A&EDB, Admission & wait of 4 hours within the emergency department. Due Attendance Avoidance Task & to: Resulting in: Finish Group, Urgent Care Strategy Group None NHSE assurance process; Reports to Governing Body via performance reports None 1. Frailty Business Case approved; additional evening front door continued; rapid action project group to be established. 2. AEC now co-located on GRH and attendances increased; improved working between ED and AEC; weekend service at GRH launced September to pull patients from ED. 3. Case for change now progressed past 1st stage of NHSE assurance process to wider STP public engagement; clinical case for change reviewed by SW Clinical Senate on 18/19 July; Page 2 of 5

189 Agenda Item 9, GBAF Risk details Risk Description Controls C6 Commissioning Implementation Executive Sponsor Mark Walkingshaw Lead Manager Maria Meatherall Lead Committee IGQC Review date Date added Failure to comply with NHS Constitution and national Acute provider contracts, and local access targets for planned care, including including AQP, PFIG, Access & Directorate 2ww, over 52 ww, 62 day cancer target, diagnostic 6- Performance meetings C15 Commissioning week target, planned follow-ups. Implementation Due to: Combination of the implementation of new patient administration system at GHNHSFT Executive Sponsor (Trakcare), clinical & managerial capacity to deliver Mark Walkingshaw changes required to recover performance and issues Lead Manager with capacity vs demand. Christian Hamilton Resulting in: Inadequate and/or delayed care, long Lead Committee waits for routine outpatient and elective procedures in IGQC some specialties. High ASI rates and poor clinic slot Review date utilisation compounded by staffing issues within the booking office. Further delays on follow up pending lists due to priortisation of cancer appointments. Gaps in Controls Assurance None Assurance provided via Performance Reports to Governing Body: GAPS in Assurance: Number of targets not being met, insufficient capacity in planned care. Lack of detailed and robust action plans from GHFT. Lack of accurate activity and RTT reporting due to TrakCare issues. Gaps in Assurance None Previous risk rating Current risk rating 4x3=12 4x3=12 4x3=12 4x3=12 Trend Progress with actions public engagement; clinical case for change reviewed by SW Clinical Senate on 18/19 July; work underway to establish next phase Downgrade of current risk + update of narrative / actions. Issues following the implementation of TrakCare and/or insufficient planned care capacity to meet demand is resulting in increasing waiting lists and inability to meet waiting time targets, impacting on the quality of local health services. Targets regularly not being met, including RTT, 62 day cancer target, 6 week wait for diagnostics, and a number of 52 week wait breaches. 1. Monthly access and performance meeting continues to discuss progress. GCCG attendance at Trust internal cancer performance meeting, access and performance and Demand and Capacity meetings. Close working with specialties under significant pressures to find alternative capacity and arrange patient transfers. Additional CCG resource provided in short term to support RTT recovery. 2. Recovery action plans in place for a number of areas and progress being monitored. 3. Monthly communications being sent to GPs regarding waiting times across providers to encourage informed choice. Waiting times have been included on G-Care as part of the referral process. 4. Some patient transfers underway for long waiters such as Urology, and work underway to progress transfers in other areas such as orthopaedics and General Surgery. Increase in Urology community outpatient services and partnership arrangement between GHFT and community provider to redirect activity to the community. Increased capacity commissioned in General Surgery, Orthopaedics, Gynaecology, Urology and ENT to support 18wks RTT and diagnostic waiting times. 5. Fortnightly call with GHFT to review progress against validation action plan and trajectory. 6. As a requirement within the Block Contract arrangement with GHFT the CCG has asked the Trust to identify key specialities with full clinical and managerial engagement to progress a number of high impact actions to reduce planned care activity both at the front and back end of pathways. To assure progress against this workplan a joint RTT Recovery Board has been set up to monitor and oversee progress against the workplan across the Trust. 7. Creation of RTT Operational Delivery Group by GHFT with CCG representation to meet every 2 weeks and prioritise remdial actions in combination with TrakCare validation plans No Update available. Date added Directorate C8 & C28 Commissioning Implementation Executive Sponsor Mark Walkingshaw Lead Manager Maria Meatherall Lead Committee IGQC Review date Date added Directorate F11- F16 Finance Executive Sponsor Cath Leech Lead Manager Andrew Beard Lead Committee IGQC Review date (Signposting & Admission Avoidance ) High Impact Action 2: Risk of failure to reduce demand and prevent unnecessary acute attendances and emergency admissions. Due to: Resulting in: Risk of failure to deliver the CCG's financial target A&EDB, Attendance & Admission Avoidance Task & Finish Group, Urgent Care Strategy Group Robust financial plan aligned to commissioning strategy. Robust contract management including activity monitoring and validation, additional monitoring of volatile budget lines such as prescribing & CHC. Internal audit of financial procedures undertaken on an annual basis None None Performance Reports to Governing Body, weekly situation report, project status updates Budgets approved by the Governing Body. Monthly reporting to CCG Governing Body. Monthly performance dashboard for larger contracts with robust out of county contract monitoring reflected within performance reports. Monthly prescribing & CHC information including trends Internal audit reports and recommendations to be reported to Audit Committee. None None 4x3=12 4x3=12 4x3=12 4x3=12 Key areas of work are: 1. Development of 7 day/week ED front door GP streaming at GRH. 2. Establishment of consultant telephone "hot advice" into major specialities 3. Clinical advice within 111 and assessment of A&E/green ambulance dispositions 4. Enhanced signposting and admission avoidance within SPCA 5. Mental Health Crisis & Liaison reducing inappropriate admissions Continual monitoring and review via the A&EDB 4-hour Improvement Plan to be undertaken through the Attendance & Admission Avoidance Task & Finish Group and A&E Delivery Board throughout 2017/18. Ongoing work to ensure financial commitments are affordable and CCG is achieving a recurrent balance (at least quarterly). The delivery of 2017/18 financial performance targets are dependent upon QIPP performance throughout the financial year.. All major contracts for 2017/18 now agreed with principles agreed for 2018/19. Initial draft of financial plans for 2018/19 has been reported to development session and discussions underway with major providers. Monthly performance meeting which reviews all contracts (including out of county) together with Contract Boards and Performance, Finance & Information Groups for larger contracts. CHC reconciliation being worked through by GCC/CCG with some recognised discrepencies having been agreed and other areas being worked through. Internal audit considered to be a low risk but procedures will be regularly reviewed (next due by Q3 2017/18) Date added Directorate F26 Finance Executive Sponsor Local Digital Roadmap - Resources (financial and workforce) may not be available to deliver the programme or projects within the STP which will Resulting in an impact on delivery and benefits. County Wide IM&T Steering Group and associated sub groups in place reporting to Delivery Board and each organisation None County Wide IM&T Steering Group and associated sub groups in place reporting to Delivery Board and each organisation None On going dialogue within the Countywide IM&T Group on resourcing and potential risk to delivery. Bidding to national funds in progress. Risks regarding capital vs revenue funding model highlighted to NHSE. Page 3 of 5

190 Agenda Item 9, GBAF Risk details Risk Description Controls Cath Leech Lead Manager Fiona Robertson Lead Committee IGQC Review date on-going Date added There is an increased risk of a cyber attack Due to: cyber threats continuing and become more Directorate sophisticated which, if successful, would Result in: F27 Finance the CCG's systems and information are at greater risk Executive Sponsor of being compromised. Cath Leech Lead Manager Fiona Robertson Lead Committee IGQC Review date on-going Date added Risk that the APMS contract for a Primary Care registered list at Eastgate House and Matson Lane Directorate and the Urgent Primary Care Centre are handed back. L5 Primary Care Due To: Unsocial behaviour of residents living above Executive Sponsor the Practice Premises at Matson Lane. Resulting Helen Goodey in:potentially no service in place for both the Lead Manager registered list and the same day access service for those that need to be seen urgently by an appropriate Helen Edwards / Jeanette primary care professionals Leading to: patient safety Lead Committee risk and damage to organisational reputation. IGQC Review date Gaps in Controls Assurance Objective 4: Build a sustainable and effective organisation, with robust governance arrangements throughout the organisation and localities. Date added Directorate Q20 Quality Executive Sponsor There could be a risk of high mortality rates at the GHFT. Due to: The HSMR (Hospital Standardised Mortality Ratio) and SMR (Standardised Mortality Ratio) are statistically significantly higher than expected within GHNHSFT overall and individually at Monthly mortality briefings provided by Dr Foster. Trustwide mortality strategy reviewed at CQRG. None Reviewed by IGQC on behalf of the Governing Body Marion Evans Andrews both acute sites resulting in: potentially higher Lead Manager mortality rates Kay Haughton Lead Committee IGQC Review date Date added Inability to report on NHS constitutional standards and Fortnightly provider, None Regular reporting to CCG Governing provide information to operational staff relating to their commissioner and regulator Body & OOH Contract Management Directorate C36 Commissioning Implementation Executive Sponsor Mark Walkingshaw Lead Manager Ayrisha Khan Lead Committee IGQC Review date service. Due to: Resulting in: update call in place. Board. Date added Risk that the transfer in providers of the OOH service Daily review of rota fill and None Regular reporting to CCG Governing from SWAST to CareUK leads to an inability to deliver visibility of recruitment plan and Body & OOH Contract Management Directorate C35 Commissioning an effective service during transition. Due to: workforce issues (filling shifts / rostering of staff). trajectory. Board. Implementation Resulting in: Reports to OOH Contract Management Board with Executive Sponsor relevant updates provided to Mark Walkingshaw A&E Delivery Board Lead Manager Maria Meatherall Lead Committee IGQC Review date Date added None There is a risk that children and young people in care do not get a review of their health needs, or that the he CCG has policies in place to reduce the probability and contracts with the CSU and CITs which include cyber security advice and services. Contract management meeting with providers Analysis of the impact of the increased numbers and the None None he CCG has policies in place to reduce the probability and contracts with the CSU and CITs which include cyber security advice and services. County Wide IM&T Steering Group and associated sub groups in place reporting to Delivery Board and each organisation Primary Care Operational Group and Primary Care Commissioning Committee recommendaion to the Governing Body Performance reports to the Governing Body Gaps in Assurance None None None None None None Previous risk rating 4x3=12 Current risk rating 4x3=12 4x3=12 4x3=12 4x3=12 3x4=12 3x4=12 4x3=12 4x3=12 4x3=12 4x4=16 4x3=12 Trend Progress with actions 1. action plan following testing in progress, dependency on the implementation of new WAN/LAN timescale 2.response action plans reviewed and being updated 3. staff comms started, training plan to be developed 4.initial review of potential network improvements carried out, costed plans developed and being reviewed by the LDR Infrastructure Group. 5.Countywide Cyber exercise planned for to test processes. First meeting has taken place. Follow up booked for 11th December Options appraisal for alternative sites in Matson completed. No viable short term options. Next meeting with councillors and commissioners from GCCG and GCC to take place on Focus on provision of approriate level of drug and alcohol support for residents of Taylor House. The SHMI is being driven by out of hospital deaths within 30 days of discharge. A decision was made to undertake a joint provider, morality review on a a number of these deaths. Data on the detail of these is not easily accessible and it is being explored how this data can be obtained. This review will report to STP clinical reference group. The LeDeR mortality review is driving the systemwide process and as such GCCG is producing information for primary care. To date the LeDeR mortality review process has not identified significant concerns. 1. A specialist has been recruited in relation to RTT 2. A&E and Diagnostics reporting now recovered. 3. Communication to primary care in progress. 4. Fortnightly meetings in place with NHSE, NHSI, commissioners and the acute trust. 1. Successful recruitment of 16 new GPs and 14 ANPs. 2. Anticipating improved shift fill from September No update available as Arshiya Khan stepping down as main contact Downgrade of current risk and recommend closure. The CCG and GCC have agreed to fund additional dedicated CIC nurses and additional nurses are in the process of being recruited to the team Page 4 of 5

191 Agenda Item 9, GBAF Risk details Risk Description Controls Directorate Q19 Quality Executive Sponsor Marion Evans Andrews Lead Manager Kay Haughton Lead Committee IGQC Review date do not get a review of their health needs, or that the healthcare plan is not implemented effectively. Due to: The number of CiC has grown significantly, meaning that the services providing RHAs are struggling to manage the increased demand. The CCG has a statutory duty to ensure that the health needs of Children in Care (CiC) are met and this includes the provision of RHAs whilst a child remains in care every 12 months for those over 5 and every 6 months for those under 5. The main service that provides RHAs (public health nursing) is the responsibility of the county council, making the situation and its resolution more complicated. Resulting in: This is known to have a negative impact on subsequent longer term health and wellbeing outcomes later in life increased numbers and the effectiveness of the current service arrangements has been undertaken, with proposals developed for a new model of provision. This is being overseen by the CiC Health Coordination Group, and decision making on next steps will be made by JCPE due to the multi-agency nature of the issue. Gaps in Controls Assurance Governing Body Gaps in Assurance Previous risk rating Current risk rating 4x3=12 4x3=12 Trend Progress with actions are in the process of being recruited to the team Date added Directorate F20 - Finance Executive Sponsor Cath Leech Lead Manager Una Rice Lead Committee Review date Shared Record Project - It will not be possible to get data from SystmOne practices in the short-term. This requires having EDSM (intra-systmone sharing) switched on which makes the entire patient record available to all other SystmOne users (i.e. national) which may put patients off and is a different model to that agreed for JUYI. The only current way to share with the JUYI solution would be via the MIG. 1. Escalation to HSCIC 2. Meet with TPP (supplier for SystmOne) 3. Seek alternative method of sharing TPP data 4. Regular calls with other shared care record programmes (Birmingham/Surrey/Nottingham/ Leeds) 5. Review options None Updates to Governing Body on shared care record - business session None 4x3=12 4x4=16 1. Escalated to HSCIC and will continue to do so through funding lead 2. Met with TPP (supplier for SystmOne). Supplier asked to provide further detail on Waltham Foreset/Prederi solution 3. Ongoing 4. Regular calls with other shared care record programmes (Birmingham/Surrey/Nottingham/Leeds) 5. Options paper to go to project board on 4th August. TPP and Kainos are engaging to discuss details of overnight load. 6. Blackpear could help in retrieving real time data. Kainos team is currently engaging with Blackpear. Awaiting outcomes. 7. We are working 2 parallel streams, one where Kainos is in talks with BlackPear who have a way to query TPP in real time, another where we look at the different options for implementing the strategic reporting soluytion from TPP. Final decision between the 2 options is to be made by mid-july. 8. Kainos have completed a proof of concept with BlackPear and confirm that they are able to extract real time data from SystmOne. 9. Following engagement with TPP they have declined to endorse the Black Pear approach i.e. using a repuposed API. Therefore strategic reporting is the only option available presently which is not a real time solution. The clinical impact will be assessed. Page 5 of 5

192 Agenda Item 15 Governing Body Meeting Date Thursday 29 March 2018 Title Integrated Governance and Quality Committee (IGQC) Minutes Executive Summary The attached minutes provide a record of the IGQC meeting held on the 14 th December Key Issues The following principal issues were discussed at this meeting: Standing Items Quality Report and Dashboard including reports from providers Risk register Assurance framework Policies Information Governance HR Report Risk Issues: Original Risk Residual Risk Financial Impact Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Patient and Public Involvement Other issues Research and Design Report Staff Survey Report Health and Safety Briefing Not applicable Not applicable Not applicable None None None Not applicable Page 1 of 2

193 Recommendation Author Designation Sponsoring Director (if not author) The Governing Body is requested to note these minutes which are provided for information. Zoe Barnes Corporate Governance Support Officer Julie Clatworthy IGQC Chair and Registered Nurse Page 2 of 2

194 Integrated Governance and Quality Committee (IGQC) Draft Minutes of the meeting held on Thursday 14 th December 2017, in the Board Room, Sanger House Present: Julie Clatworthy (Chair) JC Registered Nurse Alan Elkin AE Lay Member PPE and Vice Chair Dr Alan Gwynn (part AG GP Liaison Lead South Cotswolds meeting) Dr Caroline Bennett (part CBe GP Liaison Lead North Cotswolds meeting) Locality and Vice Chair Cath Leech (part meeting) CL Chief Finance Officer Colin Greaves CG Lay Member, Governance Dave McConalogue DM Consultant in Public Health, GCC Marion Andrews-Evans MAE Executive Nurse and Quality Lead Mark Walkingshaw (part MW Director of Commissioning meeting) Implementation Peter Marriner PM Lay Member Business In Attendance: Andrew Mitchell AM HR Business Partner Becky Parish (part meeting) BP Associate Director of Experience and Engagement Christina Gradowski CGw Associate Director of Corporate Governance Jo Davies (non-voting JD Lay Member PPE member) Julie Hapeshi (part JH Associate Director of Research and meeting) Design, Gloucestershire Research Support Services Ryan Brunsdon RB Board Administrator Teresa Middleton TM Deputy Director of Quality Emma Savage (agenda item 10) Agenda Item 15 ES Associate Director of Clinical Programmes 1.0 Apologies 1.1 Apologies were received from Mary Hutton (MH), Andy Seymour Page 1 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

195 (AS) and Sheena Yerburgh (SY). 1.2 An explanatory note was sent to the Committee prior to the meeting which suggested that agenda items ten and eleven were discussed first as the Committee was quorate at the beginning of the meeting and these items had been recommended for approval. It was noted that the Committee would not be quorate past 11am. 2.0 Declarations of Interest 2.1 There were no declarations of interests received. 3.0 Minutes of the Meeting held on 19 th October The minutes of the meeting held on 19 th October 2017 were accepted as an accurate record subject the following amendment: 3.2 Section 5.9 be amended to read MAE expressed concern that due to the reluctance of parents allowing their children to receive the Measles Mumps and Rubella (MMR) vaccination, there was currently an outbreak of measles within the County. It was also requested that a post meeting note was included after section 5.9 which established that since the meeting in October, patients had been hospitalised due to the outbreak of measles in which two patients required special care. 4.0 Matters Arising 4.1 IGQC237, Quality Report JC informed the Committee that this item regarding research and design was included within the agenda at agenda item nine and JH was to present. Item Closed. 4.2 IGQC241, Quality Report MAE advised the Committee that information regarding Surgical Site Infections (SSI) had not been made available due to reporting issues at Gloucestershire Hospitals NHS Foundation Trust (GHFT). It was added that this had been discussed with Steve Hams, Executive Director of Quality and Chief Nurse at GHFT and this remained a big item of concern for GHFT. Item to remain open. 4.3 IGQC248, Feedback from the GHFT Breaking the Cycle Event Page 2 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

196 MW informed the Committee that Breaking the Cycle actions had become part of the new discharge task force and a report was to be sent to the A&E Delivery Board in December to provide an update. MW suggested that this report, once it had gone to the A&E Delivery Board, was brought to the February 2018 IGQC meeting. Item to remain open. 4.4 IGQC254, Quality Report MAE advised the Committee that information regarding deteriorating patients was included within the Quality Report found at agenda item five but acknowledged that the main issues regarding deteriorating patients was work in progress within GHFT with a big focus in Emergency Department (ED). Item to remain open. 4.5 CBe suggested that IGQC supported that Lesley Jordan, Secondary Care Doctor for the CCG Governing Body, was included within the work around sepsis and the deteriorating patient in a ward environment. The Committee supported this suggestion and added that Lesley could report back to IGQC at a future meeting. 4.6 IGQC255, C-Diff Deep Dive Report TM reported that a working group had recently been established but noted that there was no meeting held in December 2017 to allow the group sufficient time to collate data and information in relation to C-Difficile and the next working group meeting was in January JC requested that this was brought back during the February IGQC meeting. Item to remain open. 4.7 IGQC256, C-Diff Deep Dive Report It was noted that the information regarding GP testing for C-Diff patients was not available, and was to be brought back to the February IGQC. Item to remain open. 4.8 IGQC257, Care Home Quality Report DM provided a verbal update regarding the NHS England (NHSE) offer of influenza vaccinations for care home staff and informed the Committee that guidance had been released and that NHSE were contacting all Care Homes and Domiciliary Care providers that they had details for to try and increase vaccination rates. JC requested that an update was provided during the February IGQC. Item to remain open. Page 3 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

197 4.9 IGQC258, Quality Report, Gloucestershire Care Services JC advised that the information regarding the level of closures for Minor Injury and Illness Units (MIIU) was circulated via . MW confirmed that this information was regularly provided to the A&E Delivery Board. The Committee felt assured that this was monitored appropriately and if any issues were flagged, they would be brought to IGQC. Item Closed. 5.0 Quality Report 5.1 MAE introduced the Quality Report which provided assurance that quality and patient safety issues are given the appropriate priority. The report included County-wide updates on: National Institute for Health and Care Excellence (NICE); Clinical Effectiveness; Research and Development; Safeguarding; Patient Experience and Engagement; Infection Control; and Immunisation and Vaccination. The report was taken as read. 5.2 MAE reported that the current trajectory of Clinical Pharmacists (CP) within the county was 33, but noted that recruitment remained ongoing and that CP s had to be independent prescribers who had completed the non-medical prescribing programme. MAE noted the success CP s within the practices. 5.3 MAE clarified that the team of Pharmacists also included Prescribing Support Pharmacists (PSP). 5.4 MAE advised the Committee that some of the safeguarding reports had not been publicised as they were still going through the court process. 5.5 BP highlighted that a survey had been issued to help establish a Sustainable Transformation Partnership (STP) Insight Group and feedback from the survey was to be reviewed during December 2017 which would identify gaps in representation across the County. Page 4 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

198 5.6 BP noted that the Forest of Dean (FOD) business consultation had concluded and that over 3000 surveys had returned and a mixture of qualitative and quantitative data had been received. BP added that the report was to be published on 9 th January MAE reported that a Hot Topics engagement event for community staff was held on 1 st November 2017 in which was attended by 201 delegates and that members of the local health community delivered a range of presentations on a variety of topics. 5.8 MAE highlighted that at the end of Quarter Two, there had been a total of 107 E.Coli infections which was below the 2017/18 trajectory of 257. MAE emphasised that NHSE confirmed that the CCG was the best in the Country in terms of E.Coli and noted the work that had been completed by the Specialist Infection Control Nurse at GHFT. JC queried whether an effective pathway and guidance for Urinary Tract Infections (UTI) had been implemented and developed. MAE confirmed that this was on GCare and there was a particular focus on the care of patients within Residential Homes. 5.9 MAE advised the Committee that based on the current trajectory for C.Difficile Infections (CDI), the threshold of 157 cases was likely to breached but work was being completed to lower the number of CDI cases MAE updated the Committee on the influenza vaccination rates for frontline healthcare staff and noted that; GHFT had reached 71% and passed the threshold; Gloucestershire Care Services NHS Trust (GCS) had reached 65%; and 2Gether NHS Foundation Trust (2G) had reached 74%. MAE credited the Nursing Directors within the organisations listed above for the uptake in the vaccinations JC queried what the percentage was of uptake for the influenza vaccinations within the CCG. MAE confirmed that the CCG had reached a 50% uptake of staff vaccinations JC noted that vaccination rates for school children had improved but expressed concern regarding the low uptake of flu Page 5 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

199 vaccinations for pregnant women and queried whether the numbers of vaccinations would increase. DM did not think that the number of vaccinations for pregnant women would increase and added that NHSE identified that the approach needed to be revisited to help increase the numbers of vaccinations next year TM confirmed that the uptake for flu vaccinations as at December 2017 for pregnant women was at 41%, and this was lower than December TM reported that NHSE had commissioned GHFT to provide the flu vaccination to pregnant women but noted that the specification needed to be changed. MAE added that Community Midwives were not commissioned to administer the flu vaccination MAE confirmed that the CCG had designed leaflets to try and encourage patients to have the flu vaccination and these leaflets had been delivered to every pharmacy within the County, and pharmacies had been asked to include these with repeat prescriptions The committee discussed the attached appendices and MAE expressed concerns regarding staffing across the organisations and noted that this was a common theme within each of the quality reports Appendix 1 Quality Assurance Dashboard There were no comments regarding the quality assurance dashboard Appendix 2 GHFT Quality Report MAE reported that there had been three Never Events within GHFT, and this had increased since the quality report was written and added that there had been six altogether during 2017, and this was being flagged with NHS Improvement (NHSI). MAE acknowledged that four out of the six events had occurred within Theatres and suggested that the Theatre checklist was not being used effectively. MAE added that Kay Haughton, Deputy Nursing Director at CCG, had previously raised this concern and Steve Hams, GHFT Chief Nurse, who was organising an external review of safety within the Operating Theatres. Page 6 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

200 JC highlighted the work around the planned implementation of a new National Early Warning Score (NEWS) escalation system and the addition of electronic Track and Trigger systems CBe informed the Committee that the recent Clinical Quality Review Group (CQRG) felt very positive around GHFT s recognition of the work to improve falls prevention and management and noted that GHFT had begun to explore opportunities to improve MAE advised the Committee that significant post implementation operational issues for Trakcare remained and issues particularly related to patients waiting for 2 Week Wait (2WW) appointments. JC questioned whether an in-depth safety report would be provided regarding Trakcare. MW confirmed that GHFT had their own governance arrangements that had been put in place and that Ellen Rule, Director of Transformation and Service Re-Design at CCG, was leading on the detailed recovery plan. MAE added that safety issues and quality alerts are reported from GHFT to CQRG MAE confirmed that the GHFT Care Quality Commission (CQC) action plan had been re-written and NHSI had agreed that the monitoring of the action plan was to be handed back to the CCG but added that CQC Quality Improvement Group (QIG) meetings would take place every other month which monitored the quality implications of Trakcare JC referred to the NHS Mid Staffordshire Report and wanted to ensure that there was enough scrutiny from the CCG to improve the operational Trakcare issues and that the appropriate level of support was also in place JC acknowledged that the number of mixed sex breaches had been steadily climbing and that there were constant breaches in some areas. MAE noted that this was a national issue and that a national project around mixed sex accommodation was to be completed in Appendix 3 2G Quality Report MAE expressed concern around the number of Consultant vacancies within 2G and that these vacancies were being filled with Locums at a high cost. Page 7 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

201 JC queried whether the CCG was involved within the Mental Health Intermediate Care Teams (MHITC) service review. MAE confirmed that the CCG had been involved with the MHITC service review CG queried whether there had been any benefit from previous investment within the Improving Access to Psychological Therapies (IAPT) services and noted that the access rate of 15% was unlikely to be achieved MAE informed the Committee that the CCG had agreed funding for the Royal College of Psychiatry to undertake an independent review of the care and treatment services provided at Cambian Alders and that the CCG had agreed to share the GP audit with Cambian Alders for their information MAE highlighted concerns around Arbury Court and noted that the CCG had received correspondence from a family of a patient, placed by 2G in an Out Of County provider, to discuss issues and concerns. MAE added that NHSE and NHSI had been contacted and they had involved their solicitors. MAE advised that 2G was conducting an internal review and the CCG would make a decision on whether an external review was required based on the internal review 2G provided Appendix 4 Gloucestershire Care Services Quality Report MAE informed the Committee that there were band six and five Whole Time Equivalent (WTE) vacancies against a funded establishment of WTE Appendix 5 Arriva Transport Solutions Ltd (ATSL) MAE noted that there was a serious incident which involved a collision between a subcontracted taxi and another vehicle and Arriva were keeping all commissioners up to date with their investigation Appendix 6 Any Qualified Providers Quality Report MAE reported that the CQC had concerns about the Winfield Hospital, which was part of the Ramsey Group, and that a deep dive was to be conducted in 2018 around concerns. Page 8 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

202 5.22 Appendix 7 Care Home Quality Report MAE confirmed that Gloucestershire County Council (GCC) had commissioned ten beds within a Care Home close to GHFT which helped with discharging patients and a quality assurance framework had been requested around the use of the ten beds which looked at: risk, quality and escalation Appendix 8 Primary Care Quality Report TM informed the Committee that Locking Hill Surgery had a focused re-inspection from CQC and they were pleased with the progress that had been made but the category of inadequate remained. TM added that the full inspection was due for January or February 2018 and felt comfortable that they would achieve a better outcome RECOMMENDATION: The Committee noted the contents of the Quality Report and noted the attached appendices. AG, CBe and BP left the Committee at 11:00am. 6.0 Clinical Audit Results 6.1 It was requested that this item was brought back to the February IGQC meeting. Post meeting note: This item was not discussed as the speaker invited to attend to provide a verbal update was off sick, and nobody was able to provide cover. The item was therefore carried over to the February meeting date. 7.0 Research & Design Report 7.1 JC introduced JH to the Committee who presented an overview of research activity within Gloucestershire. 7.2 JH emphasised that research was NHS core business and that there had been a number of key policy drivers to promote research and design within the NHS. 7.3 JH advised that overall management of research in the NHS in England was by the National Institute for Health Research (NIHR) Page 9 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

203 via fifteen clinical research networks and that the Gloucestershire was part of the West Of England network and added that West Of England network was the worst performing network with multiple funding cuts. 7.4 JH advised the Committee that the NIHR Network was created to allow for all patients and health professionals across England to participate in and benefit from clinical research and to integrate research with clinical care. 7.5 JH noted that funding typically covered: research delivery staff, clinical time for staff involved with research, support staff and diagnostics and lab costs and added that the funding did not cover excess treatment costs. 7.6 JH informed the Committee that there was a consultation being run until February 2018 called Supporting Research in the NHS which looked at simplifying excess treatment costs. MAE noted that money had been put into research funds with excess treatment costs, but no results of these studies had been presented. JH advised that there was often a delay in retrieving results but would be able to provide a summary of how many patients had been recruited and required new therapies. 7.7 JH acknowledged that GCS had started to recruit patients into trials, and there had been two recruitments. 7.8 JH identified that ophthalmology had the most recruitment, but the high numbers of recruitment was potentially due to a screening study which was run with schools. It was noted that Hepatology and Cardiovascular studies had commenced. 7.9 JH reported that recruitment within Primary Care for Gloucestershire was decreasing and added that this was a national issue. JH advised that this was due to studies not being made available within Primary Care and added that the local academic provider was based in Bristol JH provided and overview of the Gloucestershire Research Support Service for NIHR portfolio and non-portfolio studies and informed the Committee that funding had been applied for to pay for Research Nurse time within GCS to look at NIHR portfolio studies. Page 10 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

204 7.11 JH advised that the Gloucestershire Research Support Service provided a research governance service for non-portfolio studies which ensured that health research authority requirements had been met CL acknowledged the CCG undertook a lot of work around evaluation and analysis and felt that it would be beneficial if the CCG liaised with the Gloucestershire Research Support Service regarding the work that they complete around evaluations and analysis. JC felt that more formalised commissioning evaluations were required JH noted that there was a consortium arrangement within Gloucestershire, called Research4 Gloucestershire which included; University of Gloucestershire (UOG); GHFT; 2G; GCS; GCC; and CCG The consortium had oversight of research within the County and it was added that the responsibility for governance arrangements sat within each organisation JH advised that there was a new UK policy framework for health and social care research which had replaced the research governance framework and agreed to send a copy to MAE DM reemphasised the point made above at 7.3 and queried why the West of England Network was the worst performing network within the Country. JH suggested that the majority of other networks had a higher proportion of Chief Investigators DM queried whether there was the opportunity for non NHS organisations to apply for funding. JH confirmed that the NIHR funding streams were available to social care JC thanked JH for the presentation and felt that this provided context as to how research active the County was and requested Page 11 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

205 that the presentations were sent to the Committee via RECOMMENDATION: The Committee noted the content of the Research and Design Report and thanked JH for the presentation. 8.0 Risk Register 8.1 CGw presented the Corporate Risk Register (CRR) which comprised a total of 39 risks, two of which were graded as high red risks. The CRR provided details of significant directorate risks. There were no risks due for closure. 8.2 CGw informed the Committee that CRR had been redesigned and new directorate risk registers had been sent to each directorate risk lead with accompany guidance on completing the risk register. It also included details on how to succinctly identify and describe a risk, how to score risks and the trend arrow needed to be included. 8.3 CGw advised that a training package had been developed for the risk leads after there had been confusion of how to complete the directorate risk registers. 8.4 CGw highlighted that there were two red rated risks, and these were: risk T13 regarding Specialised Commissioning and risk F24 regarding the implementations of Trakcare. 8.5 CGw acknowledged that IGQC had previously expressed multiple concerns regarding risk T13, and informed the Committee that an action plan was included within page eight of the report along with additional information about the risk. 8.6 New Risks There was the addition of one new risk to the register which was identified as risk L5. The risk was that the Alternative Provider Medical Services (APMS) contract for a Primary Care registered list at Eastgate House and Matson Lane, and the Urgent Primary Care Centre were handed back. The risk was rated at 12 amber. The Committee approved the addition of risk L CGw advised the Committee that the rating for risk L5 was likely to be downgraded by the next IGQC meeting. Page 12 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

206 8.7 RECOMMENDATION: The Committee: reviewed the paper and the attached Risk Register; and approved the addition of one new risk. 9.0 Assurance Framework 9.1 CGw presented the Governing Body Assurance Framework (GBAF) for 2017/18 which provided details of the risks against the achievement of the CCG s strategic objectives. The framework was reviewed and one risk found at point 8.7 above was agreed for inclusion onto the GBAF. 9.2 CG noted the good progress that had been made on GBAF and felt that it was heading in a positive direction but acknowledged that it would take time. 9.3 RECOMMENDATION: The Committee noted the Governing Body Assurance Framework Policies for Approval 10.1 Corporate Records Management Policy CGw reported that the policy had been made more concise and shorter than the original which made it more accessible for staff to read and added that the guidance notes were included as appendices of the policy. JC felt that this policy was a much clearer and easier read. AG queried whether this policy was in line with the General Data Protection Regulation (GDPR). CL confirmed that Rachel Lloyd, CSU Records Management Specialist, who provided support with the review of the policy had worked alongside Tony Ware, Information Governance Manager who would have ensured the policy was compliant CL confirmed that the CCG did not store many paper records and noted that the Continuing Healthcare Team (CHC) had facilities to scan documents into CareTrak JC highlighted that appendix one, page two did not mention scanning, and that it suggested that documents were sent to offsite storage providers. CGw clarified that the Information Page 13 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

207 Governance Working Group had encouraged CCG staff to scan documents and electronically store them unless absolutely necessary PM queried whether the size of the shredding as identified within appendix three was correct and felt that 15mm x 4mm was too large. CGw confirmed that Rachel Lloyd had included the requirements CBe highlighted that appendix three did not mention the disposal of records that staff had taken home with them. CGw assured the Committee that CCG staff are not encouraged to take confidential documents out of the building. CGw agreed to include within the appendix the use of the CCG recycling systems The Committee approved the Corporate Records Policy subject the inclusion of the use of CCG recycling systems within appendix three Joint Working with the Pharmaceutical Industry TM provided a brief update on the policy and highlighted that the policy tried to be more explicit for CCG staff and highlighted that CCG staff members had to be aware of the policy. It was added that staff who worked with the pharmaceutical industry were required to report to CGw to ensure a complete record was maintained as clear guidelines and agreements needed to be signed off before work commenced JC queried whether any agreements had been signed off and where they were being monitored. CG advised that some of the agreements were monitored during the Audit Committee but emphasised TM s point at that some agreements were not clear on the working relationship with the pharmaceutical companies CBe queried whether this policy was only applicable to the pharmaceutical industry. TM confirmed that this policy included wider pharmaceutical agencies and devices CBe suggested that general practices were reminded of this policy. JC recommended that this was included within What s New. Page 14 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

208 MW confirmed that there was not a policy regarding joint working with commercial organisations and it was not embedded within this policy. CL highlighted that a guidance note on working with Commercial Organisations would be beneficial The Committee approved the Joint Working with the Pharmaceutical Industry Annual Leave Policy MAE introduced the Annual Leave Policy and highlighted that the policy had been originally approved, however there was an additional section that required to be approved regarding the purchasing of additional annual leave MAE advised the Committee that the Joint Staff Consultancy Committee (JSCC) had suggested that a section around the additional purchase of annual leave was required. It was added that other partnership organisations policies had been looked at to see whether this was included PM highlighted that the dates for when additional annual leave had to be purchased by had not been included within the additional amendment. MAE advised that the dates for when additional annual leave had to be purchased by was found within the application form The Committee approved the additional purchasing of annual leave to the annual leave policy Adverse Weather Policy MAE introduced the Adverse Weather Policy and informed the Committee that there had been an old policy which required a lot of updating. It was added that temporary guidelines had been issued to managers whilst the policy was being prepared The Committee approved the Adverse Weather Policy Secondment Policy Page 15 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

209 CGw introduced the Secondment Policy and recognised the inconsistencies regarding the application of secondments within the CCG. CGw noted that the policy focused heavily on the principles and pre-requisites of what was required for staff to undertake a secondment CGw acknowledged that within the policy, it highlighted that there was no guarantee that staff would return from secondment into the role they previously had JC queried that there were no skills assessments for clinical staff that were seconded into the CCG this was not included within the policy. CGw assured the Committee that staff that joined the CCG on secondment would have received the appropriate checks from the HR department and added that the Recruitment and Selection policy procedures would have been applied The Committee approved the Secondment Policy Commissioning Policy for Continuous Glucose Monitoring for Children and Young People aged up to 19 Years JC welcomed ES to the Committee who provided a brief overview of the Commissioning Policy for Continuous Glucose Monitoring for Children and Young People aged up to 19 Years ES reported that this policy applied to 267 Children within the County with Type 1 Diabetes and that the number of children remained static ES informed the Committee that a Continuous Glucose Monitor tested blood glucose levels every minute which accurately reported when a blood sugar level had gone out of range. ES noted that five children had been presented through the Individual Funding Request (IFR) process who asked for the CCG to fund a Continuous Glucose Monitor which had all been approved and acknowledged that the policy was to ensure that Children who met the NICE criteria received evidence based and timely treatment in order to avoid diabetes related complications in adult life JC observed that this read more like a policy statement and if it was required to be a policy, it would need to be made more succinct and the amendments would need to be presented at a Page 16 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

210 future IGQC meeting BP highlighted that the Equality Impact Assessment (EIA) was dated 2018, not ES identified that the policy was being presented to the Priorities Committee which was held on 21 st December MW added that commissioning and financial discussions were to be held during the Priorities Committee The Committee endorsed the Commissioning Policy for Continuous Glucose Monitoring for Children and Young People aged up to 19 Years as a policy statement and required the policy to be presented during IGQC in February 2018 on the basis that is was suported during the Priorities Committee in December Data Protection Policy The review period for the data protection policy required an extension until May 2018 to be updated to incorporate the General Data Protection Regulation (GDPR). The committee approved the policy extension Information Governance Policy The review period for the information governance policy required an extension until May 2018 to be updated to incorporate the General Data Protection Regulation (GDPR). The committee approved the policy extension Subject Access Request Policy The review period for the subject access request policy required an extension until May 2018 to be updated to incorporate the General Data Protection Regulation (GDPR). The committee approved the policy extension PM suggested that it would be helpful to the Committee if any polices that are brought to IGQC which have been amended, have highlighted changes in them so that the Committee can identify what has changed within the policy RECOMMENDATION: The Committee approved the following Page 17 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

211 policies; Corporate Records Management Policy; Joint Working with the Pharmaceutical Industry Policy; Additional purchasing of annual leave amendment to the Annual Leave Policy; and Adverse Weather Policy. The Committee endorsed the Commissioning Policy for Continuous Glucose Monitoring for Children and Young People aged up to 19 Years as a policy statement and required the policy to be presented during IGQC in February 2018 on the basis that is was approved during the Priorities Committee in December The Committee approved the following policy extensions; Data Protection Policy; Information Governance Policy; and Subject Access Review Policy Effective Clinical Commissioning Policies 11.1 MW introduced the Effective Clinical Commissioning Policies (ECCP) which presented IGQC with an overview of the recommendations from ECCP Working Group. The paper was taken as read MW informed the Committee that there were two policies that the ECCP Working Group had not supported the change to Interventions Not Normally Funded (INNF) and those included Ganglia removal and Botox for hyperhidrosis. The remaining seven polices had all been supported MW advised the Committee that the ECCP Working Group had endorsed the request from the Ear Nose and Throat Clinical Programme Group (ENT CPG) to remove the requirement for prior approval for Grommet insertion in Children. The procedure was to be included in the quarter one criteria based access (CBA) audit 2018/19 which ensured compliance with eligibility criteria MW highlighted that the paper recommended the removal of a policy which was Xiapex for the treatment of Dupuytren s contracture and added that NICE had published a Technology Page 18 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

212 Appraisal Guidance (TA459) in July 2017, which made the requirement for a policy redundant, as it was mandatory to commission the procedure in line with NICE recommendations JC highlighted that the paper stated that acupuncture was only funded for low back pain as an INNF but noted that it was used within midwifery. MW confirmed that acupuncture was commissioned within the maternity services and was not a subjective process BP requested that if the commissioning policies were approved whether the CCG website could be updated and if the CCG Patient Advice and Liaison Service (PALS) team could be advised of the updated policies RECOMMENDATION: The Committee approved the updates to the Clinical Commissioning Policies and endorsed the next steps set out within the paper Committee Self-Assessment 12.1 JC informed the Committee that CGw was collating the Committee self-assessments. CGw suggested that the Committee selfassessment results was brought to a future IGQC alongside the terms of reference. It was added that the deadline of the selfassessments was 5 th January RECOMMENDATION: The Committee noted the verbal update Quality and Governance Terms of Reference 13.1 CGw suggested that a review of the Committee terms of reference would be more appropriate after the Committee self-assessments were completed and returned, as mentioned above at point 12.1, as this would highlight any necessary changes that would be required RECOMMENDATION: The committee noted the verbal update and agreed with CGw s suggestion that the Terms of Reference were reviewed in February 2018 alongside the Committee Self-Assessment Information Governance Page 19 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

213 14.1 CL introduced the Information Governance (IG) report which provided an update on the CCGs IG arrangements. The report was taken as read CL identified that NHSD had issued their online IG training tool (Data Security Awareness Level 1) which replaced the annual IG training provided through the IG Training Tool. The training tool had been rolled out to all staff within the CCG and staff had been asked to complete it by the 30 th November and added that 70% of CCG staff had completed the training for this year which included online and the manual workbook CL advised that Governing Body members had received face to face IG training which included training regarding GDPR and that a scoping session for the Primary Care team was to be completed CL advised that there was a cyber security/it security group which had membership from each organisation, and the CCG was represented by a Commissioning Support Unit (CSU) team member with an expertise in IT security. The group had progressed with actions which resulted from the cyber security review that was undertaken earlier in the year and looked at how overall security could be enhanced CL informed the Committee that a cyber resilience exercise was completed on 4 th December 2017 which tested processes and procedures around IG resilience JC felt that the cyber security roadmap was very clear and beneficial. CL added that staff were regularly sent briefings in terms of what users should and shouldn t do in reference to IG and cyber security CG highlighted that appendix one mentioned that the Child Health team often left their cupboards open and he felt uncomfortable with them doing this. CL advised that this was not a CCG department but had been encouraged to close and lock their cupboards. CL left the meeting at 12:00pm RECOMMENDATION: The committee noted Information Page 20 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

214 Governance report and the attached appendices Month HR Report 15.1 CGw introduced the workforce report and noted that the report was provided to the CCG by the South Central and West Commissioning Support Unit (the SCW). The Workforce covered the six month period beginning 1 st April 2017 and ended 30 th September The report was taken as read AM informed the Committee that establishment levels had increased by seventeen members of staff since April 2017 which shown a 5.5% increase which presented a final headcount of 322 staff members. AM noted that there had been an increase of 48 members of staff within the last year, but MAE clarified that this was possibly due to the employment of the Clinical Pharmacists AE identified the implications of the increase in headcount of staff and noted an increase in noise and lack of desk space. MAE added that there was an increase in the amount of mandatory training that was required to be completed CG suggested that an analysis of why there had been such a large increase in headcount since when the CCG started in April 2013 to its headcount, as of December 2017, which would imply whether the CCG was over-staffed. AM confirmed that this analysis could be completed AM identified that the average CCG turnover rate was 11.25% based on the headcount. The rolling twelve month CCG national average for turnover as at 30 th June 2017 was 15.36% AM advised that the absence rate for the last 6 months, was 2.18% and this was a continuum of the reduction seen within the previous 6 months. AM added that 125,000 was lost in this six month period due to absences. The main reason for days lost was noted to be due to stress and depression PM queried how much sickness was self-certified compared to a sick note JC highlighted that the appraisal rates had increased to 69%. AM suggested that based upon what the CSU had implemented, Page 21 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

215 more regular shorter one to one meetings were more beneficial for staff, instead of yearly appraisals RECOMMENDATION: The committee noted the 6 Month HR Report HR Dashboards 16.1 CGw introduced the HR Dashboard Reports which had been produced by ConsultHR. The reports covered: staff in post, starters, leavers, sickness absence and sickness reasons from September 2017 to October RECOMMENDATION: The Committee noted the HR Dashboards Staff Survey Report 17.1 CGw introduced the CCG Staff Survey which was carried out for ConsultHR in July The purpose of the survey was to ascertain from CCG s employees their experiences and feelings about work. The survey provided an opportunity for the organisation to obtain systematic feedback from staff, identify what is working well and areas for improvement CGw informed the Committee that staff survey results and solutions had been presented at the HR OD Group and CCG team briefs. It was added that results had also been presented at JSCC CGw reported that the overall response rate was 65%, 191 out of 293 staff responded to the survey which provided a similar result to the 2016 response rate of 64%. The response rate was higher than the overall response rate for NHS organisations participating in the National NHS Staff Survey AE highlighted staff concerns regarding different managers behaving in different ways with similar circumstances and queried how this was going to be managed. CGw assured the Committee that a series of half-day manager workshops was to be implemented which focused on a variety of topics to help standardise manager behaviours within the CCG JC expressed concern that for the first time, discrimination had Page 22 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

216 appeared within the survey report JC noted the lack of career progression and development that was identified with the staff survey for administrative staff RECOMMENDATION: The committee noted the Staff Survey Report and the attached appendices Health & Safety Briefing 18.1 MAE Introduced the health and safety briefing which provided the Committee assurance that there were appropriate health and safety measures within the CCG. The paper was taken as read PM queried whether there had been any Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) accidents as it was not mentioned within the report. MAE confirmed that there had not been any accidents reported PM noted that the toilets needed to be inspected during the next health and safety walkabout CG recommended that a fire alarm test was run during a Governing Body Business session to ensure that all Governing Body members were aware of the procedures within the CCG RECOMMENDATION: The committee noted the Health and Safety Report Any Other Business 19.1 There were no items of any other business. The meeting closed at 12:26pm. Date of Next Meeting: Thursday 15 th February 2017, 9am in the Boardroom, Sanger House. Page 23 of 23 Minutes from Integrated Governance and Quality Committee (IGQC) 14 th December 2017

217 Agenda Item 16 Governing Body Meeting Date Thursday 29 March 2018 Title Primary Care Commissioning Committee (PCCC) Minutes Executive Summary The attached minutes provide a record of the PCCC meeting held on the 30 November Key Issues The following principal issues were discussed at this meeting: Standing Items Primary Care Quality Report Delegated Primary Care Financial Report Management of Conflicts of Interest Risk Issues: Original Risk Residual Risk Financial Impact Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Other Issues Presentation from Springbank Surgery Application to close branch surgery at Tetbury Hospital, Andoversford and Hadwen in relation to St Michael s Square and Wheatway Update on Primary Care Premises Workstream As outlined within the minutes. Not applicable Not applicable Not applicable None None None Page 1 of 2

218 Patient and Public Involvement Recommendation Author Designation Sponsoring Director (if not author) Not applicable The Governing Body is requested to note these minutes which are provided for information. Zoe Barnes Corporate Governance Support Officer Alan Elkin PCCC Chair and Lay Member Page 2 of 2

219 Primary Care Commissioning Committee (PCCC) Minutes of the Meeting held on Thursday 30 th November 2017 in the Board Room, Sanger House, Gloucester GL3 4FE Present: Alan Elkin (Chair) AE Lay Member Patient and Public Engagement Dr Andy Seymour (Non- AS Clinical Chair Voting) Cath Leech CL Chief Finance Officer Colin Greaves CG Lay Member - Governance Joanna Davies JD Lay Member Patient and Public Engagement Julie Clatworthy JC Registered Nurse Marion Andrews-Evans MAE Executive Nurse and Quality Lead Mark Walkingshaw MW Director of Commissioning (Representing MH) Implementation In attendance: Alan Thomas AT Healthwatch Representative Andrew Hughes AH Associate Director of Commissioning Becky Parish BP Associate Director Engagement and Experience Christina Gradowski CGw Associate Director of Corporate Governance Helen Edwards HE Associate Director of Primary Care and Locality Development Helen Goodey HG Director of Primary Care and Locality Development Jeanette Giles JG Head of Primary Care Contracting Jo White JWh Programme Director for Primary Care Cllr Roger Wilson RW Chair of Gloucestershire County Council Health and Wellbeing Board Ryan Brunsdon RB Board Administrator Sanjay Shyamapant SS GP at Springbank Surgery (Agenda Item 5) Deborah Matson-Beale (Agenda Item 5) There were no members of the public present. DMB Church Street Medical Executive Manager Primary Care Commissioning Committee Minutes 30/11/17 Page 1 of 13

220 1 Apologies for Absence 1.1 Apologies were received from Mary Hutton (MH). 2 Declarations of Interest 2.1 AS declared a general interest as a GP but more specifically in respect of agenda item eight, the Application from Hadwen to Close Branch surgeries St Michael s and Wheatway. 2.2 AE declared that the meeting was quorate and that he felt that AS should not be excluded from any discussions as he was a nonvoting member 3 Minutes of the Meeting held on 5 th October The minutes were approved as an accurate record. 3.2 CG highlighted that section 6.9 of the minutes which referenced the Local Medical Committee (LMC) changing its position from abstention to agreement in respect of the Application for merger and closure of a branch surgery was not reflected in the Primary Care Operational Group (PCOG) minutes, noted that these documents needed to correspond and that a post meeting note was required for the PCOG minutes. 4 Matters Arising /01/2016, Item 9.1, Any Other Business AE identified that the self-assessment for the committee was to be brought back to the January meeting. Item to remain open /03/2017, Item 7.3, Practice Nursing Strategy MAE informed the Committee that a draft strategy had been produced which was to go to Integrated Governance and Quality Committee (IGQC) in December but indicated that work was still required. Item to remain open /05/2017, Item 8.6, Primary Care Quality Report MAE highlighted that Pharmacists were still being recruited and suggested that monthly recruitment figures could be electronically Primary Care Commissioning Committee Minutes 30/11/17 Page 2 of 13

221 circulated if requested. MAE agreed to provide a further update during the January PCCC meeting. Item to remain open /10/2017, Item 6.0, Application for merger and closure of a branch surgery It was noted that the application to close the branch surgery of Hadwen (St Michaels) was included within the agenda at agenda item eight. Item Closed. 5 Springbank Presentation 5.1 AE welcomed SS and DMB to the Committee who provided a presentation update on Springbank Surgery. It was noted that it had been two years since Springbank Surgery had been in partnership with Church Street. 5.2 SS identified some of the challenges that had been faced within the partnership, these included: culture, workforce, perception of locality, Key Performance Indicators (KPIs) and Care Quality Commission (CQC). 5.3 DMB reported a challenge raised within the CQC inspection which had happened nine months into the partnership. The challenge related to public data reporting outcomes prior to the partnership. As a demonstration of improving outcomes DMB pointed to the Quality Outcomes Framework (QOF) for 2016/17 which was 98.3% compared with that for the previous year of 77%. 5.4 SS assured the committee that what had been identified within the Springbank bid had been had been delivered and this included: Partner led practice with three days covered by locums; Extended hours provision; Twelve minute appointments were being made; On the day access; Workforce development including that of the roles of the Practice Nurse, Nurse Practitioner and Clinical Pharmacists, IT improvements and systems were changed within six to eight weeks; and Close working with other health providers. 5.5 SS noted that the list size for Springbank had increased by approximately 1000 patients to 2813 patients and projected that Primary Care Commissioning Committee Minutes 30/11/17 Page 3 of 13

222 this was likely to increase to 2900 by the end of the year. DMB informed the group that possible expansion of provision was required. 5.6 SS reported that the Clinical Pharmacist role would be developed based on previous experience at Church Street Medical Practice. DMB added that there was a lead Clinical Pharmacist which ensured consistency across all practices within the partnership. 5.7 SS presented the next steps for Springbank Surgery which were: Back office programme was continuing and work with the Productive General Practice (PGP) quick start had been beneficial; Possible recruitment of Physician Associates; A new self-help website was to go live which included online access; Patient Participant Group (PGG) expansion; Continuation of Nurse training; and Premises expansion and it was added than an improvement grant had been applied for. 5.8 JC commended the progress that had been made at Springbank Surgery and felt that Springbank was a showcase for other surgeries and added that the work done provided a toolkit for quality improvement. 5.9 HG highlighted that integration within the partnership was achieved by having a lead GP take on the lead role of, for example, looking at economies and systemising processes BP expressed gratitude on behalf of patients who had praised Springbank Surgery on the work that had been undertaken within the last two years AE queried whether the KPIs that Springbank had been asked to fulfil were correct and noted that there was nothing within the KPIs which addressed the younger population. SS informed the Committee that not all KPIs were included, but were some were being evolved and developed alongside JG. Primary Care Commissioning Committee Minutes 30/11/17 Page 4 of 13

223 5.12 AE queried whether a cost benefit analysis had been carried out for the use of clinical pharmacists within the practice. DMB reported that a formal cost benefit analysis had not been completed but she was confident that their contribution was such that they would continue to form part of the team. SS added that there were three different funding streams for clinical pharmacists which were: national pilot which included centralised funding, locality funding and support pharmacists funded by the CCG JC questioned whether twelve minute appointments had been successful. SS suggested that longer appointments would be beneficial to the patients and fifteen minutes would probably be appropriate. 6 Application to Close Branch Surgery at Tetbury Hospital 6.1 JG introduced the application from Romney House Surgery to close the Branch Surgery at Tetbury Hospital The paper was taken as read. 6.2 JG informed the Committee that the reason this application had been made was because the GP who had historically held sessions at Tetbury Hospital had recently retired. It was felt that the new GP joining the practice could deliver the session within the main surgery and would more appropriately be based there where he could receive support and access the experience of his colleagues. 6.3 JG reported that patients who had recently used the branch surgery had been surveyed and the main issue against the closure highlighted was the perception of easier parking at the hospital. It was noted that there was an additional car park near to Romney House. However the survey also showed that 83% of respondents supported the closure and 92% normally visited the main surgery for appointments. 6.4 JG confirmed that the Patient Participation Group (PPG) were supportive of the application. 6.5 JC highlighted that there was no information on the Romney House website regarding the branch surgery closure and queried whether enough patient views had been solicited and collected and whether sufficient engagement had been carried out. JG Primary Care Commissioning Committee Minutes 30/11/17 Page 5 of 13

224 confirmed the scale of the survey work that specifically focussed on those who had used the branch surgery, identified that the letter and survey had been made available in the main surgery and the closure was to be reported in a newspaper circulating locally. 6.6 HG clarified that the PCOG recommended approval to close the branch surgery. 6.7 JD requested clarity as to how quickly the branch surgery would close and take effect as highlighted within the recommendations. JG informed the Committee that if the recommendation was approved, Romney House were keen for this to take effect as early as December JD expressed concern that this may not have provided enough time for patient engagement. 6.8 RESOLUTION: The Committee agreed the request to close the Branch Surgery at Tetbury Hospital from Romney House Surgery. 7 Application to Close Branch Surgery at Andoversford 7.1 JG introduced the application from Sixways Clinic to close the Branch Surgery at Andoversford. The paper was taken as read. 7.2 JG explained that the request had been made because the practice had acknowledged that the quality of care delivered within this branch surgery was compromised due to the lack of appropriate facilities to operate a modern medical surgery and patients had to travel to the main surgery site for appointments and access to nursing, additional and enhanced services. 7.3 It was noted that the branch surgery was not compliant with CQC infection control regulations and had been closed as a `temporary` measure a considerable time ago due to the poor condition of the premises. 7.4 AE identified the issue of the substantial distance between the branch surgery and the main surgery and the difficulties that would pose for those living close to the branch surgery. He expressed concern that the branch surgery was closed without the CCG having any prior knowledge. Primary Care Commissioning Committee Minutes 30/11/17 Page 6 of 13

225 7.5 In response to this second point, HG assured the Committee that an audit was being carried out on all practices which was looking at: surgery premises including branch surgeries, opening hours and what was in contract to allow practices to deliver services. 7.6 JC requested that NHS Choices was corrected so as to provide up to date information to patients. 7.7 MAE noted that the CQC no longer inspected branch surgeries. 7.8 RESOLUTION: The Committee agreed the request to close the Branch Surgery at Andoversford from Sixways Clinic. 8 Application to Close Branch Surgeries from Hadwen in relation to St Michael s Square and Wheatway 8.1 JG introduced the application from Hadwen Medical Practice to close the Wheatway Branch Surgery and St Michael s Branch Surgery. The paper was taken as read. 8.2 JG informed the Committee that during October 2015, NHS England (NHSE) supported Hadwen Medical Practice to move forward with the Primary Care premises development on their existing Glevum Way site but this was subject to the caveat that the development would lead to the closure of the two branch surgeries. 8.3 JG highlighted that phase one of the project was to be completed by early March and that phase two of the project was the refurbishment of the current Glevum Way Surgery which was to be completed by August JG identified the two proposed branch surgery closure dates as 31 st August 2018 for Wheatway Surgery and 31 st August 2019 for St Michael s Surgery. 8.5 JG reported that St Michael s Surgery was situated within an area of most deprived as measured by the index of multiple deprivation. 8.6 JG advised the Committee that a patient consultation event for the proposed closure of the Wheatway branch was held on 25 th March Primary Care Commissioning Committee Minutes 30/11/17 Page 7 of 13

226 2015. The closure of St Michael s had been discussed at several PPG meetings and the specific results of the June 2017 patient survey of those attending the branch surgery were discussed at the PPG meeting held on 20 th July JG recognised the impact on other surgeries within Gloucester City who had recently been impacted by the College Yard closure should patients decide to move if St Michael s was approved for closure. 8.8 JG noted that Hadwen s application stated that they would like to close St Michael s on 31 st August 2019, but the patient survey results proposed a closure by 31 st December 2019 which was closer to the planned timescale for the potential new development at Quayside and Blackfriars. 8.9 AE, as did the practice, felt that there was no real issue with the closure of Wheatway Branch Surgery as it was only a four minute walk from the main site AE expressed concern regarding the proposed closure of St Michael s and noted the: high levels of deprivation, that it was three miles away from the main surgery, and there was no guarantee of the Quayside and Blackfriars development being completed within the projected timescales. CG expressed further concern regarding the proposed closure date of 31 st August CG Questioned the context of the letter at appendix 1, which referred to the approval of the development at Hadwen. He noted that, the letter of approval purported to be an NHSE approval but was in fact signed by the CCG Accountable Officer. It was added that the CCG had delegated authority during this time HG felt that branch surgeries were not a sustainable solution to providing an effective service model for patients and as part of the CCG s priorities to provide good access to Primary Care, a sustainable solution included fit for purpose premises with practices working together. AE identified that as the CCG moved towards the desirable model of providing a sustainable solution there was a need to recognise that a degree of risk needed to be embraced. Primary Care Commissioning Committee Minutes 30/11/17 Page 8 of 13

227 8.13 AE acknowledged that the report stated that if the Branch Surgeries were not closed, the CCG would be faced with a cost pressure AS stated that he did not feel comfortable with a proposed closure date of 31 st December 2019 due to this being in Winter and felt that this was not in patients best interests JD questioned whether there was any flexibility around the proposed closure date. HG advised that CCG had to assess the impact on practices, the flow of patients and how well the practice manages which would influence the timespan of the closure date JC queried whether there was likely to be any staff redundancies and whether the practice management team had requested any support. JG confirmed that the practice management team had not requested any support and noted that there had been no notifications of any possible redundancies CG highlighted that the practice identified that approximately 200 patients would have had to re-register at another practice if St Michael s was agreed for closure and felt that this number was too high to be accommodated within other practices within a high deprivation area within Gloucester City. AS added that the closest practice to the branch surgery was Gloucester City Health Centre who had identified in consultation that they could not take on any patients from Hadwen Medical Practice AE suggested that if the Committee agreed the closure of the branch surgery, it was to be subject to the practice actively working with those patients who would be negatively impacted by the branch surgery closure of St Michael s to ensure that those patients had a future in terms of GP support JD requested to see the practice s change management plan which would mitigate against any identified risks. CG stated that he felt comfortable with a closure date of 31 st December 2019 but added that this date could be brought forward if a change management plan was presented. RESOLUTION: The Committee agreed; the request to close the Branch Surgery at Wheatway Primary Care Commissioning Committee Minutes 30/11/17 Page 9 of 13

228 on the proposed date of 31 st August 2018; and The request to close the Branch Surgery at St Michael s Square on the proposed date of 31 st December 2019 but subject to the practice actively working with the patient group most likely to be affected by the branch surgery closure to provide flexibility of the closure date. 9 Update on Primary Care Premises Report 9.1 AH introduced the Primary Care Premises Report which set out key progress that had been made within Primary Care for all areas of work. The report was taken as read. 9.2 AH provided an update on the proposed Gloucester City Health Centre and informed the Committee that this was part of the Quayside and Blackfriars development. It was added that when the strategic plan was submitted to the Estates and Technology Transformation Fund (ETTF), no approval was given, but Gloucester City Health Centre remained a key priority for the CCG. 9.3 AH identified that there had been no recent development around accommodation for the Gloucester City Health Centre due to an unsuccessful previous development proposal which cost the Health Centre quite a lot of money and they have subsequently struggled to find alternative premises. 9.4 CG highlighted that there was an anticipated update due for December regarding Cheltenham Town Centre. AH expanded the information within the report and described this development as a flagship scheme and added that it would be a large multi-practice Primary Care centre. AH identified that this could potentially be the most expensive scheme ever within Gloucestershire with a cost of around per square metre based on a 25 year lease. AH added that a 3.2million ETTF grant had been submitted. 9.5 JC noted positively that section 106 funding had been used. AH clarified that the section 106 funding that was included within the report was predominantly Primary Care focused. Primary Care Commissioning Committee Minutes 30/11/17 Page 10 of 13

229 9.6 AE queried why the Culverhay scheme costs had increased by 65% although noting that NHSE had agreed due diligence. AH suggested that this related to the evolution of the scheme beyond that originally planned. 9.7 RESOLUTION: The Committee noted the report. 10 Delegated Primary Care Financial Report 10.1 CL presented the report, which outlined the financial position with regard to the delegated primary care co-commissioning budgets, at the end of October The paper was taken as read CL advised that the CCG had reported an under spend of 398k against delegated budgets at the end of October, which represented an improvement from the previous month. CL informed the Committee that the underspend was primarily due to a refund in rates CL confirmed that within the year to date position, there were also some areas which had overspent and these were caused by demographic increases beyond those projected and changes around sickness and maternity payments CL assured the Committee that a breakeven position had been forecasted for 2017/18 and added that the recurrent underspend would be carried forward to 2018/ AE highlighted that work was underway to model the impact of the 2017/18 financial position into future years and noted the issue that, though not complete, the exercise had highlighted some potential pressures and an overview of the position would be discussed at a future PCOG and PCCC meeting. CL advised that the 2016/17 recurrent position had been rolled forward and tested. CL proposed that at a budget setting exercise would be undertaken at a future PCCC meeting MAE expressed disappointment with an underspend with the Learning Disabilities (LD) Direct Enhanced Service (DES) and identified that it was of high importance that quality and outcomes were improved for people with LD. HG highlighted that there had been coding issues and added that practices codes for the LD DES had not been captured and that the practices had performed Primary Care Commissioning Committee Minutes 30/11/17 Page 11 of 13

230 better in LD healthchecks than what had been reported nationally. HG added that in terms of the budget, it needed to be identified whether this was a claiming issue as well as a coding issue. HG advised that a preliminary report on the issue would be brought back for the January PCCC RESOLUTION: The Committee noted the report. 11 Primary Care Quality Report 11.1 MAE introduced the Primary Care Quality Report which provided assurance to the Committee that quality and patient safety issues were given the appropriate priority and clear actions had been identified to address them. The report was taken as read MAE reported that there had been eleven reports sent via the National Reporting and Learning System (NRLS) since April 2017 with an increased frequency since September 2017 due to the Quality Team within the CCG raising awareness at Practice Managers meetings MAE acknowledged that the majority of quality alerts related to delays in accessing treatments and appointments but noted that this was due to Trakcare MAE provided an update on a Gloucestershire practice that had received a warning notice from a CQC inspection back in July 2017 and reported that the practice had received substantial support from the CCG including a mock CQC inspection MAE highlighted that there was a measles outbreak in the Stroud and Berkeley Vale Locality in September 2017 which was now tailing off. It had probably occurred due to a large group of children who had not had Measles Mumps and Rubella (MMR) vaccination. The outbreak resulted in six individuals requiring hospitalisation during the outbreak, two of whom have required critical care. MAE emphasised that the CCG had been working with GP practices to promote MMR vaccination AE identified that the lowest figure for vaccination was for the MMR 2 doses vaccination at 88.3%. He suggested that it would be helpful to understand the geography of the vaccinations. Primary Care Commissioning Committee Minutes 30/11/17 Page 12 of 13

231 11.7 MAE informed the Committee that there had been a drive to increase the intake of the influenza vaccinations and noted that more Primary Care staff required the vaccination. MAE identified that a new initiative was to be introduced which included a flu leaflet being attached to patient s repeat prescriptions to help increase awareness MAE advised that the GP Locum Education Event was recently held with over 70 Locums attending. It was noted that the content of the day included: safeguarding, basic life support and urgent care. MAE advised that this event was likely to be repeated JC requested that future Primary Care Quality Reports included the topics of the different Primary Care complaints that had been made which would help identify any trends. MAE reported that eleven complaints had been received from eleven different practices and there were not any common themes JD queried whether there was any data regarding the uptake of influenza vaccinations within schools. MAE advised that there was a Public Protection Board meeting in December where the data would be made available JD identified the possibility of incorrect information being provided on social media regarding influenza vaccinations and felt that the CCG needed to ensure that this was challenged. MAE agreed to take this to the Public Protection Board meeting RESOLUTION: The Committee noted the report. 12 Any Other Business 12.1 There were no items of any other business. The meeting closed at 12:23pm. Date and Time of next meeting: Thursday 25 th January 2018, 10:30am, in the Board Room, Sanger House. Minutes Approved by Gloucestershire Clinical Commissioning Group Primary Care Commissioning Committee: Signed (Chair): Date: Primary Care Commissioning Committee Minutes 30/11/17 Page 13 of 13

232 Agenda Item 17 Governing Body Meeting Date Thursday 29 March 2018 Title Executive Summary Key Issues Audit Committee Minutes The attached minutes provide a record of the Audit meeting held on the 19 December The following principle issues were discussed at the meeting: Internal Audit Update and reports from the following service areas: - Eye Health benefits review - Business Continuity progress update - Contract Management post payment verification External Audit Update Counter Fraud Update - Approval of the Accountable Officer Statement on Bribery - Approval of the Counter Fraud, Bribery and Corruption Policy Corporate Registers including Gifts and Hospitality QIPP Report Procurement Decisions Aged Debtor Report The Committee also received a report providing an overview of the work undertaken on risk management, reviewed the terms of reference and received the CSU report on internal controls. Risk Issues: Original Risk Residual Risk Financial Impact Not applicable Not applicable Page 1 of 2

233 Legal Issues (including NHS Constitution) Impact on Health Inequalities Impact on Equality and Diversity Impact on Sustainable Development Patient and Public Involvement Recommendation Author Designation Sponsoring Director (if not author) Not applicable None None None Not applicable The Governing Body is requested to note these minutes which are provided for information. Zoe Barnes Corporate Governance Support Officer Colin Greaves, Audit Chair Page 2 of 2

234 Audit Committee Minutes of the meeting held on Tuesday 19 December 2017 Biffen Room, Sanger House Members Present: Colin Greaves (Chair) CG Lay Member, Governance Alan Elkin AE Lay Member, Patient and Public Experience Dr Will Haynes WH GP Liaison Lead, Gloucester City Peter Marriner PM Lay Member, Business In Attendance: Andrew Beard AB Deputy Chief Finance Officer Lynn Pamment LP Head of Internal Audit, PWC David Johnson DJ External Audit Manager, Grant Thornton Cath Leech CL Chief Finance Officer Haydn Jones (Item 9) HJ Associate Director of Finance (Business Intelligence) Christina Gradowski CGi Associate Director of Corporate Governance Dominique Lord DL Internal Audit Manager, PWC Zoe Barnes ZB Corporate Governance Support Officer Jamie Cockayne JC Finance Trainee (shadowing AB) Marion Andrews-Evans MAE Executive Nurse and Quality Lead (Item 5.3) Andy Ewens (Item 5.3) AEw Emergency Planning, Resilience and Response Manager Vicky Roissetter (Item 9) VR Business Intelligence Finance Analyst 1. Apologies 1.1 Apologies were received from Dr Hein Le Roux (HLR). 1.2 CG confirmed that the meeting was quorate. 2. Declarations of Interests 2.1 WH declared an interest as a GP as he would have an interest in discussions pertaining to primary care. As this was a general interest, it was noted that no further action was required. GCCG Audit Committee Minutes 19 December 2017 Page 1 of 15