Welcome and Introductions. To receive questions from the Public in relation to items on the agenda Apologies for Absences: To

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1 Meeting Title East Leicestershire and Rutland Clinical Commissioning Group Governing Body meeting Date Tuesday 19 January 2016 Meeting no. 26. Time 9:30am 12:30pm Chair Dr Richard Palin (Chair) Venue / Location Leicester Racecourse and Conference Centre, Oadby, Leicester, LE2 4AL B/16/1 AGENDA ITEM ACTION PRESENTER PAPER TIMING Welcome and Introductions Dr Richard Palin 9:30am B/16/2 Patient Story Dr Richard Palin DVD 9:35am B/16/3 To receive questions from the Public in relation to items on the agenda Apologies for Absences: To B/16/4 receive To B/16/5 Declarations of Interest on Agenda Topics receive B/16/6 B/16/7 B/16/8 REPORTS B/16/9 B/16/10 FINANCE B/16/11 Minutes of the meeting held on 17 November 2015 Matters Arising: Update on actions from the meeting held on 17 November 2015 Notification of Any Other Business Chairman s Report Accountable Officer s Corporate Report Finance and Activity Committee summary report (December 2015) B/16/12 Finance Report: Month 8 GOVERNANCE Memorandum of Understanding with Public B/16/13 Health, Leicestershire County Council To receive Dr Richard Palin verbal 9:50am Dr Richard Palin verbal 9:55am All verbal 9:55am To approve Dr Richard Palin A 10;00am To receive Dr Richard Palin B 10:05am To receive To receive To receive Dr Richard Palin Dr Richard Palin Karen English verbal C D 10:10am 10:10am 10:15am To receive Alan Smith E 10:20am To receive To approve Donna Enoux Kiran Loi F G 10:25am 10:35am 1

2 B/16/14 B/1615 AGENDA ITEM ACTION PRESENTER PAPER TIMING NHS 111 Procurement - Joint Committee To Jane H 10:45am approve Chapman Summary report from the Audit Committee QUALITY, PATIENT SAFETY AND PERFORMANCE B/16/16 Quality and Performance Committee summary report (December 2015 and January 2016) B/16/17 B/16/18 Corporate Performance Assurance Report Provider Performance Assurance Group summary report (November 2015) STRATEGY AND COMMISSIONING Associated policies for IVF/ICSI: Gamete Cryopreservation and B/16/19 Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSU treatment) B/16/20 B/16/21 B/16/22 B/16/23 B/16/24 Listening and Engaging Strategy Transformational plan for mental health and wellbeing services for children and young people Locality Chairs Report: Oadby and Wigston Melton, Rutland and Harborough Blaby and Lutterworth Summary report from the Strategy, Planning and Commissioning Committee (October January 2016) Summary report from the Primary Care Commissioning Committee (December 2015 and January 2016) DATE OF NEXT MEETING B/16/25 The next meeting of the East Leicestershire and Rutland CCG Governing Body will take place on Tuesday 15 March 2016, at Leicester Racecourse and Conference Centre, Oadby, Leicester, LE2 4AL. To receive To receive To receive To receive To approve To approve To approve To receive To receive To receive Warwick Kendrick Dr Tabitha Randell Jane Chapman Warwick Kendrick Dr Richard Palin Carmel O Brien Donna Enoux Locality Chairs Dr Andy Ker Tim Sacks I J K L M N O P Q R 10:55am 11:00am 11:10am 11:25am 11:35am 11:45am 11:55am 12:05pm 12:20pm 12:25pm 12:30pm 2

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5 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP Minutes of the Governing Body Meeting held on Tuesday 17 November 2015 at 9:15am at Leicester Race Course, Oadby, Leicester, LE2 4AL Present: Dr Richard Palin Chairman Mr Clive Wood Deputy Chair / Lay Member Mrs Karen English Managing Director Dr Andy Ker Clinical Vice Chair Dr Nick Glover GP, Blaby and Lutterworth Locality Lead Dr Graham Johnson GP, Blaby and Lutterworth Locality Lead Dr Vivek Varakantam GP, Oadby and Wigston Locality Lead Dr Girish Purohit GP, Melton, Rutland and Harborough Locality Lead Dr Richard Hurwood GP, Melton, Rutland and Harborough Locality Lead Dr Hilary Fox GP, Melton, Rutland and Harborough Locality Lead Dr Tabitha Randell Secondary Care Clinician Mr Warwick Kendrick Independent Lay Member Mr Alan Smith Independent Lay Member Mr Tim Sacks Chief Operating Officer Mrs Jane Chapman Chief Strategy and Planning Officer Mrs Donna Enoux Chief Finance Officer Mrs Carmel O Brien Chief Nurse and Quality Officer Dr Tim Daniel Consultant Public Health In Attendance: Mrs Daljit K. Bains Mr Joe McCrea Mr Jim Bosworth Mrs Jayshree Raval Mrs Sue Staples Mrs Jennifer Fenelon Mrs Diane Eden Ms Kiran Loi Head of Corporate Governance and Legal Affairs Interim Head of Communications and Engagement Associate Director Contracting Corporate Affairs Officer (minutes) Healthwatch Leicestershire Healthwatch Rutland Deputy Chief Operating Officer (shadowing Chief Operating Officer) Public Health (shadowing Consultant Public Health) Members of the Public: there were no members of the public present. ITEM DISCUSSION LEAD RESPONSIBLE B/15/125 Welcome and Introductions Dr Richard Palin, Clinical Chair, welcomed all to the November 2015 meeting of the East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG) Governing Body. In particular, welcomed: Mr Clive Wood (Deputy Chair / lay Member) who joined the Governing Body at the end of October 2015; Mr Jim Bosworth; Mrs Diane Eden; and Ms Kiran Loi. 1

6 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE B/15/126 Patient Story Mrs Carmel O Brien Chief Nurse and Quality Officer introduced the patient story, which described how the patient managed her diabetes since been diagnosed from an earlier age. It was highlighted that the patient had a renal transplant in 2007 and described the recovery progress whilst managing diabetes. The patient praised the care received from secondary care but highlighted that after her renal surgery her GP was unable to prescribe the medications given by the hospital and therefore they had to be obtained from the hospital only. The patient story indicated how important it is to ensure continuity of care between primary and secondary care. In addition it was highlighted that the patients should be allowed to see their regular GPs in order to maintain continuity in the care provided. Dr Nick Glover, GP, Blaby and Lutterworth Locality Lead informed that at the recent medicines reconciliation audit meeting there was discussion around how to ensure the GP IT systems, EMIS web and SystmOne, are able to interact with one another which would allow GPs to see what medication the patients have had from the hospital and would be able to prescribe them. There was discussion around encouraging patients with diabetes to carry out regular monitoring using the blood monitoring machines. In response to Dr Richard Hurwood s query, Dr Graham Johnson, GP Blaby and Lutterworth Locality Lead informed that there are three preferred blood monitoring machines used in Leicestershire. Dr Hurwood to liaise with the medicines quality team to provide a list of the preferred machines which can be issued by the practices Dr Hurwood Dr Palin asked Mrs Carmel O Brien to convey thank you to the patient for sharing her story. It was RESOLVED to: B/15/127 B/15/ RECEIVE the report. To Receive Questions from the Public in Relation to Items on the Agenda There were no questions received from members of the Public. Apologies for Absence: There were no apologies for absence. 2

7 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE B/15/129 Declarations of Interest on Agenda Topics All GP members declared an interest in any items relating to primary care where a potential conflict may arise and also where there are any items concerning the Leicester, Leicestershire and Rutland Provider Arm where GP members are minor shareholders. Dr Richard Palin declared an interest in any item relating to Leicestershire Partnership Trust and also that a member of his family is currently receiving Continuing Health Care funding. B/15/130 Minutes of the Meeting Held on Tuesday 15 September 2015 The minutes of the meeting held on Tuesday 15 September 2015 (Paper A) were accepted as an accurate record of the meeting subject to the amendment on page 19 item B/15/122, sentence in the fourth paragraph to read, ELR CCG was considered good by NHS England with action to improve some financial governance arrangements.. It was RESOLVED to: B/15/131 - APPROVE the minutes of the previous meeting with the amendment highlighted. Matters Arising: Update on Actions from the Meeting held on Tuesday 15 September The action log (Paper B) was received and it was noted that all actions were complete. Mrs Jane Chapman informed that in relation to item B/15/111 the action was not for her to provide a copy but rather to link with Mr Alan Smith in respect of the EMAS figures. Mrs Chapman confirmed that she had contacted the contracts for them to provide the performance figures. It was RESOLVED to: B/15/132 B/15/133 - RECEIVE the matters arising. Notification of Any Other Business The Chairman had not received notification of any additional items of business. Chairman s Report Dr Richard Palin presented Paper C, which provided an overview and update on some of the key constitutional and strategic areas that affect the Governing Body, including the meetings that the Chairman has attended over the last month. Dr Palin drew attention to: 3

8 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE - The appointment of Mr Clive Wood, who has recently been appointed as the Deputy Chair and Lay Member with responsibility for patient and public involvement; - An update on Better Care Together appended to the report; and - Attendance at the University Hospitals of Leicester NHS Trust s (UHL) Annual General Meeting. It was RESOLVED to: - RECEIVE the contents of the report. B/15/134 Accountable Officer s Corporate Report Mrs Karen English presented Paper D, which detailed the key activities of the Executive Management Team (EMT) since the last meeting of the Governing Body in September Mrs English drew attention to: - CCG s Annual Assurance Letter 2014/15 as appended to the report received from NHS England; - The CCG s first quarterly review of 2015/16 under the new CCG Assurance Framework took place in October The feedback received from NHS England following this was positive; - The CCG continues its work on ensuring compliance with the equalities legislation and recently carried out an external verification process. Although a requirement, it was a valuable exercise. The external verifications process involved an external group of stakeholders reviewing the CCG s equalities information to ascertain a level of achievement. The levels of achievement are then compared to internal scoring. The exercise was valuable it demonstrated that although the CCG can evidence compliance there are further improvements to be made and an action plan has been compiled to support this. It was RESOLVED to: - RECEIVE the contents of the report. 4

9 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE B/15/135 Quality and Performance Committee Summary Report (October and November 2015) Dr Tabitha Randell, Independent Secondary Care Clinician and Chair of the Quality and Performance Committee presented Paper E, which provides a summary of the items for escalation from the Quality and Performance Committee for consideration by the Governing Body to ensure that the Governing Body is alerted to emerging risks or issues. Dr Randell highlighted the key areas of discussions from the meeting held on 13 October 2015: - A new LLR GP Practice Workforce and Delivery Group that has been set up over the last 7 months, which includes representatives from ELR CCG. - LLR Caldicott Log - was presented which highlighted a number of emerging themes. - Safeguarding Performance Quarter 1 Report - was presented, which informed the Committee about new / emerging health responsibilities and risks involved in meeting the requirements of local and national agendas to safeguard vulnerable people. - Performance Assurance Report - provided an overview of key performance areas for the CCG - Patient Group Directives (PGDs) - the following PGDs were approved: o Topical chloramphenicol for the prevention of infection secondary to corneal abrasion; o Topical chloramphenicol for the treatment of acute infective conjunctivitis. Dr Randell highlighted the key areas of discussions from the meeting held on 10 November 2015: - Complaint Process - a quarterly report was presented which provided an update on complaints received and handled during the quarter with themes and trends identified and how triangulation of the information was carried out. - Research and Development an update was provided in relation to research studies conducted within care homes. It was noted that the CCG was highlighted as the highest recruiter to portfolio research, primary care studies among Leicestershire, Leicestershire and Rutland Clinical Commissioning Groups (LLR CCGs), mainly due to the GENVASC study. - Performance Assurance Report, an overview of the performance for ELR CCG was provided. - QIPP Monitoring Dashboard - a report was provided on the ELR CCG s position against 2015/16 QIPP Plan 5

10 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE for month 5. - Primary Care Quality Dashboard - the Committee received the first cut analysis of the data which populate the dashboard. It was noted that there remains an outstanding piece of work across LLR which would agree escalation levels. - Medicines Management - a report on options to facilitate decision following request to commission increased access to controlled drugs during out of hours. An options paper was presented for point of prescribing (Optimise Rx and Scriptswitch) progression plan for consideration. A report outlining the rationale for selective recommendation of branded generics was presented with the aim of obtaining approval of the evaluation criteria. Dr Richard Hurwood, GP, Melton, Rutland and Harborough Locality Lead informed that at the Quality and Performance meeting it was agreed to carry out a deep dive exercise on Potential Years of life lost (PYLL) in conjunction with Public Health and look at specific areas. Mr Clive Wood, Deputy Chair/Lay Member queried on what a deep dive meant. Mrs Karen English, Managing Director explained what a deep dive was and the purpose behind carrying out one. Mr Alan Smith, Independent Lay Member, highlighted a point on QIPP schemes and informed that at the last Finance and Activity meeting it was noted that some of the QIPP schemes were not achieved. Mrs Donna Enoux, Chief Finance Officer, explained that a meeting is taking place to review the QIPP schemes and look at the ways of showing different analysis of QIPP highlighting where the QIPP is being met and where there are pressures. It was RESOLVED to: B/15/136 - RECEIVE the report Corporate Performance Assurance Report Mrs Jane Chapman, Chief Strategy and Planning Officer presented Paper F, which provides an overview of performance for East Leicestershire and Rutland CCG and LLR where data is available for September Mrs Chapman informed that the performance and planning cycle for 2015/16 guidance had been published by NHS England which ensures that service levels are maintained or 6

11 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE improved following local strategic intentions, and standards or targets are in place. It provides the focus for NHS England s Area Team assurance process during the year. The following areas were discussed: - Everyone Counts Dashboard, which contains the NHS Constitution indicators and a number of other targets/plans that needs to be achieved by the health economy. - Mrs Chapman referred to the information on page 3 of the report stating that as at September 2015, 23 out of 55 indicators monitored failed (red) and 8 are RAG rated amber. - Mrs Chapman highlighted that 6 indicators which have changed their RAG rating are as following: a) Cancer 31 day wait have changed from amber to green. b) Cancer 31 day for surgery changed from amber to red. c) NHS 111 calls answered within 60 seconds is amber. d) NHS 111 calls abandoned after seconds is green. Mrs Jane Chapman talked through the RTT non-admitted data highlighted on page 4 of the report in detail and also went through the EMAS indicators. In response to Dr Graham Johnson s query on the nationally mandate target for Cancer waiting times, Mrs Chapman informed that the issue is with endoscopy wait which is added to the active waiting times. University Hospitals of Leicester (UHL) have now started looking into the low levels of planned procedures, which was not done before. Dr Graham Johnson informed that the report does not provide assurance in terms of the performances against cancer waits. Mrs Chapman informed that the way information has been produced reflects the historic way of working, however she assured that a new member of the team who is recently appointed will be revising the reports and will be producing a more succinct reports in the future. Dr Vivek Varakantam, GP, Oadby and Wigston Locality Lead added that UHL is working hard to resolve issues around the waiting times and actions are being taken, however it is pertinent that time is allowed for actions to be embedded. Mrs Karen English, Managing Director, informed that the CCG 7

12 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE is looking at commissioning endoscopic services from other healthcare providers in order to reduce the backlogs. She informed that the issue is around workforce as not many staff are trained in endoscopy. Mrs Jennifer Fenelon, Healthwatch Rutland informed that the figures highlighted for cancer is not new and pleaded that some actions are taken to improve the situation and performance around cancer waiting times. Dr Richard Palin, Chair reassured Mrs Fenelon that actions are being taken to improve the situation. Mrs Carmel O Brien, Chief Nurse and Quality Officer asked the board members if anyone felt that they could support Dr Varakantam at the Cancer Board meetings then it would be useful and to liaise directly with Dr Varakantam. It was RESOLVED to: - RECEIVE the report B/15/137 Provider Performance Assurance Group Summary Report (September and October 2015) Mr Warwick Kendrick, Independent Lay Member, presented Paper G, which provides assurance to the Governing Body through the Provider Performance Assurance Group (PPAG) of the collaborative contracts and the respective providers performance. Mr Kendrick highlighted the key areas of discussions: - A review on the effectiveness of PPAG took place and the purpose was to reaffirm the assurances with responsibility for action where performance consistently missed targets remaining with the CCG Boards. - Future PPAG reports to include deep dives on areas identified and to make greater use of the exception report. - Cancer - PPAG raised concerns regarding the 62 day back log still not being reduced - It was noted that the outcome of the Board to Board meeting with Leicestershire Partnership Trust (LPT) was not clear as no minutes had been produced. PPAG was therefore not sufficiently assured that concerns relating to staffing issues and data quality were being addressed appropriately. - PPAG would review the situation in three months time with a view to scheduling another Board to Board meeting with LPT and agree prior on the meeting expectations which are set out clearly and articulated 8

13 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE with an agenda. - CNCS, the Care Quality Commission (CQC) will be revisiting to review progress. Mrs Karen English, Managing Director informed the board members that a deep dive was carried out on EMAS in September 2015 and PPAG was assured of the actions taken driven by the deep dive. There was general discussion around the reporting styles of the PPAG reports and the narrative included within the reports. It was noted that future reports from PPAG will evolve as the PPAG meetings evolve. Mrs Sue Staples, Healthwatch Leicestershire highlighted that Public Health does have concerns with regards to the data produced by LPT and queried on how this was being monitored in terms of ensuring that the data is accurate. Dr Graham Johnson informed that actions have been taken to work with LPT to ensure data issues are addressed. Mrs English added that the contract square leads are engaging with Internal Auditors to provide data and are working with LPT to target the key areas to get assurances to support the monitoring of the contract. In addition LPT is being supported with new IT systems. It was RESOLVED to: - RECEIVE the report. B/15/138 Locality Chair s Report: Locality leads presented Paper H, which provides an overview of the monthly GP Locality meetings held across Blaby and Lutterworth, Oadby and Wigston and Melton, Rutland and Harborough. These meetings are key to the CCG development and allow member practices an opportunity to debate current general practice and highlight themes they wish to inform the Governing Body. Oadby and Wigston Locality: Dr Vivek Varakantam Dr Varakantam drew attention to: - Federation/Joint Working - Assurances were given that the aim from the federation point of view would be to protect practices services. The group were keen to hear more from the working group. - Prescribing Spends - Medicines Quality Team presented current prescribing spend position for the CCG and the Locality. Nationally there have been 9

14 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE increases to prices but locally they have seen significant increases. - 7 Day Working - GPs were asked for their expressions of interest over the 7 day working pilot and there was a lot of discussion around the benefits and the longer term solution. GPs were not keen to participate at this stage in a pilot but suggestions were put forward for the federation to look into different models. Melton, Rutland and Harborough Locality: Dr Richard Hurwood Dr Hurwood drew attention to: - GP Federation Working Group - the Locality received an update presentation from Dan Markovic on behalf of the ELR GP Federation Working group which was received very well by the attendees. - The death of Lord Kilpatrick, a former Dean of Leicester Medical School and President of the GMC marked his enormous contributions to medical education, particularly in the field of General practice. - Prescribing Financial Update - Medicines Management presented to the group the Prescribing Financial Update which detailed the forecast overspend in Prescribing and the proposed action plan for the CCG and practices to undertake Blaby and Lutterworth Localities: Dr Nick Glover Dr Glover drew attention to: - Prescribing Overspend Update - Medicines Quality gave a presentation to the group on the current overspend on the prescribing budget. The group expressed concerns of community pharmacies over ordering of drugs and advised action to be taken by the CCG - QIPP- the locality was asked to contribute ideas for services to help inform the commissioning intentions for 2016/17. - Blaby District Council Quarterly update The group noted the good work being done, especially relating to delayed discharges at LRI and Glenfield. It was noted that the Lightbulb project was going well although the evaluation of the project was being held back by many change over staff and lack of data from LPT. - Federation Workgroup Presentation - by Dr Nanesh Chotai presented the work carried out by the steering group towards a single ELR CCG Federation. 10

15 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE - Cancer Referral pathway There was discussion around the importance of using PRISM for cancer 2WW referral forms and rapid referral guidelines for this pathway as the locality expressed concerns over the length of waiting time of urgent referrals was taking and felt there was a need for these to have a defined upper waiting time limit. It was RESOLVED to: B/15/139 - RECEIVE the report Better Care Together (BCT) and intensive community support Mr Jim Bosworth, Associate Director Contracting presented Paper I, which sets out a vision to improve health and social care services across LLR from prevention and primary care through to acute secondary and tertiary care. Mr Bosworth informed that successful delivery of this programme will result in greater independence and better outcomes for patients and service users, supporting people to live independently in their homes and out of acute care settings. Mr Jim Bosworth informed that the vision set out by the programme is in line with the strategic direction set out by NHSE s Five Year Forward View, and responds to the challenge set out more widely in A Call to Action, delivering sustainable clinical change at a time of growing financial pressure. Mr Jim Bosworth explained that a business case has been presented to Collaborative Commissioning Board (CCB) proposing to expand and enhance Leicestershire Partnership Trust (LPT s) existing intensive community support (ICS) service in stages over the next 18 months. Mrs Jane Chapman, Chief Strategy and Planning Officer, commented that this paper mirrors what has been outlined in the Community Services Model which was presented at the last meeting of the Governing Body. Mr Jim Bosworth informed that the ICS service provides a rehabilitation service to promote independence and recovery for frail older people in the environment that they are most familiar with (i.e. their own home). The multidisciplinary service is advance nurse practitioner led, with medical input from the patient s GP as required. The service aims to prevent or reduce the need for permanent or long term care packages, by 11

16 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE promoting, supporting and encouraging self-management. There was a discussion around the business case and that it is vital to consider what IT systems would be available to ensure that there is seamless communication between Primary and Secondary care. Mr Bosworth informed that the paper in this current stage recommends Clinical Commissioning Groups (CCGs) to support the strategic direction proposed and support the initial phase of additional ICS beds. It was RESOLVED to: - RECEIVE the report and SUPPORT - the strategic direction proposed and the initial phase of additional ICS beds. B/15/140 Summary report from the Strategy, Planning and Commissioning Committee (September 2015 and October 2015) Dr Andy Ker Clinical Vice Chair presented Paper J, which provided a summary of key areas of discussion and outcomes from the Strategy, Planning and Commissioning Committee (SPCC) held in September and October Dr Ker drew attention to: - Community Stroke and Neurology Rehabilitationthe operational staffing implications of the proposed reconfiguration of existing stroke and neurology rehabilitation services were noted for further consideration by the Collaborative Commissioning Board (CCB) - Domiciliary Therapy Provision - cost effective solutions to address the backlog of 314 patients for physiotherapy and occupational therapy were being explored with Leicestershire Partnership Trust (LPT) and a clear plan with timescales will be drafted for consideration at the next SPCC meeting. Mrs Carmel O Brien, Chief Nurse and Quality Lead queried if patients were harmed whilst on the waiting list for physiotherapy and Occupational Health therapies. Dr Richard Hurwood explained that the patients did not come to any harm as for some the needs had changed from when they were initially referred into these services and therefore were seen through other pathway. Mrs Carmel O Brien informed that it would be useful to have a summary on this matter at future SPCC meeting. 12

17 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE It was RESOLVED to: - RECEIVE the report B/15/141 Summary report from the Primary Care Commissioning Committee (October and November 2015) Mr Tim Sacks, Chief Operating Officer, presented paper K, which provided summary of the key themes and issues from the Primary Care Commissioning Committee meetings held in October and November Mr Sacks highlighted key areas of discussions: - Primary Care Estates Review - Proposed process for undertaking a primary care estates review across all GP Practices within the CCG during 2015/16, which will include criteria used to assess the standards of GP premises. - It was agreed to undertake a premises review to include practice opinions / self-assessment, full premises data analysis, demographic growth, housing and CCG strategic direction. - 7-day Services in Primary Care Pilot Review and Next Steps - Following the agreement to expand the existing ELR 7day Working Pilot to a further areas, a draft 7-Day Working Practice Guide for 2015/16 was presented, which was based on the model used by the pilot Practices and approved, subject to minor changes. The updated version has been presented to Locality meetings in November 2015 and disseminated to all Practices. - Primary Medical Services (PMS) and Premium and Funding Differential Review (FDR) Reinvestment Options for 2016/17 -In line with guidance set by NHS England, the proposed options to reinvest the PMS and FDR monies back into general practice for 2016/17 were presented and reviewed. - It was agreed to approve Option 3 (CCG Priority Work streams annual funds released on a fair share basis by Practice (or groups of), to deliver specific services stipulated by the CCG - ELR CCG GP Federation: High Level Plan - The Committee received an update on the progress of the CCGs approach to support the development and implementation of GP Federations in 2015/16; and a draft ELR GP Federation Ltd: High Level Plan , which has been developed by the Federation - 75% of the GP practices have agreed to join the future ELR CCG GP Federation 13

18 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE Mr Tim Sacks acknowledged the hard work put in by Mr Jamie Barrett, Head of Primary Care in the engagement process with the GP practices and conveyed a massive thank you for the results obtained. It was RESOLVED to: - RECEIVE the report B/15/142 Annual Report from the Audit Committee Mr Warwick Kendrick, Audit Committee Chair, presented Paper L and informed that the Audit Committee is required to produce and present an Annual Report to the Governing Body which contains an overview of the principal areas of review and demonstrates how the Committee has discharged its responsibilities and met its terms of reference. This Annual Report for the CCG s Audit Committee covers the period 1 April March The report was reviewed by the members of the Audit Committee at the meeting in September 2015 and the content agreed. The report was received and noted. It was RESOLVED to: B/15/143 - RECEIVE the report Summary Report from the Audit Committee and terms of reference Mr Warwick Kendrick, Audit Committee Chair, presented Paper M and highlighted key areas of discussion during the September 2015 meeting of the Audit Committee, minutes for this meeting will be presented to the Governing Body at its next meeting. Mr Warwick also highlighted that the Committee terms of reference had been reviewed by the Counter Fraud Specialist following the publication of the NHS Protect Standards and the terms of reference were updated to reflect the reference to the new standards. The revised terms of reference were agreed by the Committee, the Committee requests that the Governing Body approve the amended terms of reference as at Appendix 2 of the report. It was RESOLVED to: - RECEIVE the report; and - APPROVE the revised terms of reference for the Audit Committee. 14

19 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE B/5/144 Emergency Preparedness Resilience and Response Core Standards update Mr Tim Sacks, Chief Operating Officer, presented Paper N. It was noted that the CCGs are required to review their emergency preparedness, resilience and response (EPRR) preparedness and compliance against the EPRR core standards on at least an annual basis. Mr Sacks informed that he and Mrs Daljit Bains had been working on the actions required and the report provides an overview of the current CCG assessment against the standards and areas where further work is required to achieve compliance. It was noted that the actions will be reviewed by the Executive Management Team and collectively across the three Leicester, Leicestershire and Rutland CCGs to ensure resilience of response and uniformity of approach. The Governing Body noted positive progress made. It was RESOLVED to: - RECEIVE the report; and - APPROVE the assessment against the EPRR standards. B/15/145 East Leicestershire and Rutland CCG s Vision and Values Mrs Carmel O Brien, Chief Nurse and Quality Officer presented Paper O, which introduced the proposed refresh of the ELR CCG Values. Mrs Carmel O Brien informed that following the publication of the Freedom to Speak Up report in February 2015 by Sir Robert Francis, which included a number of recommendations focussed on creating open and honest cultures in NHS organisations, staff undertook a piece of work to refresh the CCG values, ensuring that they are truly reflective of this vision. The paper presented the background to this piece of work, and the proposed set of values to be adopted by the CCG. ELR CCG formed the Freedom to Speak Up Steering Group and a Staff Focus Group to address the issues identified in the Freedom to Speak Up report. Mrs Carmel O Brien informed that at the July 2015 CCG Time Out event a session was facilitated with staff groups to review the values and asked if the time was right to review them as 15

20 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE part of the Freedom to Speak Up action plan. The majority view was to develop a new set of values. The CCGs new values which are being proposed are: - One Team we are at our best when we work together - Integrity we act in the way we would want to be treated and are aware of our personal impact on others - Patient-centred patients at the heart of everything we do - Ownership - we do what we say and take personal responsibility - Excellence we strive to be the best we can be Dr Nick Glover, GP, Blaby and Lutterworth Locality Lead commented on one of values highlighted on page 4 of the report for NHS England, which is different from ELR CCG as being Compassion. Mrs Sue Staples, Healthwatch, Leicestershire commented on how the values would be communicated down especially Patient-centred patients at the heart of everything we do value. Mrs Carmel O Brien informed that launch of the new values will take place at the December 2015 Timeout day and thereafter communicated. It was RESOLVED to: B/15/146 - APPROVE the report Finance and Activity Committee Summary Report Mr Alan Smith Independent Lay Member provided a verbal update on Finance and Activity Committee held November Mr Smith drew attention to the ELR CCG s financial position as being on track, however the contingency is committed in full at the year-end and therefore it does not allow for any unexpected pressures. Mrs Donna Enoux, Chief Finance Officer explained the reason why the contingency is committed in full at the year- end which is due to the 1.2m accruals recognised from 2014/15 accounts. - It was RESOLVED to: - RECEIVE a verbal update 16

21 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE B/15/147 Finance Report: Month 6 Mrs Donna Enoux, Chief Finance Officer, presented Paper P which provides an update on the 2015/2016 year to date and forecast outturn financial position at Month 6 for East Leicestershire and Rutland Clinical Commissioning Group (ELR CGG). Mrs Enoux drew attention to: - Revenue Allocations - The overall allocation for ELR CCG at Month 6 is 399,148k which is the same as at month 5. The current allocations / movements are detailed within Appendix A. - Financial Performance - The budget statement detailing performance against the budget as at 30 September 2015 was provided within Appendix B; which reflected a control total surplus of 1,788k at month 6 and 3,576k at year end which is in line with the financial plan - Acute Commissioning - at month 6, year to date spend for UHL is 64.9m, an overspend of 1.0m against the year to date budget, based on month 5 activity data, driven by over-performance on elective day cases and in-patients, out-patient procedures, A&E and Emergency. The forecast outturn position reflects an overspend of 1.5m against an annual budget of 129.3m, due to anticipated continued overperformance in these areas offset by QIPP schemes phased into the latter months of the year. - The forecast outturn position reflects an overspend of 2.0m against an annual budget of 170.7m, due to anticipated continued over-performance at UHL ( 1.5m). Out of County contracts are expected to overspend by 0.6m, due mainly to continued over-performance at Nottingham University Hospitals and Peterborough and Stamford Hospitals, but this is partly offset by an expected under-performance of 0.2m within Independent Sector contracts and QIPP schemes phased into the latter months of the year. - GP Commissioning - additional Primary Care budgets totalling 40,141k have been delegated to the CCG from NHSE as of 1st April (A net budget of 39,153k is modelled in Appendix B as the delegated budget of 988k for the Oadby Walk In Centre is recorded within the Minor Injury Unit budget) - At month 6, spend is 296k below budget, with a forecast to be 593k below budget for the full year. NHS England still has to transfer the Primary Care 17

22 Paper A East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE Transformation budget to CCGs (circa 250k) although this will be partially offset by a national top slice and an adjustment in relation to Lincolnshire Prescribing budgets. Mr Alan Smith, Independent Lay Member commented that at the recent Finance and Activity meeting there was some confusion around the allocation of the additional funding for primary care from NHS England. Mr Tim Sacks, Chief Operating Officer explained how the funding was been allocated after having discussions with NHS England. It was RESOLVED to: - RECEIVE the contents of the report. B/15/148 Date of next meeting The next meeting of the East Leicestershire and Rutland CCG Governing Body will be take place on Tuesday 19 January 2016 at Leicester Race Course, Oadby, Leicester, LE2 4AL 18

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25 Paper B East Leicestershire and Rutland Clinical Commissioning Group Governing Body Meeting 19 January 2016 NHS EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Key ACTION NOTES Completed On-Track No progress made Minute No. B/15/126 Meeting Item Responsible Officer 17 November 2015 Patient Story Richard Hurwood Action Required Dr Hurwood to liaise with the medicines quality team to provide a list of the preferred machines which can be issued by the practices To be completed by January 2016 Progress as at January 2016 Dr Hurwood to provide a verbal update at the meeting. Status AMBER 1

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28 Paper C East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 19 January 2016 Introduction Chairman s Report 1. The purpose of this report is to provide an overview and update of some of the key constitutional or strategic areas that affect the Governing Body and meetings that I have attended since my last report in November. Appointment of Lay Member with responsibility for financial oversight 2. Following an appointment process, I am pleased to announce that Mr Alan Smith has been re-appointed for a further 3 years from January 2016 to the position of lay member with responsibility for financial oversight. 3. Mr Smith will continue to have a key role in the oversight and assurance of financial oversight; in particular he will continue to chair the Finance and Activity Committee. Better Care Together update 4. An update on the Better Care Together programme is appended to this report. The report summaries progress to date and key risks and issues. Commissioning Collaborative Board 5. I attended the Commissioning Collaborative Board (CCB) meeting on 26 November 2016 when items discussed included: Urgent Care including the Emergency Department Recovery Plan and Vanguard Value Proposition, presented by Mr Toby Sanders (Managing Director, West Leicestershire CCG); Intermediate Care Pathway 3 Discharge to Assess, Non Weight Bearing and Reablement Pathways, presented by Mrs Jane Chapman (Chief Strategy and Planning Officer, East Leicestershire and Rutland CCG); Proposal for establishing East Midlands Affiliated Commissioning Committee to provide a formal way of agreeing joint commissioning policies between the 20 East Midlands CCGs, presented by Mrs Sue Lock (Managing Director, Leicester City CCG); and Transformational Plan and implementation plan for the Mental Health and Wellbeing of Children and Young People, presented by Mrs Dawn Leese (Director of Quality and Chief Nurse, Leicester City CCG). Dr Richard Palin Chairman 1

29 St. Luke s Hospital Development Paper C East Leicestershire and Rutland CCG Governing Body meeting 19 January We know that the people of Market Harborough have been waiting for this new facility to be built and I was delighted to be on site at St Luke s on 30 November 2015 to see the work starting. We are looking forward to seeing this brand new, state-of-the-art health facility come to fruition where local people will be able to access a wide range of high quality health services in a safe, fit-for purpose environment UHL Risk Summit 7. As Karen s report details, there was a Risk Summit held on 18 December 2015 following the recent Care Quality Commission visit to the Emergency Department at University Hospitals of Leicester NHS Trust. I was pleased to be there as a General Practitioner and to represent ELR CCG Quarter 2&3 Checkpoint Meeting 8. This meeting held last week with NHS England allowed the CCG to discuss our achievements and challenges including our 5 Year Strategy, finance and QIPP and clinical outcomes. Initial feedback from the area team was positive. Recommendations The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the contents of the report. Dr Richard Palin Chairman 2

30 Update for Partner Boards Status Report October 2015

31 Update for Partner Boards October 2015 Progress Report Pre-Consultation Business Case (PCBC). The PCBC, which sets out the need for the programme, describes the future model of care, gives details of pre-consultation engagement, and makes the case to commence public consultation, is now complete. Better care together (BCT) Delivery Board agreed on 12 th October 2015 to issue it to partner Boards for their consideration. Equality Impact Assessment (EIA). The programme s engagement with, and understanding of impact and mitigation for people with protected characteristics has been captured in the Equality Impact Assessment. This forms part of the PCBC and will be further developed iteratively as the proposals are refined. PPI review of PCBC. The PPI Assurance Group will consider the PCBC in two sessions during mid-october. Assurance of plans by NHS England (NHSE). The PCBC will be issued to NHSE in mid-october for assurance prior to public consultation targeted from 30 th November Clinical senate. The peer review of the plans by clinical senate concluded on 29 th September The senate panel are preparing their final report for consideration by clinicians developing the programme. Clinical summits. Workstream-specific clinical summits are underway, and to enable a greater number of staff across partner organisations to engage with the programme, staff engagement events entitled overview summits will take place on 27 th October and 3 rd November. Those in line management and practitioner roles across health and social care are particularly encouraged to attend; places can be booked by contacting Shelpa Chauhan at shelpa.chauhan@leicspart.nhs.uk. PPI Assurance Group Chair. Ballu Patel will be acting as Interim PPIAG Chair following the imminent departure of Jennifer Fenelon, who is stepping down as Chair to focus on her Healthwatch work. A substantive Chair is to be appointed. Internship scheme. The programme warmly welcomes recent graduates from the University of Leicester Lauren, Nazar and Stuart, who have recently started as interns for a 12-month period, providing support to the workstreams.

32 Update for Partner Boards October 2015 Supporting information Top Two Risks and Issues Risk or Issue Update Status Key Programme Milestones Milestone Target Date RAG Workforce: There is a risk that sufficient staff cannot be recruited or retained to fulfil the needs of the new operating models The draft workforce strategy was presented at Partnership Board on 17 th September Implementation planning is in progress. Red Consultation narrative prepared, including location perspective Business justifications for delivery of outcomes agreed September 2015 September 2015 Funding for 2016 to 2018 delivery agreed September 2015 A G G Organisational cultures: There is a risk that organisational cultures do not develop in line with the vision of the programme and changed ways of working fail to become embedded The OD programme for 15/16 has been agreed by CLG and the Partnership Board. Clinical summits to increase engagement are underway. The level of engagement has been good. Red Clinical Senate review Issuing of PCBC to NHS England NHS England and TDA agreement to proceed to Consultation August & September 2015 Mid-October 2015 November 2015 G G Not started Formal Consultation November 2015 Not started

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35 Paper D East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 NHS EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 19 January 2016 Introduction Accountable Officer s Corporate Report 1. This report sets out to the Governing Body some of the key activities the Executive Management Team (EMT) and I have been involved in since the last meeting of the Governing Body in November CCG quarterly assurance meetings 2. NHS England carried out its 2015/16 quarter 2 review of the CCG s performance against the CCG Assurance Framework on 12 January The feedback received from NHS England during the meeting was positive. It was noted that the CCG is facing a challenge in the achievement of some constitutional standards, for instance the cancer targets; however it was acknowledged that the CCG continues to improve and that NHS England is confident in our approach to improve. Delivering the Forward View: NHS Planning Guidance 2016/ /21 3. NHS England published its planning guidance, Delivering the Forward View: NHS Planning Guidance 2016/ /21, in December The guidance can be found at the following link The guidance sets out a list of national priorities for 2016/17 and longer-term challenges for local systems, together with financial assumptions and business rules. 4. The guidance requires that two separate but connected plans are produced: a) A five year Sustainability and Transformation Plan (STP), place-based (unit of planning e.g. Leicester, Leicestershire and Rutland) and driving the Five Year Forward View; and b) A one year Operational Plan for 2016/17, organisation-based but consistent with the emerging STP. 5. Whilst developing long-term plans for 2020/21, the NHS has a clear set of priorities for 2016/17 and must-do s, which includes the progress in improvement against NHS Constitution Standards. 6. The CCG is working on the requirements detailed in the planning guidance and will update the Governing Body via the Strategy, Planning and Commissioning Committee on progress. Karen English 1 Accountable Officer

36 Paper D East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 Summary of NHS England / NHS Trust Development Authority Risk Summit for University Hospitals of Leicester NHS Trust 7. On Friday 18 December 2015, the Trust Development Authority (TDA) and NHS England hosted a risk summit for University Hospitals of Leicester NHS Trust (UHL) regarding its Accident and Emergency Department. 8. Attached is the summary (Appendix 1) of the key areas of risk that triggered the risk summit and the areas identified for consideration and discussion. Long Street Surgery 9. The CCG has been working closely with Long Street Surgery since formation in 2011/12. Clinical, managerial and financial support has been given to help with a number of issues that had been raised by the PCT and subsequently NHS England. 10. In April 2015 the Care Quality Commission (CQC) inspected the Practice and graded it as inadequate. This report was formally published in October A further CQC visit took place in December 2015 and a number of significant concerns were a raised. The outcome was that the CQC requested from the Magistrates Court that the two GP partners be removed from the Long Street Surgery contract. 11. The CCG put in place care taking arrangements to ensure patient care continued; this remains in place and a decision on the long term solution will depend on the outcome of the appeal being heard by a judge in late January The CCG will ensure that whatever the courts decision, safe, high quality care, will be available for all of the patients of Long Street surgery. PUBLICATIONS 12. Publications and updates published by NHS England via its fortnightly newsletter Bulletin for CCGs can be found at the following The Executive Management Team undertakes a regular review of the content of the Bulletin and ensure actions are taken accordingly. Assurances and updates are reported through to the Governing Body as evident on the agenda and through updates in the Accountable Officer s report. Recommendation The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the contents of the report. Karen English 2 Accountable Officer

37 Summary of NHS England / NHS Trust Development Authority Risk Summit for University Hospitals of Leicester NHS Trust Background Risk summits are a tried and tested approach to understanding and mitigating risks within the health community. They aim to address potential or actual service quality problems which may mean a provider is failing to meet the essential standards of quality and patient safety. Such problems may relate to a specific service or be indicative of more serious and systemic problems within a provider organisation. A risk summit may be triggered in a number of ways. It could be the result of regular performance and quality reviews between the provider and commissioners, an external regulator (such as the Care Quality Commission or Monitor) or from concerns raised by staff, patients or other parties. When a risk summit is held, it brings together representatives from the provider organisation, commissioners, key clinical leaders, and other regulatory and stakeholders to explore and understand the issue. Together they agree what interventions, if any, may be necessary to ensure patient safety and quality can be guaranteed in the short, medium and longer term, and whether further risk summits are required. Action On Friday 18 December 2015, the Trust Development Authority (TDA) and NHS England hosted a risk summit for University Hospitals of Leicester NHS Trust (UHL) regarding its Accident and Emergency Department. The key areas of risk that triggered the risk summit were: Patient triage and risk assessment within the Emergency Department Competence of staff undertaking clinical assessment in the Emergency Department Management and escalation of the deteriorating patient within the department, including patients who trigger for the Systemic Inflammatory Response Syndrome (SIRS) criteria Delayed ambulance handovers at the Emergency Department. All key partner agencies were represented at the summit. Outcomes The risk summit identified a number of areas for consideration and discussion: demand; ambulance handover; quality governance; workforce; management of sepsis; and paediatric assessment.

38 It was agreed that a range of actions are already being undertaken both by UHL and across the LLR health system, and progress has been made. Some further actions were identified; some of these were for UHL individually, others in association with health partners (such as the TDA, Care Quality Commission, East Midlands Ambulance Services NHS Trust and the Leicester, Leicestershire and Rutland System Resilience Group), and some for individual NHS organisations attending the risk summit. These included: Demand The System Resilience Group to clarify the pace and impact of the system actions currently being undertaken. Ambulance handover UHL in association with the TDA and EMAS to address the issues leading to handover waits, including ensuring effective use of the current workforce. Quality governance UHL to detail its improvement work, including the quality dashboard and internal escalation process. The Clinical Commissioning Groups (CCGs) to review their early warning systems to ensure these are used in the most effective way. Workforce UHL to update on its internal workforce management plans. Management of sepsis UHL fully to implement the pathway consistently across the whole Trust. Paediatric assessment UHL to continue with the steps it is taking to deliver a standard and effective triage process, particularly in paediatrics. Those tasked with actions will report back to the TDA and NHS England prior to a follow-up risk summit to be held at the end of January. An oversight group already set up by the CCGs, TDA and UHL would monitor progress prior to the follow-up risk summit. A reactive line in case of any media enquiries has been prepared by NHS England and shared with the partner agencies. (Ends) gg/

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41 Paper E East Leicestershire and Rutland CCG Board meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Front Sheet REPORT TITLE: Finance and Activity Committee Summary Report of the Committee meeting 8 December 2015 MEETING DATE: 19 January 2016 REPORT BY: PRESENTER: Colin Groom, Deputy Chief Finance Officer Alan Smith, Finance and Activity Committee Chair PURPOSE OF THE REPORT: This report provides a summary of the key items discussed at the East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG) Finance and Activity Committee meeting held on 8 December 2015 and provides assurance to the Board over the level of review and challenge provided by the Committee of financial and other reporting as well as forecasting. RECOMMENDATIONS: The ELR CCG Governing Body is requested to: Receive for information the contents of the report, and take assurance from the review and challenge provided by the Committee. REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of Improve integration of local services between life for people with long-term conditions health and social care; and between acute Improve the quality of care clinical effectiveness, safety and patient experience Reduce inequalities in access to and primary/community care. Listening to our patients and public acting on what patients and the public tell us. Living within our means using public money healthcare effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that the financial reporting underpins the commissioning strategy and priorities of the CCG. The commissioning strategy and priorities have and continue to be equality impact assessed as the strategy is reviewed and refreshed and this includes the financial plans. This completes the due regard required. 1

42 Paper E East Leicestershire and Rutland CCG Board meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 19 JANUARY 2016 Introduction Finance and Activity Committee Summary Report 1. This report provides a summary of the key items discussed at the Finance and Activity Committee meeting held on 8 December 2015, the assurance the Committee has received on matters that it had considered and the level of risk currently included within the financial forecast for the year. Summary of the meeting 2. The meeting was quorate, approved the minutes of the meeting on 10 November 2015 (subject to minor noted revisions) and reviewed the progress and actions taken from previous meetings. 3. The Committee received and reviewed the financial update for month 7 (October 2015) The overall revenue allocation for ELR CCG at month 7 was 399,299k The performance against budget as at 31 October 2015 reflects a control total surplus of 2,086k at M7 and 3,576k at year end which is in line with the financial plan 3.3. Adjusting for the effect of non-recurrent allocations and expenditure, the underlying position for the CCG is forecast to be a surplus of 4,163k for the year 3.4. Acute Commissioning year to date overspend was 1,594k of which 1,057k related to UHL overperformance and 364k related to out of County providers. Forecast overspend was 2,080k of which 1,439k related to UHL and 493k related to out of County providers Non Acute Commissioning year to date underspend was 1,187k including an overspend of 110k with LPT and underspends on EMAS ( 128k), Children s Complex Care ( 167k), Continuing Healthcare ( 320k), Mental Health ECRs ( 283k), LD Pooled Budgets, Reablement and Partnerships ( 198k). Forecast underspend was 939k including an overspend of 277k with LPT and underspends on Children s Complex Care ( 286k), Community Equipment ( 150k), Mental Health ECRs ( 550k), LD Pooled Budgets, Reablement and Partnerships ( 339k). 2

43 Paper E East Leicestershire and Rutland CCG Board meeting 19 January Practice prescribing year to date overspend was 1,124k. Forecast overspend was 1,501k including the projected impact of the refreshed QIPP programme GP Co-Commissioning year to date underspend was 407k with a forecast underspend of 697k 3.8. Other Primary Care services is forecast to overspend by 104k by year end but year to date underspend was 28k as a number of the expenditure items are payable later in the year Miscellaneous including reserves year to date underspend was 909k with a forecast underspend of 2,048k supporting the forecast overspend areas highlighted above Running costs year to date underspend was 187k but due to the filling of certain vacancies and the inclusion of costs relating to the relocation to County Hall, the forecast outturn was breakeven Capital expenditure was confirmed as 50k with a forecast of 712k by year end, the majority of which being 532k of medical equipment purchases supporting the UHL Alliance. The Committee noted that Project Initiation Documents (PIDs) are currently being prepared for submission to NHS England The financial update confirmed the CCGs continued compliance against the Better Payments Practice Code, (over 99% of all invoices paid within 30 days against a target of 95%) and the timely reconciliation of all control accounts and completion of other relevant KPIs by Arden and Gem CSU The update confirmed that the CCG had breached its requirement to hold no more than 1.25% of its monthly cash draw down (main funding received from Department of Health) The target was to hold no more than 315k at 30 October 2015 and the CCG held 376k due to an intended payment of 198k scheduled for the end of the month not being transacted. The CCG has agreed additional checks with the CSU in its month end payment processes to ensure this cannot occur again The update detailed the year to date Statement of Financial Position and Cash flow statement The update detailed the main risks to the delivery of the CCGs financial targets; UHL over performance Out Of County and Independent Sector provider over performance LPT Mental Health Rehabilitation Bed charging between local CCGs Prescribing increased growth Running Cost allocation overspend 3

44 Paper E East Leicestershire and Rutland CCG Board meeting 19 January Additional requests for Winter Funding schemes Additional requests for non-recurrent transformational funding (BCT) Non achievement of QIPP schemes 4. The Committee received reports detailing the QIPP plan and performance and the latest iteration of the proposed QIPP programme The QIPP target for totals 8,081k with a further 285k Primary Care delegated budget QIPP schemes Year to date and forecast performance were confirmed at approximately 75%- 76% of plan respectively The QIPP programme for was discussed. It was confirmed that the QIPP target had initially been assumed to be c. 8m (2% of turnover) but that it was recognised that this may need to be revised to 3% due to the likely pressures facing the local economy in The Committee concluded that there were no items contained within the meeting that required escalating to the Board. Recommendation: The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE for information the contents of the report, and take assurance from the review and challenge provided by the Committee. 4

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47 Paper F East Leicestershire and Rutland CCG Board meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP BOARD MEETING Front Sheet REPORT TITLE: Finance Report November 2015 (month 8) MEETING DATE: 19 January 2016 REPORT BY: PRESENTER: Colin Groom, Deputy Chief Finance Officer Donna Enoux, Chief Finance Officer PURPOSE OF THE REPORT: This report provides an update on the 2015/16 year to date and forecast outturn financial position for East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG) RECOMMENDATIONS: The ELR CCG Board is requested to: Receive for information the contents of the report and the appendices attached Note the forecast achievement of the year end control total surplus and the associated risks and mitigations REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of Improve integration of local services between life for people with long-term conditions health and social care; and between acute Improve the quality of care clinical effectiveness, safety and patient experience Reduce inequalities in access to and primary/community care. Listening to our patients and public acting on what patients and the public tell us. Living within our means using public money healthcare effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that the financial reporting underpins the commissioning strategy and priorities of the CCG. The commissioning strategy and priorities have and continue to be equality impact assessed as the strategy is reviewed and refreshed and this includes the financial plans. This completes the due regard required. 1

48 Paper F East Leicestershire and Rutland CCG Board meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP BOARD MEETING 19 JANUARY 2016 Finance Report Introduction 1. This report provides details of the financial position for East Leicestershire and Rutland Clinical Commissioning Group (ELR CCG) for month /16. Revenue Allocations 2. The overall revenue allocation for ELR CCG at month 8 is 399,702k, an increase of 403k over month 7 due to the receipt of a non-recurrent allocation to support Children and Young People s Mental Health Services (Future in mind programme). 3. The current allocation and previous in year movements are detailed in Appendix A. Financial Performance 4. The budget statement in Appendix B details performance against budget as at 30 November 2015 and reflects a control total surplus of 2,384k at month 8 (M7 2,086k) and 3,576k at year end which is in line with the financial plan. 5. Adjusting for the effect of non-recurrent allocations and expenditure, the underlying position for the CCG is forecast to be a surplus of 4,163k for the year. Acute Commissioning 6. At month 8, year to date spend is 116.0m, an overspend of 2.2m against the year to date budget, based on month 7 activity data, mainly driven by over-performance at UHL ( 1.2m) on elective day cases and in-patients, out-patient procedures, A&E and Emergency. Out of County contracts are reporting a year to date overspend of 0.7m, predominantly due to over-performance at Nottingham University Hospitals, Kettering General Hospital and University Hospitals Coventry and Warwickshire. Non contracted activity is overspent by 0.2m and Independent Sector contracts are reporting a year to date overspend of 41k. 7. The forecast outturn position reflects an overspend of 2.8m against an annual budget of 170.7m, mainly due to anticipated continued over-performance at UHL ( 1.6m). Out of County contracts are expected to overspend by 0.9m, with continued over-performance at Nottingham University Hospitals, Kettering General 2

49 Paper F East Leicestershire and Rutland CCG Board meeting 19 January 2016 Hospital and University Hospitals Coventry and Warwickshire partly offset by underperformance at United Lincolnshire Hospitals. Non Contracted activity is expected to overspend by 0.3m and Independent Sector contracts are expected to overspend by 25k. Non-Acute Commissioning 8. The budget year to date is 78.8m, against which there is a favourable variance of 1.3m. The LPT contract is reporting an overspend of 0.1m at month 8, due to cost pressures relating to mental health rehab beds. Continuing Healthcare is underspent by 0.1m year to date. Additional month 6 underspends are within Mental Health ECRs ( 0.3m), Community Equipment Services ( 0.3m), LD Pooled Budgets, Reablement and Partnerships ( 0.3m), EMAS ( 0.1m) and Children s Complex Care ( 0.2m). 9. The annual budget is 117.7m against which expenditure is currently forecast to be underspent by 1.2m. LPT is forecast to overspend by 0.3m for the year due to cost pressures highlighted above. The material forecast underspends include Mental Health ECRs ( 0.6m), Children s Complex Care ( 0.3m), LD Pooled Budgets, Reablement and Partnerships and seasonal resilience schemes ( 0.3m) and Community Equipment ( 0.5m). Practice Prescribing 10. This area is overspent at month 8 by 1.4m. A series of targeted actions to reduce expenditure and deliver further QIPP savings in the final months of the year means that the forecast overspend is to maintain the current 1.4m overspend by year end. GP Commissioning 11. Additional Primary Care budgets totalling 40,141k have been delegated to the CCG from NHSE as of 1st April (A net budget of 39,153k is modelled in Appendix B as the delegated budget of 988k for the Oadby Walk In Centre is recorded within Primary Care Services) At month 8, spend is 0.6m below budget, with a forecast to be 1.0m below budget for the full year. This includes the impact of the transfer of the Primary Care Transformation budget to CCGs that NHS England will transact in month 10. 3

50 Paper F East Leicestershire and Rutland CCG Board meeting 19 January 2016 Miscellaneous 12. Headroom ( 3,412k) 1% of the recurrent allocation, excluding delegated primary care budgets, has been set aside to invest in non-recurrent transformation schemes. There has been 2.8m of expenditure incurred to date (predominantly relating to the annual 1.7m CHC Risk Share provision) with the full year expenditure expected to be in line with plan. Further details of all these schemes are outlined in Appendix C. 13. Contingency ( 1,788k) 0.50% of the total allocation has been put aside as a contingency to offset any overspends and in year cost pressures that may arise. The full value of the contingency has been committed year to date to offset overspends in the commissioning budgets and support achievement of the required control total surplus. 14. The remaining 1.6m of year to date miscellaneous expenditure includes prior year under accruals of 1.4m. Running costs 15. These are showing an underspend of 0.2m year to date against a budget of 4.6m, mainly due to vacancies in the early part of the year. By year end, the forecast is to breakeven against the annual budget of 6.9m as a number of vacancies have been filled and the CCG is beginning to incur additional spend relating to the relocation of the CCG to County Hall, and the restructuring of the contracting teams across the 3 CCGs. Capital 16. The CCG has received confirmation of a Capital Allocation of 1,311k. Planned expenditure against this allocation is detailed in Appendix D. 17. There is 301k uncommitted capital funding after allowing for 100k to build a new car park at the Glenfield site in preparation for the relocation of the CCG to the County Hall site, plus a 32k Comms/IT cost pressure. Project Initiation Documents (PIDs) are currently being produced for each capital scheme to be submitted to NHS England for approval. QIPP 18. The CCG has produced QIPP schemes for 2015/16 totalling 8,081k with a further 285k Primary Care delegated budget QIPP schemes. The detailed report in Appendix E showing financial performance against all the budget areas containing QIPP schemes is currently reporting an overspend of 3.8m for the year. However 4

51 Paper F East Leicestershire and Rutland CCG Board meeting 19 January 2016 only a proportion of this variance relates to performance of the QIPP schemes, and the remainder is driven by other factors. Better Payment Practice Code (BPPC) 19. The BPPC performance for the CCG as at month 8 is shown in Appendix F and demonstrates compliance with the cumulative BPPC 95% targets as follows: NHS creditors (number) 99.26% NHS creditors (value) 99.96% Non NHS creditors (number) 99.21% Non NHS creditors (value) 99.39% GEM Performance 20. The Month End Summary CFO Report received from Arden and GEM CSU stated that all KPI s in relation to the finance service specification were achieved during month All control codes were reconciled by the agreed deadlines and the full reconciliation pack has also been distributed. The VAT submission code remains at red status but agreement has now been reached with the CSU over the clearance of this balance to ensure the CCG is not exposed to any financial risk. Flagged as amber this month is a balance relating to recovery of salary overpayments that need to be paid over to the staff member s previous employer. All other accounts are rated green. 22. All payroll pay overs were made by the deadlines. Statement of Financial Position and Cash Flow Statement 23. Appendix G outlines the Statement of Financial Position for ELR CCG as at month 8. Trade Receivables and Trade Payables have been broken down to show age of debtors and creditors. All overdue receipts and payments are regularly reviewed and actions undertaken to resolve. 24. Appendix H outlines the Cash Flow Statement for ELR CCG for 2015/16. Mainly due to the settlement of creditors relating to the previous year, by month 7 the CCG had to draw down slightly more cash than a straight 1/12 th monthly profile would suggest. The November cash draw-down request was reduced accordingly and the cumulative position to the end of November is now 1.7m behind an equal 1/12 th profile. This position will unwind as payments begin to be made for seasonal resilience and some of the other schemes due to be paid in the later months of the year 5

52 Paper F East Leicestershire and Rutland CCG Board meeting 19 January 2016 Risk 25. The main risks that have the potential to adversely affect the CCG s financial position for 2015/16 are highlighted below: UHL continued over performance Out Of County and Independent Sector provider over performance LPT Mental Health Rehabilitation Bed charging between local CCGs Prescribing increased growth Additional requests for Winter Funding schemes Additional requests for non-recurrent transformational funding (BCT) Non achievement of QIPP schemes (existing or new) Summary 26. The financial position of ELR CCG is reporting a control total surplus of 2,384k at month 8 and 3,576k at year end, in line with the financial plan. It must be noted, however, that there are financial risks attached to the current forecasted position as highlighted in the paragraph above. Recommendation: The East Leicestershire and Rutland CCG Board is requested to: Receive for information the contents of the report and the appendices attached. Note the forecast achievement of the year end control total surplus and the associated risks and mitigations 6

53 ELR CCG Allocation 2015/16 Appendix A M1 M2 M3 M4 M5 M6 M7 M8 Movement from M1 '000 '000 '000 '000 '000 '000 '000 '000 '000 Recurrent allocation (programme) Recurrent baseline 341, , , , , , , ,166 0 Primary Care Co-Commissioning 39,941 39,941 39,941 39,941 39,941 39,941 39,941 39,941 0 Better Care Fund 5,344 5,344 5,344 5,344 5,344 5,344 5,344 5,344 0 Medway PAS Environmental Controls (Blatchfords) Disaggregation of Leicestershire HV contract Transfer of co-commissioning 0.5% contingency Repatriation of prescribing of immunosuppressant post renal transplant (205) (205) (205) (205) (205) (205) Tier 3 Neurology Commissioning Responsibility Transfer - NHS England Total recurrent allocation (programme) 386, , , , , , , , Non recurrent allocation (programme) Return of previous year surplus 3,310 3,310 3,310 3,310 3,310 3,310 3,310 3,310 0 ETO/DTR funding GP IT GP IT - Transition funding Waiting list validation and improving operational processes Eating disorders Liaison Psychiatry - Mental Health UEC Vanguard sites - Liaison Psychiatry CAMHs Transformation Funding Total non recurrent allocation (programme) 4,030 4,030 4,880 4,889 5,050 5,050 5,184 5,587 1,557 Total allocations (programme) 390, , , , , , , ,625 2,144 Recurrent allocation (running costs) Recurrent baseline 7,077 7,077 7,077 7,077 7,077 7,077 7,077 7,077 0 Total allocations (running costs) 7,077 7,077 7,077 7,077 7,077 7,077 7,077 7,077 0 TOTAL ALLOCATIONS 397, , , , , , , ,702 2,144 Capital Allocation 1,311 1,311 1,311 1,311 1,311 1,311 1,311 1,311 0

54 East Leicestershire & Rutland CCG Summary /16 Month 8 Budget ( 000) Year to Date Full Year Forecast Worst Case Forecast Expenditure Variance Expenditure Variance Budget ( 000) Variance ( 000) ( 000) ( 000) ( 000) ( 000) Best Case Forecast Variance ( 000) Total allocation 268, , , , Acute Commissioning 113, ,046 2, , ,532 2,815 3,031 2,417 Non-acute Commissioning 78,778 77,445 (1,334) 117, ,491 (1,170) 499-2,327 Practice Prescribing 31,334 32,721 1,387 47,191 48,629 1,438 2, GP Commissioning 26,102 25,468 (634) 39,153 38,201 (951) Primary Care Services 5,481 5,474 (7) 8,222 8, Miscellaneous (inc reserves) 5,849 4,454 (1,395) 6,265 4,005 (2,260) ,377 Total Programme Expenditure 261, , , , ,043-2,453 Total Running Costs 4,610 4,383 (228) 6,917 6, Total Expenditure 265, , , , ,043-2,503 Surplus Programme control total 2,276 2,049 (228) 3,416 3, ,043 2,453 Running Costs control total Total control total 2,384 2, ,576 3, ,043 2,503

55 ELR Headroom Planned Schemes Appendix C Month 8 Annual plan YTD expenditure Scheme name East Specific '000 Collaborative 000 Total '000 East Specific '000 Collaborative 000 Total '000 Likely FOT FOT Slippage Comments UHL Non-Recurrent Funding - Transformation Non-Recurrent Funding - RTT ,330-1, ,330 - Other CHC provision risk share 1,726 1,726 1,726 1,726 1,726 - Better Care Together Programme staff costs Minor Injury & Minor Illness Review and Re Procurement /16 Contribution notified by NHS England 58 2,024 2, ,885 1,939 2,082 - Total 1,388 2,024 3, ,885 2,824 3,

56 ELR CCG Capital Additions Plan 2015/16 Month 8 Capital Scheme Asset Type Scheme Description CCG Financial Plan NHSE Approved Capital schedule Year to date Expenditure CCG spending forecast (to be approved) Forecast Variance from CCG Financial Plan Forecast Variance from NHSE Approved Capital schedule Comments Appendix D Communications IT New IT equipment 2, ,585 1,585 Communications Intangible MOOD software 10, ,680 10,680 Communications Intangible Combined Intra/internet capability 17, ,114 24,114 31,099 61,099 Communications IT Server (to host website) ,220 12,220 Communications Intangible Phone App Pilot ,500 Communications Subtotal 30, ,599 61,099 31,099 61,099 CCG Property PPE Car Parking at Glenfield site , , ,000 CCG IT IT IT replacement (RRP) and new server 50,000 50,000 9,157 20,507 (29,493) (29,493) St Lukes Development P&M Group 4 (ultrasound, dental and diagnostic) 117, , St Lukes Development F&F Group 3 (FF&E) 65, , (209,072) (433,000) St Lukes Development F&F Group 2 (artwork) 11, St Lukes Development IT IM&T Equipment 14,640 44, St Lukes Subtotal 209, , (209,072) (433,000) Alliance P&M Endoscopy replacement 82,000 82,000 82,000 Alliance P&M Theatre Equipment 120, , ,000 Alliance P&M Imaging equipment 54,000 54,000 54,000 Alliance P&M Outpatient equipment 48,000 48,000 7,055 48, Alliance P&M ECT machine for Ophthalmology Surgery 78,000 78,000 78,000 Alliance P&M Ophthalmology machine - OP 150, , ,000 Alliance Subtotal 532, ,000 7, , No longer expecting any CCG capital expenditure on St Lukes in 2015/16 Latest estimate is between 250k- 380k required in 2015/16, including a 50k contingency built in for any emergency equipment replacements. Confirmation to follow regarding the spending plan approved by the November Management Board. CCG Assets - SUBTOTAL 821,072 1,015,000 64, ,606 (107,466) (301,394) GP IT - NHSE assets IT Practice Mergers 0 20,000 20,000 0 GP IT - NHSE assets IT Technology Refresh 0 276, ,000 0 Not applicable to CCG Plan as these are NHSE assets; pending full authorisation from Paul Baumann BCT Excluded as has its own plan All Assets - TOTAL 821,072 1,311,000 1,009,606 (107,466) (301,394)

57 East Leicestershire & Rutland CCG QIPP Performance /16 Month 8 Appendix E1 Gross Budget ( 000) QIPP Plan ( 000) Year to Date Net Budget ( 000) Expenditure ( 000) Variance ( 000) Gross Budget ( 000) QIPP Plan ( 000) Full Year Forecast Net Budget ( 000) Expenditure ( 000) Variance ( 000) Area of Expenditure Point of Delivery QIPP Scheme(s) Acute Commissioning UHL Contract Emergency Admissions (net of MRET & Readmissions) COPD (Pulmonary Rehab) (104) (157) CVD (Stroke Anti-coagulation Pathway) (65) (97) GP Operational Framework Hot Clinics (ACS) (96) (172) GP Operational Framework 7 Day Working Roll Out (147) (264) GP Operational Framework Care Homes (EoL) 29,711 (117) 28,504 28, ,325 (210) 43,304 43, Care Plan Management in Care Homes - UTIs (35) (63) Care Plan Management - Cellulitis (7) (12) BCF (Pilot of 7-day access, Integrated Crisis response, Rapid Assessment for frail older people and Integrated Falls Pathway) (637) (955) BCT - Long Term Conditions - Exercise as Medicine 0 (90) Daycase BCT - Planned Care - Left-Shift Hernia Daycase 8,822 (2) 8,820 9, ,154 (5) 13,149 13, OP New OP FUp GP Operational Framework Diabetes (22) (34) GP Operational Framework OP End of Life Care & Referral Management (64) (64) 5,864 5,720 5, ,855 8,493 BCT - Planned Care - OP Decommissioning (58) (248) BCT - Long Term Conditions - Chronic Breathlessness Pathway 0 (16) GP Operational Framework Diabetes (39) (59) BCT - Planned Care - OP Decommissioning (68) (290) BCT - Long Term Conditions - Remote monitoring Cardiac Devices 5, ,891 6, ,183 (3) 8,792 BCT - Long Term Conditions - Primary Care Education (Survivorship) 0 (20) BCT - Long Term Conditions - Chronic Breathlessness Pathway 0 (19) 8, , Out of County Contracts Independent Sector all PODs (split to follow) all PODs (split to follow) BCF - Integrated health and social care pathways (26) (39) GP Operational Framework OP End of Life Care & Referral Management 16,892 (7) 16,848 17, ,299 (7) 25,205 26, BCT - Planned Care - OP Decommissioning (11) (47) Elective Inpatient Thresholds (110) (200) GP Operational Framework OP End of Life Care & Referral Management 4,953 (4) 4,832 4, ,430 (4) BCT - Planned Care - OP Decommissioning (7) (28) Total Acute Commissioning 72,240 (1,626) 70,614 72,617 2, ,244 (3,103) 106, ,980 2,839 Non-Acute Commissioning LPT Contract Out of County Mental Health Placements (557) (835) 35,229 34,656 34, ,844 Ashby Hospital Bed Closure (17) (25) 51,984 52,236 Continuing Healthcare Fast Track Task and finish group ( ) 3 Months Overdue Reviews ( ) LD workstream 17,942 (1,351) 16,591 16,449 (142) 26,914 (73.866) 24,380 24, Authorising Eligibility (1, ) Funding and Personal Health Budgets (83.333) Total Non-Acute Commissioning 53,171 (1,924) 51,247 51,233 (14) 79,758 (3,394) 76,364 76, CCG Prescribing GP Prescribing Medicines Management 30,793 (1,002) 29,791 31,187 1,396 46,376 (1,500) 44,876 46,318 1,442 Total CCG Prescribing 30,793 (1,002) 29,791 31,187 1,396 46,376 (1,500) 44,876 46,318 1,442 Other GP Co-Commissioning DES Co-Commissioning (96) (145) 26,292 26,102 25,468 (634) 39,438 MPIG Correction factor (93) (140) 7,198 7, ,153 38,201 (951) Total Other 26,292 (190) 26,102 25,468 (634) 39,438 (285) 39,153 38,201 (951) CCG Running Costs Running Costs Running Costs Reduction 4,667 (57) 4,610 4,383 (228) 7,002 (85) 6,917 6,917 0 Total CCG Running Costs 4,667 (57) 4,610 4,383 (228) 7,002 (85) 6,917 6, Grand Total 187,163 (4,799) 182, ,887 2, ,818 (8,367) 273, ,300 3,849

58 East Leicestershire & Rutland CCG Appendix F Better Payment Practice Code November 2015 NHS Creditors Non NHS Creditors A B C D E F A B C D E F % Value No of Bills % of No of Bills No of Bills % of Value of Bills Value of Bills of Bills Value of Bills Value of Bills Paid Bills Paid Paid Paid Bills Paid Paid Within Paid Within Paid Paid Within Paid Within Within Within Within Within Within Period Target Within Period Target Target Target Period Target Target Target No of Bills Paid Within Period % Value of Bills Paid Within Target No. No. % '000 '000 % No. No. % '000 '000 % April ,863 17, ,449 3, May ,974 17, ,096 3, June ,238 19, ,377 4, July ,937 17, ,545 2, Aug ,785 18, ,679 2, September ,419 17, ,631 4, October ,193 19, ,255 2, November ,525 18, ,219 3, Totals 2,027 2, % 146, , % 6,211 6, % 26,251 26, %

59 Statement of Financial Position Balance as at 31 March 2015 Balance as at 30 September 2015 Balance as at 31 October 2015 Balance as at 30 November 2015 '000s '000s '000s '000s Non Current Assets: Premises, Plant, Fixtures & Fittings 1,320 1,221 1,202 1,191 IM&T Other Long-term Receivables TOTAL Non Current Assets 1,366 1,273 1,266 1,259 Sub Analysis 30 November 2015 Current Assets: Inventories Value Trade Receivables Trade Receivables Volume ( '000) UHL Maternity Prepayment 1,349 1,349 1,349 1,349 Not yet due 5 2 Prepayments In Month 108 5,395 4,869 3, days 9 60 Recharges to CCGs Recharges to NHSE and Co Commissioning days UHL/Alliance Urgent Care Centre recharges to Accrued Income 1,948 1, days other CCGs and UHL/Alliance VAT days 5 10 Cash and Cash Equivalents TOTAL Current Assets 4,784 9,507 8,320 6, k received in December TOTAL ASSETS 6,150 10,780 9,587 7,858 Current Liabilities: Trade Payables (1,625) (3,182) (2,490) (2,341) Trade Payables Volume Prescribing Accruals (7,390) (7,954) (8,247) (8,200) Not yet due 171 2,247 Other Accruals (7,486) (8,089) (9,222) (10,196) 1-30 days Payroll Creditors (163) (161) (166) (175) days 16 (26) Provisions (84) (36) days 9 16 Borrowings 91+ days Total Current Liabilities (16,748) (19,422) (20,125) (20,912) 266 2,341 TOTAL LIABILITIES (16,748) (19,422) (20,125) (20,912) ASSETS LESS LIABILITIES (Total Assets Employed) (10,598) (8,641) (10,538) (13,054) Value ( '000) Appendix G TAXPAYERS EQUITY General Fund (Opening Balance, Fixed) (18,752) (10,601) (10,601) (10,601) Income & Expenditure (year to date) (335,183) (199,428) (232,973) (265,990) Parliamentary Funding (year to date) 343, , , ,823 Co Commissioning (year to date) 0 18,022 20,885 23,712 Other Reserves Total (10,598) (8,641) (10,538) (13,054)

60 Appendix H East Leics and Rutland 03W Cashflow reporting Month /16 Year to date Forecast 2015/16 April May June July August September October November December January February March '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Receipts Balance b/fwd NCB-Drawdown 316,630 26,400 25,288 28,749 27,564 26,200 26,000 25,200 24,000 24,800 25,700 25,000 31,729 Other (including VAT) 4, Total Receipts 320,889 27,202 25,848 29,606 27,989 26,623 26,577 26,019 24,961 25,366 26,081 25,251 31,983 Payments Creditors NHS 234,686 18,491 18,448 20,477 20,683 20,290 19,261 20,487 19,111 20,198 19,214 18,518 19,508 Creditors CHAPS 69,229 6,753 5,885 7,270 5,442 5,268 6,255 3,704 4,797 3,984 4,878 5,327 9,666 Salary CHAPS 2, Pensions Tax & NI 1, Standing Orders /Direct Debits PCS Payments 12,125 1, ,267 1, , ,217 Total - Expenditure 320,689 26,939 25,606 29,382 27,832 26,372 26,276 25,573 24,828 25,166 25,881 25,051 31,783 Balance c/fwd April May June July August September October November '000 '000 '000 '000 '000 '000 '000 '001 Cumulative Cash Drawn 26,400 51,688 80, , , , , ,401 Assumed Drawdown in equal 1/12ths 26,386 52,772 79, , , , , ,087 Cumulative Variance to equal 1/12ths profile 14 (1,084) 1,280 2,458 2,272 1, (1,686)

61 G

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63 Paper G ELR CCG Governing Body Meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Front Sheet REPORT TITLE: Memorandum of Understanding the Public Health Core Offer to ELR CCG MEETING DATE: 19 January 2016 REPORT BY: SPONSORED BY: PRESENTER: Kiran Loi, Dr Tim Daniel Tim Sacks, Chief Operating Officer Kiran Loi, Public Health Specialty Registrar PURPOSE OF THE REPORT: To share and agree the Memorandum of Understanding of the core offer of public health support to ELR CCG. To share the agreed priorities of specific input by public health over RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report and APPROVE: 1. The Memorandum of Understanding - the Public Health Core Offer 2. The agreed priority areas for public health input and support in 2016 REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of life for people with long-term conditions x Improve integration of local services between health and social care; and between acute and primary/community care. Improve the quality of care clinical x Listening to our patients and public effectiveness, safety and patient experience acting on what patients and the public tell us. Reduce inequalities in access to healthcare x Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). x x EQUALITY ANALYSIS 1. An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate. This completes the due regard required. 1

64 Paper G ELR CCG Governing Body Meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Memorandum of Understanding The Public Health Core Offer 19 th January 2016 Background 1. Public Health historically assumed the lead for three major responsibilities on behalf of the NHS and local communities: Health Improvement lifestyle factors and the wider determinants of health; Health Protection preventing the spread of communicable diseases, leading the NHS response to major incidents, and screening programmes; and, Healthcare public health working in collaboration to ensure health services deliver high quality health care best meeting the needs of the local population and maximising health outcomes. 2. The Health and Social Care Act 2012 transferred the primary responsibility for health improvement and health protection at the national level to Public Health England, and at the local level to Local Authorities. Responsibility for strategic planning and commissioning of NHS services transferred to NHS England and to Clinical Commissioning Groups (CCGs). 3. The Health and Social Care Act 2012 also places responsibility on clinical commissioning groups (CCGs) for delivering improvement in the quality of services, reducing inequalities and promoting integration of services. To achieve this, the Department of Health has reserved a key role for local authority based public health teams to provide public health expertise to the local NHS commissioners of health care services. 4. Local Authorities and the Director of Public Health must deliver on a number of public health statutory duties; these include, amongst others: a. The Public Health Core Offer to the NHS, including the provision of advice to local CCGs; this is to be agreed between local authorities and CCGs b. To improve the health of the population, through services such as smoking cessation, physical activity etc. c. The provision of the NHS Health Checks programme d. Access to sexual health services e. Delivery of the Child Measurement Programme f. Delivery of the health visiting service 2

65 Paper G ELR CCG Governing Body Meeting 19 January 2016 Leicestershire County Council Public Health Team 5. Leicestershire County Council Public Health (LCC PH) team is led by a Director of Public Health and the department is a recognised public health training location. West Leicestershire CCG (WL CCG) and East Leicestershire and Rutland CCG (ELR CCG) each has a named senior Public Health lead from the County Public Health team to provide strategic public health leadership and ensure links are made to the most appropriate members of the Public Health team for defined pieces of work. 6. The LCC PH team comprises of public health consultants, public health managers, and administrative and business support. The department is a training location offering placements to F2 doctors, public health specialty registrars, and ITP GP registrars. 7. The LCC PH team is led by Mike Sandys, Director of Public Health for Leicestershire County Council and Rutland County Council. The current public health leads are described in table 1 below. Table 1: Public Health leads in Leicestershire County Council Name and Title Lead Portfolio Areas Mike Sandys Provision of the public health offer to Leicestershire and Director of Public Health Rutland Dr Tim Daniel Lead for ELR CCG Public Health Consultant Education & Training Support to University Hospitals of Leicester Rob Howard Public Health Consultant Julian Mallinson Public Health Consultant Dr Mike McHugh Public Health Consultant Dr Elizabeth Orton Public Health Consultant Vivienne Robbins Public Health Consultant Kiran Loi Public Health Specialty Registrar Children s Public Health Wider Determinants of Health Rutland Council Substance Misuse Tobacco Control District Councils Lead for West Leicestershire CCG Mental Health Cancer Health Inequalities Clinical Governance Obesity Physical Activity Healthy Eating Oral Health Workplace Health Sexual Health Health Protection NHS Health Checks Support to ELR CCG Support to Rutland Council 3

66 Paper G ELR CCG Governing Body Meeting 19 January 2016 Public Health Core Offer 8. The statutory duty for Public Health to provide local NHS commissioners with public health expertise and support is known as the Core Offer. This Public Health Core Offer is intended to ensure that the CCGs receive appropriate access to, and benefit from, local public health leadership, advice and specialist skills including: Public health intelligence; Epidemiology; Surveillance; Needs assessment Skills to tackle health inequalities; Effectiveness and efficiency assessments; Evidence review; Health protection; and, Commissioning health improvement across clinical and other pathways. 9. The Core Offer is to be provided under a Memorandum of Understanding (MOU) to CCGs from the local authority public health function. It should be agreed between local authorities and CCGs and locally reviewed. Local Public Health Offer 10. The Leicestershire County Council public health department will provide support and input to ELR CCG as stipulated within the MOU; see Appendix 1. Support to the CCGs will be offered by staff from across the public health team in order to ensure the highest possible level of expertise is made available. 11. Specific CCG priority areas have been identified for public health support through 2016; these areas are outlined in table 2 below. This support will be delivered by Kiran Loi and other members of the LCC PH team, with Dr Tim Daniel providing oversight. Table 2: Specific areas of public health support to ELR CCG in 2016 Area of support Lead Involvement Community services baseline review Kiran Loi To develop a needs assessment for community health services, and inform future models of service delivery Vanguard urgent Tim Daniel / Kiran To inform the future urgent and out of hours and OOH care Loi delivery model considering evidence base and population needs Core Plus review Kiran Loi Provide public health oversight of the review Evaluations Tim Daniel / Kiran Loi Design and deliver evaluations of the urgent care vanguard and of the GP seven day service pilot 4

67 Paper G ELR CCG Governing Body Meeting 19 January In order to provide public health advice and support, the following ELR CCG committees will be attended through 2016: ELR CCG Governing Body Board meetings and extraordinary meetings Primary Care Commissioning Committee Strategy, Planning and Commissioning Committee Quality and Performance Committee 13. The local public health offer will be reviewed regularly as CCG priorities are reviewed and developed. A local action plan will be regularly reviewed between ELR CCG members and the Leicestershire County Council public health department. Recommendation The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report and APPROVE: 1. The Memorandum of Understanding - the Public Health Core Offer 2. The agreed priority areas for public health input and support in

68 Leicestershire County Council Public Health and West Leicestershire and East Leicestershire and Rutland Clinical Commissioning Groups Memorandum of Understanding-The Core Offer 2015/16 1. Purpose: The purpose of this Memorandum of Understanding (MOU) is to establish a framework for the working relationship between the Leicestershire County Council Public Health Directorate and West Leicestershire and East Leicestershire and Rutland Clinical Commissioning Groups. This MOU aims to deliver improvements in population health and wellbeing, through effective disease prevention, health improvement and commissioning of health and other services. 2. Background: Public Health has been a part of the NHS since During this time, the profession has assumed the lead for three major responsibilities on behalf of the NHS and local communities: Health Improvement-lifestyle factors and the wider determinants of health. Health Protection-preventing the spread of communicable diseases, leading the NHS response to major incidents, and screening programmes Healthcare public health-working in collaboration to ensure health services deliver high quality health care best meeting the needs of the local population and maximising health outcomes. The Health and Social Care Act 2012 has transferred the primary responsibility for health improvement and health protection at the national level to Public Health England, and at local level to Local Authorities. Responsibility for strategic planning and commissioning of NHS services has transferred to NHS England and to Clinical Commissioning Groups (CCGs). 1 P age

69 The Health and Social Care Act, 2012 also places responsibility on clinical commissioning groups (CCGs) for delivering improvement in the quality of services, reducing inequalities and promoting integration of services. Good population health outcomes, including reducing health inequalities, rely not just on health protection and health improvement, but on the quality and accessibility of health care services provided by the NHS. AS a result of the Health and Social Care Act, the Department of Health has reserved a key role for local authority based public health teams to provide public health expertise to the local NHS commissioners of health care services. This Public Health Core Offer to the CCGs is intended to ensure that the CCGs receive appropriate access to, and benefit from, local public health leadership, advice and specialist skills including public health intelligence, epidemiology, surveillance, needs assessment, skills to tackle health inequalities, effectiveness and efficiency assessments, evidence review, health protection and commissioning health improvement across clinical and other pathways. Support to the CCGs will be offered by staff from across the public health team in order to ensure the highest possible level of expertise is made available. Leicestershire County Council Public Health (LCC PH) team is led by a Director of Public Health and the Department is a recognised public health training location. West Leicestershire and East Leicestershire and Rutland CCGs each has a named senior Public Health lead from the County Public Health team to provide strategic public health leadership and ensure links are made to the most appropriate members of the Public Health team for defined pieces of work. The Core Offer will reflect the Leicestershire Health and Well Being Board (HWBB) priorities and CCG operational plans. The Joint Strategic Needs Assessment (JSNA) will move away from being a profile of health status towards supporting specific priorities with outcome focused advice from Public Health. 3. Recent developments Recent developments including the push for greater integration between health and social care mean there are further opportunities for collaborative working between LCC PH and WL and ELR CCG as part of the core offer: Better Care Together Better Care Fund Delegated commissioning of primary care services by CCGs. 2 P age

70 Co-commissioning of care pathways between Public Health and CCGs e.g. obesity, sexual health pathways Requirements for robust clinical governance arrangements for PH commissioned clinical services 4. Areas of shared values between PH Directorate and CCGs: Leicestershire County Council Public Health and WL and ELR CCGs will work in partnership together to: achieve agreed outcomes and ensure that a productive and constructive relationship continues to be developed and maintained deliver improvements in the health of the county s population, through disease prevention, health protection and commissioning health services maintain performance on national and locally agreed outcome measures and priorities ensure that local commissioning fully reflects the population perspective implement a mutually agreed joint work plan to deliver both NHS commissioning and Public Health priorities for the local population as set out in the JSNA and Joint HWBS Public Health input in the following areas is considered to have value by both the CCGs and Public Health: Involvement with the CCGs priority setting processes Reduction in clinical variation (primary and secondary care) Service design, re-design and co-design Evidence of cost effectiveness Primary, secondary and tertiary prevention Tackling inequalities in health Mental health and physical/mental multi-morbidity Harm from health system overuse Building resilience and independence Health and social care integration System leadership, brokerage and strengthening of relationship between CCGs and local authority (including district councils) Development of Public Health skills within CCGs (support from Public Health team for CCGs to become intelligent customers ) 3 Page

71 Co commissioning opportunities 5. Public Health products: The following is a list of specialist Public Health products where the input of Public Health has clear added value for CCGs: Health Needs Assessment-especially in areas where there are known gaps in knowledge Health Equity Audit Service Design, re-design and evaluation Cost-benefit analysis Programme budgeting Pathway design-to incorporate prevention Modelling Health Impact Assessment Social return on investment Horizon scanning Support for integration Public Health Intelligence Commissioning support, population need and benchmarking Literature searches, evidence gathering and critical appraisal Monitoring and evaluating frameworks Evaluating performance outcomes and metrics System leadership E.g. Public Health will work with the CCGs on developments e.g. diabetes pathway to include appraising the evidence, expected prevalence and incidence to determine service capacity, pathway and guideline development, model cost options. 6. Specific areas of mutual support (see Appendix 1 for specific examples) 6.1. Health improvement The Health and Social Care Act, 2012 gives Leicestershire County Council a statutory duty to improve the health of the population from April Meanwhile, CCGs have been given responsibility to secure continuous improvement in health and to reduce inequalities in the outcomes achieved by health services. These responsibilities require action along the entire care pathway from primary prevention to tertiary care. CCGs are expected to support implementation of preventative measures to 4 Page

72 reduce the burden of disease that results from smoking, alcohol, obesity, sexual health and falls. Therefore Leicestershire County Council, the Public Health Directorate and WL and ELR CCGs have a collective interest in health improvement. The expectations for 2015/16 are: Leicestershire County Council Public Health Directorate will: Refresh its current strategies and action plans to improve health and reduce health inequalities, with input from CCGs Lead on the commissioning of cost effective, equitable lifestyle services based on local needs and evidence of good practice Ensure that lifestyle services are evaluated and monitored and that they support CCGs in their role of improving health and addressing health inequalities. Lead media campaigns on lifestyle issues, and provide staff who can do media interviews. Support primary care to improve health- for example by offering training opportunities for staff, and through targeted health information campaigns. Facilitate partnership working between CCGs, local partners and residents to integrate and optimise local efforts for health improvement and disease prevention. The Clinical Commissioning Groups will: Contribute to strategies and action plans to improve health and reduce health inequalities. Work with constituent practices to help maximise their contribution to disease prevention-for example by taking every opportunity to address smoking, alcohol, and obesity in their patients and by optimising management of long term conditions. Ensure that primary prevention and lifestyle services are considered within the commissioning process, and are an integral part of all care pathways. Play a full part in the work of the Leicestershire Health and Wellbeing Board. 6.2 Health protection: The Health and Social Care Act, 2012 provides that the Secretary of State for Health is responsible for taking steps for the purpose of protecting the health of the population. From April 2013 local authorities through their DPH will be required to ensure that plans are in place to protect the health of the local population from threats ranging from relatively minor outbreaks to full-scale emergencies, and to prevent as far as possible those threats arising in the first place. The scope of this duty will include local plans for immunisation and 5 Page

73 screening, as well as the plans acute providers and others have in place for the prevention and control of infection, including those which are healthcare associated. Responsibilities for health protection are shared between local authorities, Public Health England, Clinical Commissioning Groups, NHS England Area Teams and the providers of health and social care services. The public health role of the council is one of local leadership and assurance that the system protects the health of the residents of the county. As with health improvement, Leicestershire Public Health Department and each Clinical Commissioning Group have a collective interest in ensuring that arrangements for health protection are robust. The expectations for 2015/16 are that: Leicestershire Public Health Directorate will: Through LLR Prepared (Local Resilience Forum) and Local Health Resilience Partnership (LHRP); o Ensure that strategic plans are in place for responding to the full range of potential emergencies e.g. pandemic flu, fuel crises, flooding, and other major incidents, and that the capacity and skills are in place to co-ordinate the response to emergencies, through strategic command and control arrangements. o Ensure that these plans are adequately tested o Ensure that CCGs have access to these plans and an opportunity to be involved in any exercises o Ensure that any preparation required e.g. training, access to resources has been completed. Input into the Leicestershire Infection Prevention and Control strategy and group Provide support in the event of an outbreak and seek assurance that investigations following an outbreak are conducted in a robust and effective way. Work in conjunction with Public Health England and the NHS England National Commissioning Board in providing specialist advice to the Clinical Commissioning Group and constituent practices on health protection issues Through the LLR health protection board, oversee the quality and performance of national screening programmes NHS England Clinical Commissioning Groups will: Ensure senior level attendance at LLR Prepared, LHRP and LLR Health Protection Board 6 Page

74 Develop robust strategic plans for responding to emergencies and health protection issues.. Participate in exercises when requested to do so. Ensure that any provider contracts they have responsibility for include appropriate business continuity arrangements. Work with constituent practices to develop business continuity plans to cover action in the event of the most likely emergencies. Meet the requirements of a category 2 responder by cooperating, providing information, ensuring resilient communications and supporting the response to emergencies. 6.3 Population health and social care: The Health and Social Care Act, 2012 establishes CCGs as the local commissioners of NHS services and gives them a duty to continuously improve the effectiveness, safety and quality of services. The Leicestershire Health and Wellbeing Board will identify the needs of the local population and ensure that these needs are addressed through Clinical Commissioning Groups, Public Health and social care commissioning plans and activities. Public Health support for CCG NHS commissioning is a mandatory service to be provided by local authorities, funded from the ring-fenced public health budget. The expectations for 2014/2015 are that: Leicestershire Public Health Directorate will: Support the WL and ELR CCGs in their contribution to the JSNA. LC PH will refresh the JSNA to specify the needs of the population and ensure that this is relevant at the level of each CCG. The production of the JSNA will be complemented by a programme of targeted needs assessments. Deliver routine and bespoke analyses and interpretation of health services information through using public health informatics and Clinical Effectiveness tools Ensure that profile and insight data is used to help target services and reduce health inequalities Support clinical validation of data where necessary for commissioning purposes Support the CCGs contribution to the Leicestershire Health and Well-Being Strategy Provide a legitimate context for setting priorities using comparative effectiveness approaches and public engagement and identify areas for disinvestments including using programme budgeting and marginal analysis (PBMA) in this process 7 P age

75 Support CCGs in agreeing their commissioning intentions Support the clinical effectiveness functions of the CCG including input into assessing the evidence for the formulation of clinical commissioning policy e.g. NICE guidance, Work on care pathways service specifications and quality indicators, including review of the evidence of effectiveness and work with clinicians to improve patient outcomes. Provide specialist support in relation to named patient funding requests. This will include being responsible for changes to eligibility criteria, triaging requests and providing advice to the IFR Panel on individual cases. Public health staff will sit on the IFR Panel and the IFR Review Panel. Support the CCG in the achievement of the indicators in the NHS outcomes frameworks for Domain One-preventing people from dying prematurely, Domain Three-Helping people to recover from episodes of ill health or following injury and Domain Five-Treating and caring for people in a safe environment and protecting them from avoidable harm Provide specialist support to ensure effective health and social care integration including Better Care Together, Better Care Fund Support co-commissioning of pathways encompassing primary prevention through to tertiary prevention e.g. obesity pathways Support the CCG to deliver delegated commissioning of high quality primary care services Liaise with NHS England in relation to Specialised Services Promote collaborative working through Greater East Midlands Commissioning Support Unit and clinical networks Respond to media requests for interviews on topical healthcare issues. Clinical Commissioning Groups will: Incorporate specialist public health advice into decision making processes, in order that public health skills and expertise can inform key commissioning decisions. Utilise specialist Public Health skills to identify and understand high risk and/or under-served populations in order to target services at greatest population need and towards a reduction of health inequalities Contribute through commissioning and provision to delivery of the Public Health Outcomes, Domain Two-Health Improvement, Domain Three-Health Protection, Domain Four-Healthcare Public Health and Preventing Premature Mortality Contribute through intelligence and capacity to delivery of the JSNA 8 P age

76 Provide access to CCG quality assurance mechanisms and advice and assistance in relation to clinical governance issues in supporting public health commissioning of clinical services e.g. sexual health services 7. Communication between Public Health and the CCGs: It is recommended that members of the Public Health Core Offer team meet regularly with both CCGs in order to determine, review and update the agreed work programme. Summary This MOU establishes a framework for the working relationship between the Leicestershire County Council Public Health Directorate and West Leicestershire and East Leicestershire and Rutland Clinical Commissioning Groups. This will help ensure improvements in population health and wellbeing, through effective disease prevention, health improvement and commissioning of health and other services to match local health need. The MOU needs to retain a degree of flexibility and responsiveness to reflect the rapidly changing health and social care landscape in which it exists. Author Dr Mike McHugh Consultant in Public Health Leicestershire County Council 1/9/15 9 P age

77 Appendix 1: Public health advice to NHS commissioners: Specific examples Strategic planning: assessing needs Public health advice to NHS commissioners Supporting clinical commissioning groups to make inputs to the joint strategic needs assessment and to use it in their commissioning plans Examples Joint strategic needs assessment and joint health and wellbeing strategy with clear links to clinical commissioning group commissioning plans Development and interpretation of neighbourhood/locality/practice health profiles, in collaboration with the clinical commissioning groups and local authorities Neighbourhood/locality/practice health profiles, with commissioning recommendations Providing specialist public health input to the development, analysis and interpretation of health related data sets including the determinants of health, monitoring of patterns of disease and mortality Clinical commissioners supported to use health related datasets to inform commissioning Health needs assessments for particular conditions/disease groups including use of epidemiological skills to assess the range of interventions from primary/secondary prevention through to specialised clinical procedures Health needs assessments for condition/disease group for intervention/commissioning recommendations Strategic planning: reviewing service provision Public health advice to NHS Examples commissioners Identifying vulnerable populations, Vulnerable and target populations clearly 10 P age

78 marginalised groups and local health inequalities and advising on commissioning to meet their health needs. Geodemographic profiling to identify association between need and utilisation and outcomes for defined target population groups, including the protected characteristics covered by the equality duty. identified; public health recommendations on commissioning to meet health needs and address inequalities Support to clinical commissioning groups on interpreting and understanding data on clinical variation in both primary and secondary care. Includes public health support to discussions with primary and secondary care clinicians if requested Public health recommendations on reducing inappropriate variation Public health support and advice to clinical commissioning groups on appropriate service review methodology Public health advice as appropriate Strategic planning: deciding priorities Public health advise to NHS commissioners Applying health economics and a population perspective, including programme budgeting, to provide a legitimate context and technical evidence base for the setting of priorities Examples Review of programme budget data Review of local spend/outcome profile Advising clinical commissioning groups on prioritisation processes governance and best practice Agreed clinical commissioning group prioritisation process Work with clinical commissioners to identify areas for disinvestment and enable the relative value of competing demands to be assessed Clear outputs from clinical commissioning group prioritisation 11 P age

79 Critically appraising the evidence to support development of clinical prioritisation policies for populations and individuals Clinical prioritisation policies based on appraised evidence Horizon scanning: identifying likely impact of new National Institute for Health and Clinical Excellence guidance, new drugs/technologies in development and other innovations within the local health economy and assist with prioritisation Public health advice to clinical commissioners on likely impacts of new technologies and innovations Procuring services: designing shape and structure of supply Public health advice to NHS Examples commissioners Providing public health specialist advice on Public health advice on focusing the effectiveness of interventions, including commissioning on effective/cost effective clinical and cost effectiveness (for both services commissioning and decommissioning) Providing public health specialist advice on appropriate service review methodology Providing public health specialist advice to the medicines management function of the clinical commissioning group Public health advice to medicines management, for example ensuring appropriate prescribing policies Procuring services: planning capacity and managing demand Public health advice to NHS Examples commissioners Providing specialist input to the development Public health advice on development of care of evidence-based care pathways, service pathways/specifications/quality indicators specifications and quality indicators to improve patient outcomes Public health advice on modelling the contribution that interventions make to Public health advice on relevant aspects of modelling/capacity planning 12 P age

80 defined outcomes for locally designed and populated care pathways and current and future health needs Monitoring and evaluation: supporting patient choice, managing performance and seeking public and patient views Public health advice to NHS Examples commissioners Public health advice on the design of Clear monitoring and evaluation framework monitoring and evaluation frameworks, and for new intervention/service public health establishing and evaluating indicators and recommendations to improve quality, benchmarks to map service performance outcomes and best use of resources Working with clinicians and drawing on comparative clinical information to understand the relationship between patient needs, clinical performance and wider quality and financial outcomes Providing the necessary skills and knowledge, and population relevant health service intelligence to carry out health equity audits and to advise on health impact assessments Health equity audits Public health advice in health impact assessments and meeting the public sector equality duty Interpreting service data outputs, including clinical outputs Public health advice on use of service data outputs. 13 P age

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83 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING REPORT TITLE: MEETING DATE: REPORT BY: SPONSORED BY: PRESENTER: Front Sheet NHS 111 Procurement 19 January 2016 Jane Chapman, Chief Strategy and Planning Officer Karen English, Accountable Officer Jane Chapman, Chief Strategy and Planning Officer EXECUTIVE SUMMARY AND PURPOSE OF THE REPORT: 1. A Joint Committee has been established to procure NHS 111 services across the East Midlands. 2. The Governing Body of East Leicestershire and Rutland CCG currently retain decision making authority for the re-procurement and award of the NHS 111 contract. However, it is considered that this will create significant difficulties in approving the contract award decision in a timely way across the East Midlands. The work of the Procurement Committee is now at the stage where delegation is required for CCGs to be involved in the procurement process in a streamlined and effective way. 3. The Governing Body is therefore asked to delegate decision making to the NHS 111 Procurement Committee and to understand the implications of so doing, and the alternatives if it chooses not to. In line with the CCG s Constitution, only the Governing Body can establish a joint committee which involves exercising any of its commissioning functions jointly; and can delegate decision making to a joint committee to exercise those functions. 4. The Governing Body is also asked to note the nomination of Tamsin Hooton, Director of Urgent and Emergency Care, to represent the CCG in decision making of the Procurement Committee. RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: APPROVE the delegation of decision making for the award of the NHS111 contract across the East Midlands to the NHS 111 Procurement Committee NOTE that, should be previous recommendation be approved, Tamsin Hooton will represent East Leicestershire CCG (along with the other 2 LLR CCGs) on the NHS 111 Procurement Committee. AGREE that ELR CCG will work with the other 2 LLR CCGs to nominate a lay person to join the Procurement committee.

84 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of life for people with long-term conditions Improve integration of local services between health and social care; and between acute and primary/community care. Improve the quality of care clinical Listening to our patients and public effectiveness, safety and patient experience acting on what patients and the public tell us. Reduce inequalities in access to healthcare Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that this report relates to commissioning support rather than clinical service delivery. The CCG is committed to fulfil its obligations under the Equality Act 2010, and to ensure services commissioned by the CCG are non-discriminatory on the grounds of any protected characteristics. The CCG will work with providers, service users and communities of interest to ensure if any issues relating to equality of service are identified and addressed This completes the due regard required. RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The report highlights a new risk in terms of the potential for a new provider of NHS 111 services to be appointed through the procurement process and the associated impact on the system wide urgent and emergency care pathway / process. The risk score is currently assessed as 9 (amber significant).

85 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 19 January 2016 NHS111 Procurement INTRODUCTION 1. The Terms of Reference of a proposed new joint committee to oversee the procurement process (to be known as the Procurement Committee ) for the East Midlands CCGs collaborative procurement for NHS 111 services was presented, and discussed at, the extraordinary meeting of East Leicestershire and Rutland CCG Governing Body in December The Procurement Committee is currently operating as an Advisory Group under an interim Memorandum of Understanding. Tamsin Hooton, Director of Urgent and Emergency Care currently represents the Chief Operating Officer and/or Chief Strategy and Planning Officer at meetings of the Advisory Group. 3. Work has progressed within the Procurement committee, with a timetable for the procurement being agreed. An Invitation to Tender has been issued with contract award being scheduled for the end of March At the meeting of the Procurement Committee held on 23 October 2015, it was agreed that it was not viable to be dependent upon individual Governing Bodies making key decisions during the process and that CCGs where delegation had not been agreed were asked to discuss [the above points] as soon as possible with their Governing Bodies with a view to securing delegated authority. This meeting was attended by Sue Malpas on behalf of the LLR CCGs. 5. The draft specification for NHS111 has been based on guidance from NHS England and was circulated to LLR CCGs for comment on 1 st December, with comments requested back to the Regional team on the 11 th December; LLR comments were collated and fed back to the Regional procurement committee within the timeframe and a final specification was agreed at the Procurement Committee on 18 December The process for agreeing the specification indicates the difficulties that would arise if the process for taking key 111 procurement decisions, such as agreeing the tender questions and marking schemes, agreeing the evaluation and moderation of bid scores, needed to pass through the Governing Bodies of all CCGs in the East Midlands. 6. This paper seeks a view from the CCG on delegated decision making in respect of procuring NHS111 services as part of a Regional procurement when the current contract with DHU ceases on 30 September The Governing Body

86 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 of ELR CCG is asked to delegate decision making to the 111 Procurement Committee as a joint committee of the Governing Body. 7. The alternative options for the CCG are to ask the procurement committee to continue to work as an advisory group through the procurement process, with formal sign off of decisions coming to Governing Bodies, or to pull out of the procurement and manage a separate CCG/LLR procurement for 111. DELEGATING DECISION MAKING AND CONSEQUENCES 8. In common with any joint committee, the decisions of the Procurement Committee will require an element of consensus that may mean member CCGs don t have full control over all aspects of decision making. 9. There is also the likelihood of stranded costs being incurred if a single contract is awarded across the East Midlands as there are currently 2 providers delivering NHS111. The Governing Body of ELR CCG should also acknowledge, therefore, its share of any potential liability for stranded costs for either of the current service provider; detail is attached at appendix B 10. The constitution of ELR CCG allows for the delegation of decision making to a joint committee in the exercise of its commissioning functions. 11. If the CCG choose not to delegate decision making to the Procurement Committee then it is likely that: The CCG would not be covered by the joint contract award decision. To mitigate this, the contract award decision would need to be taken by the CCG Governing Body either in parallel with the meetings of the Procurement Committee relating to contract award (likely to be impractical in terms of timing), or the LLR CCGs would need to ratify the decision for contract award post hoc, with the risk that if a different decision was taken to the rest of the East Midlands, the CCG could end up without a contract provider. The CCG may be able to join an existing contract once awarded, but there may be a premium cost to this and there would have been no opportunity to influence the contract. There may also be a timing issue between the current contract coming to an end and a new arrangements being put in place leading to risk of loss of service continuity. 12. The terms of reference of the Procurement Committee are attached as appendix A and it should be noted that decisions will be made by consensus. Where consensus does not exist and a vote is necessary, a 75% majority of

87 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 those voting members present will be required. It also describes the consequences of CCGs withdrawing from the process once committed. 13. A contribution of 20,000 per CCG has been requested to cover the costs of procurement. Any unused sums will be returned following the procurement. This sum is within officers financial limits, and has already been committed but the Board should note the contribution. REPRESENTATION ON THE JOINT COMMITTEE 14. The Procurement Committee allows for representatives from all the other CCGs in the East Midlands region. As Director of Urgent and Emergency Care, Tamsin Hooton has been nominated by the managing directors of the three LLR CCGs to represent them on the committee. 15. The Terms of Reference of the Procurement Committee allow for attendees to carry proxy votes on behalf of absentees so there should not be any loss of representation compared to if all 3 CCGs had representatives. 16. The Committee membership includes possibility of lay representation form each county as a non-voting member. LLR has not yet nominated lay representation. RECOMMENDATION: The East Leicestershire and Rutland CCG Governing Body is requested to: APPROVE the delegation of decision making for the award of the NHS111 contract across the East Midlands to the NHS 111 Procurement Committee NOTE that, should be previous recommendation be approved, Tamsin Hooton will represent East Leicestershire CCG (along with the other 2 LLR CCGs) on the NHS 111 Procurement Committee. AGREE that ELR CCG will work with the other 2 LLR CCGs to nominate a lay person to join the Procurement committee

88 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 Provision of NHS 111 Services Commissioned by Derbyshire, Nottinghamshire, Northamptonshire, Leicestershire and Lincolnshire CCG s 1. Purpose Terms of Reference: Procurement Committee 1.1 The purpose of the Procurement Committee is to oversee, agree, direct and mobilise arrangements for the procurement and implementation of new 111 service arrangements for all Participating CCGs (as listed in Appendix A) (the Project). 1.2 The Procurement Committee is a formal group consisting of nominated representatives from each Participating CCG. Members of the Procurement Committee will have delegated authority to consider, approve, reject, direct and progress work that delivers the Project s intentions. Procurement Committee members will provide overall assurance to the commissioning organisations they represent on the progression of the Project including key stages of the procurement process. 1.3 The Project is intended to deliver a successful procurement which ultimately enables recommendations for contract award to be made to the Procurement Committee. The Procurement Committee will then approve and authorise the contract award (subject to the10 day standstill period). 1.4 The Procurement Committee is established in accordance with section 14Z3 of the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) which allows CCGs to establish joint committees to exercise certain commissioning functions relating to the procurement of NHS 111 services. 2. Objectives 2.1 The key objectives of the Procurement Committee are to: - Provide a managed structure and approach which supports the successful delivery of the Project - Identify and enable participation and stakeholder engagement in shaping the development of the specification and related service arrangements - Facilitate the flow of information to ensure clinical engagement is reflected in key documentation - Consider and approve the most appropriate means to secure future service arrangements in this area that deliver value for money and meet patients needs - Develop, agree and sign off key documents and specifications that will form the basis of the contract and procurement documentation - Represent commissioners in the evaluation of suppliers submissions and make recommendation for contract award to the lead commissioning organisations

89 3. Duties of the Procurement Committee Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January The Procurement Committee will perform the following functions on behalf of the Participating CCGs: - receive, consider, approve or otherwise, minutes, Project documentation and/or proposals, including but not limited to the tender documentation (including the scoring mechanisms) and the draft contract - ensure all agreed decisions are in line with national policy requirements and development of best practice - provide assurance of the proposed procurement strategy ensuring consideration of differing or conflicting views before determining the final procurement strategy to be adopted - direct activity to better inform commissioning decision and the successful delivery of the Project - Agree the financial envelope for the services and ceiling cost per call price - Agree appropriate costs for administering the Joint Committee and running the procurement (including legal and commissioning support fees) and oversee invoicing of CCGs based on population share - Approve and authorise the final outcome of the procurement - Sponsor the paper that is presented, for information only, to Participating CCGs governing bodies detailing the progress of the Project including (but not limited to) the outcome of the procurement. 4. Membership 4.1 Permanent membership of the Procurement Committee will consist of a representative from each of the Participating CCGs who is an employee or officer of that CCG (unless otherwise agreed with the Chair). These are the members of the Procurement Committee that will take decisions that concern the delivery and activities of the Project. Voting Representatives must be either an employee or officer of the appointing CCG.

90 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 Voting Representatives Role Name & Job Title Representing Nominated Alternate Commissioner Isobel Scoffield Nottingham City CCG Commissioner Ian Ellis Ashfield & Mansfield CCG Commissioner Tba Newark & Sherwood CCG Commissioner Stewart Newman Nottingham North & East CCG Commissioner Tba Nottingham West CCG Commissioner Elizabeth Harris Rushcliffe CCG Commissioner Samantha Erewash CCGs Millbank Commissioner Jim Connelly Hardwick CCG Commissioner Simon Harris & North Derbyshire CCG Darran Green Commissioner Mike Hammond Southern Derbyshire CCG Commissioner Sarah Stringer Lincolnshire East CCG Commissioner Sarah Newton Lincolnshire West CCG Commissioner Tba South Lincolnshire CCG Commissioner Tba South West Lincolnshire CCG Commissioner Tamsin Hooton East Leicestershire & Tbc Rutland CCG Commissioner Tamsin Hooton West Leicestershire CCG Tbc Commissioner Tamsin Hooton Leicester City CCG Tbc Commissioner Neil Boughton Nene CCG Commissioner Tba Corby CCG 4.2 Each Voting Representatives is entitled to nominate an Alternate, who shall be listed in the above table, to attend a meeting of the Procurement Committee on their behalf. Alternates must be an employee or officer of the same CCG (unless otherwise agreed with the Chair) and they must be fully briefed and able to perform the role identified in section 5. Where possible, the Chair should be notified in writing before the meeting at which an Alternate will attend. 4.3 Details of the initially appointed Alternates are listed in the fourth column of the above table. 4.4 Voting Representatives are entitled to appoint a proxy from one of the other Voting Representatives by notice in writing to the Chair. Proxies shall be entitled to exercise all or any of the Voting Representatives rights to attend, speak and vote at meetings.

91 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January Financial representation is covered by Procurement Committees attendees. Non-Voting* Representatives Role Name & job title Representing Procurement Committee Chair* Dawn Smith Project Team - SRO Project Lead Tba Project Team Procurement Lead Emily Armstrong Arden & GEM Procurement Lay Representative Tba Derbyshire Lay Representative John Tower Nottinghamshire Lay Representative Tba Lincolnshire Lay Representative Tba Leicestershire Lay Representative Tba Northamptonshire 4.6 Participating CCGs within each relevant county will agree and appoint their Lay Representative. 4.7 The Chair shall have a casting vote in the event of a tie. Please see section 6 for further details*. Arden and GEM CSU 4.8 Arden & GEM CSU will attend and provide the following support to the Procurement Committee: Role Name Role Procurement Lead Emily Armstrong Interim Head of Procurement North Alternate procurement representative Doug Hershaw Interim Associate Director of Procurement 4.9 Arden & GEM CSU will facilitate the function of the Procurement Committee, offer professional advice and support and implement the agreed decisions within the remit of the Project Initiation Document (PID) that Arden & GEM CSU and Commissioners have agreed to Arden and GEM CSU is responsible for preparing reports on the progress of the procurement following each meeting to be reported in accordance with the reporting requirements set out in paragraph For the avoidance of doubt the Arden & GEM CSU representatives shall attend Procurement Committee meetings as non-voting members / observers. Temporary Members 4.12 In addition to the above representatives the Procurement Committee may include other temporary non-voting representatives and/or invite observers as deemed

92 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 necessary. These additional members will act in a supporting capacity as advisors only and will not have any voting rights. Changes in Representatives 4.13 Each Participating CCG is entitled to remove its Voting Representative and to appoint a replacement Voting Representative by written notice to the Chair at any time. All representatives must be an employee or officer of the appointing CCG Each Voting Representative is entitled to remove their Alternate and to appoint a replacement Alternate by written notice to the Chair at any time. Replacement Alternates must be an employee or officer of the same CCG Participating CCGs are entitled to remove the Lay Representative for their County and to appoint a replacement representative at any time provided the Participating CCGs in that County all agree and they give a written notice to the Chair to this effect Non-Voting Representatives who are not Lay Representatives may be removed and replaced by [INSERT DETAILS]. Conflicts of interest 4.17 Voting Representatives, Non-Voting Representatives, temporary non-voting members and observers shall comply with Nottingham City CCG s Conflict of Interest policy (see appendix B). This includes (but is not limited to) requirements to: sign a conflict of interest declaration prior to attending their first meeting; and declare any interest arising thereafter prior to or at the start of any meeting of the Procurement Committee. Confidentiality 4.18 Voting Representatives, Non-Voting Representatives, temporary members and observers must keep all privileged or sensitive information confidential. Withdrawal of Voting Representatives 4.19 Voting Representatives may only withdraw from the collaborative procurement process after the publication of the Contract Notices in the Official Journal of the European Union in exceptional circumstances. Where such a withdrawal occurs the Participating CCG s membership of the Procurement Committee shall automatically cease as a consequence Any disputes as to whether there are exceptional circumstances for a withdrawal will be determined by the relevant NHS England locality director.

93 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January Any CCG withdrawing from the collaborative procurement process after the publication of the Contract Notices in the Official Journal of the European Union shall be liable for any and all additional costs to the Participating CCGs in connection with the collaborative process including, but not limited to, the costs of any reprocurement which may be required as a result of a participating CCG s withdrawal If a new CCG wishes to join the collaborative re-procurement process at any time this must be approved by the Procurement Committee If a new CCG joins the collaborative procurement process they are automatically entitled to appoint a voting representative and these terms of reference will be amended to reflect accordingly. Roles of Individuals 4.24 These will be the core role of individuals who are members of the Procurement Committee: Commissioners: representatives representing the named commissioning organisations. They will receive, consider, review and make decisions on Project activity at each stage. They may contribute to work and Project activity and will lead on certain aspects of work reporting to the Procurement Committee. They will provide the link with clinicians and operational project group ensuring conflicts of interest are managed in full in line with appendix B. Chair: this will be the Senior Responsible Officer from Nottingham City CCG, as the Lead Commissioner. They will maintain oversight of Project delivery and be the Commissioners representative in any direct dealing with Arden & GEM CSU Deputy Chair: the Procurement Committee will nominate a named Deputy Chair who will act as the Chair in the Chair s absence. Arden & GEM CSU: personnel from Arden & GEM CSU will support and deliver Project activity. These individuals are identified in 4.4 of this document Stakeholders: individuals who are invited to be Non-Voting Representatives or observers of the Procurement Committee will provide professional support and advice and not be party to decision making. Lay Representative: individuals who are lay members of a CCG governing body who are appointed to be Non-Voting Representatives of the Procurement Committee by the Participating CCGs in each County will provide specific experience and expertise. 5. Quorum & Voting Ratios 5.1 No business shall be transacted at any meeting unless a quorum is present.

94 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January The quorum for meetings shall be a minimum of one Voting Representative from each County. A Voting Representative or their Alternate counts towards the quorum by being present either in person or by proxy. 5.3 In the event that a vote is required a resolution will be agreed by a majority of those Voting Representatives who are present at the meeting in person or by proxy and eligible to vote (i.e. no conflict of interest). Each Voting Representative shall have one vote. 5.4 In the event of a tie the Chair will be given a casting vote. Reserved matters 5.5 The quorum required for the following agenda items will be two Voting Representatives from each County: approval of the specification and weighting to be used in the procurement; approval of the preferred bidder (or where a decision is made not to appoint a preferred bidder); proposals to allow other CCGs to join the Procurement Committee; proposed amendments to these terms of reference; and proposals to make a material change to the scope of the Project or the procurement documentation (including the service specification) 5.6 Where a vote is required for any of the decisions listed in 6.5 above a 75% vote in favour of the outcome will be required from those Voting Representatives present at the meeting. 6. Frequency of meetings 6.1 The frequency of meetings will be subject to variation reflecting the peaks and troughs of activity; however a minimum of 3 meetings is likely during the procurement process. A full schedule of meetings for agreement will be presented prior to the first meeting and agreed at the first Procurement Committee. Venues will be confirmed to reflect travel for participants. 6.2 Urgent meeting of the Procurement Committee if required will be convened by Project\Procurement Lead at the request of the Chair. 6.3 Where possible the Procurement Committee will conduct business virtually and exploit technology where appropriate. The members of the Procurement Committee may participate in meetings from different locations where they can communicate to the others any information or opinions they have on a particular item of business of the meeting simultaneously.

95 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January A decision of the Procurement Committee may take the form of a resolution in writing or by , copies of which have been signed by each voting member of the Procurement Committee or to which each voting member has otherwise indicated agreement in writing or by Conduct of Meetings 7.1 An agenda for each meeting will be circulated with supporting documents or paperwork at least five working days before the meeting, unless the meeting is an urgent meeting and has been called at short notice. Papers tabled at the meeting will only be accepted with the approval of the Chair. Notice of the venue or process for communicating in the event of a virtual meeting will also be circulated. 7.2 Minutes, actions, those members present and those in attendance and details of any conflicts of interest declared arising from Procurement Committee meetings will be recorded by Arden & GEM CSU and once approved by the Chair will be circulated to Procurement Committee members within five working days of the meeting. 8. Reporting Responsibilities 8.1 The Voting Representatives of the Procurement Committee hold responsibility for reporting on the progress of the Project to their organisations. All such reports will be in an identical format prepared by Arden & GEM CSU and, following approval by the Chair, they will be circulated to Voting Representatives to share with their CCG within an agreed consistent timeframe. 8.2 Each Voting Representative is responsible for circulating the minutes of each meeting within their CCG. 8.3 Each Voting Representatives shall ensure that all reports and minutes are circulated within their CCG with due regard to any conflicts previously declared by GP members, members of their Governing Body and its committees and employees of the Participating CCG. 8.4 To support the requirements of 9.1 at the end of each Procurement Committee meeting the key outcomes, critical issues, tasks and delegations will be agreed. 9. Review of Terms of Reference 9.1 These terms of reference may be amended at any time provided that such amendments are approved in accordance with paragraphs 6.5 and 6.6 of these terms of reference and such amendments fall within the scope of the delegated functions of the Procurement Committee. Date agreed:

96 Date(s) revised: Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016

97 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 Appendix A Participating CCGs The following CCGs are members of the Procurement Committee: County CCG Date admitted as a member Derbyshire Erewash CCGs Hardwick CCG North Derbyshire CCG Southern Derbyshire CCG [October 2015] [October 2015] [October 2015] [October 2015] Leicestershire Lincolnshire Nottinghamshire Northamptonshire East Leicestershire & Rutland CCG West Leicestershire CCG Leicester City CCG Lincolnshire East CCG Lincolnshire West CCG South Lincolnshire CCG South West Lincolnshire CCG Nottingham City CCG Mansfield & Ashfield CCG Newark & Sherwood CCG Nottingham North & East CCG Nottingham West CCG Rushcliffe CCG Nene CCG Corby CCG [November 2015] [November 2015] [November 2015] [November 2015] [October 2015] [October 2015] [October 2015] [October 2015] [October 2015] [November 2015] [October 2015] [October 2015] [October 2015] [October 2015] [November 2015] [November 2015]

98 Paper H East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 Appendix B Conflict of Interest Policy CO_003_Conflicts_of _Interests_Policy.pdf

99 Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group Extract from September 2015 reporting illustrating stranded costs 6. Additional Terms: Participating And Non-Participating CCGs Agreement in principle to the terms associated with stranded costs was agreed at the East Midlands Congress in May Stranded Costs are a reference to the costs to the incumbent providers of delivering their current NHS 111 contracts that would continue beyond the end of that contract to the extent that the CCGs have an obligation or have agreed to fund those costs. Based on population share, all CCGs, whether or not they participate in the collaborative procurement through the Procurement Committee, agree to provide funding to cover any Stranded Costs arising from existing contracts to the extent that these are to be borne by any of the CCGs rather than the incumbent providers. Any Stranded Costs which are to be borne by the CCGs will be shared across all CCGs based on population split, irrespective of whether the current provider for the CCG is the chosen provider for the new NHS 111 service. For example, if Care UK submits a bid and is selected as the future provider of 111 services for all of the counties listed in section 2.1 of this paper (above), the Lincolnshire CCGs above in section 2.1 will also contribute to any Stranded Costs arising from DHU no longer holding a 111 contract (to the extent that these costs are to be borne by any of the CCGs). This is to avoid any suggestion of bias towards incumbent providers on behalf of the participating CCGs.

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103 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 NHS EAST LEICESTERSHIRE AND RUTLAND CCG GOVERNING BODY MEETING Front Sheet Title of the report: Audit Committee summary report (November 2015 meeting) Report to: Governing Body meeting Date of the meeting: 19 January 2016 Report by: Presented by: Daljit K. Bains, Head of Corporate Governance and Legal Affairs Warwick Kendrick, Independent Lay Member and Chair of the Audit Committee PURPOSE OF THE REPORT: This report aims to provide a summary of the key areas of discussion and outcomes from the Audit Committee meeting held in November The report provides assurance to the Governing Body in respect of the effectiveness of risk management systems and processes across the CCG; and also items for escalation for consideration by the Governing Body ensuring that the Governing Body is alerted to emerging risks or issues. RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report. REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of life for people with long-term conditions Improve integration of local services between health and social care; and between acute and primary/community Improve the quality of care clinical effectiveness, safety and patient experience care. Listening to our patients and public acting on what patients and the public tell us. Reduce inequalities in access to healthcare Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in respect of this report. The Audit Committee, through its review of effectiveness in risk management systems and processes, also seeks assurances in respect of compliance with statutory requirements, including compliance with the Equality Act. The equality analysis can be found within each document, for example, within the policy documents referred to within the Board Assurance Framework. 1

104 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The Audit Committee has the remit to seek assurance in respect of the implementation and maintenance of an effective risk management system and process underpinning all strategic aims through seeking assurance in respect of the regular review of the corporate risks captured within the Board Assurance Framework. 2

105 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 NHS EAST LEICESTERSHIRE AND RUTLAND CCG GOVERNING BODY MEETING 19 January 2016 Summary report from the Chair of the CCG Audit Committee Summary and outcome of meeting 1. The CCG Audit Committee met in November The minutes for the September 2015 meeting were approved and are appended at Appendix The following provides a summary of the key areas of discussion during the November 2015 meeting, minutes for this meeting will be presented to the Governing Body at its next meeting: a) Counter Fraud progress report: an update was provided in relation to the completion of the Self-Assessment Review Toolkit (SRT). An overall amber rating was reported with a number of actions being identified by the Counter Fraud Service requiring follow up during the year, in order to mitigate risk and improve compliance levels. An action plan has been developed to monitor progress and evidence for future SRT updates/nhs Protect quality inspections. The Committee noted that actions were progressing well and there were no risks to escalate. b) External Auditors KPMG: the External Auditors presented the External Audit progress report. It was noted that confirmed that meetings with CCG staff have taken place to discuss relevant current and emerging issues in respect of the accounts and value for money conclusion. c) Internal Audit Progress Report: the regular report was presented providing an update on progress against the Internal Audit Plan for 2015/16 which is progressing well. Attention was drawn to the Cyber Security and Risk Survey Benchmarking Report booklet which highlights issues around the current level of understanding of cyber security risks and how these are being addressed. A hard copy of the booklet has been provided to all members of the Governing Body for information. d) Follow-up of audit recommendations: this report by the management team was received and it was noted that audit recommendations are being completed in a timely manner. e) Primary Care Commissioning Committee Register of Conflicts and Actions taken: the Committee welcomed the first report on the register of conflicts from the Primary Care Commissioning Committee which detailed the steps taken within the Primary Care Commissioning Committee to manage the conflicts within the meetings. The Audit Committee will continue to receive this register at agreed intervals to seek assurance on the management of conflicts of interest. 3

106 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 f) Board Assurance Framework 2015/16: an updated version of the Board Assurance Framework 2015/16 was presented. The Executive Management Team have reviewed the corporate risks on the Board Assurance Framework to ensure they reflect the current Two Year Operating Plan. It was noted that there has been good progress with the Board Assurance Framework, one of the BAF risks was agreed to be closed and archived. g) Waiver of Standing Orders: the Committee received the updated report on waivers of standing orders and noted the contents. h) Losses and Special Payments: the report was noted. RECOMMENDATIONS The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report. 4

107 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 APPENDIX 1 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP Minutes of the Audit Committee meeting held on Wednesday 16 September 2015 at 10:00am in Meeting Room 1, East Leicestershire and Rutland CCG Office, Unit 2 & 3, Bridge Business Park, 674 Melton Road, Thurmaston, Leicester, LE4 8BL Present: Mr Warwick Kendrick Mr Alan Smith Dr Tabitha Randell In Attendance: Mr John Cornett Mrs Annette Tudor Mrs Carmel O Brien Mrs Donna Enoux Mrs Daljit K. Bains Mrs Khatiza Issa Independent Lay Member (Chair) Independent Lay Member Secondary Care Clinician Director, KPMG Deputy Director, 360 Assurance Chief Nurse and Quality Officer Chief Finance Officer Head of Corporate Governance and Legal Affairs Corporate Governance and Risk Officer (minutes) ITEM DISCUSSION LEAD RESPONSIBLE AC/15/76 Apologies Received: Mrs Yola Geen, Manager, KPMG AC/15/77 Declarations of Interest There were no declarations of interest made. AC/15/78 AC/15/79 Minutes of the Previous Meeting of ELR CCG Audit Committee held on Wednesday 15 July 2015: The minutes of the Audit Committee meeting held on Wednesday 15 July 2015 (Paper A) were approved as an accurate record. Matters Arising: Update on Actions The action log was reviewed (Paper B) and the following update was provided: AC/15/80 AC/15/65 Progress Report and Technical Update (KPMG) It was agreed with Mr Kendrick that Mrs Bains would share a copy of the NHS England CCG Bulletin and the CCG internal tracker with the members of the Audit Committee after the meeting in September Requested for action to be closed. Amendments to the Terms of Reference Mr Warwick Kendrick presented Paper C Audit Committee revised terms of reference. Mr Kendrick confirmed that that 5

108 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE the terms of reference have been reviewed by the Counter Fraud Specialist following the publication of the NHS Protect Standards. Mr Kendrick has asked Mr Tim Sacks (Chief Operating Officer) to provide a briefing on how conflicts of interest is being handled, as the Audit Committee should have sight of all conflict of interest decisions that have been made. Mrs Daljit Bains confirmed that a template for conflicts of interest will be presented at the next Primary Care Commissioning Committee following which the report is expected to be presented at the November 2015 meeting of the Audit Committee. Mr John Cornett requested that a bullet point be added into the terms of reference under External Audit in relation to a policy to be in place for any non audit work that External Audit undertake. Mrs Bains confirmed that that this is covered within the CCG s Constitution. Mr Kendrick confirmed that subject to amendments, the amended terms of reference will be presented for approval at the next Governing Body meeting in November It was RESOLVED to: AGREE the amendments to the terms of reference for onward approval by the Governing Body.. AC/15/81 Annual Report from Chair of Audit Committee to the Governing Body Mr Kendrick presented the Draft Annual Report from the Audit Committee Chair to the Governing Body (Paper D). Mr Kendrick informed that the Audit Committee is required to produce an Annual Report to the Governing Body which contains an overview of the principal areas of review and demonstrates how the Committee has discharged its responsibilities and met its terms of reference. The Annual Report for the CCG s Audit Committee covers the period 1 April March Mr Smith commented that for paragraph 3 to add in that the extraordinary meeting took place to approve the final accounts. Mrs Annette Tudor suggested that an assurance table could 6

109 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE be appended with the list of Internal Audit reviews undertaken and the level of assurance provided. Mrs Bains informed that she will also add in a paragraph regarding the updated Counter Fraud Standards. It was agreed that Mrs Bains to make the amendments as discussed. Mrs Bains It was RESOLVED to: AGREE the Annual Report from Chair of Audit Committee for presentation to the Governing Body. AC/15/82 Progress Report (KPMG) Mr John Cornett presented the External Audit progress report and technical update (Paper E). Mr Cornett confirmed that planning work for the audit is continuing, and that further discussions with officers at the CCG will take place to identify key issues that will contribute to the planning approach. Mr Cornett referred the Committee to Appendix A (Technical update) and highlighted two documents which may be helpful to read: Guidance for Audit Committees and UKG: Lord Rose s report. Better leadership for tomorrow NHS Leadership Review. It was RESOLVED to: RECEIVE the Progress report and Technical update. AC/15/83 Internal Audit Progress report Mrs Annette Tudor, Deputy Director, 360 Assurance, presented the Internal Audit progress update and drew attention to the audit work completed and further work that is currently ongoing / planned. Mrs Tudor confirmed the following reports have been issued since the last Audit Committee meeting: 2014/15 Plan: - Primary Care Payments Community Based Services (Significant assurance) - Patient Experience (Full assurance) 2015/16 Plan - Patient and Public Engagement (Significant assurance) 7

110 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE It was noted that the follow-up review for Quality Monitoring in Care Homes (1314/ELRCCG/09/F) has been issued and that the Audit Committee should now seek direct assurance regarding the implementation of the two outstanding actions. Mrs Carmel O Brien confirmed that the Identification & Monitoring of QIPP Schemes planning meeting should include both the Chief Finance Officer and the Chief Strategy Officer. Mrs Tudor confirmed that the Conflicts of Interest review is to commence as soon as the information is received from the CCG, and would like the Audit Committee members input into this audit review. Mr Alan Smith raised whether an Information session on Conflicts of Interest can be arranged for the Governing Body, as this area needs to be understood by all. Mrs Daljit Bains informed that she had already alerted the Managing Director and the Chair to this. Mrs Tudor highlighted the Developments and Updates, and informed that the Cyber Security Survey has been provided to the CCG for circulation to all Governing Body members to undertake and the closing date for responses was 4 September Assurance will be capturing responses within a benchmarking report that will highlight the current level of understanding of risk to security and how these are being addressed. Mrs Tudor referred the Committee to Appendix A Key Performance Indicators, as part of the ongoing programme of improvement and the delivery of the Internal Audit plan and current performance against the targets. The Committee approved the proposed Key Performance Indicators. Mrs Tudor informed that in May 2015, 360 Assurance won the CIPFA Public Services Audit Award 2015, and has also been awarded the Institute of Internal Auditors (IIA) Outstanding Team Public Sector Award for The Committee congratulated Mrs Tudor and the team at 360 Assurance. Mrs Tudor continued with the rest of the progress report. 8

111 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE It was RESOLVED to: RECEIVE the Internal Audit Progress Report. APPROVE the Key Performance Indicators AC/15/84 Follow up of Audit Recommendations (management report) Mrs Daljit K Bains informed that Paper G is the management s response to internal audit findings providing assurance in respect of actions being tracked and implemented. Appendix 1 shows the current position and progress in implementing Internal Audit recommendations. It was noted that Internal Audit has issued the follow-up report for the Quality Monitoring in Care Homes and have closed the review. However there are two outstanding actions which Audit Committee need to seek assurance of. Mrs Carmel O Brien commented that she will need to consider the two remaining actions as with the collaborative arrangements being changed and Arden and GEM CSU contracting team are moving to ELR CCG, the actions may not be relevant and may be superseded. It was noted that the following audit review reports relating to the audit plan for and the audit plan for have been issued and Significant Assurance has been provided: - Primary Care Payments Community Based Service - Patient and Public Engagement It was RESOLVED to: RECEIVE the Follow up of Audit Recommendations (management report). AC/15/85 The Financial Control Environment Assessment self-assessment (as submitted to NHSE in August) Mrs Donna Enoux provided a summary of Paper H (Financial Control Environment Assessment). Mrs Enoux informed that NHS England wrote to all CCGs in July 2015 to request completion of a Financial Control Environment Assessment. ELRCCG completed their Financial Control Environment Assessment in July/early August and attended a meeting with NHS England on 17 August 2015 to discuss and finalise the scoring in each of 9

112 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE the 18 areas before submitting the final template on 31 August The meeting was attended by the Chair of the Audit Committee, Chief Finance Officer and Deputy Chief Finance Officer who met with senior members of the NHS England Finance Team. ELRCCG had initially scored areas as the following: - Excellent 10 - Good 7 - Moderate 1 - Improvement needed nil Discussion on each of the areas with NHS England resulted in the revised scoring below which reclassified four of the excellent areas to good : - Excellent 6 - Good 11 - Moderate 1 - Improvement needed nil The overall scoring of ELRCCG was considered good by NHS England. The actions to improve financial governance arrangements are already being implemented. Mrs Enoux referred the Committee to Appendix A, which was the final return submitted to NHS England. Mr Kendrick congratulated the Finance team for their work towards this assessment. It was RESOLVED to: RECEIVE The Financial Control Environment Assessment, self-assessment. AC/15/86 The updated Board Assurance Framework and Directorate Risk Registers Mrs Carmel O Brien provided a summary of Paper I (the Board Assurance Framework and the Directorate level risk registers) update. Mrs O Brien informed that the content of the BAF has been reviewed by the Executive Management Team (EMT) in August 2015 and that further updates are expected by end September 2015, Mrs O Brien referred the Committee to 10

113 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE Appendix 1 and stated that amendments made to the document have been highlighted in red. Discussions took place regarding the BAF risks, the following points were discussed: - BAF Risk 3 Mrs O Brien confirmed the residual risk is at 12 (Amber) as currently there is no evidence to support this yet. - BAF Risk 5 The risk category should be Quality and Financial and the gross inherent risk rating to be 4x4=16 = Red. - BAF Risk 6 It was noted that currently investments are being looked at and assurance is not in place yet. - BAF Risk 10 Mrs Enoux confirmed the net residual risk still remains high at 5x4=20 (Red) until outcomes of controls in place can begin to be evidenced in the financial position. - BAF Risk 12 It was noted to review the risk rating scores for this risk. Mrs Bains drew the Committee s attention to Appendix 2 which provided a mapping of the risks from the 2014/15 Board Assurance Framework to the 2015/16 Board Assurance Framework. The purpose of the mapping was to enable the Committee to track where risks had been archived, superseded, evolved or remained the same in the new version of the Board Assurance Framework. Mrs Bains also referred the Committee to the summary of amendments across the directorate level risk registers as detailed within Table 1. It was noted that in line with review of the Board Assurance Framework, directorate level risk registers are being reviewed and therefore some registers were not attached. It was noted that there has been good progress with the Board Assurance Framework, however some lead officers are not meeting deadlines for updating the documents and it was suggested that Mr Kendrick write to Chief Officers reminding them that the Board Assurance Framework and directorate risk registers must be completed and kept up to date. Mr Kendrick / Mrs Bains It was RESOLVED to: RECEIVE the updated Board Assurance Framework and directorate level risk registers. 11

114 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE AC/15/87 Waiver of Standing Orders Mrs Donna Enoux, presented the waiver of standing orders in relation to the procurement of goods and services (Paper J), and informed the Committee that there have been no new waivers of standing orders to report for the period ended 16 September Mrs Enoux informed that an action related to Waivers is recommended within the Primary Care Payments Community Based Services Internal Audit review. Mrs Tudor asked Mrs Enoux to liaise with her colleagues at 360 Assurance and to close down the action. Mrs Enoux It was RESOLVED to: RECEIVE the report for the period ended 16 September AC/15/88 Losses and Special Payments Policy Mrs Donna Enoux presented the Losses and Special Payments Policy and informed that the policy was previously inherited from the PCT. The policy has recently been reviewed to ensure it is current and accurately reflects the CCGs financial policies. In a response to Mr Kendrick s query, Mrs Enoux explained that fruitless payments is a payment for which liability ought not to have been incurred, or where the demand for the goods and service in question could have been cancelled in time to avoid liability. Even though fruitless payments will be legally due to the recipient they are to be classed as losses since no benefit will have been received in return. In a response to Mr Alan Smith s query, Mrs Enoux confirmed that the Governing Body and the Audit Committee will be informed of losses written off and special payments authorised by officers. Power to write off losses and make special payments will normally be exercised by two or more nominated senior officers and within delegated limits set by the Governing Body of above 250,000, this limit has been cross referenced to the Scheme of Delegations. The Committee approved the Losses and Special Payments Policy. It was RESOLVED to: APPROVE the Losses and Special Payments Policy. 12

115 Paper I East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 ITEM DISCUSSION LEAD RESPONSIBLE AC/15/89 Losses and Special Payments Report Mrs Donna Enoux presented Paper L, a report detailing losses and special payment, and informed the Committee that there have been no write offs approved or actioned up to 16 September It was RESOLVED to: RECEIVE the report for the period ended 16 September AC/15/90 AC/15/91 Any Other Business No further items of business were discussed. Date of Next Meeting The next meeting of the Audit Committee to take place on Wednesday 18 November 2015, 10:00am 12:30pm, Meeting Room 1, ELR CCG. 13

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118 Paper J East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Front Sheet REPORT TITLE: Summary Report from the Quality and Performance Committee December 2015 MEETING DATE: 19 January 2016 REPORT BY: SPONSORED BY: PRESENTER: Khatiza Issa, Corporate Governance & Risk Officer Carmel O Brien, Chief Nurse and Quality Officer Dr Tabitha Randell, Secondary Care Consultant (Chair) PURPOSE OF THE REPORT: The purpose of this report is to provide a summary of the items for escalation from the Quality and Performance Committee for consideration by the Governing Body and to ensure that the Governing Body is alerted to emerging risks or issues. RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report and note the risks and issues highlighted. REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of life for people with long-term conditions Improve the quality of care clinical effectiveness, safety and patient experience Reduce inequalities in access to healthcare Improve integration of local services between health and social care; and between acute and primary/community care. Listening to our patients and public acting on what patients and the public tell us. Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that the individual reports, policies and strategies presented to the Committee are equality impact assessed as appropriate. This completes the due regard required. 1

119 Paper J East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The report aligns to the following risks in the Board Assurance Framework: BAF 1 - The quality of care provided by acute providers does not match commissioner s expectation with respect to quality and safety. BAF 2 - The quality of care provided by non-acute providers does not match commissioner s expectation with respect to quality and safety. BAF 3 - The quality of care provided by primary care providers does not match commissioner s expectation with respect to quality and safety. BAF 8 - Increased pressure on the Emergency Department which could result in sub-optimal care due to ability to access urgent care services. 2

120 Paper East Leicestershire and Rutland Governing Body Meeting EAST LEICESTERSHIRE AND RUTLAND CLINCIAL COMMISSIONING GROUP GOVERNING BODY MEETING 19 January 2016 Summary Report from December 2015 Quality and Performance Committee Introduction 1. The purpose of this report is to provide a summary of the items for escalation from the Quality and Performance (Q&P) Committee for consideration by the Governing Body and to ensure that the Governing Body is alerted to emerging risks or issues. 2. The Committee agreed that the following quality and performance issues be brought to the attention of the Governing Body. Patient Safety and Infection Control Quarter 1 and 2 update 3. The Committee received the Patient Safety update for quarters 1 and 2 and a summary of the number and type of incidents reported was provided. 4. It was noted by the Committee that the NHS England new Serious Incident reporting framework has been introduced and commissioners and providers are working together to introduce the changes described in the framework. 5. Update on Healthcare Associated infections was provided and the analysis and themes were described. It was noted that ELRCCG had 2 cases of MRSA BSI reported, following a Post Infection review no care failings were identified in any of the cases. 6. It was highlighted to the Committee that the trajectories for Clostridium Difficile infection (CDI) for ELRCCG is over, however the Infection Control Nurse is continuing to review all positive and negative cases. 7. It was noted under the mandatory reporting requirements UHL and LPT continue to report the number of E.coli and MSSA BSI cases, and currently there are increased numbers of E.coli. Nurse Revalidation 8. Update was provided to the Committee on the final revalidation process for all nurses and midwives and the implications for practices. From April 2016 all nurses and midwives who are due to re-register will start using the new revalidation process. 9. The Committee notes that various pieces of information have been shared with all Practice Nurses via setting out details as and when available. The Chief Nurse and Deputy Chief Nurse have briefed nearly all practice nurses during visits to those practices that have taken up the offer of a visit. 10. The Committee highlighted that all member practices are encouraged to ensure that their employed nurses have available opportunities to support revalidation and have steps to achieve this. 3

121 Paper East Leicestershire and Rutland Governing Body Meeting PYLL Deep Dive 11. The Committee received the report on the Deep Dive of the target and current position of Potential Years of Life Lost (PYLL). 12. It was noted by the Committee that the PYLL measure for ELRCCG increased between 2013 and 2014, however this change was not statistically significant and ELRCCG are not significantly an outlier. 13. ELRCCG has consistently remained under the national average for the initial targets set by NHS England. It has to be acknowledged that there was a rise in the PYLL figure in 2014 and further considerations should be made to understand this. All the local plans, including GP support and investment framework, Better Care Together and Better Care Fund link to this target. As these programmes are further rolled out there should be an improvement on this target too. 14. The Committee agreed for the PYLLs data to be looked further and take forward by nominated leads. CCG Performance Report 15. The Committee received the Performance Assurance report which provided an overview of performance for ELR CCG and LLR data available for October It was confirmed there have been no changes to the RAG ratings this month in the overall rating but some shifts in actual performance. 16. The Committee noted that there has been a change of one indicator from Blue to Green within the NHS Outcomes Framework. 17. The Committee requested for the indicator ELR level EMAS to be taken off the report as it is not a corporate standard. QIPP Monitoring Dashboard 18. The Committee received a report which provided an overview of ELR CCG s position against 2015/16 QIPP Plan for month The Committee received the new QIPP Dashboard report for review and comment, and was informed that the intention is to move to the new template for all QIPP reporting across the subcommittees of the Board and to the Local Area Team 20. The QIPP schemes which were RAG rated red were highlighted to the Committee. 21. The Committee was informed that there have been recommendations in NHS guidance for the way QIPP is to be looked at and delivered next year. 22. The Committee agreed to escalate the above concerns to the Governing Body. RECOMMENDATIONS The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report and note the risks and issues highlighted. 4

122 Paper J East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Front Sheet REPORT TITLE: Summary Report from the Quality and Performance Committee January 2016 MEETING DATE: 19 January 2016 REPORT BY: SPONSORED BY: PRESENTER: Jayshree Raval Corporate Affairs Officer Carmel O Brien, Chief Nurse and Quality Officer Dr Tabitha Randell, Secondary Care Consultant (Chair) PURPOSE OF THE REPORT: The purpose of this report is to provide a summary of the items for escalation from the Quality and Performance Committee for consideration by the Governing Body and to ensure that the Governing Body is alerted to emerging risks or issues. RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report and note the risks and issues highlighted. REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of life for people with long-term conditions Improve the quality of care clinical effectiveness, safety and patient experience Reduce inequalities in access to healthcare Improve integration of local services between health and social care; and between acute and primary/community care. Listening to our patients and public acting on what patients and the public tell us. Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that the individual reports, policies and strategies presented to the Committee are equality impact assessed as appropriate. This completes the due regard required. 1

123 Paper J East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: The report aligns to the following risks in the Board Assurance Framework: BAF 1 - The quality of care provided by acute providers does not match commissioner s expectation with respect to quality and safety. BAF 2 - The quality of care provided by non-acute providers does not match commissioner s expectation with respect to quality and safety. BAF 3 - The quality of care provided by primary care providers does not match commissioner s expectation with respect to quality and safety. BAF 8 - Increased pressure on the Emergency Department which could result in sub-optimal care due to ability to access urgent care services. 2

124 Paper J East Leicestershire and Rutland Governing Body Meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINCIAL COMMISSIONING GROUP GOVERNING BODY MEETING 19 January 2016 Summary Report from January 2016 Quality and Performance Committee Introduction 1. The purpose of this report is to provide a summary of the items for escalation from the Quality and Performance (Q&P) Committee for consideration by the Governing Body and to ensure that the Governing Body is alerted to emerging risks or issues. 2. The Committee agreed that the following quality and performance issues be brought to the attention of the Governing Body. Patient Experience Update Quarter 3 3. The Committee received a quarter 3 update in relation to listening to and acting upon the patients experience. ELR CCG has set out to develop an engagement strategy that would ensure that the patient voice is at the heart of the CCG and secure continuous improvements in the quality of services commissioned. 4. We are listening project involves taking an ELR CCG branded listening booth out and about across East Leicestershire and Rutland so that patients, public and carers can talk about their experiences in terms of the service and care received from their local healthcare. The plan will be to continue to visit all areas of the CCG in each 3 month period 5. Between October and December 2015, the ELR CCG listening booth visited 11 locations and feedback from these visits have been collated to build themes and trends and look at potential improvements. Care home residents and housebound 6. Overall, feedback from the public is very positive. The main concern in primary care was ability to book appointments with the GP but when patients were seen, they were happy with their care. Comments will be fed back to individual practices as relevant. Experience of secondary care was also generally very good, primarily referring to UHL. Main themes of concern with UHL were around waiting times, parking and communication/staff attitudes. These have also been passed on to UHL. 7. A number of patient stories have been sourced through the listening booth events and these will be shown at future Governing Body meetings. LLR General Practice Workforce Delivery Group update 8. The Committee received an update on LLR General Practice Workforce Delivery Group update. 3

125 Paper J East Leicestershire and Rutland Governing Body Meeting 19 January The Committee was informed that the Delivery Group has achieved the following for workforce developments in General Practice since the last update: Promote fellowship opportunities to attract newly qualified GP trainees to LLR. Development of transition training module for HCAs into Nursing. Implementation of non-medical prescribing courses and Advanced Nurse Practitioner (ANP) courses for practice nurses, plus some additional funding to support extra training for nursing staff. 10. The Committee was informed that the delivery group will continue to identify opportunities to optimise the available workforce within the existing constraints, taking advantage of regional initiatives through its relationship with HEEM and will continue to report on risks and progress. 11. The committee also wished to acknowledge the fact that primary care had continued to function as normal during the junior doctors strike, with the right for GP trainees to take industrial action fully recognised by all clinical members of the committee. The committee was reassured that patient care had not been compromised in primary care. Performance Assurance Report 12. The Committee received the Performance Assurance report which provided an overview of performance for ELR CCG and LLR on data available for November The Committee was informed that the everyone counts dashboard did not indicate any changes in ratings since August It was agreed that the performance report to be amended for future Quality and Performance meetings to provide a more succinct report and that this would be best achieved with input from the relevant clinical leads. Dr Purohit volunteered to provide a general clinical overview of the report, with Dr Varakantam specifically reviewing the cancer updates. 15. The committee noted that ELR performance for IAPT has improved although it still remains under the national target for referrals but above the national average for successful outcomes. NHS111 referral rates to ED remain above target and have increased, which is a concern. A query will be raised via the contract route. QIPP Monitoring Dashboard 16. The Committee received a report which provided an overview of ELR CCG s position against 2015/16 QIPP Plan for month The Committee received a detailed dashboard which detailed activity at month 7. Greater East Midlands Commissioning Support Unit (GEMCSU) has delivered a workshop to share new reporting to support QIPP monitoring and development of future QIPP schemes. 18. The Committee were asked to note that the QIPP schemes are on track. 4

126 Paper J East Leicestershire and Rutland Governing Body Meeting 19 January The Committee agreed to escalate the above concerns to the Governing Body. RECOMMENDATIONS The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the report and note the risks and issues highlighted. 5

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129 Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Front Sheet REPORT TITLE: Performance Assurance Report MEETING DATE: 19 th January 2016 REPORT BY: SPONSORED BY: Carrie Harris, Performance Manager (Arden & GEM) Jane Chapman, Chief Strategy & Planning Officer PURPOSE OF THE REPORT: This report provides an overview of performance for East Leicestershire & Rutland CCG and LLR where data is available for November RECOMMENDATIONS: The East Leicestershire and Rutland CCG Board is requested to: NOTE the contents of the report and APPROVE the documents attached. REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of life for people with longterm conditions Improve integration of local services between health and social care; and between acute and primary/community care Improve the quality of care clinical effectiveness, safety and patient experience Listening to our patients and public acting on what patients and the public tell us Reduce inequalities in access to healthcare Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement) EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report as it is judged that it is not proportionate on the basis that the Performance Assurance reporting underpins the commissioning strategy and priorities of the CCG. This completes the due regard required. RISK ANALYSIS AND LINK TO BOARD ASSURANCE FRAMEWORK: This report aligns to 1.1 Failure to meet performance against targets due to limited capacity to deliver resulting in deteriorating position and inability to demonstrate good 1

130 performance. Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January Purpose of the Report (including link to objectives) This report provides an overview of Performance for 2015/16. It is based on national guidance and covers indicators within Everyone Counts Guidance, the NHS Outcomes Framework, the Quality Premium and the Quality Dashboard. 2. Recommendations The Governing Body members are asked to: Note current performance. The report provides a dashboard and reports indicators by exception, with additional detail and improvement narrative provided where performance is below expected levels. Please note the format and content of this report is currently under review. 3. Background As part of the performance and planning cycle for 2015/16, guidance was published by NHS England. This guidance ensures that service levels are maintained or improved following local strategic intentions, and standards or targets are in place. It provides the focus for NHS England s Area Team assurance process during the year. The performance report is the vehicle to ensure that an appropriate governance and assurance process is in place for CCGs. It is in development, and where data is available at CCG level this will be populated. The report focuses on a set of dashboards covering: Everyone Counts Guidance NHS Outcomes Framework Quality Premium Better Care Fund Where standards or targets are not being achieved, these high risk exceptions will be documented in depth, including monthly activity levels and action plans being undertaken either by service providers, commissioners or CCGs. A performance comparison for 4 Trusts used by ELR patients (UHL, Peterborough, Kettering, and Coventry and Warwickshire) is also included in the report. 2

131 Everyone Counts Dashboard Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 This dashboard contains the NHS Constitution indicators, and a number of other targets/plans that need to be achieved by the health economy. It also covers some local priorities for the CCG such as End of Life and the position of NHS 111. As at November the position is as follows: Indicator RAG Rated for November 2015 Red Amber Green Blue Previous month: Indicator RAG Rated for October 2015 Red Amber Green Blue NB Blue indicates an indicator where data is not yet available As at November 2015, 23 out of 57 indicators monitored failed (red) and 8 are RAG rated amber. There have been no changes to the RAG ratings since August 2015 but some shifts in actual performance. Red Indicators Potential years of life lost (PYLL) from causes amenable to healthcare Target = Health related quality of life for people with long term conditions The CCG did not achieve a reduction, an increase of 16.27% was observed between 2013 and National target is for a 3.2% reduction year-on-year from A deep dive into this indicator is in progress. 2013/ /15 The target of 76.8 was not met in 2014/15. GPs will continue to monitor their work to ensure all patients with Long Term 2014/15 Target = 76.8 Conditions are appropriately managed. IAPT - Proportion of people that enter treatment against the level of need in the general population 14/15 Sept-15 Oct % 13.7% 14.1% 2015/16 Target = 16% Composite measure on emergency admissions Patient pathway is currently being reviewed. IAPT services are being taken over by a new provider. Smooth transition will be ensured via commissioner chaired meetings and monthly contract/performance management meetings. 14/15 Sept-15 Oct /16 Target = 116 per month Rate of emergency readmissions within 30 days Urgent care action plan has been updated to focus on actions over the next 3 months and focusses on admission avoidance and flow & discharge. 14/15 Sept-15 Oct

132 Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January /16 Target = Reduction to 14/15 Composite indicator comprised of (i) GP services and GP out of hours 2013/ / /15 Target = 5.8 Estimated diagnosis rate for people with dementia 2014/15 Oct-15 Nov % 59.2% 59.1% 2015/16 Target = 66.7% Cancer 31 Day Waits - Surgery 14/15 Sept-15 Oct % 86.9% 88.0% 2015/16 Target = 94% Cancer 62 Day Waits Urgent GP referral 14/15 Sept-15 Oct % 78.4% 77.0% 2015/16 Target = 85% EMAS Category A (Red 2) 8 mins Provider Level 2014/15 Oct-15 Nov % 68.63% 66.97% 2015/16 Target = 75% Mixed Sex Accommodation 14/15 Oct-15 Nov (YTD) 2 (YTD) 2015/16 Target = 0 The performance of the composite indicator for GP services and GP out of hours has remained static between 13/14 and 14/15, however as an improvement was required the indicator has been RAG rated red. Dementia figures now feature on practice profile dashboards. Lower performers are being contacted via phone. Multi agency care planning workshops are being held. The Cancer action plan aims to address the step-down of patients from Intensive Care, to pull Cancer patients through the system more quickly. Additional clinical staff in Head and neck, Urology and Dermatology will impact positively on performance. The UHL detailed Rapid Action Plan includes actions to improve performance of the 62 day waits. UCC Loughborough clinicians to ride with EMAS crews to promote referrals to UCCs during Dec-Jan. An eight-week action plan has been agreed to speed up handover at LRI. 2 breaches occurred in July. These breaches occurred at Medway Maritime Hospital in Kent. Cancelled operations % of patients not re-admitted within 28 days No breaches occurred in November 14/15 Oct-15 Nov % 98.0% 98.3% 2015/16 Target = 100% Number of 52 week Referral to Treatment Pathways 14/15 Aug-15 Sept /16 Target = 0 The breach in September was in Urology. The RTT team have since carried out refresher training sessions to ensure all staff all have up to date knowledge of the RTT processes. 4

133 UHL Ambulance handover time: 30 minutes / 60 minutes 30 Mins 14/15 Oct-15 Nov % 21.4% 21.8% 2015/16 Target = 0% 60 Mins 14/15 Oct-15 Nov % 11.4% 12.5% 2015/16 Target = 0% Crew clear delays: 30 minute / one hour 30 mins 14/15 Oct-15 Nov-15 N/A 3.3% 3.5% 2015/16 Target = 0% 1 hour 14/15 Oct-15 Nov-15 N/A 0.7% 0.9% 2015/16 Target = 0% Satisfaction with the Quality of Consultation at a GP Practice Satisfaction with the Overall Care received at Surgery Quality of Consultation at a GP Practice Jan 14 Jul14-Mar15 Sep /15 Target = 446 Overall Care received at Surgery Jan 14 Sep14 Jul 14- Mar15 86% 85% 2014/15 Target = 86.8% Overall experience of NHS Dental Services Jan 14 Sep14 Jul 14- Mar15 84% 83% 2014/15 Target = 84% Access to GP Services Jan 14 Sep14 Jul 14- Mar15 74% 72.4% 2014/15 Target = 74% Access to NHS Dental Services Jan 14 Sep14 Jul 14- Mar15 96% 95% 2014/15 Target = 96% Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 An eight-week action plan has been agreed to speed up handover times at LRI. Proposals include improving processes at A&E and assessment bays, improving patient flow, speeding up discharge processes and continued work to tell patients the importance of getting medical help before their condition needs A&E treatment. The CCG are contacting the underperforming practices to discuss how they can be supported to improve the position for the next data release. The results will also be cross referenced with the practices FFT scores, complaints data and feedback received through the CCG Listening booth to look for trends and areas for improvement. Proportion of people that wait 6 weeks or less from referral to completing a course of IAPT treatment ELR performance has improved although 14/15 Aug-15 Sept-15 remains under the national target. Actions to N/A 43% 44% improve performance include a pathway 2015/16 Target = 75% review being undertaken to ensure 5

134 NHS111 Final Disposition A&E NHS111 Final Disposition Primary/Community care Final Disposition A&E 2014/15 Oct-15 Nov % 7.9% 8.6% 2015/16 Target = 5% Final Disposition Primary/Community care 2014/15 Oct-15 Nov % 47.8% 47.6% 2015/16 Target >=55% Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 appropriate patients are referred to the service and patients are discharged in a timely manner. NHS111 continue to fail to comply with the indicators and this is being considered and reviewed within the new National Metrics and the revised specification for the NHS 111 will be used for the procurement. A&E Waiting Time 2014/15 23 rd Nov th Dec % 90.25% 89.42% 2015/16 Target = 95% National target is not being achieved. This is primarily driven by record ED attendances and emergency admissions but has also been contributed to by staffing issues. Work has started on building a larger ED to meet demand. This is due to be completed by December Full action plan monitored at Urgent Care Board. AMBER INDICATORS Diagnostic Test Waiting Time 2014/15 Aug-15 Sept % 93.9% 93.4% 2015/16 Target = 99% Cancer 2 Week Wait 2014/15 Sept-15 Oct % 89.7% 90.0% 2015/16 Target=93% EMAS Category A (Red 1) 8 mins Provider Level The Trust is working with a number of IS providers to obtain extra capacity. The extra capacity is working alongside a robust action plan aimed at addressing general performance issues in Gastroenterology UHL is working intensively with the Endoscopy Department to address the current underperformance. UHL is working with CCGs to improve the quality of 2WW referrals. 2014/15 Oct-15 Nov % 72.72% 71.78% 2015/16 Target = 75% EMAS Category A19 minute transportation time 2014/15 Oct-15 Nov % 91.06% 91.26% 2015/16 Target = 95% UCC Loughborough clinicians to ride with EMAS crews to promote referrals to UCCs during Dec-Jan. An eight-week action plan has been agreed to speed up handover at LRI. Number of primary care completed care plans in care homes 2014/15 Q1 15/16 Q2 15/16 N/A 76.75% 78.0% 2015/16 Target = 97% 6 Care Home care planning forms part of the GP Support and Investment Framework for 2015/16. GPs will continue the work from 2014/15 GP Support and Investment

135 NHS111: Calls answered within 60 seconds 2014/15 Oct-15 Nov % 94.40% 94.1% 2015/16 Target = 97% Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 Framework for all care home patients to have a care plan. For Q2 three practices have not yet submitted their data, but data received has shown increase in care plans. NHS111 continue to fail to comply with the indicators and this is being considered and reviewed within the new National Metrics and the revised specification for the NHS 111 will be used for the procurement. The remaining indicators are either Green or are awaiting publication of data. Details of delivery actions are in the attached KPI report on pages NHS Outcomes Framework There are 77 indicators within the NHS Outcomes Framework. Data for many of these will be published throughout 2015/16 as detailed in the KPI report. Baselines and plan for 2015/16 have been populated where available, or a target is highlighted indicating Higher or Lower than the baseline. As at November 2015, the position is as follows: Indicator RAG Rated for November 2015 Red Amber Green Blue Previous month: Indicator RAG Rated for October 2015 Red Amber Green Blue Domain 1 Preventing people from dying prematurely Page 15 Red Amber Green Blue Data for 2 indicators has been published this month: Neonatal mortality and Stillbirths, and 1 year survival from all cancers. These are both achieving the required targets. All other indicators remain unchanged Domain 2 Enhancing quality of life for people with long term conditions Page 16 Red Amber Green Blue Data for Employment of people with mental illness has been published. As the difference in employment rate between England population and people with mental illness has increased the indicator has not achieved required levels, and is therefore rated red. All other indicators remain unchanged Domain 3 Helping people to recover from episodes of ill health or following injury Page 17 7

136 Red Amber Green Blue Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 The position for these indicators remain unchanged Domain 4 Ensuring people have a positive experience of healthcare Page 18 Red Amber Green Blue The position for these indicators remain unchanged Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm Page 19 Red Amber Green Blue Quality Premium 2014/15 The position for these indicators remain unchanged The Quality Premium for 2014/15 is included on page 20 of the KPI report. Data has been populated based on the 14/15 outturn positions. The estimated value of the Quality Premium is 177,188. Quality Premium 2015/16 The Quality Premium for 2015/16 is included on page 21 of the KPI report. Provisional data for 2015/16 has been populated where data is available. The CCG is currently in the position to receive 330,750 In September 2015 it was provisionally confirmed by the NHS England Area Team that only the RTT Incomplete target would be used for the Quality Premium calculation and would be worth 30% of funding (Instead of 10% each for Admitted, Non-admitted and Incomplete). Therefore this change has been reflected in the Quality Premium 2015/16 calculations. Trust Level Comparison The trust level comparison table provides A&E, Cancer and RTT data for UHL, Kettering, Peterborough, UHCW and NUH hospitals on page 22. National data is used in this section to ensure that the reporting period is aligned across the Trusts therefore the data and RAG ratings for UHL may differ in this section to the main body of the report. Please note that data for A&E is a monthly snapshot of data, the data is not a cumulative position for the year. Better Care Fund Leicestershire County Council - Position as at Q2 2015/16 RED INDICATORS Metric 6: Emergency admissions for injuries due to falls in people aged 65 and over: Performance is showing that emergency admissions are reducing but the target has not yet been met 8

137 Sept 2015 Red Amber Green Blue Paper K East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 AMBER INDICATORS Metric 4: Total non-elective admissions into hospital: Performance shows admissions are reducing based on provisional data, which suggests performance is going in the right direction Metric 5: Patient service user experience: Current data shows a decline in patient/service user satisfaction, further data will be published in March 2016 Rutland County Council - Position as at Q2 2015/16 Sept 2015 Red Amber Green Blue The 2 blue indicators do not have data available due to these being published annually. Please see tables on page 23. 9

138 East Leicestershire and Rutland CCG Governing Body Performance Report, January 2016 (Reporting period - November 2015) 1 of 23

139 TABLE OF CONTENTS SECTION 1 HIGH RISK EXCEPTIONS Everyone Counts Potential Years of Life Lost 3 Increase the quality of life for people with long term conditions 3 IAPT access 3 Dementia 3 Composite measure on avoidable emergency admissions 4 Rate of Emergency Readmissions within 30 Days of Discharge 4 Diagnostic test waiting times 4 A&E 4 hour waiting time 5 Cancer 2 week wait 5 Cancer 31 day wait 6 Cancer 31 day wait - surgery 6 Cancer 62 day waits 6 EMAS category A (Red 1) 8 minute response time 7 EMAS category A (Red 2) 8 minute response time 7 EMAS category A 19 minute transportation time 7 Mixed Sex Accomodation 7 Cancelled operations 8 52 week waits 8 Ambulance Handover times 8 Crew clear 9 Satisfaction with the Quality of Consultation at a GP Practice 9 Satisfaction with the Overall Care Received at Surgery 9 Satisfaction with the Overall experience of Dental Services 9 Access to GP Services 9 Access to Dental Service 9 Care Home patients with a Primary Care Care-plan 9 Employment of People with Long Term Conditions 9 Antibiotic Prescribing 10 SECTION 2 SECTION 3 EVERYONE COUNTS DASHBOARD This framework/dashboard details the key performance indicators that the CCG will monitor with providers and partners in local government to ensure sustainable high quality care for all. NHS OUTCOMES FRAMEWORK This framework provides an overview of how well the NHS is performing, and is the primary accountability mechanism for the CCGs with NHS England focusing on health outcomes. There have been a number of changes from 2014/15 framework, and these have been included SECTION 4 QUALITY PREMIUM 2014/ /16 21 SECTION 5 TRUST LEVEL COMPARISONS This dashboard shows a comparison between the main ELR providers 22 SECTION 6 BETTER CARE FUND Leicestershire County Council 23 Rutland County Council 23 2 of 23

140 SECTION 1 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP EVERYONE COUNTS KEY PERFORMANCE INDICATORS - HIGH RISK EXCEPTIONS 2015/16 Indicator RAG Rated for November 15 R A G B EA1 Potential years of life lost (PYLL) from causes considered amenable to healthcare (also part of 1a of the Outcomes Framework) Definition: Measures the numbers of years of life lost by every 100,000 persons dying from a condition, which is usually treatable Indicator Standard Lower Threshold Latest Period YTD Annual Trend Potential years of life lost (PYLL) from causes considered amenable to healthcare (2014) (2015) N/A 2014 Calendar year Target ELR This indicator identifies the number of years of life lost by every 100,000 persons dying from a condition which is usually treatable. It is measured in a way which allows for comparisons between populations with different age profiles and over time. The national target is to reduce by 3.2% between 2012 (baseline) and The CCG did not achieve a reduction, an increase of 16.27% was observed between 2013 and National target is for a 3.2% reduction year-on-year from A deep dive into this indicator is in progress. EA2: Increase the quality of life for people with long term conditions Definition: Health-related quality of life for people with long term conditions Indicator Standard Lower Threshold Latest Period YTD Annual Trend Health-related quality of life for people with long term conditions N/A 14/ /12 12/13 13/14 14/15 11/12 12/13 13/14 14/15 15/16 16/17 17/18 18/19 Target EL&R No new data from last month. This indicator measures the health-related quality of life for people who identify themselves as having one or more long-term conditions. Results for 14/15 were released in October 15, there has been a decline in the health-related quality of life for people with long term conditions, which is based on the GP Patient Survey. This is red rated, given that the standard has not been met in 14/15.Long term conditions are measured through the Support and Investment Framework for 2015/16 on a quarterly basis. GPs will continue their work to ensure that all patients with Long Term Conditions are appropriately managed EA3: IAPT Definition: IAPT Access - Proportion of people that enter treatment against the level of need in the general population Indicator Standard Lower Threshold Latest Period YTD Monthly Trend IAPT 16% N/A Oct % 20% 15% 10% 5% 0% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 16% 16% 16% 16% 16% 16% 16% 16% 16% 16% 16% 16% 16% 2014/15 EL&R Patients 15.96% 17.30% 11.43% 17.22% 13.04% 12.35% 14.26% 11.13% 8.39% 10.96% 13.00% 12.40% 13.10% 2015/16 EL&R Patients 13.30% 12.10% 13.50% 14.20% 13.90% 15.00% 16.30% 14.10% A pathway review is being undertaken to ensure appropriate patients are referred to the service and patients are discharged in a timely manner. The up take of self-referrals should increase as a result of engagement with GP s, community venues and adult social services. After a successful retendering exercise the Improving Access to Psychological Therapies service has been awarded to a new provider. LPT to work alongside the new service provider to ensure a smooth transition. The smooth transition of Improving Access to Psychological Therapies service between Leicestershire Partnership Trust and Nottinghamshire Healthcare NHS FT will be ensured through commissioner chaired transition meetings with both providers and through monthly contract and performance management meetings. EAS1: Dementia Diagnosis Definition: Estimated diagnosis rate for people with dementia Indicator Standard Lower Threshold Latest Period YTD Monthly Trend Dementia 67% N/A Nov % 80.00% 60.00% 40.00% 20.00% 0.00% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 66.7% 2014/ % 47.68% 48.47% 47.67% 47.10% 48.10% 47.91% 48.00% 49.40% 49.62% 50.34% 54.00% 54.00% 2015/16 Data not available 58.20% 58.60% 56.80% 58.40% 59.20% 59.10% 59.10% Dementia figures have now been added onto the practice profile dashboards and regular dementia communtions are sent to GP practice dementia leads and are included in the GP bulletin. Practices within the lowest quartile are being suppored via phone calls. The communications team are working on increasing the ELR dementia awareness profile strategy. Care planning workshops are being held and include multi agency stakeholders. Localised dementia services (health, social and voluntary sectors ) are being scoped to pull together service packs for practices. 3 of 23

141 SECTION 1 Composite Measure on Avoidable Emergency Admissions PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP EVERYONE COUNTS KEY PERFORMANCE INDICATORS - HIGH RISK EXCEPTIONS 2015/16 Definition: Composite indicator of -Unplanned hospitalisation for chronic ambulatory care sensitive conditions - Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s - Emergency admissions for acute conditions that should not usually require hospital admission -Emergency admissions for children with lower respiratory tract infections (LRTI) Indicator Standard Lower Threshold Latest Period YTD Monthly Trend Composite measure on avoidable emergency admissions (116 per month) 50 N/A Oct CH 26/10 0 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar FOT 2015/16 Plan /15 EL&R Patients for all providers /16 EL&R Patients for all providers A&E attendances and admissions remain higher than last year (5.0% and 8% respectively). The urgent care action plan has been updated to reflect actions to be delivered over the next 3 months focusing on admission avoidance, UHL & LPT flow & discharge. Pathway co-ordinators in Bed Bureau to divert GP admissions from 1st Nov. Primary Care Co-ordinators supporting Clinical Decisions Unit at Glenfield. LLR System-wide Urgent & Emergency care Vanguard transformation programmes agreed with NHS England. OF 3b: Rate of Emergency Readmissions within 30 Days of Discharge Indicator Rate of emergency admissions within 30 days of discharge Standard zero % change or a reduction from 2014/15 Lower Threshold N/A Latest Period Oct-15 YTD (Oct) (FOT) Trend Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar FOT 2015/16 Target /15 30 Day Readmission Rate /16 30 day Readmission Rate For actions see: Composite Measure on Avoidable Emergency Admissions EB4: Diagnostic Test Waiting Time Definition: Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral (All providers at EL&R CCG level) Indicator Patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral Standard Lower Threshold Latest Period YTD Trend 99% 94% Sept % 110% 105% 100% 95% 90% 85% 80% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 2014/15 EL&R patients at all providers 99.4% 99.3% 99.4% 99.2% 98.5% 99.1% 99.2% 98.4% 97.7% 95.3% 99.0% 98.1% 98.5% 2015/16 EL&R patients at all providers 97.7% 99.1% 94.7% 90.1% 88.4% 91.1% 93.4% Imaging A plan is well developed and part implemented to eradicate the Cardiac MRI issue and the impact of this are beginning to be felt. Unfortunately this will not be seen in full in October due to challenges with the scanners. In order to mitigate the impact of unplanned down time, the Imaging team are focusing on booking as early as possible in the month. Endoscopy The Trust is working with a number of IS providers to obtain extra capacity, including Medinet, Circle, Your World Doctors and Nuffield. The Trust will also be part of an initiative led by the Tripartite around securing extra capacity within the Independent Sector and other NHS Trusts for Endoscopy, UHL has submitted its requirements for this process but so far has obtained no extra capacity via this route. The extra capacity is working alongside a robust action plan aimed at addressing general performance issues in Gastroenterology, with particular focus on ensuring that all lists are fully booked and efforts to improve Cancer performance via access to Endoscopy tests. There has also been a management review in the department and an Endoscopy Manager has been appointed to focus solely on the service, in post since early September. 4 of 23

142 SECTION 1 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP EVERYONE COUNTS KEY PERFORMANCE INDICATORS - HIGH RISK EXCEPTIONS 2015/16 EB5: A&E Four Hour Waiting Time Definition: % Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department (Data is at UHL level) Indicator A&E Waiting Time - % of people who spend 4 hours or less in A&E Data is for all patients going into A&E at UHL Standard Lower Threshold 95% 90% Latest Period YTD 29/12/15 YTD Monthly Trend 89.42% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 2014/15 % of people who spend 4 hours or 86.92% 83.12% 89.15% 92.52% 91.26% 91.60% 89.47% 89.10% 83.09% 89.67% 89.34% 91.92% 88.70% less in A&E 2015/16 % of people who spend 4 hours or less in A&E 92.00% 92.22% 92.68% 92.28% 89.98% 90.32% 89.07% 81.73% 84.73% 89.42% National target is not being achieved. This is primarily driven by record ED attendances and emergency admissions but has also been contributed to by staffing issues. Work has started on building a larger ED to meet demand. This is due to be completed by December Full action plan monitored at Urgent Care Board.Single Front Door Streaming Service (introduced 3 November 2015). Updated joint EMAS / UHL protocol agreeing the process for patients who cannot be offloaded immediately from ambulances at the LRI site. Nursing numbers have been increased in main ED and paediatric ED. Paediatric and adult elective patients have been taken down in advance of the day of surgery to allow medical and emergency surgical outliers. Winter communications plan launched. Vanguard UEC proposition submitted. 100% 95% 90% 85% 80% 75% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar EB6: Cancer 2 Week wait Definition: % of patients seen within two weeks of an urgent GP referral for suspected cancer Indicator Cancer 2 Week Wait - % of patients seen within two weeks of an urgent GP referral for suspected cancer Standard Lower Threshold Latest Period YTD Monthly Trend 93% 88% Oct % 94% 93% 92% 91% 90% 89% 88% 87% 86% 85% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 93% 2014/15 EL&R patients at all providers 89.3% 94.9% 94.6% 93.0% 92.9% 92.3% 91.6% 92.3% 93.1% 93.2% 94.6% 92.4% 92.8% 2015/16 EL&R patients at all providers 92.6% 89.1% 91.3% 89.0% 88.1% 88.3% 91.7% 90.0% 2 Week Wait UHL is working intensively with the Endoscopy Department to address the current underperformance. More broadly, the Trust is working with CCGs to improve the quality of 2WW referrals, specifically in relation to correct process, use of appropriate clinical criteria, and preparation of patients for the urgency of appointments. 31 day wait The Cancer action plan aims to address the step-down of patients from Intensive Care, in order to pull Cancer patients through the system more quickly. It also includes significant investment in more clinical staff, including a nurse specialist in Urology and consultants in Head & Neck and Dermatology. This additional capacity will impact positively on performance; however while the recruitment processes are underway, staff recruitment has been problematic with a shortage of appropriate candidates. 62 day wait Efforts to improve 31 day and 2WW performance will help to improve the 62 day position. Improvements in Endoscopy will significantly help performance in Lower/ Upper GI. Additionally the appointment of three band 7 service managers with responsibility for managing cancer pathways in UHL s worst performing tumour sites will provide the key focus required; all are now in post. 5 of 23

143 SECTION 1 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP EVERYONE COUNTS KEY PERFORMANCE INDICATORS - HIGH RISK EXCEPTIONS 2015/16 EB9: Cancer 31 day wait - surgery Definition: % of patients receiving subsequent treatment for cancer within 31 days where that treatment is surgery Indicator Cancer 31 Day Waits - % of patients receiving subsequent treatment for cancer within 31 days where that treatment is surgery Standard Lower Threshold Latest Period YTD Monthly Trend 94% 91% Oct % 120% 100% 80% 60% 40% 20% 0% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 2014/15 EL&R patients at all providers 96.3% 100.0% 96.9% 91.3% 91.2% 92.9% 89.3% 85.2% 86.4% 89.7% 100.0% 83.3% 91.9% 2015/16 EL&R patients at all providers 92.0% 88.2% 88.9% 90.3% 76.7% 86.7% 95.8% 88.0% For actions see EB6: Cancer 2 week wait EB12: Cancer 62 Day Waits Definition: % of patients receiving first definitive treatment for cancer within 62-days of an urgent GP referral for suspected cancer Indicator Cancer 62 day wait - % of patients receiving first definitive treatment for cancer within 62-days of an urgent GP referral for suspected cancer Standard Lower Threshold Latest Period YTD Monthly Trend 85% 80% Oct % 86% 84% 82% 80% 78% 76% 74% 72% 70% 68% 66% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 2014/15 EL&R patients at all providers 92.2% 90.5% 73.4% 85.7% 86.3% 78.3% 82.9% 79.7% 96.3% 78.2% 74.1% 84.4% 83.0% 2015/16 EL&R patients at all providers 81.6% 73.2% 78.4% 75.9% 75.6% 78.4% 76.5% 77.0% For actions see EB6: Cancer 2 week wait 6 of 23

144 SECTION 1 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP EVERYONE COUNTS KEY PERFORMANCE INDICATORS - HIGH RISK EXCEPTIONS 2015/16 EB15 i: EMAS Category A (Red 1) 8 minute response time Definition: Category A Red 1 incidents: presenting conditions that may be immediately life threatening and the most time critical and should receive an emergency response within 8 minutes irrespective of location in 75% of cases. Indicator Category A (Red 1) 8 minute response time Standard Lower Threshold Latest Period YTD Monthly Trend 75% 70% Nov % 80% 78% 76% 74% 72% 70% 68% 66% 64% 62% 60% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 2014/15 Category A (Red 1) 8 minute 76.21% 73.97% 75.01% 70.71% 70.64% 72.65% 72.57% 72.96% 62.85% 68.63% 70.23% 73.16% 71.60% response time 2015/16 Category A (Red 1) 8 minute response time 75.14% 77.44% 73.74% 75.02% 71.13% 70.57% 66.72% 65.61% 71.78% UCC Loughborough clinicians to ride with EMAS crews to promote referrals to UCCs during Dec-Jan. Implement mobile device (smartphone) with Mobile Directory of Services (MDoS) access. Pilot testing occurred to decide device of choice. Increase use of alternatives to admission by EMAS crews by referral to UCC Loughborough, OPU and use of Falls Pathway. Develop process to enable EMAS access to GP medical opinion and prescriptions, in & out of hours. Circulate service description to all front line staff daily, to ensure all EMAS shifts covered. An eight-week action plan has been agreed to speed up the time it takes for EMAS crews to pass patients to A&E staff at Leicester Royal Infirmary. EB15 ii: Category A (Red 2) 8 minute response time Definition: Category A Red 2 incidents: presenting conditions that may be immediately life threatening but less time critical than Red 1 and should receive an emergency response within 8 minutes irrespective of location in 75% of cases. Indicator Category A (Red 2) 8 minute response time Standard Lower Threshold Latest Period YTD Monthly Trend 75% 70% Nov % 80% 75% 70% 65% 60% 55% 50% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 2014/15 Category A (Red 2) 8 minute 77.02% 74.59% 75.27% 71.60% 72.48% 71.92% 72.25% 71.54% 58.29% 65.18% 69.64% 71.00% 70.20% response time 2015/16 Category A (Red 2) 8 minute response time 74.67% 74.31% 72.97% 70.33% 65.40% 66.16% 58.43% 56.88% 66.97% For actions see EB15 i: EMAS Category A (Red 1) 8 minute response time EB16: Category A 19 minute transportation time Definition: Category A 19 incidents: Presenting conditions, which may be immediately life threatening and should receive an ambulance response at the scene within 19 minutes irrespective of location in 95% of cases. Indicator Standard Lower Threshold Latest Period YTD Monthly Trend 100% 95% 90% Category A 19 minute transportation time 95% 90% Nov % 85% 80% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 2014/15 Category A 19 minute 96.01% 95.09% 95.27% 93.22% 94.17% 93.62% 93.6% 93.75% 85.88% 90.5% 93.55% 93.2% 92.80% transportation time 2015/16 Category A 19 minute transportation time 94.06% 94.03% 93.53% 91.80% 88.96% 89.60% 86.3% 85.34% 90.26% For actions see EB15 i: EMAS Category A (Red 1) 8 minute response time EBS1: Mixed Sex Accommodation Definition: All providers of NHS funded care are expected to eliminate mixed sex accommodation, except where it is in the overall best interest for the patient, in accordance with the definitions. Indicator Mixed Sex Accommodation (MSA) Breaches Standard Zero Tolerance Lower Threshold Latest Period YTD Monthly Trend N/A Nov Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan /15 EL&R patients MSA breaches /16 EL&R patients MSA breaches breaches occurred in July. These breaches occurred at Medway Maritime Hospital in Kent. 7 of 23

145 SECTION 1 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP EVERYONE COUNTS KEY PERFORMANCE INDICATORS - HIGH RISK EXCEPTIONS 2015/16 EBS2: Cancelled Operations Definition: % of patients readmitted within 28 days (Data is at UHL level and for all patients) Indicator Cancelled Operations - % of patients re-admitted within 28 days at UHL level Standard Lower Threshold Latest Period YTD Monthly Trend 100% N/A Oct % 102.0% 100.0% 98.0% 96.0% 94.0% 92.0% 90.0% 88.0% Standard/Plan Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 2014/15 UHL Cancelled Operations - % of patients offered binding date 90.6% 96.1% 99.0% 97.9% 87.3% 97.9% 97.9% 98.1% 96.1% 92.9% 93.8% 99.0% 95.60% within 28 days or funded at patients choice 2014/15 Number of patients - all CCGs at UHL 2015/16 UHL Cancelled Operations - % of patients offered binding date 97.5% 100.0% 97.9% 99.3% 92.5% 99.0% 100.0% 98.3% within 28 days or funded at patients choice 2015/16 Number of patients - all CCGs at UHL There were no breached in October. The breach of the 28 day rebooking target in September was for general surgery. Senior Managers are working together to improve theatre capacity in the long term. A number of work streams have started in UHL aimed at reducing OTD cancellations. List over runs form a significant risk to OTD performance. The process of exception reporting is now better able to identify any over booked lists by the theatre managers working with theatre staff. 52 Week Waits Definition: Number of 52 week Referral to Treatment Pathways Indicator Standard Lower Threshold Latest Period 52 week wait 0 N/A Sep YTD Trend Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Planned Trajectory /15 Total Number of Referrals /16 Total Number of Referrals The breach in September was in Urology and was caused by inadequate staff knowledge, which meant a patient s pathway was incorrectly stopped. The RTT Team delivered a refresher training session for the Urology admin staff on 19th October. They will also be developing some flow charts and SOPs relating to different scenarios to support their learning. EBS7i: Ambulance handover time - Number of handover delays of over 30 minutes EBS7ii: Ambulance handover time - Number of handover delays of over 1 hour Definition: The number of handover days of longer than 30 minutes, and of those the number over one hour Indicator Ambulance handover time - Number of handover delays of over 30 minutes Ambulance handover time - Number of handover delays of over 1 hour Standard Zero Tolerance Zero Tolerance Lower Threshold Latest Period YTD Monthly Trend N/A Nov % N/A Nov % 30% 25% 20% 15% 10% 5% 0% Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD Standard/Plan 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 2014/15 Number of handover delays of 17.5% 20.2% 14.0% 13.6% 14.5% 17.4% 24.20% 23.20% 25.30% 23.10% 21.30% 22.20% 19.9% over 30 minutes 2014/15 Number of handover delays of 4.0% 5.0% 1.9% 1.3% 1.2% 2.40% 5.20% 5.00% 10.20% 7.10% 9.80% 9.40% 5.3% over 1 hour 2015/16 Number of handover delays of 22.2% 21.9% 19.6% 19.8% 21.0% 21.5% 22.60% 24.10% 21.8% over 30 minutes 2015/16 Number of handover delays of over 1 hour 7.5% 6.9% 8.9% 9.6% 12.4% 14.50% 18.30% 20.50% 12.5% An eight-week action plan has been agreed to speed up the time it takes for EMAS crews to pass patients to A&E staff at Leicester Royal Infirmary. Difficulties continue in accessing beds from ED leading to congestion in the assessment area and delays ambulance handover. Proposals include: Improving processes at A&E and in the assessment bays. Improving the flow of patients through the hospital and making every effort to reduce numbers attending A&E Attempting to speed up discharge processes. Continued work to tell patients the importance of getting medical help before their condition worsens and ends up being an emergency. 8 of 23

146 SECTION 1 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP EVERYONE COUNTS KEY PERFORMANCE INDICATORS - HIGH RISK EXCEPTIONS 2015/16 EBS8a: Ambulance Crew Clear delays of > 30 minutes at UHL EBS8b: Ambulance Crew Clear delays of > 60 minutes at UHL Indicator EBS8a: Ambulance Crew Clear delays of > 30 minutes at UHL EBS8b: Ambulance Crew Clear delays of > 60 minutes at UHL Standard Zero Tolerance Zero Tolerance Lower Threshold Latest Period YTD Trend N/A YTD Nov 3.5% 15 N/A 0.9% 5.0% 4.5% 4.0% 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Jun-15 Jul-15 Jan-16 Apr- 15 May- 15 Aug- 15 Sep- 15 Oct- 15 Nov- 15 Dec- 15 Feb- 16 Mar- 16 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 YTD Standard/Plan 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% over 30 minutes 2.1% 2.0% 2.90% 4.10% 3.90% 4.10% 4.10% 4.50% 3.5% over 1 hour 0.4% 0.4% 0.40% 0.60% 1.00% 0.90% 1.40% 1.80% 0.9% For actions see EBS7i: Ambulance handover time - Number of handover delays of over 30 minutes/ EBS7ii: Ambulance handover time - Number of handover delays of over 1 hour EB1: Satisfaction with the Quality of Consultation at a GP Practice EB2: Satisfaction with the Overall Care Received at Surgery Outcomes Framework 4aiii: Overall experience of Dental Services Outcomes Framwork 4.4i: Access to GP Services Outcomes Framework 4.4ii: Access to Dental Service Indicator Standard Lower Threshold Latest Period YTD Trend Jan 13 - Sept 13 Jul 13 - Mar 14 Jan 14 - Sept 14 Jul 14 - Mar 15 Trend Satisfaction with the Quality of Consultation at a GP Practice Satisfaction with the Overall Care received at Surgery Overall Experience of NHS Dental Services 446 N/A % N/A 85.0% 86% 86% 86% 85% 84.0% N/A Jul 14 to Mar % 84% 86% 84% 83% Access to GP Services 74.0% N/A 72.4% 72% 72% 74% 72% Access to NHS Dental Services 96.0% N/A 95.0% 93% 95% 96% 95% Key questions from the GP survey are included in the ELR CCG Practice Profiles and for part of the discussions at the annual Practice quality visits. With regard to the results of the July survey, ELR CCG have noted that five practices are performing below the standard across each of the questions. The CCG will be contacting these practices to discuss this performance and how they can be supported to improve this position for the next data release. The results will also be cross referenced with the practices FFT scores, complaints data and feedback received through the CCG Listening booth to look for trends and areas for improvement. LP1: Number of Primary Care Completed Care Plans in Care Homes Indicator Standard Lower Threshold Latest Period YTD Trend LP1: Number of primary care completed care plans in Care Homes to reach 97% by April 2016, based on current levels of 95% completed care plans 95% N/A Q2 15/ % Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 YTD Standard/Plan 97% 97% 97% 97% % with care plan 75.76% 78% 78.00% Care Home care planning forms part of the GP Support and Investment Framework for 2015/16. GPs will continue the work from 2014/15 GP Support and Investment Framework for all care home patients to have a care plan. For Q2 three practices have not yet submitted their data, but data received has shown increase in care plans. OF 2.2: Employment of People with Long Term Conditions Indicator Standard Lower Threshold Latest Period YTD Trend OF 2.2 Employment of people with long term conditions (The difference in employment rate between England population and people with a long term condition) 11.1% Leics LA 2.8% Rutland N/A Jan 15 - Mar % Leics LA 19.7% Rutland Numbers for Rutland are small, and a small variation can result in a large diffence in the percentages. The employment rate for people with LTC in Rutland is 54.8% compared to 74.5% of those without LTCs. The figures for England are 60.4% (with LTC) and 73.5% (without LTC). 9 of 23

147 SECTION 1 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP EVERYONE COUNTS KEY PERFORMANCE INDICATORS - HIGH RISK EXCEPTIONS 2015/16 QP: Improving antibiotic presecribing Indicator Standard Lower Threshold Latest Period YTD Trend Improving antibiotic presecribing, consisting of three parts: Part a) reduction in the number of antibiotics prescribed in primary care Part b) reduction in the proportion of broad spectrum antibiotics prescribed in primary care Part c) secondary care providers validating their total antibiotic prescription data a) b) c) TBC N/A Q2 15/16 a) b)12.02% c) TBC a) b) c) TBC Part A: Reduction in the number of antibiotics prescribed in primary care (STAR/PU) Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD 2015/16 Standard/Plan 1% reduction (Year end figure should equal 1.141) /16 (12 month rolling data) Part B: Reduction in the proportion of broad spectrum antibiotics in primary care (Co-Amoxiclav, Cephalosporins and Quinolones) Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD 2015/16 Standard/Plan Annual prescribing target of 11.3% 11.30% 2015/16 (12 month rolling data) 11.70% 11.60% 11.60% 11.50% 11.50% 11.40% 11.40% 10 of 23

148 SECTION 2 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP Everyone Counts Annex A Measures THE FORWARD VIEW INTO ACTION - PERFORMANCE INDICATORS FOR 2015/16 Indicator EA1 EA2 EA3 Description Latest Baseline Position Outturn Standard/ Target Lower Threshold Latest Period Potential years of life lost (PYLL) from causes considered amenable to healthcare NA Health-related quality of life for people with / long term conditions NA 14/ IAPT - Proportion of people that enter treatment against the level of need in the Mar % 16.0% NA Oct % general population YTD/ FOT Monthly Trend EA4 Composite measure on emergency admissions: of: Unplanned hospitalisation for chronic ambulatory care sensitive conditions, Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s, Emergency admissions for acute conditions that should not usually require hospital admission, Emergency admissions for children with lower respiratory tract infections (LRTI). 2014/ /16 NA Oct-15 Oct FOT EA5 Patient Experience of Hospital Care Decrease NA EA7 I & ii Composite indicator comprised of (i) GP Services & (ii) GP Out of Hours. Reduce negative responses to survey Hospital deaths attributable to problems in care 2013/ / /16 NA 14/ In Development, available for measuring a national ambition in Autumn 2015 & local EA8 ambition in 2016/17 Data expected Dec EA10 One Year Survival from all cancers Higher than baseline NA Everyone Counts Annex A Supporting Measures Indicator EAS1 Description Estimated diagnosis rate for people with dementia Latest Baseline Position Outturn Standard / Target Lower Threshold Latest Period YTD/ FOT Monthly Trend Mar % 66.7% NA Nov % EAS2 IAPT Recovery Rate Mar % 53% NA Oct % EAS3 EAS4 EAS5 Proportion old people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services 2013/ (Leicestershire) Improvement or zero % change NA 13/14 Data expected Feb 16 Healthcare acquired infection (HCAI) measure Mar-15 (MRSA) 0 Zero Tolerance NA Oct-15 0 Healthcare acquired infection (HCAI) measure Mar-15 (Clostridium difficile infections) NA Oct of 23

149 SECTION 2 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP Everyone Counts Annex B Measures THE FORWARD VIEW INTO ACTION - PERFORMANCE INDICATORS FOR 2015/16 Indicator Description Latest Baseline Position Outturn Standard/ Target Lower Threshold Latest Period EB1 RTT - Admitted Patients Mar % 90% 85% Sep % EB2 RTT - Non-Admitted Patients Mar % 95% 90% Sep % EB3 RTT - Incomplete Pathways Mar % 92% 87% Sep % Diagnostic Test Waiting Time EB4 Patients waiting for a diagnostic test should Mar-15 have been waiting less than 6 weeks from 98.5% 99% NA Sep % referral EB5 EB6 EB7 EB8 EB9 YTD/ FOT Monthly Trend A&E Waiting Time - % of people who spend % Mar % 95% 90% Nov-15 hours or less in A&E 29/12/15 YTD Cancer2WeekWait-%ofpatientsseenwithin two weeks of an urgent GP referral for Mar % 93% 88% Oct % suspected cancer Cancer2WeekWait-%ofpatientsseenwithin two weeks of an urgent referral for breast symptoms where cancer is not initially suspected Cancer 31 Day Waits - % of patients receiving first definitive treatment within 31 days of a cancer diagnosis Cancer 31 Day Waits - % of patients receiving subsequent treatment for cancer within 31 days where that treatment is surgery Mar % 93% 88% Oct % Mar % 96% 91% Oct % Mar % 94% 89% Oct % EB10 Cancer 31 Day Waits - % of patients receiving subsequent treatment for cancer within 31 Mar-15 days where that treatment is an anti cancer 99.7% 98% 93% Oct % drug regimen EB11 Cancer 31 Day Waits - % of patients receiving subsequent treatment for cancer within 31 Mar-15 days where that treatment is radiotherapy 96.5% 94% 89% Oct % treatment course EB12 Cancer 62 Day Waits - % of patients receiving first definitive treatment for cancer within 62 Mar-15 days of an urgent GP referral for suspected 83.0% 85% 80% Oct % cancer Cancer 62 Day Waits - % of patient receiving EB13 first definitive treatment for cancer within 62 days of referral from an NHS Cancer Screening Service Mar % 90% 85% Oct % Cancer 62 Day Waits - % of patients receiving EB14 first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status Mar % 100% 100% Oct % Everyone Counts Annex B Measures Continues. Indicator Description Latest Baseline Position Outturn Standard/ Target Lower Threshold Latest Period YTD/ FOT Monthly Trend EB15 i Mar % Nov % Ambulance Clinical Quality - Category A (Red 1) 75% 70% 8 minute response time 53.8% Mar-15 Nov % ELR EB15 ii Mar % Nov % Ambulance Clinical Quality - Category A (Red 2) 75% 70% 8 minute response time 56.49% Mar-15 Nov % ELR EB16 Mar % Nov % Ambulance Clinical Quality - Category A 19 95% 90% minute transportation time 86.28% Mar-15 Nov % ELR 12 of 23

150 SECTION 2 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP THE FORWARD VIEW INTO ACTION - PERFORMANCE INDICATORS FOR 2015/16 Everyone Counts Annex B Supporting Measures Indicator Description Latest Baseline Position Outturn Standard/ Target Lower Threshold Latest Period EBS1 Mixed Sex Accommodation (MSA) Breaches Mar-14 5 Zero Tolerance NA Nov-15 2 YTD/ FOT Monthly Trend EBS2 Cancelled Operations - % of patients not re-admitted within 28 days Mar % (UHL only) 100% NA Oct % (11 patients across UHL and alliance) EBS3 EBS4 EBS5 EBS6 EBS7 i EBS7 ii Mental Health - Care Programme Approach (CPA) - %of patients under adult mentalillness on CPA who were followed up within 7 days of discharge from psychiatric in-patient care Mar % 95% 90% Nov % Number of 52 week Referral to Treatment Mar-15 Pathways 14 Zero Tolerance NA Sep-15 1 UHL Trolley waits in A&E - Number of patients who have waited over 12 hours in A&E from Mar-15 1 Zero Tolerance NA Oct-15 0 decision to admit to admission UHL Urgent operations cancelled for a second Mar-15 time 0 Zero Tolerance NA Oct-15 0 UHL Ambulance handover time - Number of handover delays of over 30 minutes 14/ % Zero Tolerance NA Nov % UHL Ambulance handover time - Number of handover delays of over 1 hour 14/15 5.3% Zero Tolerance NA Nov % EBS8a Crew Clear delays of > 30 minutes 14/15 new indicator Zero Tolerance NA Nov % EBS8b Crew Clear delay of > 1 hour 14/15 new indicator Zero Tolerance NA Nov % Trend Key: = Little or no change, = Improvement, = Deterioration Indicator Description Latest Baseline Position Outturn Standard / Target Lower Threshol ED1 Satisfaction with the Quality of Consultation at a GP Practice Jan NA ED2 Satisfaction with the Overall Care received at Sept 14 Surgery (average last % 86.8% NA ED3 Satisfaction with Accessing Primary Care surveys) 69.0% 70% NA EH1 EH2 EH3 Local Priority Proportion of people that wait 6 weeks or less from referral to completing a course of IAPT treatment Proportionofpeople thatwait18weeksorless from referral to completing a course of IAPT treatment Re-focusing service provision on less severe cases (IAPT) Apr 14- Mar-15 Apr 14- Mar % 80.0% Q1-50% Q2-55% Q3-63% Q4-75% Q1-75% Q2-80% Q3-85% Q4-95% d Latest Period Jul 14 to Mar 15 Jul 14 to Mar 15 Jul 14 to Mar 15 YTD/ FOT Monthly Trend % 72.4% NA Sep % NA Sep % In Development, available for measuring a national ambition in Autumn 2015 & local ambition in 2016/17 Indicator Description Baseline Period Baseline Standard/ Target Lower Threshold Latest Period YTD/ FOT Monthly Trend LP1 Number of primary care completed care plans in Care Homes to reach 97% by April 2016, based on current levels of 95% completed care plans Mar % 97.0% NA Q2 15/ % LP2 Increase the number of deaths that occur in the usual place of residence and hospices to 50% of all deaths Feb % 50.0% NA Sep % 13 of 23

151 SECTION 2 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP Additional Indicators THE FORWARD VIEW INTO ACTION - PERFORMANCE INDICATORS FOR 2015/16 Indicator Description Baseline Period Baseline Standard/ Target Lower Threshold Latest Period YTD/ FOT Monthly Trend NHS111 Calls answered within 60 seconds 9.0% 95% 90% Nov % Calls abandoned after 30 seconds 7.2% 2.9% 5 Nov % % of calls triaged 92.8% 80% 70% Nov % 14/15 Final Disposition - A&E 7.2% 5% 6-8% Nov % Final Disposition - Emergency ambulance 9.0% 10% 12% Nov % Final Disposition - Primary/Community care 52.4% >=55 N/A Nov % Trend Key: = Little or no change, = Improvement, = Deterioration 14 of 23

152 SECTION 3 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP NHS OUTCOMES FRAMEWORK 2015/16 DOMAIN 1: PREVENTING PEOPLE FROM DYING PREMATURELY Indicato r Description Baseline Period Baseline Target 2015/16 Latest Period YTD Trend OVERARCHING INDICATORS 1a Potential years of life lost (PYLL) from causes considered amenable to healthcare (measures the number of years of life lost per 100,000 registered patients from conditions which are usually treatable) (2014) (2015) i Adults 2013 ii Children & Young People b Life Expectancy at 75 i Males 2013 ii Females c Neonatal mortality and still births 2012 IMPROVEMENT AREAS Reducing premature mortality from the major causes of death Blaby:2,101.2 Harborough:1,990.3 Melton:2,682.2 Oadby and Wigston:2,852.7 Rutland: 1,870.9 Below Baseline 2013 England data only: Leicestershire: 11.6 Rutland: Leicestershire: 13.8 Rutland: Blaby: 4.6 Harborough: 6.0 Melton: 8.7 Oadby and Wigston: 1.6 Rutland 14.8 Below Baseline 2013 Increase to Baseline Increase to Baseline Reduction to baseline Data expected in Dec 2015 Data expected in Dec 2015 Data expected Feb 2016 Data expected Feb Under 75 mortality rate from cardiovascular disease Below Baseline Under 75 mortality rate from respiratory disease Below Baseline Under 75 mortality rate from liver disease Below Baseline Under 75 mortality rate from cancer Below Baseline i 1 year survival from all cancers ii 5 year survival from all cancers 2012 England 47.9 iii iv 1 year survival from breast, lung and colorectal cancer 5 year survival from breast, lung and colorectal cancer v 1 year survival from cancers diagnosed at stage 1& England 51.4 Higher Than Baseline Higher Than Baseline Higher Than Baseline Higher Than Baseline In Development In Development Expected Dec 15 Data expected Dec 15 In Development Expected Dec 15 vi 5 year survival from cancers diagnosed at stage 1&2 In Development Reducing premature death in people with serious mental illness 1.5i Excess under 75 mortality rate in adults with serious mental illness 2013 Leicestershire: Rutland: Lower Than Baseline 2014 Leicestershire: Rutland: Excess under 75 mortality rate in adults with ii common mental illness Suicide & mortality from injury of undetermined iii intent among people with recent contact from NHS services Reducing deaths in babies and young children In Development In Development 1.6 i Infant mortality (Infant mortality is defined as the number of babies dying before the age of one for every 1,000 live births.) 2012 Rutland: 3.0 Blaby: 2.8 Harborough: 3.6 Melton: 5.2 Oadby and Wigston: 0.0 Reduction to baseline 2013 ELR CCG: ii 5 year survival from all cancers in children 2011 England data: 81.3 Reducing premature death in people with a learning disability Excess under 60 mortality in adults with learning 1.7 disabilities Higher than baseline In Development 2011 Publication date TBC 15 of 23

153 SECTION 3 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP NHS OUTCOMES FRAMEWORK 2015/16 DOMAIN 2: ENHANCING QUALITY OF LIFE FOR PEOPLE WITH LONG TERM CONDITIONS Indicat or Quality Premium Measure Description OVERARCHING INDICATORS Health-related quality of life for people with 2 long-term conditions IMPROVEMENT AREAS Ensuring people feel supported to manage their condition Proportion of people feeling supported to 2.1 manage their own condition Improving functional ability in people with long term conditions Baseline Period Baseline Target 2015/16 Latest Period YTD Trend 2013/ / July 13 - March Higher Than Baseline July 14 - March Employment of people with long term conditions (The difference in employment July 14 - Sept rate between England population and people 14 with a long term condition) 11.1% Leics LA 2.8% Rutland Lower Than Baseline Apr 15 - Jun % Leics LA 23.2% Rutland Reducing time spent in hospital by people with long term conditions 2.3 i 2.3 ii Unplanned hospitalisation for chronic ambulatory care sensitive conditions (All Providers) National Unplanned hospitalisation for chronic ambulatory care sensitive conditions (All Providers) Local Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s (All Providers) National Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s (All Providers) Local Enhancing quality of life for people with carers 2.4 Health-related quality of life for carers Enhancing quality of life for people with mental illness Employment of people with mental illness (The difference in employment rate between 2.5i England population and people with mental illness) Health-related quality of life for people with ii mental illness Enhancing quality of life for people with dementia Estimated diagnosis rate for people with 2.6 i 2.6 ii dementia A measure of the effectiveness of postdiagnosis care in sustaining independence and improving quality of life Improving quality of life for people with multiple long-term conditions Health-related quality of life for people with 2.7 three or more long term conditions 2013/ / (14/15) 2013/ /15 Jul 13 - Sept 14 July 14 - Sept (14/15) % (2014/15) (2015/16) 2014/ Oct (2014/15) (2015/16) 2014/ Oct-15 Higher Than Baseline Lower than baseline IN DEVELOPMENT Provisional 66.5 (Oct15) (FOT) Provisional 14.5(Oct 15) (FOT) Not included in RAG count Not included in RAG count Jul 14 - Mar Apr 15 - Jun % Mar % 66.7% Oct % IN DEVELOPMENT IN DEVELOPMENT 16 of 23

154 SECTION 3 Indicat or Quality Premiu m Measur e Description OVERARCHING INDICATORS Emergency admissions for acute conditions that should not usually require hospital admission (All Providers) National 3a Emergency admissions for acute conditions that should not usually require hospital admission (All Providers) Local 3b Rate of emergency readmissions within 30 days of discharge (All Providers) Baseline Period Baseline 2013/ Target 2015/ (2014/15) (2015/16) Latest Period YTD Trend 2014/ / Oct / Reduction or zero % change 2013/14 & 2014/15 (TBC) Oct Provisional 73.1 (Oct) (FOT) (Oct) (FOT) Not included in RAG count IMPROVEMENT AREAS Improving outcomes from planned treatments 3.1 Total health gain as assessed by patients for elective procedures i Physical health-related procedures a) Hip replacement 2013/ / b) Knee replacement 2013/ / Increase c) Groin Hernia 2013/ / d) Varicous veins 2013/14 No. of pts too small for analysis 2014/15 No. of pts too small for analysis ii Psychological therapies IN DEVELOPMENT iii Recovery in quality of life for patients with mental illness IN DEVELOPMENT Preventing lower respiratory tract infections (LRTI) in children from becoming serious Emergency admissions from children with (2014/15) lower respiratory tract infections (LRTI) 2013/ /15 Provisional (All Providers) National (2015/16) 3.2 Emergency admissions from children with lower respiratory tract infections (LRTI) (All Providers) Local 2014/ Oct-15 Improving recovery from injuries and trauma 3.3 Survival from major trauma In Development Improving recovery from stroke Proportion of stroke patients reporting an 3.4 improvement in activity/lifestyle on the In Development Modified Rankin Scale at 6 months Improving recovery from fragility fractures 3.5i Proportion of patients with hip fractures Higher than recovering to their previous levels of baseline mobility/walking ability at 30 days ii Proportion of patients with hip fractures Data not available Higher than recovering to their previous levels of 2013 due to small numbers baseline mobility/walking ability at 120 days 2014 Helping older people to recover their independence after illness or injury 3.6 i 3.6 ii 3.7i Decaying teeth ii Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation service Proportion offered rehabilitation following discharge from acute or community hospital Tooth extractions in secondary care for children under 10 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP NHS OUTCOMES FRAMEWORK 2015/16 DOMAIN 3 HELPING PEOPLE TO RECOVER FROM EPISODES OF ILL HEALTH OR FOLLOWING INJURY Dental health 13/14 13/ (Leics) 62.1 (Rutland) 4.0 (Leics) 2.7 (Rutland) Higher than baseline Higher than baseline In Development In Development 14/15 14/ (Oct) (FOT) Data not available due to small numbers 83.5 Leics LA 100 Rutland 1.8 Leics LA 3.0 Rutland Not included in RAG count 17 of 23

155 SECTION 3 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP NHS OUTCOMES FRAMEWORK 2015/16 DOMAIN 4. ENSURING PEOPLE HAVE A POSITIVE EXPERIENCE OF HEALTHCARE Indicat Description Baseline Period Baseline or OVERARCHING INDICATORS Composite indicator comprised of (i) GP 4a Services & (ii) GP Out of Hours. Reduce I & ii negative responses to survey iii Overall experience of NHS Dental Services Measures the weighted percentage of people who report their overall experience of NHS dental services as very good or fairly good. Target 2015/16 Latest Period YTD Trend 2013/ / Jan-Mar 14 and Jul - Sept % Higher Than Baseline Jul-Sept 2014 and Jan-Mar % 4b Patient experience of hospital care 2013/ / Friends & Family Test - UHL 4c - Inpatient Score 14/15 96% 95% Sep-15 97% - A&E Score (Type 1 & 2) 14/15 96% 94% Sep-15 95% - Maternity Antenatal 14/15 96% 94% Sep-15 95% 4d Patient experience characterised as poor or worse i Primary Care IN DEVELOPMENT - annual ii Hospital Care IN DEVELOPMENT - annual IMPROVEMENT AREAS Improving people's experience of out-patient care 4.1 Patient experience of outpatient services - Higher Than 2011/ UHL Baseline 14/15 In development Improving hospitals' responsiveness to personal needs 4.2 Responsiveness to in-patients' personal needs - Higher Than 13/ UHL Baseline 14/ Improving people's experience of accident and emergency services 4.3 Patient experience of A&E services - UHL Improving access to primary care services 4.4i 4.4ii Access to GP Services Measures the weighted percentage of people who report their experience of making a GP appointment as fairly good or very good. Access to NHS Dental services Measures the weighted percentage of people who report their experience of getting access to NHS dental services as fairly good or very good. Jan-Mar 14 and Jul - Sept 2014 Jan-Mar 14 and Jul - Sept 2014 Improving women and their families' experience of maternity services 74% 96% Higher Than Baseline Higher Than Baseline Higher Than Baseline 2014 Jul-Sept 2014 and Jan-Mar 2015 Jul-Sept 2014 and Jan-Mar 2015 Data expected Feb % 95.00% 4.5 Women's experience of maternity services 2013 Labour & Birth 8.9 Staff Score 8.4 Care in Hospital 7.8 Higher Than Baseline 2013 Data expected Feb 16 Improving experience of care for people at the end of their lives 4.6 Bereaved carers' views on the quality of care in the last 3 months of life % Higher Than Baseline Improving experience of healthcare for people with mental illness Patient experience of community mental Higher Than % 2013 health services- LPT Baseline Improving children and young people's experience of outpatient services Children and young people's experience of 4.8 IN DEVELOPMENT outpatient services Improving people's experience of integrated care 4.9 People's experience of integrated care IN DEVELOPMENT TBC - Only England data available Data expected of 23

156 SECTION 3 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP NHS OUTCOMES FRAMEWORK 2015/16 DOMAIN 5. TREATING AND CARING FOR PEOPLE IN A SAFE ENVIRONMENT AND PROTECTING THEM FROM AVOIDABLE HARM: KEY AREAS WHERE PROGRESS WILL BE Indicat or Quality Premiu m Measur e Description OVERARCHING INDICATORS Hospital deaths attributable to problems in 5a care Severe harm attributable to problems in 5b healthcare IMPROVEMENT AREAS Reducing the incidence of avoidable harm Deaths from venous thromboembolism (VTE) 5.1 related events Incidence of healthcare associated infection 5.2i (HCAI) Incidence of MRSA Baseline Period Baseline Target 2015/16 Latest Period YTD Trend 13/ Reduction 13/14 To be announced 14/15 3 Zero Tolerance Oct ii Incidence of c.difficile 14/ Oct Proportion of patient with category 2, 3 and 4 pressure ulcers 5.4 Hip fracture from falls during hospital care Improving the safety of maternity services 5.5 Admission of full-term babies to neonatal care 2012 Improving the culture of safety reporting 6.1 England (39,243 admissions 640,787 births) IN DEVELOPMENT IN DEVELOPMENT IN DEVELOPMENT IN DEVELOPMENT Reduction Months in arrears 5.6 Patient safety incidents reporting Oct 13 - Mar 14 UHL - 36 LPT - 67 KGH - 28 PSFT - 33 NUH - 40 Increase in reporting April 14 - Sept 14 UHL - 38 LPT - 49 KGH - 30 PSFT - 33 NUH of 23

157 SECTION 4 PERFORMANCE ASSURANCE FRAMEWORK 2014/15 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP QUALITY PREMIUM Measure Outcomes Framework DOMAIN 1: PREVENTING PEOPLE FROM DYING PREMATURELY 13/14 Baseline/Outturn 2014/15 Standard 14/15 Current Position (Monthly/ Quarterly/ Annual) % of quality premium Value for CCG Measure achieving Quality premium funding Reducing potential years of life lost (PYLL) from causes considered amenable to healthcare and including addressing locally agreed priorities for reducing premature mortality (Definition: Reduction of no less than 3.2% between 2013 and 2014 calendar years agreed with HWB Board and NHE E area team taking into account premature mortality and other relevant needs set out in the local joint health & well being strategy) % reduction between 2013 & % 236,250 N 0 DOMAIN 2: ENHANCING QUALITY OF LIFE FOR PEOPLE WITH LONG TERM CONDITIONS Improving Access to Psychological Therapies (Definition: achieve IAPT access levels of at least 15% by 31 March 2015 and if the CCGs access level was 13% or greater by March 2014, to further increase levels by March 2015 to an additional amount agreed by the CCG and Health & Well Being Board and NHS E area team of no less than an additional 3%) 14.3% 2013/14 Achievement of 17% by March % 15% 236,250 N 0 DOMAIN 2: ENHANCING QUALITY OF LIFE FOR PEOPLE WITH LONG TERM CONDITIONS & DOMAIN 3: HELPING PEOPLE TO RECOVER FROM EPISODES OF ILL HEALTH OR FOLLOWING INJURY Domain 2/3 - Composite avoidable emergency admissions measure (Definition: Reduction, or a zero percentage change in emergency admissions for the following conditions for a CCG population between 2013/14 and 2014/15 or the indirectly standardised rate of admissions in 2014/15 at less than 1,000 per 100,000 population Individual emergency admissions indicators are monitored in the NHS Outcomes Framework Reduction or zero % change 2013/14 between 2012/13 & 2013/14 New measure % 393,750 N 0 DOMAIN 4. ENSURING PEOPLE HAVE A POSITIVE EXPERIENCE OF HEALTHCARE (UHL) Friends & Family Test. (1) Friends & Family Test (a) CCGs to agree a plan with local providers with specified actions for addressing issues identified from 2013/14 FFT results - achievement within milestones (b) obtain assurance from providers that action has been taken in response to FFT feedback (c) Support providers to co-ordinate the roll out of FFT by end of 2014/15 (2) Improved average score achieved between 2013/14 & 2014/15 for Patient In-Patient Experience - improvement in people experiencing poor care Agreed & Milestones in Place, 74.1 negative responses reduced % 236,250 Y 236,250 between Q1 & Q4 Improved average score in 2013/14 & 2014/15 for In- Patient Experience Domain 5: Reporting of medication-related safety incidents Agreed specified level of reporting increase 15% 236,250 Y 236,250 Local CCG Measures End of Life - Deaths at place of choice measured through deaths at home, nursing home, residential homes and hospices. 52.3% Mar-14 50% 55.2% (Mar 15) 15% 236,250 Y 236,250 NHS Constitution & Pledges Quality Premium Achieved from Outcomes Framework and Local Measures 708,750 Referral to Treatment Times Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral 93.9% Mar-14 92% (Lower threshold 87%) 96.6% -25% - 177,188 Y 0 A&E Waits - Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department 88.4% 95% (YTD 31/03/14) (Lower threshold 90%) 88.7% -25% - 177,188 N - 177,188 Cancer waits - Maximum 2 week wait from urgent GP referral to first out-patient appointment for suspected cancer 94.7% 2013/14 93% (Lower threshold 88%) 92.8% -25% - 177,188 N - 177,188 Category A Red 1 incidents, which resulted in an emergency response arriving at the scene of the incident within 8 minutes - (conditions that may be immediately life threatening and the most time critical) QUALITY PREMIUM ACHIEVED (CURRENT POSITION) MAXIMUM QUALITY PREMIUM AVAILABLE 71.26% YTD Mar 14 (EMAS) 75% (Lower threshold 70%) 71.60% -25% - 177,188 N - 177,188 Quality Premium Adjustments for NHS Constitution Measures - 531, ,188 1,830,000 RAG Rating Green - all relevant indicators on track for achievement of Quality Premium Amber/Green - not all indicators on track for achievement of Quality Premium Amber/Red - At least one indicator statistically significantly off track for achievement of the Quality Premium Red - All indicators statistically significantly off track for achievement of the Quality Premium CCG Population > Price per head > Potential Quality Premium > ,575, of 23

158 SECTION 4 Measure Reduce Premature Mortality Reducing potential years of life lost (PYLL) from causes considered amenable to healthcare and including addressing locally agreed priorities for reducing premature mortality Urgent and emergency care Delayed transfers of care which are an NHS responsibility Mental health Reduction in the number of patients attending an A&E department for mental health-related needs who wait more than four hours to be treated and discharged, or admitted, together with a defined improvement in the coding of patients attending A&E Patient safety Improving antibiotic presecribing, consisting of three parts: Part a) reduction in the number of antibiotics prescribed in primary care Part b) reduction in the proportion of broad spectrum antibiotics prescribed in primary care Part c) secondary care providers validating their total antibiotic prescription data PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP 2015/16 Standard 1.2% reduction between 2012 & 2015 The total number of delayed days caused by delayed transfers of care in 2015/16 should be less than the number in 2014/15 A&E primary diagnosis coding to be at least 90% AND 95% of mental health patients to be seen within 4 hours Part a) 1% reduction on 13/14 QUALITY PREMIUM Part b) 10% reduction on 13/14 or below England 13/14 median (11.3%) whichever is smaller Part c) Public Health England to certify this has occurred Baseline (2012) 13.8 per 100,000 popn (Leics County 14/15) a) b) /16 Current Position (Monthly/ Quarterly/ Annual) (2014) 7.3 (YTD 17/12/15) % of quality premium Value for CCG Measure achieving Quality premium funding 10% 157,500 N 0 30% 472,500 Y 472,500 In development 30% 472,500 Y 472, month rolling data (Oct14- Sept15) month rolling data (Oct14- Sept15) 11.40% c) TBC c) TBC Overall achievement of antibiotic prescribing 10% 157,500 N 0 Local Priority (1) Number of primary care completed care plans in Care Homes to reach 97% by April 2016, based on current levels of 95% completed care plans 97% 95% Q2 78% 10% 157,500 N 0 Local Priority (2) Increase the number of deaths that occur in the usual place of residence and hospices to 50% of all deaths 50% 52.30% 54.00% 10% 157,500 Y 157,500 Quality Premium Achieved from Outcomes Framework and Local Measures 1,102,500 Referral to Treatment Times Patients on incomplete nonemergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral A&E Waits - Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department Maximum two week (14-day) wait from urgent GP referral to first outpatient appointment for suspected cancer Category A Red 1 incidents, which resulted in an emergency response arriving at the scene of the incident within 8 minutes - (conditions that may be immediately life threatening and the most time critical) RAG Rating NHS Constitution & Pledges 92% 95.0% 95.6% -30% - 330,750 Y N/A 95% 88.7% 89.42% 29/12/15-30% - 330,750 N - 330,750 93% 92.8% 90.0% -20% - 220,500 N - 220,500 75% 71.6% 71.78% -20% - 220,500 N - 220,500 Quality Premium Adjustments for NHS Constitution Measures QUALITY PREMIUM ACHIEVED (CURRENT POSITION) MAXIMUM QUALITY PREMIUM AVAILABLE Green - all relevant indicators on track for achievement of Quality Premium Red - All indicators statistically significantly off track for achievement of the Quality Premium CCG Population > Price per head > Potential Quality Premium > - 771, ,750 1,575, ,575, of 23

159 SECTION 5 PERFORMANCE ASSURANCE FRAMEWORK 2015/16 EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP Provider Comparison TRUST LEVEL COMPARISONS OF UHL, PETERBOROUGH AND KETTERING HOSPITALS A&E Cancer RTT Data Source: UNIFY 4 hour wait 2ww 31 day 62 day Incomplete Monthly Snapshot Oct 2015 Q2 2015/16 Oct /16 Target 95% 93% 96% 85% 92% Commentary Cancer Cancer performance remains a concern for 62 days and 62 day backlog. Performance continues to be monitored via the joint Cancer & RTT Board. The CCG formally requested a Remedial Action Plan (RAP) from the Trust at the end of October During November the RAP and revised recovery trajectory for 62 day performance will be agreed; however indications are this will be June The final report following the IST visit to the CCG has now been received and an action plan developed. These actions will be fed into the UHL Remedial Action Plan or progressed through Primary Care as appropriate. Cancer will be reviewed in more detail as part of the deep dive. UHL 88.90% 87.33% 95.57% 77.63% 93.60% A&E A&E 4 hour performance has deteriorated from Q2 onward. Attendances and admissions remain higher than last year (5.0% and 8% respectively as at 20 Nov 15). The greatest challenge to A&E performance remains organisational flows, with discharges still being problematic. The ED Streaming Service has been implemented by UHL in partnership with Lakeside+ since 3/11/15, but as yet the expected benefits have yet to be realised. Commissioners have requested that a contractual Remedial Action Plan (RAP) and recovery trajectory be submitted. In addition, LLR have been selected as part of the Urgent and Emergency Care Vanguard programme to accelerate system-wide improvements to care and outcomes A&E Achieved 95% A&E target for the last 5 days seen an improvement due to reduction in attendance levels. Not achieved against A&E target for the month. Kettering 92.10% 92.73% % 76.81% 87.9% RTT Issues with data and 8 patients (all orthopaedic) breaching 52 week wait had been highlighted. It was confirmed all patients had already been treated. Internal work is ongoing to understand the impact. Further discussion to take place at the next RTT meeting. Incomplete off plan. Information suggesting off trajectory but the trust is yet to understand the impact of information issues. 62 Day Cancer 62 day wait target not achieved. Seeing an increase in referrals, specifically gynaecology where there has been a change in reporting patterns (20% overall increase based on the previous year). Not seeing an increase in cases. Peterborough 96.40% 94.71% % 88.41% 94.40% All targets achieved RTT The RTT performance target is still not being met and these are reported through the Finance and Performance Committee. UHCW 93.30% 94.38% 98.89% 85.31% 87.50% Actions Taken; 1) Focus on incomplete pathway reduction through a deep dive exercise. Issues better understood, remedial actions in place. 2) Revised trajectory submitted to COG and RTT Board. 3) Particular focus on Surgery Group specialities to deliver better performance. 4) UHCW is working with the CCG to transfer some activity to the private sector, specifically General Surgery and T&O. Spire Nuffield Woodlands Fitzwilliam 22 of 23

160 SECTION 6 PERFORMANCE ASSURANCE FRAMEWORK 2014/15 EAST LEICESTERSHIRE CLINICAL COMMISSIONING GROUP BETTER CARE FUND - LEICESTERSHIRE COUNTY COUNCIL 24/11/15 Integration Exec BCF Metrics Target 14/15 Current Data (Accumulative) Target 15/16 15/16 RAG DOT METRIC 1: Permanent Green admissions of older people (aged 65 and over) to residential and nursing care homes, per 100,000 population METRIC 2: Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement / rehabilitation services 73.30% 93% 83.3 Green BETTER CARE FUND - RUTLAND COUNTY COUNCIL Q2 Position Commentary The number of permanent residential admissions fell in Q2 of to the lowest level seen in the last 10 quarters, bringing the programme back on target for this metric. Averaging out the first two quarters of , there have been lower levels of admissions overall than the BCF projection. The pattern of people remaining home 91 days after discharge remains positive. The Q2 rate was 93%, exceeding the BCF Projection target and improving on Q1, which, at 88% was also above target. Front line staff have been reminded that formal BCF reporting will be based on whether people discharged between 1 Oct and 31 Dec 2015 are still at home 91 days later. METRIC 3: Delayed transfers of care from hospital per 100,000 population (average per month) METRIC 4: Total emergency admissions into hospital, per 100,000 population Green Green Considerable attention is being dedicated to reducing delayed transfers of care and the impact is reflected in this metric. The total number of DTOC days in Q1 was lower than the previous 2 years' quarterly figures, albeit still marginally over the Q1 target (722 per 100,000 as opposed to 664). Q2 figures are better still, well below the target for Q2 and previous quarters, showing 489 delayed days per 100,000 population. Rutland met its pay for performance target for non-elective admissions (NELs) in the first two quarters of this calendar year, showing an overall trend of steadily reducing NEL days. Although NEL days are up somewhat in Q2 relative to Q1 (back to Q4 levels), they are below the BCF target projection. Pending formal confirmation, it appears from that the Pay for Performance target has fortunately once again been met. Because ELR CCG forecasting anticipates growing numbers of non-elective admissions over the coming quarters, anonymised data is being analysed by the CCG to look for patterns that can help to focus interventions avoiding admissions. Initial analysis will be brought to the December 2015 Integration Executive. METRIC 5: Patient / service user experience 92.1 Not available - see commentary 93.1 Blue No RAG rating - this is an annual statistic and not yet available. Target was missed by just over 1% in METRIC 6: Injuries due to falls in people aged 65 and over (per 100,000 population) 1839 Not available - see commentary Blue There is no formal RAG rating as currently this is annual Public Health data. AMBER rating on local proxy falls data from Health used to indicate direction of travel in the national Quarter 1 BCF return. This indicated that the level of falls was higher than ideal if the Public Health target is to be met. There were 77 relevant falls in Q4 of (against a notional target of 77) and 88 in Q1 of (a rising trend, and higher than the notional Q1 target of 80). Local data is being prepared for the national Q2 BCF return - awaiting September's figures. Speclialist falls prevention interventions are getting underway to complement and boost the impact of mainstream services already available. 23 of 23

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163 Paper L East Leicestershire and Rutland CCG Governing Body 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING REPORT TITLE: MEETING DATE: 19 January 2016 REPORT BY: SPONSORED BY: Front Sheet Assurance Report from the Provider Performance Assurance Group (PPAG) November 2015 Daljit K. Bains, Head of Corporate Governance and Legal Affairs, ELR CCG Karen English, Managing Director PRESENTER: Warwick Kendrick, Independent Lay Member PURPOSE OF THE REPORT: This report is from the Provider Performance Assurance Group (PPAG), a meeting held in common of the 3 Leicester, Leicestershire and Rutland CCGs, providing the Governing Body with assurance about the arrangements in place to collaboratively monitor the contracts and performance of our key providers. RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the assurance report from PPAG. 1

164 Paper L East Leicestershire and Rutland CCG Governing Body 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 19 January 2016 Assurance Report from the Provider Performance Assurance Group (PPAG) Introduction 1. The purpose of this report is for the Provider Performance Assurance Group (PPAG) to provide the Governing Body with a summary of the assurance received from the Contract Leads in relation to performance across the collaborative contracts, and the respective providers performance. 2. In addition, the report provides a summary of the items for escalation from PPAG during November 2015 for consideration by the Governing Body and to ensure that the Governing Body is alerted to emerging risks or issues. 3. PPAG is a meeting held in common consisting of members from across each of the 3 Leicester, Leicestershire and Rutland CCGs. PPAG s role is to: Receive assurance and hold to account the Contract Leads; Advise, make suggestions and recommend actions on provider performance as appropriate; and Provide onward assurance to the respective Governing Bodies. Provider review and areas of concern 4. At the meeting in November 2015, PPAG received a report from each of the Contract Leads and agreed to draw the Governing Body s attention to the following areas of performance. Deep-dive 5. The deep-dive at the November meeting focused on cancer performance in University Hospitals of Leicester NHS Trust (UHL) for performance as at September PPAG noted that performance against the cancer standards was still an issue, in particular across the following areas: 2 week wait target; 62 day from referral from screening service to first definitive treatment; 62 day from urgent GP referral to first definitive treatment target performance reduced from 81.3% in August 2015 to 76.5% in September 2

165 Paper L East Leicestershire and Rutland CCG Governing Body 19 January In addition, it was noted that a new trajectory for predicted recovery had been agreed; Challenges were noted in respect of capacity in ITU / HDU and in relation to diagnostics. For instance, lack of capacity in endoscopy has impacted on lower and upper GI cancer performance; and Administrative processes also continue to have an impact on the performance of the cancer targets. 7. PPAG was advised that a detailed, single remedial action plan was now in place to address the issues highlighted, the action plan is reviewed by the Joint Cancer / RTT Board. Input is being received from the national Intensive Support Team (IST) to advise on how UHL can improve its processes and look to implementing good practice from elsewhere across the country. Feedback from the IST will be incorporated into the remedial action plan. Arriva Patient Transport Limited 8. At present the provider is still not meeting its key performance indicators, although maintaining a steady state. 9. Arriva has been asked to undertake a root cause analysis in relation to the aborted journeys to determine the causes of these. 10. It was noted that a new quality schedule inclusive of key quality measures is now in place, which aims to provide a more robust link to patient outcomes. East Midlands Ambulance Service (EMAS) 11. PPAG noted that EMAS performance has slipped across the region in October 2015, in particular across: Red 1, Red 2 and Red A19 indicators. Performance has deteriorated during the summer months and PPAG members expressed a concern about what performance would look like in winter. The contract leads continue to monitor performance. 12. Hospital handovers remain an issue, with a significant proportion of frontline operational hours lost through handover delays. 13. PPAG noted actions being explored to support better flow through University Hospitals of Leicester NHS Trust s Emergency Department, these options will need to be formalised through a multi-agency discussion. PPAG were in support to proceed with a multi-agency approach to this and focus on a system approach for resolving the issues. 3

166 Paper L East Leicestershire and Rutland CCG Governing Body 19 January 2016 CNCS (out of hours) 14. PPAG received positive assurance that CNCS was improving performance against key indicators and in relation to strengthening governance and Board arrangements. The CQC revisited CNCS a couple of weeks ago and will be providing feedback on their findings. 15. It was agreed that the Board-to-Board meeting with CNCS scheduled for December 2015 would be postponed to January 2016 so that feedback from the CQC revisit could be considered prior to the Board-to-Board meeting. University Hospital of Leicester NHS Trust (UHL) 16. A&E 4-hour wait performance has deteriorated from Q2 onwards with year-todate performance at 87% as at 20 November It was noted that attendances and admissions remain higher than last year (5% and 8% respectively). It was noted that the greatest challenge to A&E performance remains organisational flows, with discharges being problematic. This was also referred to when considering the performance report in relation to EMAS. 17. PPAG was alerted to a risk in relation to nursing vacancies at UHL and the recent cap on the use of agency staff. It was noted that positive actions had been taken by the Trust s Director of Nursing and Medical Director, however staffing levels remains a concern. 18. Furthermore, PPAG members were informed that the position in relation to nursing staff in paediatrics is also challenging, UHL is in the process of putting actions in place to mitigate the risk. Leicestershire Partnership Trust (LPT) 19. Bradgate Unit it was noted that the Bradgate Unit Wards are currently utilising high numbers of temporary workers to support nursing vacancies, sickness and maternity cover. The vacancy rate continues to be an ongoing concern and this is being reviewed and handled through the Clinical Quality Review Group meetings. 20. Intensive Community Support / District Nurse Staffing levels with the opening of the new Intensive Community Support beds, concern was expressed about the potential impact of this on staffing levels in district nursing. This will be kept under review. 21. Children s Services PPAG was alerted to the deterioration of performance of the target percentage of patients waiting 13 weeks or less referral to treatment for CAMHS (complete pathway) from 72.7% in September 2015 to 58.8% in October 2015 with a target of 95%. Actions are in place to address and mitigate risks. 4

167 Paper L East Leicestershire and Rutland CCG Governing Body 19 January 2016 Continuing Healthcare (CHC) 22. Discussion took place about the format of reporting on this area in future PPAG meetings. 23. PPAG requested a deep-dive into CHC and personal health budgets in January 2016, with options for future arrangements of reporting on the Arden and GEM SLA and service provided by providers. RECOMMENDATIONS East Leicestershire and Rutland CCG Governing Body is requested to: RECEIVE the assurance report from the Provider Performance Assurance Group. 5

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170 Paper M East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING REPORT TITLE: MEETING DATE: REPORT BY: SPONSORED BY: PRESENTER: Front Sheet Associated policies for IVF/ICSI for: Gamete Cryopreservation and Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSU treatment) 19 January 2016 Desra Robinson, Contracts & Provider Performance Manager, Leicester City CCG Chris Trzcinski, Deputy Chair, West Leicestershire CCG Jane Chapman, Chief Strategy and Planning Officer Dr Richard Palin, Chair SUMMARY: The policies associated to the IVF/ICSU policy generated by EMSCG in 2011 have only ever been in draft form, which meant that LLR CCG s were vulnerable to challenge. In January 2015 a previous CCB paper agreed as ratified the draft policies for use for: 1 Gamete Cryopreservation and 2 Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSU treatment) A Contract Variation was presented to the UHL team and it transpires that the policies received by the Contracting Team were not the latest versions. The policies have been discussed at the Commissioning Collaborate Board (CCB) and the recommendations detailed within the report are as agreed by the CCB. Introduction 1 There are two associated policies linked to the IVF/ICSI process for: Gamete Cryopreservation Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSU treatment) 2. The policies associated to the IVF/ICSU policy generated by EMSCG in 2011 have only ever been in draft form, which meant that LLR CCG s were vulnerable to challenge as queries had been raised by the trust and patients as to the 1

171 Paper M East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 eligibility criteria in these circumstances and the contracting team have used the draft policy to make a decision to accept/reject. 3. In January 2015 a previous CCB paper agreed as ratified the draft policies known to the contracting team at that time. 4. A review of the policies sent to the UHL team highlighted that in fact they had received other policies to which they were working. 5. On reviewing the policies from UHL to those in the CCB/CV documents confirmed there were anomalies and the latest copies are now to be formally requested for re-approval. 6. Guidance has changed and been incorporated and in practice being used within the trust and the commissioners need to formally agree until a formal review of these policies has been carried out. 7. In addition there is no draft policy at all in relation for LLR Surrogacy policy, therefore, it is important to identify who will take forward this issue. 8. A review of the eligibility form for the IVF/ICSI process which is managed by the Leicester City CCG contracts team is required. The current form asks for the male BMI but this is not a part of the criteria within the IVF/ICSI policy. This question has been removed from the eligibility form. 9. For Surrogacy the CCGs do not have a policy as advised in the previous CCG paper, it is understood that this was not routinely commissioned by EMSCG in this region and no documentation is available for this process. In terms of risks to the CCG s this would be a lower priority risk. 10. Further investigation will be required by the Commissioning Team and Clinical Advisors to confirm the details of the policies and what is required for the LLR CCG s. A Policy for Surrogacy will need to be developed to the requirements and evidence background. 2

172 4 Summary of the variances between the policies Paper M East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 Policy Name Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSI) treatment) Incorrect Contracts team documents badged as East Midlands Collaborative Policy WL CCG draft documents badged as LLR with version control UHL operational policy document badged as West Leic CCG with no version control NICE guidance 2004 updated 2013 Age Range years years years Up to 42 years Number of cycles Three cycles Three cycles Three cycles Up to six cycles BMI range for men <35 Not included Not included Only refers to female BMI Policy Name Gamete/Embryo cryopreservation Incorrect Contracts team documents badged as East Midlands Collaborative Policy WL CCG draft documents badged as LLR with version control UHL operational policy document badged as West Leic CCG with no version control NICE guidance 2013 PCT references Noted as PCT Noted as CCG Noted as CCG Not applicable Age Female up to 42 years Female up to 42 years Female up to 42 years - Males up to age 55 years No male age limit No male age limit Storage of eggs Section 5 - patient pathway - 10 years or 43 rd birthday for women 10 years 10 years 10 years 3

173 Paper M East Leicestershire and Rutland CCG Governing Body meeting 19 January 2016 RECOMMENDATIONS: The Governing Body is asked to: RECOMMEND - approve the attached interim draft policies for all LLR CCG s adopting the West Leicestershire CCG draft document which is applicable to all LLR eligible patients regardless of provider and rebrand as LLR for:- Gamete Cryopreservation & Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSU treatment) To also:- Review and approve an updated eligibility form which has the male BMI question removed. Identify who will be tasked with formally reviewing these policies in the future including the formulation of a LLR CCG Surrogacy Policy. Appendix 1 Gamete Cryopreservation Appendix 2 Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSU treatment) Appendix 3 4

174 B Leicester, Leicestershire and Rutland Leicester, Leicestershire and Rutland Collaborative Commissioning Policy Gamete/Embryo cryopreservation Reference number: Title: Version number: CTrz2 Gamete/Embryo Cryopreservation 2 Policy approved by: Date of Approval Date Issued: 17 th March reissued November 2015 Review Date: Document Author(s): Dr C J Trzcinski (with support from the Leicester infertility Centre Consultants) Assistant Director: 1

175 B Leicester, Leicestershire and Rutland Collaborative Commissioning Policy Gamete/Embryo cryopreservation Policy Statement Equality statement Clinical Commissioning Groups (CCGs) in the Leicester, Leicestershire and Rutland (LLR) are committed to ensuring equality of access and non-discrimination, irrespective of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. In carrying out its functions, the CCGs must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which they are responsible, including policy development, review and implementation Due Regard. The CCG commitment to equality means that this policy has been screened in relation to paying due regard to the Public Sector Equality Duty of the Equality Act 2010 to eliminate unlawful discrimination, harassment, victimisation; advance equality of opportunity and foster good relations Background Statement Gamete/embryo cryopreservation is a technique that can be used to preserve the fertility of individuals through the freezing of sperm, eggs or embryos. Gamete/embryo cryopreservation will be commissioned in individuals undergoing medical or surgical treatment who may be at risk of permanent infertility as a result of their treatment. Gamete cryopreservation will not be commissioned for social reasons, or if gametes are being frozen for use by individuals other than the patient receiving treatment. Provision of gamete preservation under the terms of this policy is made without prejudice to the future determination of any subsequent fertility treatment. Surrogacy The NHS in LLR will not provide routine funding for the medical treatment required to give effect to a surrogacy arrangement because: (a) this treatment is not considered by the NHS in LLR to be a priority for NHS investment, (b)the NHS in LLR is unlikely to be in a position to be able to 2

176 B reach an assessment as to whether the parties have concluded a lawful surrogacy arrangement, and (c) The NHS in LLR is concerned that the funding of such treatment raises substantial risks that NHS bodies and doctors providing care connected to surrogacy arrangements would be exposed to unknown medico-legal risks. Surrogacy, or any assisted conceptions involving surrogacy do not form part of this policy. Training Dissemination There are no known training issues. To all CCGs and relevant trusts Leicester, Leicestershire and Rutland Collaborative Commissioning Policy Gamete/Embryo cryopreservation Section Contents Page 1 Introduction 5 2 Definition 5 3 Aims and Objectives 5 4 Criteria for commissioning 5 5 Patient pathway 6 6 Epidemiology 7 7 Evidence-base 8 8 Financial considerations 11 9 Audit requirements Date of review 11 3

177 B 1. Introduction This policy sets out the criteria for access to NHS-funded gamete cryopreservation services for patients who are the responsibility of Clinical Commissioning Groups (CCGs) in Leicester, Leicestershire and Rutland (LLR). It covers the provision of gamete cryopreservation and storage for individuals undergoing certain medical and surgical treatments who may be at risk of permanent infertility as a result of their treatment. 2. Definition(s) Cryopreservation is a technique that freezes an individual s eggs or sperm for use in future fertility treatment. Cryopreservation of sperm is a well-established technique used to maintain an individual s fertility. Cryopreservation of eggs is a newer technology, though has been widely used in relation to cancer treatment for a number of years. 3. Aim and Objectives The aim of the policy is to identify those individuals who will be eligible to receive NHS-funded cryopreservation of their gametes. It should be noted that the policy does not address NHS funding for the future use of frozen gametes. Provision of gamete freezing and storage under the terms of this policy is made without prejudice to the future determination of funding of any subsequent fertility treatment. 4. Criteria for commissioning Patients eligible for NHS-funded gamete cryopreservation should be about to commence treatment that may cause permanent infertility as a result of their treatment. Conditions considered appropriate for gamete cryopreservation are: malignancies requiring chemotherapy malignancies requiring total body irradiation or radiotherapy that may affect an individual s reproductive organs conditions requiring male urological or female gynaecological surgery other autoimmune conditions requiring the use of Chemotherapy (eg:- Rheumatoid arthritis) Women who are preparing for medical treatment for cancer that is likely to make them infertile, should only be offered oocyte cryopreservation if they meet all of the following criteria: they are well enough to undergo ovarian stimulation and egg collection; and there is sufficient time available to harvest eggs before the start of their cancer treatment 4

178 B Women who are undergoing gynaecological surgery should only be offered oocyte cryopreservation if, following surgery, pregnancy would still be viable. Individuals should also meet the following criteria: Age Females of reproductive age up to 42 years old (stimulation treatment to take place prior to individual s 43 rd birthday) Registered GP Previous sterilisation Consent Exclusion criteria There is no age limit for male..surgical sperm retrieval (SSR) can be performed in exceptional circumstances for male patients. Registered with a GP in Leicester Leicestershire and Rutland Individuals who have previously been sterilised will not be eligible for cryopreservation Written consent to treatment and gamete storage will be required Individuals will not be eligible for NHS-funded gamete cryopreservation if: Gametes are being frozen for non-medical or non-surgical reasons, for example for social reasons their infertility is as a result of a congenital disorder Future use of frozen gametes will be in line with all relevant policies in place at the time. Cryopreservation of ovarian or testicular tissue is still considered to be an experimental procedure and therefore funding of this is not included under this policy. Links with fertility treatment policies Meeting the criteria for NHS-funded gamete cryopreservation does not automatically entitle individuals to subsequently receive NHS-funded assisted conception treatment. In order to receive subsequent NHS funding an individual will be required to meet the eligibility criteria outlined in policies in place at the time relating to assisted conception and IVF/ICSI, or the prevailing relevant policy of a successor organisation at that time 5. Patient pathway Treatment will only be funded at centres licensed by the Human Fertilisation and Embryology Authority. Access into services for gamete cryopreservation will be by consultant referral. The consultant responsible for the care resulting in infertility will be required to provide the following information for all individuals referred for gamete cryopreservation: name date of birth 5

179 B address GP details of the underlying condition confirmation that the treatment carries with it a significant risk of permanent infertility for female cancers, confirmation that the use of stimulation drugs as part of the egg retrieval process will not be detrimental to the patient In order for commissioners to monitor uptake of gamete/embryo cryopreservation as a result of this policy, referrals should be submitted to the relevant CCG for notification. Treatment provided will be the most appropriate for their individual clinical circumstances and will include: confirmation that the individual meets the inclusion criteria for gamete cryopreservation as detailed in this policy, and does not meet any of the exclusion criteria screening, as a minimum, for HIV, hepatitis B and hepatitis C prior to treatment. People found to test positive for one or more of these should be offered specialist advice and counselling and appropriate clinical management written consent for cryopreservation of individual s gametes/embryos provision of medication for stimulation of gamete/embryo production, as required harvesting of gametes/embryos gamete/embryo freezing The NHS will fund the storage of eggs/embryos for a maximum period of 10 years, Sperm will be stored for a maximum period of 10 years. Individual patients can choose to continue the storage of their gametes/embryos beyond this period but this must be paid for privately. On the death of the patient NHS funding for gamete/embryo storage will cease. However, if it is lawful to do so and there is a legally binding document is signed by the patient allowing the use of frozen sperm or eggs after death, NHS funding of gamete/embryo cryopreservation will continue for up to a total of 10 years. 6. Evidence Base Cryopreservation of sperm is a well-established technique. Cryopreservation of eggs is a much newer technology, although is demonstrating improved results at a fast pace. In 2009 the HFEA reported that approximately 900 babies had been born worldwide following egg freezing, with 5 live births in the UK, but with many thousands of eggs having been stored in the UK. 1 It should be noted that due to the relatively novel nature of oocyte cryopreservation, only a relatively small proportion of the oocytes that have been frozen have subsequently been used in fertility attempts. 1 Human Fertilisation and Embryology Authority (2009) www. Hfea.gov.uk/46.html 6

180 B In addition, the risks of oocyte cryopreservation will not be quantified until a much greater number of babies have been born using these techniques. NICE guidelines The NICE clinical guidance 11 Fertility: assessment and treatment for people with fertility problems 2 recommends that men and adolescent boys preparing for medical treatment that is likely to make them infertile should be offered semen cryostorage because the effectiveness of this procedure has been established. The guidelines recommend that women preparing for medical treatment that is likely to make them infertile should be offered oocyte or embryo cryostorage as appropriate if they are well enough to undergo ovarian stimulation and egg collection, if this will not worsen their condition and sufficient time is available. The guidelines also state that women should also be informed that oocyte cryostorage has very limited success. However, it should be noted that the clinical guidelines were published eight years ago, when oocyte cryopreservation techniques were not as developed. Individuals with cancer who wish to preserve their fertility are a specific group considered within the NICE guidance, and the following recommendations are made: when discussing cryopreservation with people before starting chemotherapy or radiotherapy that is likely to affect their fertility, follow the procedures recommended by the Royal Colleges of Physicians, Obstetricians and Gynaecologists and Radiologists at diagnosis, the impact of the cancer and its treatment on future fertility should be discussed between the person diagnosed with cancer and their cancer team for cancer-related fertility preservation, do not apply the eligibility criteria used for conventional infertility treatment there should be no fixed lower age limit for cryopreservation for fertility preservation in people diagnosed with cancer when deciding to offer fertility preservation to people diagnosed with cancer, take the following factors into account: diagnosis, treatment plan, expected outcome of subsequent fertility treatment, prognosis of the cancer treatment, viability of the stored/post-thawed material when using cryopreservation to preserve fertility in people diagnosed with cancer, use sperm, embryos or oocytes offer sperm cryopreservation to men and adolescent boys who are preparing for medical treatment that is likely to make them infertile use freezing in liquid nitrogen vapour as the preferred cryopreservation technique for sperm offer oocyte or embryo cryopreservation to women of reproductive age (including adolescent age) who are preparing for medical treatment for 2 NICE (2004) Clinical guidance 11: Fertility: assessment and treatment for people with fertility problems 7

181 B cancer that is likely to make them infertile if: they are well enough to undergo ovarian stimulation and egg collection and this will not worsen their condition and enough time is available before the start of their cancer treatment in cryopreservation of oocytes and embryos, use vitrification instead of controlled-rate freezing if the necessary equipment and expertise is available store cryopreserved material for an initial period of 10 years do not continue to store cryopreserved sperm, beyond 10 years, for a man whose normal fertility has restored by the time he is discharged from oncology follow-up The updated NICE guidance is due to be published October British Fertility Society The British Fertility Society published guidelines for oocyte cryopreservation in The guidance highlights that there is strong evidence for use of oocyte cryopreservation, and that oocyte survival rates may be higher using vitrification techniques compared to slow-freezing. However the guidance also report that the long-term safety and efficiency of vitrification remain to be confirmed. Other evidence The Royal College of Physicians, the Royal College of Radiologists and the Royal College of Obstetricians and Gynaecologists published a guidance report on the effects on reproductive functions in individuals undergoing cancer treatment in The report recommends that sperm banking should be universally available and funded to all males commencing treatment which has a risk of future infertility. The report considered that egg storage was still developmental, but it should be noted that the report was published a number of years ago when oocyte cryopreservation techniques were not as advanced. A recent systematic review included five randomised controlled trials of oocyte preservation, undertaken between 2005 and Oocyte survival rates following cryopreservation ranged from 65-97% and clinical pregnancy rates using vitrification freezing techniques ranged from 38-65%. The meta-analysis reported no significant difference in ongoing or clinical pregnancy rates between vitrified and fresh oocytes and significantly higher oocyte survival and fertilisation rates using vitrified oocytes compared to slow-frozen oocytes. The authors concluded that vitrification is an efficient method to preserve oocytes, but due to the small number of studies included further clinical trials with larger samples sizes are required to strengthen the conclusion. 3 Cutting, R. et al (2009) Human oocyte preservation: Evidence for practice Human Fertility 12(3): Royal College of Physicians, The Royal College of Radiologists and the Royal College of Obstetricians and Gynaecologists (2007) The effects of cancer treatment on reproductive functions: Guidance on management 5 Cobo, A. and Diaz, C. (2011) Clinical application of oocyte vitrification: a systematic review and meta-analysis of randomised controlled trials Fertility and Sterility 96(2):

182 B 7. Financial considerations The treatment costs for egg retrieval and freezing are approximately 2,700 per patient. The treatment costs for sperm freezing are approximately 300 per patient per year. If surgical sperm retrieval is required then this would cost an additional 850 per patient. Using the potential demand estimates provided in Table 1, the estimated costs for each CCG are provided in Table 2. It should be noted however, that the recent number of Individual Funding Requests received by each CCG is considerable less than the demand estimates. It should also be noted that implementing this gamete cryopreservation policy may increase the number of individuals requesting NHS-funded assisted conception treatment, however these costs have not been considered within this policy. It should also be noted that provision of NHS-funded treatment under this policy does not automatically entitle individuals to receive NHS-funded assisted conception treatment. Individual CCGs will be required to determine their funding mechanism for this policy. Table 2: Estimated costs of gamete cryopreservation, by previous PCT Locality Estimated costs ( ) Derbyshire County and Derby City PCT Cluster 87,900 Leicestershire County and Rutland and Leicester City PCT Cluster 95,100 Lincolnshire PCT Cluster 69,600 Northamptonshire and Milton Keynes PCT Cluster 87,900 Nottinghamshire County and Nottingham City PCT Cluster 91,500 Total 432, Date of Review The levels of demand should be reviewed after 12 months to determine better estimates of future demand for gamete cryopreservation services under this policy. 9

183 B Leicester, Leicestershire and Rutland POLICY DOCUMENT Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSI) treatment) Reference number: CTrz1 Title: Version number: IUI DI Policy 2 Policy approved by: Date of Approval Date Issued: Re-issued November 2015 Review Date: Document Author(s): Dr C J Trzcinski (withinput from Leicestershire Infertility Centre Consultants) IUI & DI Policy (excluding IVF/ICSI) Page 1 of 10

184 B Leicester, Leicestershire and Rutland Collaborative Policy Intrauterine (IUI) and Donor Insemination (DI) Policy (excluding In vitro fertilisation (IVF) & Intracytoplasmic sperm injection (ICSI) treatment) Contents i. Version control sheet Section 1 Policy 2 Criteria 3 Treatment 4 Epidemiology 5 Glossary 6 References 7 Review Page Appendix 1 Assessment & Treatment Algorithm 12 IUI & DI Policy (excluding IVF/ICSI) Page 2 of 10

185 B 1 Policy This paper sets out the criteria for access to NHS funded fertility services for patients who are the responsibility of Leicester, Leicestershire and Rutland (LLR) Clinical Commissioning Groups (CCGs). This policy covers the provision of Donor Insemination (DI) and Intrauterine Insemination (IUI) only and should be read in conjunction with the East Midlands Specialised Commissioning Group Commissioning Policy for IVF / ICSI within Tertiary Infertility Services. It sets out the minimum entitlement and service that will be provided for NHS fertility services across the health community. IVF and ICSI services are commissioned separately by the East Midlands Specialised Commissioning Group. Couples requiring Pre- Implantation Genetic Diagnosis will be considered under the current East Midlands Specialised Commissioning Group Commissioning Policy for Pre-Implantation Genetic Diagnosis. Initial investigation of patients is usually carried out by a network of specialist gynaecologists at NHS Hospital Trusts throughout the East Midlands area. Access to fertility services for routine tests, investigation and diagnosis is available via GP referral. In any healthcare system there are limits set on what NHS funded care is available and on what people can expect. CCGs are required to achieve financial balance; they have a complex task in balancing this with an individual s rights to health care. It is the purpose of the criteria set out here to make the limits on fertility treatment fair, clear and explicit. The National Institute for Clinical Excellence (NICE) provides guidance on NHS fertility services and the same principles have been used to develop the local policy. This policy should be read in conjunction with the NICE Fertility Guidance available on their web site. Review of clinical studies of couples seeking treatment; provide the following approximated proportions for the principal causes of infertility. A significant proportion of couples will have more than one cause and the distribution varies between primary and secondary infertility. Ovulatory failure 27% Low sperm count or quality 19% Tubal damage 14% Endometriosis 5% Others 5% Unexplained 30% There is evidence that infertility causes considerable emotional stress and distress, which may affect many areas of couples' lives and can result in social handicap. There are three main types of fertility treatment: medical treatment (such as drugs for ovulation induction); surgical treatment (e.g. laparoscopy for ablation of endometriosis); and assisted reproduction. IUI & DI Policy (excluding IVF/ICSI) Page 3 of 10

186 B Assisted conception techniques include: - Intrauterine insemination (IUI) - In vitro fertilisation (IVF) - Intra-cytoplasmic sperm injection (ICSI) - Donor insemination (DI), oocyte (egg) donation (OD) and cryo-preservation (oocytes and/or embryos) NB: Provision for IVF/ICSI is not covered by this policy. Refer to the East Midlands Specialised Commissioning Group Commissioning Policy for IVF / ICSI within Tertiary Infertility Services. NICE does not recommend assisted conception procedures like gamete intrafallopian transfer (GIFT) or zygote intrafallopian transfer (ZIFT) and these will not be funded by the NHS. 2 Criteria All patients are eligible for consultation and advice in primary care. Patients in the reproductive age group who fail to conceive after frequent unprotected sexual intercourse for one to two years (or by undertaking 6 cycles of Donor Insemination without conceiving or by having a defined tubal blockage thereby preventing conception) should be offered further clinical investigation including semen analysis and assessment of ovulation as appropriate. Where there is clear reproductive pathology, infertility of any duration will be considered. This will include patients who cannot achieve full sexual intercourse due to disability. Eligibility for NHS funded treatment will be assessed against the treatment referral criteria and this may, in turn, affect the decision to investigate Agreed eligibility criteria have been set so that patients with the best chance of success are given priority over others in order to produce the best outcomes. Following referral, patients should have a prognostic estimate that the successful outcome of a cycle will be greater the 10%. Patients who do not meet the criteria within this policy are still entitled to access the primary and secondary care for consultation. Further investigations can be performed if appropriate. Ovulation induction with clomiphene citrate can be accessed within a dedicated secondary or tertiary care unit when clinically appropriate.. Medication should only be prescribed following clinical investigation in line with the NICE Clinical Practice Algorithm, Fertility - Assessment and treatment for people with fertility problems, In order to achieve the maximum benefit for the resources available the following referral criteria should be used by referring physicians. IUI & DI Policy (excluding IVF/ICSI) Page 4 of 10

187 B The establishment of these access criteria should be undertaken by the patients GP to ensure that only appropriate patients who meet the terms of the policy are referred. Woman s Age years NB: Patients should be informed that any stimulation treatment must take place before the patient s 43rd birthday. This applies to both fertility procedures under this policy and IVF/ICSI Man s Age 55 years or younger, if applicable Woman s BMI >19 BMI <30 Welfare of Child The welfare of any resulting children is paramount. In order to take into account the welfare of the child, the centre should consider factors which are likely to cause serious physical psychological or medical harm, either to the child to be born or any other child who may be affected by the birth. This is a requirement of the licensing body, Human Fertilization and Embryology Authority. Family Structure No living children from current or previous relationship(s), including adopted children, but excluding foster children. There needs to be an explicit and recorded assessment that the social circumstances of the family unit have been considered within the context of the assessment of the welfare of the child. In all considerations of parental status, there should be an explicit statement that children adopted by either partner should have the same status as biological children Smoking Neither partner is a current smoker Registered GP The patients are registered with an LLR GP Consent Written consent to treatment is required from both parties Any cycle of infertility treatment already undertaken (whether NHS or self funded) will be taken into account when determining NHS funding entitlement. IUI & DI Policy (excluding IVF/ICSI) Page 5 of 10

188 B In the rare or exceptional circumstances where a patient or clinician feel that the patient represents a special case then an application can be made to the CCG s Individual Funding Request Panel for consideration of exceptional funding. For patients to be considered for exceptional funding, an Individual Funding Request Form must be completed in full and submitted to the Individual Funding Request Team for consideration. 3 Treatment The treatment protocol recommended by NICE (2013) should be followed. Lifestyle, medical treatments for infertility should be attempted before considering options like IUI, IVF and ICSI where clinically appropriate. NHS funding will provide a maximum of 3 cycles of donor insemination (DI) or a maximum of 3 cycles of intrauterine insemination (IUI) treatment. First treatment to start within 18 weeks of referral Suitable patients should undertake DI (subject to availability and/or patient choice) or IUI before being considered for IVF/ICSI under the East Midlands Specialised Commissioning Group Commissioning Policy for Tertiary Infertility Services Patients who do not conceive after treatment in accordance with this policy will have a full entitlement to IVF in line with the stated eligibility criteria in the East Midlands Specialised Commissioning Group Commissioning Policy for IVF / ICSI within Tertiary Infertility Services 1 st April 2011v2) Couples who choose not to have IUI and progress straight to IVF, will not be permitted to be offered IUI if IVF fails. Donor Sperm will be funded only where azoospermia or severe oligospermia is present or to avoid transmission of inherited disorders to a child where the patients meet the other eligibility criteria. Embryo freezing and storage is available to patients meeting the eligibility criteria for IVF / ICSI. Refer to the East Midlands Specialised Commissioning Group Commissioning Policy for IVF / ICSI within Tertiary Infertility Services for details. Ovarian or testicular tissue storage will not be carried out outside a clinical trial. These are currently experimental. In addition to the previous criteria the following patients will not be eligible for NHS funded IVF/ICSI treatment: Sterilised patients and those patients who have had a sterilisation reversed IUI & DI Policy (excluding IVF/ICSI) Page 6 of 10

189 B Surrogacy is not commissioned as part of this policy 4 Epidemiology Infertility is defined, in accordance with the EMSCG Commissioning Policy for IVF / ICSI within Tertiary Infertility Services, as failure to conceive after frequent unprotected sexual intercourse for one to two years in couples in the reproductive age group or by undertaking 6 cycles of Donor Insemination without conceiving or by having a defined tubal blockage thereby preventing conception. If the couple fail to conceive after one year they are eligible to consultation. They can only proceed to assisted conception if they have tried for two years or if there is an obvious reproductive pathology such as tubal block or severe oligozoospermia. Around 84% of couples attempting to conceive are successful after trying to one year, after two years this figure rises to 92%. Female fertility declines with age and for women aged 38, only about 77 out of 100 who have regular unprotected sexual intercourse will get pregnant after 3 years. The need for such services may increase due to the trend towards later first pregnancies and an increasing number of remarriages. Demand is increasing due to more public awareness of treatment possibilities. It is likely that there is unexpected and/or unmet demand, particularly from women with secondary infertility (those who have conceived before but do not necessarily have a child). 5 Glossary of terms: Term In Vitro Fertilisation (IVF) Intra-cytoplasmic Sperm Injection (ICSI) Intra Uterine Insemination (IUI) Donor Insemination (DI) Oocyte (Egg) Donation (OD) Body Mass Index (BMI) Meaning This is a process whereby eggs are removed from the ovaries and fertilised with sperm in the laboratory. It is utilised in the PGD process in order for the fertilised eggs (embryo s) to be tested for a specific genetic abnormality, with an unaffected embryo subsequently being placed in the woman s womb. (HFEA, 2009). This is a technique that can be used in IVF whereby a sperm is injected into the egg to assist in fertilisation. (NHS Direct, 2009). Insemination of sperm into the uterus of a woman The introduction of donor sperm into the vagina, the cervix or womb itself The process by which a fertile women donates her eggs to be used in the treatment of others or for research Body Mass Index (BMI) is a number calculated from a person's weight and height. BMI provides a IUI & DI Policy (excluding IVF/ICSI) Page 7 of 10

190 B reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems. IUI & DI Policy (excluding IVF/ICSI) Page 8 of 10

191 B Appendix 1: Assessment and Treatment Algorithm Subfertility Assessment and Treatment Algorithm Initial advice for couples concerned about delays in conception: Cumulative probability of pregnancy in general population: o 84% in first year o 92% in second year Fertility declines with a woman s age Lifestyle advice: o Sexual intercourse every 2-3 days o 1-2 units alcohol/week for women; 3-4 units/week for men o Smoking cessation programme for smokers o BMI for women o Information about prescribed, over-the-counter and recreational drugs o Information about occupational hazards Offer preconception advice: o Folic acid Initiate investigation if: Failure to conceive after regular unprotected sexual intercourse for 2 years in the absence of known reproductive pathology. Investigations o Semen analysis (compare with WHO reference values o Ovulation assessment o Tests for tubal occlusion (should only be carried out if results of semen analysis and ovulation assessment are known) Early investigation if: History of predisposing factors (such as amenorrhoea, oligomenorrhoea, pelvic inflammatory disease or undescended testes); Woman s age 35 years People with HIV, Hepatitis B, Hepatitis C or those with prior treatment for cancer Management strategies Male factor fertility problems Hypogonadotrophic hypogonadism Ejaculatory Oligospermia Obstructive azoospermia Drug IUI up to 3 Surgery* Gonadotrophin DI up to 3* IUI & DI Policy (excluding IVF/ICSI) Page 9 of 10

192 B Management strategies for subfertility Female factor fertility problems If no pregnancy with azoospermia, bilateral tubal occlusion or 2 years infertility and the woman is aged years offer 1 cycle of IVF/ICSI Ovulatory Problems Tubal WHO group 1 WHO group 2 Gonadotrophins with LH activity or GnRH Hyperprolactinaemia Clomifene citrate or tamoxifen (up to 12 months if ovulating) Mild tubal disease: Tubal Surgery Proximal tubal occlusion: Tubal catheterisation or cannulation Minimal/mild endometriosis: Surgical ablation or resection and adhesiolysis at laparoscopy If no pregnancy, offer: Stimulated IUI up to 3 cycles Bromocriptine If ovulating but not pregnant after 6 months offer clomifene citrate + IUI (up to 3 cycles) If no ovulation with clomifene, offer: Metformin + clomifene citrate or hmg, ufsh or rfsh with ultrasound monitoring or Ovarian drilling Moderate/severe endometriosis Surgery If no pregnancy with bilateral tubal occlusion or 2 years infertility and the woman is aged years offer 1 cycle of IVF/ICSI IUI & DI Policy (excluding IVF/ICSI) Unexplained fertility problems (Normal semen analysis, no ovulation disorders, no tubal occlusion) Clomifene citrate Unstimulated IUI or fallopian sperm perfusion up to 3 cycles IVF x 1 stimulated cycle Page 10 of 10

193 Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group REQUEST FOR SPECIALISED INFERTILITY TREATMENT - IVF/ICSI EFFECTIVE FROM 1 st December 2015 ALL NEW CONSULTANT/GP REFERALS The establishment of the following access criteria should be undertaken by the couples Secondary Care Consultant/GP. CCGs across the East Midlands will be responsible for the commissioning of IUI and DI treatments. Name Patient Details: Female Partner Date of Birth Address NHS No GP Details: GP name Address Secondary Provider Consultant Consultant name & Fertility unit attended Address Eligibility Criteria: Criteria Met If Yes, Details Women s age years Man s age 55 years or younger Women s BMI >19 BMI <30 Welfare of the child. Family Structure. Smoking No adverse factors that are likely to cause harm to a child No living children from current or previous relationships Both partners must not be a current smoker Previous self-funded cycles. Failure to conceive after frequent unprotected sexual intercourse for one to two years (6 months for patients over 35 yrs) Undertaken 6 cycles of Donor Insemination without conception Patient has defined tubal blockage thereby preventing conception Couples who have selffunded will be entitled to 1 NHS cycle provided they have not received more than 2 cycles OR OR

194 Criteria Met? If Yes, Details No previous sterilisation/reversal of sterilisation of either partner This request for funding of ONE IVF cycle is NOT part of a surrogacy plan. Prognostic estimate that the successful outcome of a cycle would be greater than 10% Declaration: The information we have provided on this form is correct and complete. We understand that the information we have given may determine whether or not the patients are eligible to receive NHS funding and treatment. If the information we have provided is found to be false then this may result in any agreed treatment being terminated with immediate effect. If it is suspected that false information has been provided then this form and other relevant information about this application for funding may be shared with NHS Protect or Counter-Fraud specialists from the funding health body to investigate. If false information is found to have been knowingly provided then we understand we may be liable to criminal prosecution in addition to civil recovery proceedings to recover the cost of any treatment. GP or Consultant Authorisation: Completed by: Date: Signature.. Patient Authorisation: Patient #1 Completed by: Date:. Signature Patient Authorisation: Patient #2 Completed by:.. Date:.. Signature.. Further information: completed form to be sent to:- NHS Leicester City CCG, St Johns House, 30 East Street, Leicester, LE1 6NB; Telephone: ; city.contracts@nhs.net

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197 Paper N East Leicestershire and Rutland CCG Governing Body Meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING Front Sheet REPORT TITLE: Listening. Responding. Delivering. Listening and Engagement Strategy Update MEETING DATE: 19 January 2016 REPORT BY: SPONSORED BY: PRESENTER: Joe McCrea Interim Head of Communications Carmel O Brien, Chief Nurse and Quality Officer Carmel O Brien, Chief Nurse and Quality Officer PURPOSE OF THE REPORT: The purpose of this report is to provide an update to the CCG s Listening and Engagement Strategy RECOMMENDATIONS: The East Leicestershire and Rutland CCG Governing Body is requested to: APPROVE the updated strategy. REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of life for people with long-term conditions Improve the quality of care clinical effectiveness, safety and patient experience Reduce inequalities in access to healthcare Improve integration of local services between health and social care; and between acute and primary/community care. Listening to our patients and public acting on what patients and the public tell us. Living within our means using public money effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). Page 1 of 4

198 Paper E East Leicestershire and Rutland CCG Governing Body Meeting 17 November 2015 BACKGROUND: The update to the CCG s Listening and Engagement strategy continues the trajectory and builds on the foundations laid by our Informing and Involving strategy. The updated strategy responds to the clear and consistent message delivered through our 2015 NHS Ipsos Mori 360 stakeholder survey as well as views and opinions gleaned from our 2015 Summer of Listening exercise and at our 2015 Annual General Meeting. These showed: the fundamentals of our existing listening and engagement activity are sound and fit for purpose; there are areas of particular strength that are valued by our stakeholders and partners; we could improve some aspects of our activities to deliver real excellence; and a greater emphasis on demonstrating and communicating specific feedback and responses to what we had heard would be particularly welcome and valued. In all we do, we seek to increase both the reach and the impact of our engagement. In particular, we want to achieve four aims: increase the number of people with whom we engage within those organisations with whom we are already engaged; widen the range of organisations and individuals with whom we engage, in particular going beyond the normal NHS and social care family to engage people in their wider lives and activities; increase the quality of our engagement and the experience of those with whom we engage; and increase the visibility of what we do with what we hear and improve the ways in which we provide specific feedback on specific topics. The strategy also includes recent initiatives in relation to how we listen to our own staff, such as our Freedom to Speak Up programme and staff-led refresh of our organisational values. Page 2 of 4

199 LINK TO BOARD ASSURANCE FRAMEWORK The importance of getting communication and engagement right to ensure we are truly listening, responding and delivering are reflected in the arrangements we have put in place for governance and accountability. While the CCG Governing Body retains overall responsibility for delivery, we have implemented structures and practices which encourage close and regular scrutiny of public involvement and engagement. Whilst the fundamentals of our governance arrangements remain unchanged, the updated Strategy introduces further support to enhance them, particularly in the ways in which data, information and knowledge is collated, reported on and made available. Page 3 of 4

200 Listening. Responding. Delivering. Listening and Engagement Strategy Update January 2016

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202 Contents Page Executive Summary 1 The importance of clinically-led engagement 4 Increasing our reach 5 Active Listening and LEAPs 7 Listening. Responding. Delivering. 10 Listening to our staff 12 We come to you 14 Governance 15 Appendix A: Our duty to involve 16 Appendix B: Building on the 2013 Strategy 18

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204 Executive Summary This document contains our updated clinically-led Listening and Engagement Strategy. It includes measures to build our overall capacity and approach as well as specific strands of engagement over the coming year comprising our Engagement Plan. The update to the strategy continues the trajectory and builds on the foundations laid by our Informing and Involving strategy. That strategy put in place the fundamental building blocks of a modern and imaginative capacity for listening and engagement. In particular, by: organising and grouping all stakeholders into groups, so we could tailor and deliver focused listening and engagement to each; understanding their preferred methods of engagement and ensuring that our activities match these preferences; introducing new and innovative ways to ensure that the authentic voice of patients and local people are heard at the heart of our organisation, for example through our Listening Booth and introduction of Patient Stories as a standing item at the start of all our Governing Body meetings; setting out clear objectives, underpinned by specific activities and tied to demonstrable outcomes; ensuring that our listening and engagement is aligned with and reinforces the vision and values of our organisation; ensuring that the listening and engagement strategy delivers our legal requirements for equality and openness; ensuring the delivery and operation of effective governance and accountability for the strategy within our wider organisation; and managing the delivery of activities and support from external suppliers and partners, particularly through our Commissioning Support Unit. The updated strategy responds to the clear and consistent message delivered through our 2015 NHS Ipsos Mori 360 stakeholder survey as well as views and opinions gleaned from our 2015 Summer of Listening exercise and at our 2015 Annual General Meeting. These showed: the fundamentals of our existing listening and engagement activity are sound and fit for purpose; there are areas of particular strength that are valued by our stakeholders and partners; we could improve some aspects of our activities to deliver real excellence; and a greater emphasis on demonstrating and communicating specific feedback and responses to what we had heard would be particularly welcome and valued. In all we do, we seek to increase both the reach and the impact of our engagement. In particular, we want to achieve four aims: increase the number of people with whom we engage within those organisations with whom we are already engaged; widen the range of organisations and individuals with whom we engage, in particular going beyond the normal NHS and social care family to engage people in their wider lives and activities; increase the quality of our engagement and the experience of those with whom we engage; and increase the visibility of what we do with what we hear and improve the ways in which we provide specific feedback on specific topics. The strategy also includes recent initiatives in relation to how we listen to our own staff, such as our Freedom to Speak Up programme and staff-led refresh of our organiational values. Active Listening and LEAPs At the heart of our new strategy lies the concept of Active Listening. This can also be described as listening for a purpose. As a membership organisation, this includes listening to the views of our local GP Practices, as well as our own staff, our patients and local stakeholders. It means having a continual awareness that we don t just listen and engage for the sake of it or as an end in itself, but in order to deliver - and be seen to deliver - concrete outcomes and improvements in our strategies and the services we commission for local people. We look to deliver the concept of Active Listening in reality through the establishment of a series of Listening and Engagement Active Partnerships (LEAPs). Some of these build on what we know works and what we have done hitherto, for example: our provider Quality Visits - both timetabled and ad hoc as required; our GP Practices mechanisms for hearing and engaging the patient voice, including Patient Participation Groups, and Patient Reference Groups; our own Patient and Public Engagement Group, comprising attendees from local voluntary sector organisations, PPG/PRG Chairs and local Healthwatch; our forums for engaging with particular groups of GPs and their staff working on the ground, such as our Locality Meetings, Practice Nurses Forum and Practice Managers Forum; and our existing relationships with local statutory bodies and elected representatives, for example through Health and Well-being Boards and Health Overview and Scrutiny Committees. Listening. Responding. Delivering. 1

205 We build on these foundations through a drive to establish new Listening and Engaging Active Partnerships, in particular: a review and refresh of our public membership scheme - recently brought in-house; strengthening and deepening our ties and planned activities with local Healthwatch and the voluntary sector - including Voluntary Action Leicestershire and Voluntary Action Rutland; strengthing our drive to engage seldom heard groups and ensuring that their voice is heard and acted upon; reaching out beyond our immediate and familiar networks in health and social care to embrace and engage with organisations and individuals involved in complementary networks and interests - for example in environmental, sporting, cultural and educational spheres; and our involvement in Commissioning for good patient experience - a national project with Macmillan Cancer and NHS England to develop commissioning tools and processes that support positive patient experiences of care. Listening. Responding. Delivering. The traditional way in which the NHS acts upon and provides feedback on what it hears is often branded as a You Said, We Did approach. This typically involves collating a wide range of opinions and suggestions, analysing them behind the scenes and publishing a broad brush overall themed response, citing limited examples of specific items to illustrate the broad plan of action. This has served the NHS well, but we know from our own recent listening activities during 2015 that our stakeholders feel they don t have enough sight of what specifically happened as a result of specific views they gave. This means that when they are subsequently asked for their views on another topic, they can suffer from what they call consultation fatigue - feeling that they repeatedly make the effort to provide their views without equal effort being made to give them specific feedback on their individual views and concerns. Our own organisational brand is centred on the strapline Listening. Responding. Delivering. This strategy sets out how we operationalise that strapline to place it at the heart of what we do. This includes an updated approach incorporating improved business processes and communication channels that address our stakeholders expressed concerns and increase our capacity for providing indiviudal feedback where required. We come to you A key plank of our listening and engagement approach to date has been a determination to ensure that people shouldn t be forced to come to us to give their views and opinions, nor to make their voice heard. Instead, we have made strong efforts to go to them. This is the philosophy that underpins our Listening Booth, now in its second year of operation. In its first year, the Listening Booth travelled to over 25 locations, speaking to almost 200 people and allowing them to talk to us outside health locations, approaching them when they are feeling relaxed and have the time to talk about their experiences of healthcare. The latest figures available show that between April and December 2015, the Listening Booth increased its reach and impact by hearing over 550 comments and pieces of feedback in just 9 months. The Listening Booth asks people 3 simple questions: Have you had a recent experience of the NHS or social care? Tell us about it... What stood out as really positive? What could have been done differently? The information collated through the Listening Booth is used to ensure that local people s views are at the heart of our quality monitoring and decision making. It is also used to develop patient stories, spot themes and trends about local health and social care services, inform service improvements or make changes to the services we provide. Our new strategy introduces further new ways in which we can communicate and engage with local people in ways that avoid them having to come to us - whether by letter, phone call or web - each and every time simply to find out if anything new has happened or anything new of particular interest to them is planned or happening. We do this through imaginative investment in our web, digital and social media capabilites. In particular, we have introduced a facility via our new website called myccg which we believe to be a first amongst NHS Clincal Commisioning Groups. All registered myccg users can comment on any item on our website and get involved in threaded dicussions and questions and answers. 2 Listening. Responding. Delivering.

206 We are also looking to use social media in ways that go beyond merely using it as another publishing channel. Rather than using social media simply to tell the NHS, social care and the wider world what we are doing and what we are thinking, we are looking to use social media to give frontline staff, carers, patients and families their voice and their spaces to interact with us and and each other. We are using a specialist NHS Social Media tool called Find SoMeone in Health to identify and approach followers of Twitter accounts that demonstrate a relevance to our target areas but do currently follow our own Twitter This enables us to engage via Twitter with audiences who would not normally feature on our radar or whom may not be aware of what we do and/or hear messages and information from us that would be of use and help. We have created a new podcast channel ELR CCG TV containing video news items from the CCG plus background films introducing our people and explaining what we do. It is always available to anyone and always free. Any episode can be watched online or downloaded without subscribing. Subscribers automatically receive new episodes to their computer or mobile device. Coming soon, we intend to produce regular podcast on items of interest plus material produced by our stakeholders and broadcast by us. We are asking them what topics they would most like us to produce with them or what programmes and material they would like to see. We are also harnessing the power of mobile devices to improve how local people can access local services at the right time and in the right place. Our new mobile App NHS Now allows users across East Leicestershire and Rutland to get self-care advice or find their nearest, most appropriate and most convenient local health service currently open to them at any time of the day or night. The App is time and location aware. This means that users get real-world, real-time details, opening times and directions to a range of their local NHS services. Users can ask to see either all locations or those that are open for service at the specific time of using the App. The range of services include: GP Practices, Pharmacies, Dentists, Urgent Care and A&E Users can choose to see all or only emergency pharmacies. For dentists, users can choose between all or emergency dentists and/or to see only those currently accepting new NHS patients. It has been warmly welcomed by local Healthwatch and patient representatives, as well as staff working in our GP Practice membership. It can be downloaded free of charge by searching for NHS Now on the Apple App Store or Google Play. New listening and engagement infrastructure Supporting the development and operation of the new strategy are a series of new tools and infrastructure in which we have invested over These include: a significantly improved website; a new GP Practice Extranet; a new Staff Intranet; an expanded range of social media channels; and ELRCCG MOOD database to underpin augmented Listening Responding Delivering business processes and reports. Specific engagement strands for Our main focus of specific activity is centred on 4 strands: engagement on a future Community Services Model; engagement on our Primary Care strategy and plans for GP Federations; engagement to feed into and support the Leicester. Leicestershire and Rutland Better Care Together programme - in particular supporting the BCT workstreams on mental health, learning disabilities and older people; and engagement on our future commissioning intentions. Listening. Responding. Delivering. 3

207 The importance of clinically-led engagement As an organisation, we are proud to say we are clinically led and praised by our local NHS England colleagues for visibly being so. That s not simply a phrase we use. It s central to what we re about and how we do things. It means that our aims and priorities are driven by local family doctors and other clinicians, rooted in their own local communities across East Leicestershire and Rutland. Clinicians are in the majority in our decision makers. A recent study by the NHS Confederation and YouGov asked people - What would persuade you to support changes in your local NHS services? The top 2 answers were: Evidence it will improve care; and Support from local health/care staff. These 2 factors were more important either than evidence it would save money or general communication or generic public engagement from and by the NHS. We believe it s crucially important to have clinically-led engagement at the heart of how we take this forward and just as important not just to do it - but to be seen to have done it. We will, for example. be making much more use of web and video to raise the profile of our clinical leaders and explain the crucial leadership role they play in our organisation and its strategies. These people are respected and trusted by local people and their families to have their best interests at heart and deeply committed to helping them get healthy and stay healthy. Or when they fall ill, to make sure they get the very best treatment and care possible, in the right place at the right time, and delivered with compassion and respect. Clinically-led engagement is all about harnessing that respect and trust and placing it at the heart of NHS decision-making and local strategies. We listen and learn using a wide variety of methods and channels. Then we collate what we hear and our clinical leaders, supported by our internal staff, decide how we should take action on what we have heard. Right in principle. Right in practice. We support clinically-led engagement because it s the right thing to do in principle. But it also happens to be the best way in practice to engage local people and communtites in local change and improvement. It s what they want and prefer. And it gives the greatest guarantee of ultimate success. Our clinical leaders therefore play a vital and visible leadership role in our engagement activites and processes. We re proud of our record to date in carrying out innovative clinically-led engagement. But we re always looking for ways to get better. We have major challenges and innovations we wish to bring forward in the coming year in primary care and community services. We are also entering our third year of deciding and delivering our overall commissioning priorities. 4 Listening. Responding. Delivering.

208 Increasing our reach Hitherto, our reach has been built on the following main strands: our Be Healthy, Be Heard public membership - with around 4,300 people who signed up at some point in the past to receive communications from the CCG and/or its predecessor the Primary Care Trust; a stakeholder database made up of 1,381 groups covering everything from local councils to schools and sports clubs - normally with a single named contact or address; a Public and Patient Engagement Group (PPEG) with quarterly get-togethers facilitated by the CCG; and a range of forums and/or groups with whom we interact as part of our day-to-day commissioning activities - for example Practice Manager Forum, Practice Nurses Forum, Locality Meetings and Protected Learning Time (PLT) events. Our local stakeholders and those with whom we engage tell us that there is much we do which they like and value. In the most recent NHS England CCG 360 stakeholder survey, 76% of our stakeholders said they were Very or Fairly Satisfied with our engagement with them, a very slight increase on our score the year before. So we know that once we have succeeded in reaching to people and organisations, they like what we do. As part of our Engagement Plan , we want to increase both the depth and the width of our engagement reach. In particular, we have two aims: increase the number of people with whom we engage within those organisations with whom we are already engaged; and increase the range of organisations and indivduals with whom we engage, in particular going beyond the normal NHS family to engage people in their wider lives and activities. Increasing the numbers To help us achieve our first aim, we have recently brought in-house and integrated the management and operation of the hitherto separate externally hosted databases underpinning our public membership scheme and our stakeholder groups. We have also completed a thorough data-cleansing exercise as a pre-cursor to introducing a new facility via myccg allowing members to update their details online and register their interests in particular services/ strategies/conditions. Bringing these databases in-house has given us greater ability to track and understand how many people we know about within each organisation with whom we engage. This has shown, for example, that for the majority of our stakeholder groups, we have a single named contact or in some cases a generic account. We will systematically work through these 1,300-plus organisations, using the named contact or generic account as a bridgehead into the organisation s wider membership, offering them the opportunity to engage with us direct as well as via their organisational lead. We will also strengthen our drive to engage seldom heard groups and ensuring that their voice is heard and acted upon. Some of these groups may well prefer us to engage with a single named contact and to give us their views and experiences via face-to-face activities. The important thing is for us to consciously be aware of and document these preferences, so we can ensure we are really meeting people s preferred options. We have set ourselves a target of at least doubling the total number of people with whom we engage within those organisations with whom we are already engaged Listening. Responding. Delivering. 5

209 Increasing the range Like most NHS organisations, the vast majority of our engagement takes place with people within the context of our day-to-day business or their own direct recent experience of the NHS - whether that s a visit to their local GP surgery or care setting or receiving care in their own homes, for example through health vistors or care staff. Our day-to-day engagement activites also tend to focus on these settings, through for example leaflets and posters available at the local surgery, meetings with primary care staff and patients, advice delivered via family doctors or via staff carrying out care in people s homes. This is - and should remain - the core of our listening and engagement activity. It enables us to understand the views and experiences of those currently using and experiencing our services. And it forms a vital part of our quality strategy. We are strengthening the ways in which we can support our engagement with our frontline staff through, for example, creating a new GP Practice Extranet so that practice managers and clinical staff - including community nursing staff -working on the frontline can exchange views and opinions with us and more easily keep up to date with what we are doing. Our work with organisations representing seldom heard groups will help us increase the range of those whose voices and opinions we hear, by taking advice from them on the optimum way to engage with their members and communities. However, the people and organisations directly engaged through these activities during any particular period are only a sub-set of the overall population. Our commissioning responsibiliities are not just to deal with the here and now, but to engage and plan for the medium and longer terms. So everyone in our area has an interest in what we do and what we plan to do. But there are plenty of people who neither participate nor wish to participate in organisations. We have been looking at how we can reach beyond our day-to-day operational contexts to encompass a wider cross-section of our population. This is, for example, one of the reasons why our Listening Booth goes out to speak to people directly and face-toface in locations beyond specific health and social care settings - for example coffee mornings, libraries and shopping centres. Over the coming period, we will look to be even more imaginative about the locations we choose to deploy our Listening Booth - for example by linking up with major sporting, cultural, environmetal or tourism events across Leicestershire and Rutland. We will contact organisations organising such events to see what opportunities exist. We also believe that social media can play a significant role in this regard. Millions of people across the UK use social media daily to find and interact with like-minded people and organisations who share their interests, concerns and priorities - for example young mums and dads, people interested in mental health issues, maybe even people interested in diet or alternative therapies. Often, these people do not naturally come into contact with our organisation, but their voices matter. We believe we can identify and reach out to these people using social media. For example, an insight into their interests can sometimes by gleaned the organisations and accounts whom they choose to follow on Twitter. We will use a specialist NHS Social Media tool called Find SoMeone in Health to identify and approach followers of Twitter accounts that demonstrate a relevance to our target areas but do currently follow our own Twitter This enables us to engage via Twitter with audiences who would not normally feature on our radar or whom may not be aware of what we do and/or hear messages and information from us that would be of use and help. Initial analysis from Find SoMeone in Health has already identified: 504 people or organisations who follow the Twitter accounts of the Leicester Mercury AND NHS England but not NHSELRCCG, including Active Oadby Wigston and Rutland C Spirit working to support people in rural areas ; 589 people or organisations who follow MIND and the Leicester Mercury, but not NHSELRCCG, including Action Homeless - a Leicester and Leicestershire charity tackling the causes and consequences of homelessness; and 1,150 people or organisations who follow MumsnetLeics but not NHSELRCCG. We will also cross-reference and identify particular groups or individuals who are not currently engaged around a particular strategy, but whose profile or existing patterns of interest in a particular condition would suggest that they would naturally have an interest therein. 6 Listening. Responding. Delivering.

210 Active Listening and LEAPs At the heart of our new strategy lies the concept of Active Listening. This can also be described as listening for a purpose. As a membership organisation, this includes listening to the view of our local GP Practices, as well as our own staff, our patients and local stakeholders. It means having a continual awareness that we don t just listen and engage for the sake of it or as an end in itself, but in order to deliver - and be seen to deliver-concrete outcomes and improvements in our strategies and the services we commission for local people. We are building on strong foundations. During we made considerable progress in ensuring that we embedded effective systems to ensure that the CCG is able to monitor, challenge and scrutinise provider performance to ensure improvements in the quality of care commissioned. We have developed Patient experience dashboards for our main acute providers as well as the local out of county providers where our residents may choose to access hospital services. Continued work with our local Healthwatch organisations to act on intelligence received about provider performance; Understanding and scoping quality assurance systems within primary care; Development of quality schedules for Optometry, Pharmacy and General Practice Community Based Services contracts; Agreeing systems with NHS England to establish closer links and share intelligence of primary care quality risks including establishing systems of escalation where necessary; Development of a Care Home Strategy group to ensure all teams within the CCG whose work involves care homes is executed in a streamlined manner, to ensure quality care is delivered and compliance is monitored effectively by maintaining an overview of work streams to deliver a care home plan setting out aims, objectives, metrics, leads and time scales; and Systematic scrutiny and oversight of settings of care for people within inpatient settings in learning disability services to ensure that safe and effective discharge arrangements are in place. The Listening Booth In its first year, the Listening Booth travelled to over 25 locations, speaking to almost 200 people and allowing them to talk to us outside health locations, approaching them when they are feeling relaxed and have the time to talk about their experiences of healthcare. The latest figures available show that between April and December 2015, the Listening Booth increased its reach and impact by hearing over 550 comments and pieces of feedback in just 9 months. The Listening Booth allows us to speak to the public, patients and carers outside of health locations; approaching people when they are feeling relaxed and have the time to talk about their experiences of healthcare. The idea is to focus on how people feel and their attitudes and opinions. The booth is designed to complement the data already available through patient surveys and other large scale feedback mechanisms. Nine indicators have been developed, incorporating publicly available data and data sourced by contracting teams. Indicators include a selection of patient safety and patient experience indicators to provide a high level overview of the quality of care being provided at each Trust. The dashboards are reported to the ELR CCG Quality and Performance Committee on a quarterly basis. Other examples of listening for a purpose include: regular contacts through Quality Contracting Teams with our neighbouring CCGs to monitor the quality of care being provided by our out of county providers; We continue to review and refresh the data sets used against the domains of the NHS Outcomes Framework and ensure consistency and validation of data sources. Alongside this we have embedded systems which allow for feedback from service users using Healthwatch members and stakeholder events as well as via our Listening Booth. We collect both positive and negative feedback from patients. The Listening Booth asks people 3 simple questions: Have you had a recent experience of the NHS or social care? Tell us about it... What stood out as really positive? What could have been done differently? Listening. Responding. Delivering. 7

211 The Listening Booth also forms an integral part of specific consultations and engagement programmes. By accessing a wide range of locations with the listening booth, representatives of seldom heard groups are able to participate in these consultations and engagments. For example: during 2014, it was used heavily for our Urgent Care Consultation; during , it was used to inform our engagement on the Planned Care strand of the Better Together programme; and even more recently, it was used heavily for our engagement on our Community Services Model The feedback received has been broken down into themes and trends, with feedback also provided to providers of services. This information has been used to influence changes in the way we commission services, and also to influence improvements in the quality of care being provided, where patients have highlighted issues. Moving forward, as part of this updated strategy, we intend to further develop the impact and efficacy of the Listening Booth in the following ways: we will incorporate the findings from Listening Booth feedback into our new ELR CCG MOOD Repository, increasing our ability to analyse and report on trends, themes and find examples of feedback to inform specific strategies; we will investigate how we can develop a virtual Listening Booth available via our new website, so people can provide us with feedback even when we are not in their area; we will look to deploy the same Listening Booth question formats in paper form with our GP practices, providers and stakeholders; as previously mentioned, we will look to be even more imaginative about the locations we choose to deploy our Listening Booth; and Listening Booth feedback will be at the heart of our augmented Listening. Responding. Delivering process. Patient Stories and ELR CCG TV Patient stories have become an integral part of our public Governing Body meetings. We use patient stories to drive changes and influence commissioning decisions through clinical discussions in these meetings. We have been able to demonstrate meaningful changes arising out of the use of patient stories at Governing Body meetings. Our Patient Stories allow real patients to tell us their real-life experiences in their own words. Some highlights include: Improvements to managing the risk of clostridium difficle infection; Input into the acute mental health pathway redesign; Focus on complex children s care system; the impact of fragmentation of pathways for patients who live on borders; and continuing challenges around the cancer diagnosis/ treatment pathway. A large part of the power of Patient Stories derives from them being the authentic voice of real people captured on video talking about real life experiences and real examples in their own terms and their own language. As part of this new Strategy we will significantly expand our capacity for capturing real voices through video and film. This will be done through a new service we are introducing called ELR CCG TV. ELR CCG TV contains video news items from the CCG plus background films introducing our people and explaining what we do. It is always available, any time of the day or night. And it is always free - to watch, download or subscribe. Material can be watched online at podbean.com or via itunes podcast (ELR CCG TV). It can downloaded or delivered by subscription to PCs, Macs, laptops, and Apple and Android mobile devices. We intend to produce regular podcasts on items of interest plus material produced by our stakeholders and broadcast by us. Crucially, when we work with stakeholders to produce material giving their own views and those of their members, ultimate editorial control will remain with the stakeholder. not ourselves. In this way, we can ensure the patient and stakeholder voice remains vibrant and genuine. 8 Listening. Responding. Delivering.

212 Listening and Engagement Active Partnerships We will look to further deliver the concept of Active Listening in reality by establishing a series of Listening and Engagement Active Partnerships (LEAPs). Each LEAP partnership will be specifically defined and documented in terms of: its purpose; its participants; the outcomes it seeks to deliver; the methods and timescale by which it will deliver; and the roles of each participating partner in its success. The outputs from each LEAP will be incorporated into ELR CCG MOOD and integrated with other listening and engagement insights. We will build on these foundations through new Listening and Engaging Active Partnerships, in particular: a review and refresh of our public membership scheme - recently brought in-house; strengthening and deepening our ties and planned activities with local Healthwatch and the voluntary sector - including Voluntary Action Leicestershire and Voluntary Action Rutland; strengthing our drive to engage seldom heard groups and ensuring that their voice is heard and acted upon; and reaching out beyond our immediate and familiar networks in health and social care to embrace and engage with organisations and individuals involved in complementary networks and interests -for example in environmental, sporting, cultural and educational Some LEAP partnerships will build on what we know we have done hitherto, for example: our provider Quality Visits - both timetabled and ad hoc as required; our GP Practices mechanisms for hearing and engaging the patient voice, including Patient Participation Groups, and Patient Reference Groups; our own Patient and Public Engagement Group, comprising attendees from local voluntary sector organisations, PPG/PRG Chairs and local Healthwatch; our forums for engaging with particular groups of GPs and their staff working on the ground, such as our Locality Meetings, Practice Nurses Forum and Practice Managers Forum; and our existing relationships with local statutory bodies and elected representatives, for example through Health and Well-being Boards and Health Overview and Scrutiny Committees. Listening. Responding. Delivering. 9

213 Listening. Responding. Delivering. The traditional way in which the NHS acts upon and provides feedback on what it hears is often branded as a You Said, We Did approach. This typically involves collating a wide range of opinions and suggestions, analysing them behind the scenes and publishing a broad brush overall themed response, citing limited examples of specific items to illustrate the broad plan of action. This has served the NHS well, but we know from our own recent listening activities during 2015 that our stakeholders feel they don t have enough sight of what specifically happened as a result of specific views they gave. This means that when they are subsequently asked for their views on another topic, they can suffer from what they call consultation fatigue - feeling that they repeatedly make the effort to provide their views without equal effort being made to give them specific feedback on their individual views and concerns. This was the most striking finding from the Our Engagement with you survey we carried out as part of our 2015 Summer of Listening exercise: 39% of respondents said they had never seen feedback from the CCG on a specific strategy or plan; 42% said they had never seen feedback on general topics or themes; and 70% said they had never received personal feedback on something they had said. Comments received included: We tell you what we want but you don t listen - it appears that your consultations at times are all about ticking the boxes Look for a wider breadth in your dealings with voluntary sector organisations The danger of such an attitude being prevalent amongst our stakeholders is that when they are subsequently asked for their views on another topic, they could suffer from what they call consultation fatigue - feeling that they repeatedly make the effort to provide their views without equal effort being made to give them specific feedback. Our own organisational brand is centred on the strapline Listening. Responding. Delivering. This strategy sets out how we operationalise that strapline to place it at the heart of what we do. This includes an updated approach incorporating improved business processes and communication channels that addresses our stakeholders expressed concerns and increases our capacity for providing indiviudal feedback where required. I have heard Healthwatch on local radio but not you Maybe make inroads into your clients 10 Listening. Responding. Delivering.

214 Our updated strategy seeks to address this challenge through improved business processes and communication channels built on the Listening. Responding. Delivering approach. With these improved business processes: each specific item of listening and/or engagement will be individually logged; all items will be collated into one central repository (ELR CCG MOOD) and analysed across our range of listening activities and channels; each item will go through a structured process, asking; 1. is something specific being suggested? 2. do we do it already? 3. if we don t, is it something we could/would do? where requested, each individual will receive specific feedback on their specific item, even where the response is simply to thank them and confirm action is already in hand to address their specific concern; and a searchable anonymised directory of all listening and engagement items received and our specific responses will be published on our website and made available for download. Listening. Responding. Delivering. 11

215 Listening to our staff Our listening and engagement activites don t just cover our external members and stakeholders. They include the staff who work for us. During 2015, we were delighted to receive recognition by Health Service Journal and Nursing Times in its new Best NHS plces to work Award described as a celebration of NHS organisations that have worked hard to promote great staff engagement and create an environment where people can enjoy their work. Knowing we are building on firm foundations, during 2016 we will be completing work on two key initiatives in relation to our continuing listening and engagement with our staff. In February 2015 the Freedom to Speak Up report was published by Sir Robert Francis QC. The report outlines the findings of an independent review into creating open and honest reporting cultures in the NHS. Many of the recommendations of the Freedom to Speak Up review relate to the creation of an open, honest and transparent culture within NHS organisations, with a focus on ownership from staff across all levels. In response, the CCG formed the Freedom to Speak Up Steering Group (F2SU) and a Staff Focus Group to address the issues identified in the Freedom to Speak Up report. One of the first pieces of work for both groups was to determine the appetite of staff to refresh the ELR CCG values, to reflect these recommendations and ensure that the culture of the CCG is in line with this vision. Refresh of organisational values An organisational value is a belief that a specific mode of conduct is preferable to an opposite or contrary mode of conduct. More and more studies show that successful organisations place a great deal of emphasis on their values which represent frameworks for the way we do things. Values usually underpin an organisations vision and strategic aims. They relate to how organisations deal with their beliefs about people and work and define nonnegotiable behaviours. Values also provide a framework for achieving an organisation s vision and increasing the effectiveness of the organisation. In July 2015 at the CCG s Time Out event we facilitated a session with staff groups to review the values and asked if the time was right to review them as part of the Freedom to Speak Up action plan. The output from the day was used by the Freedom to Speak Up Focus Group to develop a new set of values and descriptions. During 2016, we will develop a programme of work to identify areas in which we will embed the values, for example, values based leadership, values based recruitment and appraisals. We will then roll out this programme of work to embed the values and Incorporate the values into the CCG s Constitution. 12 Listening. Responding. Delivering.

216 Freedom to Speak Up Action Plan The refresh of the ELR CCG values is just one initial output from the F2SU Group and its agreed Action Plan. Other items included in the Action Plan, that will be brought forward during 2016, were broken down into categories, with specific questions about culture, monitoring providers, policies, recruitment and also the Governing Body ensuring ownership of the plan. Culture and workforce are also included in the action plan. Teams in the CCG have already undertaken personality tests in the form of Myers Briggs to help understand how colleagues and teams can work together in an open and respectful culture. There is a specific section for Primary Care in the plan to support primary care colleagues. The CCG is also offering support to nurses to raise concerns. Listening. Responding. Delivering. 13

217 We come to you A key plank of our Listening and Engagement approach to date has been a determination to ensure that people shouldn t be forced to come to us to give their views and opinions, nor to make their voice heard. Instead, we have made strong efforts to go to them. This is the philosophy that underpins our Listening Booth, now in its second year of operation. In the past year alone the Listening Booth travelled to over 25 locations, speaking to almost 200 people and allowing them to talk to us outside health locations, approaching them when they are feeling relaxed and have the time to talk about their experiences of healthcare. It is also to philosophy that underlies our Patient Stories - by us going out to record real people and bringing their voices to the heart of our decision-making at our Governing Body. Our new strategy introduces further new ways in which we can communicate and engage with local people in ways that avoid them having to come to us - whether by letter, phone call or web - each and every time simply to find out if anything new has happened or anything new of particular interest to them is planned or happening. We do this through imaginative investment in our web, digital and social media capabilites. In particular, we have introduced a facility via our new website called myccg which we believe to be a first amongst NHS Clincal Commisioning Groups. Using myccg, anyone can create their own free myccg Account. When they do so, they can select to receive via either Instant Updates or a Daily Summary. All registered myccg users can also comment on any item on our website and get involved in threaded dicussions and questions and answers. We are looking to use social media in ways that go beyond merely using it as another publishing channel. Rather than using social media simply to tell the NHS, social care and the wider world what we are doing and what we are thinking, we are looking to use social media to give frontline staff, carers, patients and families their voice and their spaces to interact with us and and each other. As previously explained, we are using a specialist NHS Social Media tool called Find SoMeone in Health to identify and approach followers of Twitter accounts that demonstrate a relevance to our target areas but do currently follow our own Twitter This enables us to engage via Twitter with audiences who would not normally feature on our radar or whom may not be aware of what we do and/or hear messages and information from us that would be of use and help. Our new podcast channel ELR CCG TV will contain material produced by our stakeholders and broadcast by us. We are asking them what topics they would most like us to produce with them or what programmes and material they would like to see. containing video news items from We are also harnessing the power of mobile devices to improve how local people can access local services at the right time and in the right place. Our new mobile App NHS Now allowa users across East Leicestershire and Rutland to get self-care advice or find their nearest, most appropriate and most convenient local health service currently open to them at any time of the day or night. The App is time and location aware. This means that users get real-world, real-time details, opening times and directions to a range of their local NHS services. Users can ask to see either all locations or those that are open for service at the specific time of using the App. The range of services include: GP Practices; Pharmacies; Dentists; Urgent Care; and A&E. Users are able to choose to see all or only emergency pharmacies. For dentists, users can choose between all or emergency dentists and/or to see only those currently accepting new NHS patients. It has been warmly welcomed by local Healthwatch and patient representatives, as well as staff working in our GP Practice membership. It can be downloaded free of charge by searching for NHS Now on the Apple App Store or Google Play. 14 Listening. Responding. Delivering.

218 Governance The importance of getting communication and engagement right to ensure we are truly listening, responding and delivering are reflected in the arrangements we have put in place for governance and accountability. While the CCG Governing Body retains overall responsibility for delivery, we have implemented structures and practices which encourage close and regular scrutiny of public involvement and engagement. The following committees of the Governing Body have a remit to seek assurance in respect of patient involvement and engagement: the Strategy, Planning and Commissioning Committee - ensures patient involvement and engagement forms part of the business planning and commissioning processes and plans; and the Quality and Performance Committee - has oversight for the development of and monitoring of patient engagement plans and activities. The clinical members of the Governing Body for part of the membership of these committees. This approach is aimed at instilling the principles of good engagement and communication throughout the organisation whilst demonstrating our commitment to clinical leadership. Furthermore, on a project-by-project basis, the Executive Management Team and clinical members of the Governing Body oversee the communication and engagement activity in conjunction with the Head of Communications and Engagement. The CCG hosts Patient and Public Engagement Group (PPEG) meetings with representatives from Patient Participation Groups, local Healthwatch organisations and other key local patient group. PPEG is chaired by the CCG Deputy Chair. PPEG contributes to the development of engagement plans for the CCG s commissioning intentions; communication and engagement plans for ELR CCG projects and assists ELR CCG in promoting opportunities for patients and the public to be involved in shaping commissioning plans and influencing CCG decisions. Additionally, it is important to note that representatives from Healthwatch Leicestershire and Healthwatch Rutland sit in attendance at ELR CCG s Governing Body meeting and add extra scrutiny, challenge and support to our work. Further support for Governance in the updated strategy Whilst the fundamentals of our governance arrangements remain unchanged, this new Strategy introduces further support to enhance them, particularly in the ways in which data, information and knowledge is collated, reported on and made available. The new ELR CCG MOOD Repository will now bring together and integrate for the first time in-house data and knowledge that previously was held either externally or in separate locations or business processes. This will include: our Be Healthy Be Heard public membership - previously stored and managed externally, now brought in house and data cleansed; workflow management and reporting on each item in our augmented Listening Responding Delivering business processes; outputs and summaries from our Locality Meetings; outputs and summaries from our Listening Booth; insights from our Patient Stories; and project and programme delivery of the various strands of this Listening and Engagement Strategy. The MOOD Repository will underpin an intuitive web interface to the data and knowledge held therein. It also will be configured to provide regular reports and analyses through a series of web-based dashboards. We will initially look to make these available internally to management and staff to support the governance structures described here.. In the medium term, we will investigate the feasibility and efficacy of making as much of the information as is practical and reasonable - taking into account Data Protection, privacy and commercial considerations - freely available to the wider world via the web and mobile devices. Listening. Responding. Delivering. 15

219 Appendix A: Our duty to involve ELR CCG is committed to involving and informing local people but it is also important to note that we are also legally obliged to do so. The statutory duties are described below. Over and above these, we are also mindful that the Francis Report (2013) strengthens the patient voice and we will ensure all responsibilities passed to CCGs are included in our plans. The NHS Constitution The NHS Constitution came into force in January It places a statutory duty on NHS bodies and explains a number of rights which are a legal entitlement protected by law. One of these is the right for people to be involved directly or through representatives in: the planning of healthcare services; the development and consideration of proposals for changes in the way those services are provided; and the decisions to be made affecting the operation of those services. The Equality Act 2010 Section 149 of the Equality Act 2010 states that a public authority must have due regard to the need to a) eliminate discrimination, harassment and victimisation, b) advance Equality of Opportunity, and c) foster good relations. It unifies and extends previous disparate equality legislation. Our plans for adherence to this legislation and our commitment to ensuring equality for all are set out in section 8 of this document. The Health and Social Care Act 2012 The Act sets out the Government s long-term plans for the future of the NHS. It is built on the key principles of the NHS - a comprehensive service, available to all, free at the point of use, based on need, not ability to pay. I t sets out how the NHS will put patients at the heart of everything it does, focus on improving those things that really matter to patients, empower and liberate clinicians to innovate, with the freedom to focus on improving healthcare services. It makes provision for CCGs to establish appropriate collaborative arrangements with other CCGs, local authorities and other partners, and it also places a specific duty on CCGs to ensure that health services are provided in a way which promotes the NHS Constitution. Specifically, under Section 242 CCGs must involve and consult patients and the public:: in our planning of commissioning arrangements in the development and consideration of proposals for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and in decisions affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact. The Act also updates Section 244 of the consolidated NHS Act 2006 which requires NHS organisations to consult relevant overview and scrutiny committees on any proposals for a substantial development of the health service in the area of the local authority, or a substantial variation in the provision of services. ELR CCG has made a firm commitment to fulfil and embrace our legal duties regarding public and patient involvement by ensuring that involving, listening to, and acting on the views of local people, are at the heart of delivering our vision for local healthcare. ELR CCG will comply with all current legislation and policy in delivery of this strategy. Equality and diversity ELR CCG will champion equality and human rights in all that we do. This is especially important for communication and engagement activities. Communicating to our diverse audiences is a mainstream activity for ELR CCG and we will ensure we assess the equality impact of our work, assessing projects on an individual basis. This will ensure that all our communication and engagement activities meet with the necessary guidance and address key needs as far as possible. Our equality assessments will not only form part of the planning process, but will also be undertaken during evaluation to ensure that lessons are learned, good practice is noted and findings are shared widely for the benefit of future activities. 16 Listening. Responding. Delivering.

220 Ensuring that we meet equality and human rights needs will include, but not be limited to: Availability of materials in different languages and formats Targeted marketing for greater impact understanding those receiving the message and how they would like us to communicate with them Engaging and involving people using multiple approaches that meet the needs of individuals and groups and where possible taking a direct and personalised approach Reaching people where they congregate and when they are most interested in health settings, shopping precincts, libraries, community interest group meetings, places of worship, school activities and meetings, easonal events, charitable activities, local neighbourhood and council-run events Listening. Responding. Delivering. 17

221 Appendix B: Building on the 2013 Strategy The starting point for designing this clinically-led Listening and Engagement Strategy was to build on what we know works - both from within our own direct experience and from experience across the wider NHS. In particular, we have built on the foundations laid - and lessons learned - by: Our origininal strategy - refreshed in September 2013 strategy - Informing and involving our approach to communications and engagement ; Our highly successful engagement during 2014 underpinning creation of our new Urgent Care Service and Urgent Care Centres; Informing and involving our approach to communications and engagement (2013) Our 2013 strategy explained our legal duties to involve people and/or their representatives in our decision-making through: The NHS Constitution; The consolidated NHS Act 2006; The Equality Act 2010; and The Health and Socal Care Act The Informing and Involving strategy focussed on 3 objectives and associated outcomes, which remain the foundation of what we will do. These are: Objective To fully embed the patient voice within our commissioning decisions in order to deliver improved patient outcomes To facilitate ongoing and meaningful dialogue with local people To manage and safeguard ELR CCG s reputation and statutory duties Outcome People in East Leicestershire and Rutland feel they have a voice in the decisions made by the CCG and can see how they have influenced local NHS services. The people of East Leicestershire and Rutland will be well informed and will have a good understanding of services available to them. People will have the information they need to help them to improve their own health and well being and how their voice can be heard. The people of East Leicestershire and Rutland are confident that ELR CCG is a trustworthy and credible organisation which is acting with a mandate from the public and is meeting legal requirements and standards. 18 Listening. Responding. Delivering.

222 The 2013 strategy grouped our stakeholders into 6 groups - set out in the centre of this page. These remain at the heart of our strategy. We are carrying out systematic refresh of our named lead contacts within each of these groups to ensure our records are completely up to date. Where we have only small known members of a particular group, we will use our lead contact as a bridgehead to attract further members. These KPIs will remain and be augmented by further engagement KPIs as a result of our refresh of our Service Level Agreement with our Communications and Engagement provider. The 2013 strategy set out 5 Key Performance Indicators, to be used to measure the effectiveness of the strategy and its implementation. These are: Public Awareness (e.g. website hits, social media reach); Patient and Public Engagement and Formal Consultations (e.g. number of surveys produced, number of people reached by engagement/ consultation, response rates, public views on effectiveness of consultation and engagement); Media Relations and Reputation Management (e.g. media enquiries handled, proactive releases issued, media coverage generated); Stakeholder Management (e.g. number of briefings produced, response rates to engagement); Membership (e.g. number of bulletins, magazines, membership events and response rates); and Internal communications (e.g. staff survey results, practice engagement activities). Listening. Responding. Delivering. 19

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225 Paper O East Leicestershire and Rutland CCG Board meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING REPORT TITLE: Front Sheet Transformational plan for mental health and wellbeing services for children and young people MEETING DATE: 19 January 2016 REPORT BY: PRESENTER: Colin Groom, Deputy Chief Finance Officer Donna Enoux, Chief Finance Officer PURPOSE OF THE REPORT: This report provides the Governing Body with an update on the Children and Young People (CYP) Transformation Plan co-ordinated by the CYP Better Care Together (BCT) Steering Group and overseen by the Commissioning Collaborative Board (CCB). RECOMMENDATIONS: The ELR CCG Governing Body is requested to: APPROVE the plan as presented on behalf of ELR CCG. NOTE that the BCT CYP Steering Group will ensure implementation of the plan. APPROVE that any variation on the plan and decisions regarding finalisation of financial resource allocation can be delegated to the CCG representatives i.e. the Managing Director, Chief Finance Officer and Chief Strategy and Planning Officer who have delegated authority to make decisions at the Commissioning Collaborative Board (CCB). REPORT SUPPORTS THE FOLLOWING STRATEGIC AIM(S) : Transform services and enhance quality of Improve integration of local services between life for people with long-term conditions health and social care; and between acute Improve the quality of care clinical effectiveness, safety and patient experience Reduce inequalities in access to and primary/community care. Listening to our patients and public acting on what patients and the public tell us. Living within our means using public money healthcare effectively Implementing key enablers to support the strategic aims (e.g. constitutional and governance arrangements, communications and patient engagement). EQUALITY ANALYSIS An Equality Analysis and due regard to the positive general duties of the Equality Act 2010 has not been undertaken in the development of this report on the basis that the transformation plan is being overseen by the BCT Steering Group and the CCB and supports the commissioning strategy and priorities of the CCG. The commissioning strategy and priorities have and continue to be equality impact assessed as the strategy is reviewed and refreshed. This completes the due regard required. 1

226 Paper O East Leicestershire and Rutland CCG Board meeting 19 January 2016 EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 19 JANUARY 2016 Transformational plan for mental health and wellbeing services for children and young people Introduction 1. Co-ordinated by the CYP BCT Steering Group, the 3 LLR CCGs submitted a joint application for funding to support the transformation of mental health and wellbeing services for Children and Young People to NHS England on 13 November Leading up to submission, CCB had reviewed earlier iterations of this plan during the summer and agreed for it to be progressed by the CYP BCT Steering Group. 3. Confirmation of the approval of the programme was received from NHS England on 1 st December 2015 and the 3 LLR CCGs have now received the 1.87m of non-recurrent funding in their financial allocation. ELR CCG s share of the programme is approximately 30% and ELR CCG have therefore received 564k of funding. Operational Delivery 4. The CYP BCT Steering Group are responsible for the implementation of the plan and have created 4 specific delivery groups to progress internal bids for funding throughout the remainder of this financial year and into These groups are as follows: 4.1. Health Promotion and Prevention 4.2. Early Help and Short Term Interventions 4.3. Health Commissioning Community based services for CYP with eating disorders Intensive community and home treatment Access to CAMHS 4.4. Workforce Development 5. Each delivery group have a mix of CCG, Local Authority, Provider and Patient support representation and are responsible for assessing service enhancement areas and progressing and prioritising development proposals for review by the Steering Group. 6. LLR CCGs have been working with Leicester Partnership Trust throughout the year to progress the enhancement of the Eating Disorders Services for Children and Young People in anticipation of receipt of this funding. Following confirmation of funding, this programme can now be progressed. 2

227 Paper O East Leicestershire and Rutland CCG Board meeting 19 January A full copy of the submitted plan is attached to this report. The summary funding streams are contained on page 50 of this document. 8. It should be noted that funds received in to support the programme were received non-recurrently and CCGs are currently reviewing the confirmed recurrent allocations for to ascertain any impact on the programme. Recommendation: The East Leicestershire and Rutland CCG Governing Body is requested to: APPROVE the plan as presented on behalf of ELR CCG. NOTE that the BCT CYP Steering Group will ensure implementation of the plan. APPROVE that any variation on the plan and decisions regarding finalisation of financial resource allocation can be delegated to the CCG representatives i.e. the Managing Director, Chief Finance Officer and Chief Strategy and Planning Officer who have delegated authority to make decisions at the Commissioning Collaborative Board (CCB). 3

228 LEICESTER, LEICESTERSHIRE AND RUTLAND BETTER CARE TOGETHER Transformational plan for mental health and wellbeing services for children and young people November 2015

229 Contents 1. Introduction & Vision for Principles and Values National Context Level of Need and Local Context Transformational Plan for Governance and Transparency Indicative Financial Allocations Implementation Plan Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 2 of 62

230 1. Introduction & Vision for 2020 This document sets out Leicester, Leicestershire and Rutland s multi-agency transformational plan to improve the mental health and wellbeing of children and young people up to the age of 25. It is a five year plan, based on the principles set out in Department of Health s Task Force Report, Future in Mind: Promoting and improving our children and young people s mental health and wellbeing. Future in Mind offers a framework and resources to improve the mental health wellbeing of all children. This report sets out our joint plan to achieve this. Our plan reflects what we know about our current services and what children, young people and carers in our area tell us they want. We know that we have a strong track record of joint commissioning, partnership and innovation. We also have many examples of excellent and innovative services and many further improvements are underway. However, we also know that the current system is fragmented, lacks transparency and requires a new approach to the use of resource. Children and young people have made it clear to us that they want education, information and advice about mental health, access to early, non-stigmatising help, and to be treated with respect by friendly staff, using approaches that we know work. Our vision is that children will have access to the right help at the right time through all stages of their emotional and mental health development. For this to happen, services such as education, social care, health, police, housing and justice will need to align. We will be required to develop shared priorities, joint commissioning, and improve the interfaces between our agencies so that organisational boundaries are not barriers to care. In Leicester, Leicestershire and Rutland we are committed to achieving this as part of the programme of work called Better Care Together (BCT). Through BCT we will strengthen the co-commissioning and partnership working across our agencies. We will also determine collectively and transparently how to use our resources effectively and efficiently to deliver the care that is valued by children, young people and their carers. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 3 of 62

231 Mental health has been defined by the World Health Organisation as a state of well-being in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. 1 It is more that the absence of mental illness or disabilities. In this plan we use the term mental health and wellbeing to address all children and young people: those who are healthy and resilient, as well as those with emerging or serious mental health difficulties. The agencies and stakeholders that have been involved in shaping this transformation plan include the local and regional commissioners and providers of health services (CCGs, NHS England East Midlands Specialised Commissioning and Health and Justice Commissioning, Leicestershire Partnership Trust), our three local authorities and the Police and Crime Commissioner. There has been strong engagement with Voluntary Action Leicestershire and Healthwatch. There is further work to do to broaden the engagement with schools, colleges and other educational settings. There has been extensive engagement with children, young people and their families and we are particularly grateful to them for sharing their experiences, which have been central to shaping this plan. An Easy Read summary of this plan will be published on our local websites in November We will launch the Transformational Plan in January to March 2016 through a series of engagement events. This plan marks the start of our journey. Only by working in partnership, sharing expertise and making best of finite resources can we achieve the improvements in mental health outcomes that we all want to see, and make a reality of the vision Sam Gyimah, Department for Education Future in mind (2015) If you do one thing, just get people who know what they are doing to work together better. Young person, Leicester Mental health: strengthening our response. World Health Organisation August 2014 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 4 of 62

232 Our vision is that by 2020, every child and young person in Leicester, Leicester and Rutland will be able to affirm the following: Self- care and prevention Early help and primary care Specialist care Urgent care and crisis response My family and I are able to look after my emotional and mental wellbeing and development day to day. I learn about mental health and how to protect myself at school or college. We can access trusted self-care advice when and where we like including websites, education settings, GPs and children s centres My parents / carers have access to support and guidance I am confident in talking about issues which affect my mental health We can get high quality support to help me overcome emotional and mental health challenges quickly and locally, without being stigmatised. I will be able to make informed choices about the kind of help I would like. I and those who care for me will be listened to. I will be supported to become resilient and independent. I and my carers will be helped to navigate the system and services. I am involved in peer support groups and community networks in my area. I will be helped by a specialist team quickly if my mental health problems are serious I will receive support which is safe, reliable and tested. I will be involved in setting my own treatment goals and deciding if I am getter better. With my consent, services will work together with me and my family to give us the best support. I will be involved in decisions to transfer or reduce my care. My views and experience will help to improve care for others I can access intensive support from a range of organisations working together. I will be seen promptly if I attend the Emergency Department I will not be judged by staff for my mental health problems. I will be kept as safe as possible during a crisis. I will be able to access a bed within a reasonable distance from home I will be supported to return home safely as soon as possible. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 5 of 62

233 Our vision is that by 2020 our services will be shaped as follows: Self- care and prevention Early help and primary care Specialist care Urgent care and crisis response All schools and colleges educate about mental health, tackling stigma and building resilience. Early joint assessment for children and young people who might need extra support High quality therapeutic and medical support provided by experienced and qualified staff. Services work together to provide intensive out of hours support for children, young people and families at risk of crisis. Information about children and young people s mental health is provided through a range of formats including websites, social media, and publications. Front line staff have access to training and support on mental health issues amongst children and young people All services provide equality of access and support to all children and young people. High quality low intervention services delivered locally across LLR by range of organisations. Care navigators who can support children, young people and cares make informed choices to find the right service for them. Outcome measures are used to assess individual improvements and to plan the development of services Organisations share information and work together to support the child, young person and their family Specialist services for children and young people with eating disorders Specialist services for vulnerable children and young people such as young offenders, Looked After Children and those with learning disabilities Services work swiftly together to support anyone admitted to the Emergency department Specialist hospital beds are available for those that need them. Young people s views inform the improvement of services Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 6 of 62

234 HEADLINES There are 250,000 children and young people up to the age of 19 in Leicester, Leicestershire and Rutland. It is a uniquely diverse community with significant variations in economic prosperity, quality of life and health outcomes. 68% of children and young people in Leicester City are from an ethnic minority background children and young people in LLR are looked after by a local authority, 32,000 have special educational needs, and 3466 were recorded as victims of crime in 2014/15. It is estimated that 1 in 10 school children will have a diagnosable mental health or neurodevelopmental condition. This equates to approximately 19,000 school children in our region. Difficulties include Autism Spectrum Disorder, ADHD, anxiety, depression, self-harm, psychosis, obsessive compulsive disorders and eating disorders. The specialist Child and Adolescent Mental Health Service (CAMHS) supports about 3,500 children and young people per year. The average waiting time for an assessment by the specialist CAMH Service is 13 weeks from referral. About 80 children and young people a year will require specialist treatment in hospital. Often this hospital will be a long way from their home. Through the five year transformational plan we will do the following: Promote mental health and resilience through campaigns in schools and to the general public. The standard will be for the campaign to reach all 250,000 children over the period of five years and ensure that 90% of schools are engaged in supporting the mental health and development of pupils through this plan Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 7 of 62

235 Provide quick access to a multi-agency assessment and support service for children and young people with emerging or low level mental health needs. The standard is for all children to receive an assessment within four weeks of referral and for 10,000 children and young people per year to receive early help and support services. Improve the access to the specialist CAMHS service to reduce waiting times and improve communication with children, young people and carers. The standard will be that child or young person to wait more than 13 weeks for contact and engagement from CAMHS Establish a specialist community team to support young people with an eating disorder. The standards will be an access time of four weeks from referral to assessment for routine cases, one week for urgent cases. The team will see 100 new cases per year. Establish a multi-agency team that will support families at risk of a crisis due to the mental health or disturbed behaviour of a child or young people. The standard is for the team to operate 7 days a week from 8am-11pm. The team will reduce the number of children and young people presenting at Emergency Department for acute mental health or behavioural problems. No child or young person will stay at the Emergency Department more than 4 hours. No child or young person will be taken to a police cell as a Place of Safety. Improve the capacity and capabilities of practitioners to work with children and young people with mental health issues. Standard is to have specialist workforce with clinical skills and experience in Cognitive Behavioural Therapy, Systemic Family Therapy, and Psychodynamic Psychotherapy as core interventions. Targeted and universal practitioners will have training in generic child mental health and have access to support and advice. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 8 of 62

236 We will measure the success of this plan in the following ways: A survey of what children and young people understand about mental health and how they feel about their own health. The number of educational settings that are part of this plan, and are working to improve understanding on mental health and support their students. The number of children, young people, parents and carers who access early support and interventions. How children, young people parents and carers rate this support. The number of children and young people assessed by the specialist CAMH service. How long it takes from a referral to CAMHs to seeing a practitioner. How long it takes to see a specialist if you have an eating disorder or psychosis. Hospital admission rates for self-harm and attempted suicide The number of young people who attend the Emergency Department due to an acute mental health problem who have to wait more than four hours to be seen by a specialist. The number of children and young people who are held in a police cell as a place of safety. The number of practitioners who receive training in child mental health Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 9 of 62

237 PLAN ON A PAGE ENABLERS TRANSFORMATION VALUES Collaborative Commissioning between health, education, social care and youth justice A consortium of voluntary, community and public sector providers Strong open governance and transparency in resource allocation Use of evidence based therapeutic help and quality standards Measuring outcomes and impact and using this to shape service developments A schools-based campaign to promote mental wellbeing and resilience that will reach every child young person and family. Quick access to multi-agency first response, early support and help. A range of high quality early help offers for children young people and families. A single gateway to a community mental health and wellbeing service. Specialist clinical support for vulnerable children and young people. Specialist clinical support for children and young people with eating disorders Intensive package of support for young people and families at risk of acute mental health problems Direct engagement and co-design with young people, parents and carers Develop the workforce through training, career progression & joint working Ensure equality of access and service for all Practitioners support each through information sharing, advice and guidance. Information and choice for children young people and families Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 10 of 62

238 CARE PATHWAY FOR CHILDREN AND YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS Workforce Development, Training and Support Information Sharing Schools, GPs, Parents, Young People First Response Early Help & Support Telephone advice or basic face to face assessment Specialist Mental Health Access Team Target Group 5,000 CYP Intensive Community Support & crisis management Public Health Campaign with Schools Target Group: 250,000 CYP VCS /Community group delivered low intensity early interventions 10,000 children in LLR Troubled Family approaches Specialist CAMHS inc. Eating Disorders Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 11 of 62

239 2.1 Engagement with children, young people and families 2 Principles and Values Children, young people and their families are central to the development of this plan and to the task of transforming services and approaches to mental health. There have been specific engagement events to discuss experiences of mental health problems, and ideas for improving services. This has included engagement with youth parliament representatives, young people s council, youth police commissioners, looked after children and parents and carers. Young people have led a seminar on their experience of self-harm. The CAMHS service recently formed a panel of ex- CAMHS service users to advise the practitioners on how to improve CAMHS. As the transformational plan is developed and implemented, children, young people and families will be part of the governance arrangements and be involved in the delivery of specific initiatives. This will be through involvement in commissioning panels, staff recruitment panels and service user panels. An Easy Read version of the plan will be published on websites. Young people have told us they want to be taught about mental health issues within schools and for schools to promote an open culture where they are encouraged to talk about mental health issues. They want their teachers to be skilled in supporting pupils with mental health issues. They want their parents to also have advice and support. Young people want help to build resilience and to be part of peer support groups. This can include support through social media and the internet. They would like to be able to access support such as counselling and workshops, with choice about when and where they meet. They would particularly like easier access to advice and support at evening or weekends, perhaps through a phone line or website. They have spoken about their experience of self-harm and eating disorders. Many young people report a positive experience of the care they received. This is often down to forming a strong trusting therapeutic relationship with their worker. Finally they want to be involved in shaping their own care and support plans. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 12 of 62

240 Best Practice Rutland Health Watch and Rutland Youth Council. Survey of 965 students on mental health concerns. HealthWatch Rutland and Rutland Youth Council carried out a series of engagement events with pupils in local schools to talk about concerns and issues facing young people. The most striking findings came about through a session held with Rutland s Youth Council. A series of concerns (life out of school; drugs and alcohol; transport; sexual health; mental health) were identified and then classified in order of urgency. It was discovered that the overwhelming problem was that of mental health (stress, depression, eating disorders, self-harm) The Youth Team then prepared a questionnaire concerning the problems of mental health, advised by a team from the University of Leicester. Three schools were selected for the survey and meetings were conducted in assemblies and tutorials to explain the aims. 965 young people attending 3 schools and colleges in Rutland, in Year 9 (26%), Year 10 (28%), Year 11 (21%) and Year 12&13 (25%) completed the survey. The findings were shared at number of workshops with partner agencies and with the school children themselves. The workshops were led and facilitated by young people from the Youth Council. The recommendations included: Create a culture where mental health is not taboo. End the stigma. Focus on prevention and coping strategies. Include mental health on the educational curriculum Increase the number of counsellors in school or someone to talk to when needed. Student/staff forums to monitor and discuss ongoing areas of concern with peer mentoring. Acknowledge that it is everyone's responsibility and inculcate a better understanding of what is available and how it can be accessed. Make sure early intervention and adolescent and child mental wellbeing is properly funded and provided. Publicise appropriate websites much more widely Educate parents, pupils and staff together to ensure that the stigma is ended and these issues can be spoken about honestly and without fear. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 13 of 62

241 2.2 Partnership commissioning and collaborative working There is a strong commitment from all organisations to work in partnership to secure the transformation in care that young people want. This requires systems co-ordination: to ensure that services work better together, and to jointly plan the development of new services. Future in Mind is the catalyst which presents the opportunity to tackle the issues of fragmented and disjointed planning, and to work collectively towards a shared vision. There are already excellent examples of collaborative commissioning across Leicester, Leicestershire and Rutland. We plan to build on these projects and extend the model of partnership commissioning to the whole pathway. There are fundamental opportunities now for joint commissioning including pooled budgets. We will build on current work, set out below and learn from examples from other services. The Young Person s Team which provides mental health assessments and interventions for Looked After Children, young offenders and those who are homeless. We know that these young people are particularly vulnerable to mental health problems. The team is jointly commissioned by CCGs and local authorities. It provides training and guidance for social care staff and foster parents, as well as direct work with young people. The Leicester City Early Intervention in Psychology service which provides individual and group work support for children and young people aged up to 19 with issues around anger, anxiety, self-esteem or low mood which do not meet the threshold for a specialist CAMHS intervention. This work is commissioned in partnership between the City CCG and City Council. The service receives clinical supervision from the CAMHS service. The Healthy Schools Programme. This is a partnership between the Leicestershire County Public Health and local schools, academies and colleges which takes a whole school approach to improving the health and wellbeing of pupils and students. The programme promotes the link between good health, behaviour and achievement through four key areas: healthy eating; physical activity; personal, social and health education (PSHE); and emotional health and well-being. The programme has recently appointed two healthy school Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 14 of 62

242 advisers to support schools to improve pupils' mental/emotional health and wellbeing, delivery of mental health promotion training in schools including positive psychology coaching skills (Youth Mental Health 1st Aid training), suicide & self- harm awareness training. The school nursing service has developed specific expertise to support children and young people who self-harm. It has successfully piloted the use of joint posts with the CAMHS service to ensure that all school nurses have skills and confidence in supporting children with mental health issues. The service has also developed an innovative CHATHEALTH application for mobile technology which enables all children to contact the school nursing service at any time on an anonymous basis. There is a vibrant, diverse and strong voluntary and community group sector which provides a range of holistic services which support children, young people and their families. These services often work in collaboration to support the whole family. Health for Teens and Health for Kids websites which have a range of information and advice for children, young people and parents. These websites have been co-designed with young people and will be developed to contain more self-help information and resources. Leicestershire and Leicester City Public Health Teams and LLR CCGs have jointly commissioned an on-line counselling service for young people. This commenced in October A new service which offers advice, support and access to online counselling for children and young people aged in Leicester City, Leicestershire and Rutland. The service, Kooth, offers easily accessible professional support to young people who are experiencing a wide range of emotional and mental health issues. The service will link to existing local services to ensure young people receive the help they need easily and quickly. Collaboration between Leicestershire Public Health and Voluntary Sector: Teenage Mediation ( The talk²sort mediation service works with young people aged and families who may be having Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 15 of 62

243 problems at home or with their relationships. The service supports people to look at ways of resolving conflict, often working with issues such as arguments, breakdowns in communication and relationships, difficult emotions, mental health problems and concerns around substance misuse. CCG and local authority commissioned workshops for young people on protective behaviours and self-esteem. These workshops build resilience and self-worth, and reduce the risk of problems escalating. Police, mental health and probation services have worked collaborative to commission and provide the Mental Health Triage Car which provides an out-of- hours mobile mental health assessment service for adults and young people. This has led to a 40 % reduction in the Police use of S136 powers, where people are detained by the police for a mental health assessment. 2 The local authorities and CCGs are actively involved in regional work across the East Midlands. This includes participation in the East Midland Strategic Clinical Network and CAMHS Working Group. We also participated in a regional mapping of readiness to implement the Future in Mind recommendations. We will establish specific links with neighbouring health and social care communities to consider best practice on issues such as eating disorders and crisis and home treatment services Joint commissioning from the CCGs and the University Hospitals of Leicester of a Paediatric Psychology service which supports the psychological needs of children and young people with long term or life limiting physical health conditions. 2 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 16 of 62

244 2.3 Equality and Health Inequalities All partners affirm their commitment to meet the requirements of the Equality Act 2010, the Human Rights Act 1998 and the Health and Social Care Act We will ensure that our plans promote services which are accessible to all, free from discrimination or harassment, tackle stigma and promote positive relationships and community cohesion. In particular we will consider the impact for those young children known to be vulnerable to mental disorders. This includes children and young people; looked after by the local authority, living in families with difficulties around mental health or substance misuse, involved in anti-social or criminal behavior, with physical, sensory or learning disabilities or special educational needs, with housing needs, victims of neglect or sexual exploitation, who are carers for others, who are a refugee or asylum seeker who are gay or bi-sexual, Leicester, Leicestershire and Rutland is a particularly diverse area. Leicester City has one of the highest percentage ethic minority populations in the country, and there are significant levels of poverty. Rutland is one of the most rural counties in England and is relatively affluent. A key aspect of our approach will be to tackle stigma within communities and promote awareness and openness about mental health and developmental difficulties. As this plan is developed it will undergo a full equality impact assessment to ensure that the needs of all children and young people with protected characteristics, as well as those who are vulnerable are addressed. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 17 of 62

245 2.4 Workforce Development A skilled, confident workforce is key to the successful delivery of all services. Presently, there are 80 full- time equivalent clinical posts within the specialist CAMH service. This is less than the guidelines recommended by the Royal College of Psychiatrists. The CAMH service has established a workforce development plan. This covers issues such as recruitment, leadership development, and training in specific therapeutic approaches such as cognitive behavioural therapy and Interpersonal Psychotherapy. Other practitioners, in public, voluntary, community and independent sectors, working with children, young people and their families also need understanding and confidence in working with mental health issues. We will provide a programme of training and support for all practitioners, drawing on the expertise of our experienced clinicians. This will include multi-agency face-to-face and online training in child and adolescent mental health case management support, and an advice line. 2.5 Children & Young People s Improving Access to Psychological Therapies Programme (CYP-IAPT) The three CCGs have applied twice, as part of larger consortia, to join the national CYP-IAPT programme. Unfortunately the consortium bid was unsuccessful on both occasions. Our partnership is therefore not currently part of the programme. There is no local CYP-IAPT training provider within the Midlands and East Region. We are keen to support the Leicestershire Education and Training Board to develop a course. In the meantime, the workforce development plan for the specialist CAMHS service recognises the need to develop leadership skills, and therapeutic skills in approaches such as CBT, IPT and family therapy. The service is also extending the regular use of clinical outcome measures in line with the CYP-IAPT guidelines. We will invest in IT infrastructure to ensure that our services are well placed to make clinical and planning use of systematic outcome monitoring. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 18 of 62

246 3 National Context In the past few years there has been a plethora of national reviews and reports with regard to the mental health and wellbeing of children and young people. They have all concluded that the current system of care requires significant improvement. This chapter provides an overview of the most relevant reports and identifies the key findings that we have taken into consideration when creating this Leicester, Leicestershire and Rutland transformational plan. 3.1 Future in Mind (Department of Health 2015) The Department of Health and NHS England Task Force on CAMHS reported on March The recommendations from this report will form the basis for government policy through this Parliament. The report, Future in Mind 3, found that there was a clear economic, health and moral case for early intervention to promote resilience and prevent escalation to serious mental health concerns. Many health conditions show first signs in childhood, and if left untreated, can develop into conditions that need regular care. 75% of mental health problems in adult life (excluding dementia) start by the age of 18. Early intervention can avoid expensive and longer-term interventions into adulthood. The report sets out 10 aspirations for the development of services, with an emphasis on promoting resilience, prevention and early intervention. It states that organisations need to dismantle the artificial barriers between services, and plan and commission services together. The objective is easy access to the right support at the right time. This requires a clear joined-up approach with intelligent use of information, accountability and transparency to drive improvements in delivery of care and standards of performance. Care will be provided for the most vulnerable children and young people. Along with this the workforce, both universal and specialist, needs development to enhance capacity and capabilities. 3 Future in Mind: promoting and improving our children and young people s mental health and wellbeing. Dept of Health and NHS England 2015 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 19 of 62

247 3.2 Right here, right now CQC report on crisis care for people with mental health problems 2015 & Mental Health Concordat 4 The recent CQC report found variation in the experience of care for people during a mental health crisis. People raised concerns about delays in receiving support, co-ordination of help from different agencies and attitudes of some staff which were not compassionate or understanding. The report found that 31% of those under 18 who were detained by the Police under section 126 were taken to a police cell as a Place of Safety. The national target is that no person aged under 18 will be taken to a police cell in future as a place of safety. The Mental Health Concordat requires local agencies to develop co-ordinated support for people of all ages who experience a mental health acute episode or crisis. 3.4 Mental Health and Behaviour in Schools: Advice for School Staff (DfE 2015)5 This guide sets out the evidence that in order for pupils to succeed, schools must have a role in supporting them to be resilient and mentally healthy. It advises that schools can promote mental health by having a healthy school approach, committed leadership, access to specialist support, enabling peer support and mentoring, continuous staff development, and work in partnership with children young people and parents. The guide is supported by advice for schools on commissioning emotional support services such as counselling. Schools could do this independently or with other schools, or in partnership with the local authority and CCG. 3.5 Achieving Better Access to Mental Health Services by 2020 (DH 2014)6 Achieving Better Access to Mental Health Services by 2020 outlines the first waiting time standards for mental health. This is part of the drive for parity of esteem, where people with mental health conditions can expect the same level of service as those with physical ailments. For 2016 there will 4 Right Here, Right Now: help, care and support during a mental health crisis. Care Quality Commission Mental Health and behaviour in schools: advice for school staff. Department for Education Achieving Better Access to Mental Health Services by Department of Health / NHS England 2014 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 20 of 62

248 be a national standard that at least 50% of people of all ages referred for early intervention in psychosis will start treatment within two weeks. There will also be requirement for all CCGs to commission specialist community services for children with eating disorders. These children are at high risk of serious illness and mortality. A waiting time standard for access to this specialist service will be set for 2016/ Eating Disorders There is a specific requirement set out in Achieving Better Access for all CCGs to commission specialist community services for children with eating disorders. Eating disorders such as anorexia nervosa and bulimia nervosa are debilitating mental disorders with high mortality rates 7. If untreated within the community, it is likely that a young person with an eating disorder will require a long period of hospitalisation to stabilise the medical condition and then treat the underlying psychological condition. NICE clinical guidance recommends family interventions for those with anorexia and cognitive behavioural therapy for children and adolescents with bulimia. 8 The Department of Health will expect all CCGs to have commissioned such services for their region to be operational from 2016/17. They will be multi-disciplinary teams, providing a range of evidence based interventions. There will be a specific access waiting time target of 4 weeks from referral to commencement of treatment for routine cases, 1 week for urgent cases. 3.7 National review of CAMHS Tier 4 (DH 2014)9 This report identified a national shortage of hospital beds for children. It recommended an investment in extra capacity and strong joint working between specialist commissioners and local clinicians to improve the access to hospital and facilitate earlier discharge. The report also found that intensive community support services for children and their families can prevent the need for admission. It is still the case that many young people have to be placed in a hospital far away from their home. 7 Guidance for commissioners of eating disorder services: Joint Commissioning Panel for Mental Health 8 Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders: National Institute for Clinical Excellence Child and adolescent mental health services (CAMHS) Tier 4 report 2014 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 21 of 62

249 3.8 Children and Family Act 2014 and Children with Special Educational Need or Disability This Act sets out clear responsibilities for education, health and social care organisations to work together to meet the needs of children and young people up to the age of 25 with Special Educational Needs or Disability (SEND). Each local authority must publish a local offer of health social care, education and training services that are available. There must be a single education, health and care health plan for every child which can run up to the age of 25. The young person or their parent can ask for a personal budget to choose how elements of their care plan will be met. Many organisations manage services differently for children and for young adults. There is often a cut-off at an age between 16 and 19. The Act will require services to re-examine these structures and ensure at the very least that there is planned and co-ordinated transition between services. The Act also requires authorities to provide support for young carers and for families, post adoption. The Winterbourne Review has highlighted specific problems in the long term health and social care residential services for people with learning disabilities. All CCGs have been tasked to develop Transformational Care plans. This plan must also consider the needs of adolescents and young people with learning disabilities and mental health problems, and their transition into adult services. 3.9 Equality Act 2010 & Humans Right Act The Equality Act requires all public bodies to give due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic and those who do not share it; Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 22 of 62

250 give regard to the need to reduce inequalities between patients in access to, and outcomes from, healthcare services and in securing that services are provided in an integrated way where this might reduce health inequalities The National Joint Commissioning Panel for CAMHS 10 has identified some children as having higher risk factors for emotional distress and mental disorders. It is also accepted that there is stigma attached to mental health problems and illnesses within numerous communities. We will ensure that our plans promote services which are accessible to all, free from discrimination or harassment, tackle stigma and promote positive relationships and community cohesion. In particular we will consider the impact for those young children known to vulnerable to mental disorders. The Human Rights Act 1998 sets out a number of fundamental rights of all citizens including children and young people. These include: freedom from torture and inhumane and degrading treatment respect for private and family life no punishment without law freedom of expression We will ensure that all services supporting children, young people and their carers adhere to these rights. It will also be important to tackle inequalities in access to health services and in health outcomes. 10 Guidance for commissioners of CAMHS: Joint Commissioning Panel for Mental Health 2013 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 23 of 62

251 3.10 Key findings from the national agenda for the Transformational Plan The national agenda has highlighted the following key issues that will be addressed within our local transformational plan There should be access standards for all services. There will be a national requirement from 2016/17 that at least 50% of children and young people referred for early intervention in psychosis will start treatment within two weeks; Local services for children and young people with eating disorders should be commissioned. There will be a national access time standard for this service of 4 weeks for a routine referral and 1 week for an urgent referral from 2017/18. Schools should adopt a healthy schools approach and offer emotional support services such as counselling, group work and peer support. Intensive community support services should be established that can prevent the need for admission and keep children and young people close to home Services for young people with special educational needs and disabilities should be clearly planned with adult services to ensure planned and co-ordinated transition; Targeted support should be available to young carers; Target support post-adoption; A place of safety for children and young people should be available for times of mental health crisis; Access to hospital beds should be improved and earlier discharge facilitated Some children and young people have higher risk factors and preventative and specialist services should be able to respond to their needs. All services should be free from discrimination, harassment and victimization, tackle stigma, and address health inequalities All services should promote or protect the rights of the child. In particular, they must adhere to the Humans Rights Act. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 24 of 62

252 4. Level of Need and Local Context 4.1 Children and Young People in Leicester, Leicestershire & Rutland There are approximately 250,000 children aged up to 18 in Leicester, Leicestershire and Rutland (Census 2011). Leicester City has one of the highest percentage ethnic minority populations of any area in England % of school children are from a Black or Ethnic Minority background, predominately South Asian. Leicester City Council estimates that the local Somali community comprises about 10,000 people. There are between 6,000 and 8,000 migrants of working age from Poland, Portugal, Slovakia, Latvia and Lithuania, including 1,000 2,000 people from the Slovak Roma community. Other new communities include asylum seekers and refugees. There are as many as 150 languages and dialects spoken in Leicester. Approximately 35% of children live in poverty and 64% in total live in families on low income. Poverty and low income levels correlate with poorer child health outcomes. The significant young ethnic minority population requires services to have a strong understanding of cultural norms and experience of discrimination that can impact on emotional health, as well as access to good language support services. The staffing population should reflect the diversity of the communities we serve. The CHIMAT Report 12 on child mental health reported that Leicester had higher levels of childhood obesity, tooth decay and a higher infant mortality rate than the national average. Admission rates to hospital for self-harm for those aged have decreased in recent years and are lower than the national average. Leicester City s Health and Wellbeing strategy , Closing the Gap 13 has strategic priorities to improve outcomes for children and young people and to improve mental health and emotional resilience. The focus is on prevention and early intervention. This can help prevent emotional and behavioural difficulties, under-attainment at school, truancy and exclusion, criminal behaviour, drug and alcohol misuse, teenage pregnancy and 11 Leicester Joint Strategic Needs Assessment 2012/ Leicester City Council 12 Child Health Profile Leicester June 2015: Public Health England 13 Closing the Gap: Leicester s Joint Health and Wellbeing Strategy Leicester City Council 2013 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 25 of 62

253 the subsequent need for high cost statutory social care in later life. The strategy also calls for intensive support for families with multiple problems and to tackle discrimination and stigma. Leicestershire and Rutland are rural and relatively affluent counties. The health of children is generally better than the national average. There are however issues around rural isolation and social or academic pressure that influence mental health. Leicestershire s Health and Wellbeing Strategy sets out priorities to get it right from childhood and improving mental health and wellbeing. It states that one of the most significant challenges to the health of the population is caused by the intergenerational cycle of health inequalities. Targeting families with the greatest overall needs (as per the Supporting Leicestershire Families initiative that has been developed in locally) is key to ensuring that the most vulnerable children have the best opportunity for good health and wellbeing throughout their lives. Rutland hosts two military bases with 700 children living there. The Rutland Joint Health and Wellbeing Strategy has priorities to support the emotional health and wellbeing of children, young people and their families, and to support vulnerable teenagers make a smooth transition into adulthood. 4.2 Prevalence rates for mental health and developmental conditions The last national survey of prevalence of mental health conditions in children was conducted in This indicated that, at the time, in an average class of 30 schoolchildren, 3 will have a diagnosable mental health disorder 17. The survey, extrapolated to Leicester, Leicestershire and Rutland indicates that 14 Leicestershire s Health and Wellbeing Strategy Leicestershire County Council Rutland Joint Health and Wellbeing Strategy Rutland County Council and East Leicestershire CCG 16 Green H, McGinnity A, Meltzer H, Ford T, Goodman R (2005). Mental health of children and young people in Great Britain, YoungMinds Mental Health Statistics. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 26 of 62

254 11,000 children will have a conduct disorder: 6,250 will have anxiety: 1,700 will have diagnosable depression: 2,850 will have severe ADHD. The specialist CAMH service provides therapeutic and medical interventions to assess and support children with mental health or neurodevelopmental needs. The current case load indicates the spread of conditions that the service supports. Condition Number of open cases Anxiety 360 Conduct 50 Depression 139 Eating Disorder 100 Psychosis 11 Obsessive Compulsive Disorder 23 Self-Harm 78 Stress 70 Neurodevelopmental (ASD and ADHS) 562 Other Often a child or young person will present with two or more related mental health conditions. Other service such as pediatrics, health visitors, school nurses and educational psychology also provide significant support for children with neurodevelopmental and mental health conditions. Nevertheless the data would suggest that if there are 21,000 children and young people with potential mental health or neurodevelopmental concerns, only one in twenty is receiving specialist assessment and therapeutic support from CAMHS. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 27 of 62

255 4.3 Baseline Workforce Data The charts below set out workforce data for the specialist CAMHS service including primary mental health, community CAMHS, specialist CAMHS teams and local Tier 4 hospital services. Role Grade WTE Medical Consultant 13 Specialty Doctor 1 Nursing Qualified 46 Unqualified 11 OT Qualified 8 Apprentice 1 Psychology 22 Therapy 7 Overall Total % of staff have an ethnic minority background. They range in age from with 20% aged over 50. 4/5 of staff are female. There are a wide range of other services, in health, social care, education, youth offending amongst others, which work with children with mental health problems and their families. 4.4 Baseline financial data The three CCGs fund the specialist CAMHS service to the value of 6.5 million in 2015/16. They also fund under children s services such as Paediatrics, disabled children s services and speech and language therapy which also work with many children and young people who will have Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 28 of 62

256 associated neurodevelopmental or mental health conditions. Adult mental health services (which receive CCG funding of 80million per year) also support young people aged Local Authority Children s and Early Help services are funded at around 25million per annum. This includes a range of specialist services (such as Educational Psychology) and generic child and family services. NHS England (East Midlands) estimates an annual cost of 3.5 million per year on hospital and specialist services for children and young people from Leicester, Leicestershire and Rutland. The Office for the Police Commissioner has committed 140,000 per annum to commission emotional support services for child victims of crime as a contribution to a partnership approach. There is a commitment from the partners to this plan to deploy existing budgets alongside the Transformational Plan funding to jointly address the issues facing our local communities. 4.5 Vulnerable Children and Young People There are approximately 1110 Looked after children in Leicester, Leicestershire and Rutland. The numbers have steadily risen over the past five years from 837 in Most are placed within foster placements. National research, Meltzer et al (2003) 18, showed that 46% of looked after children had a least one psychiatric diagnosis. There are approximately 9,000 children in need. A local health needs assessment has highlighted mental health as a key issue, with access to early support vital. 18 The mental health of young people looked after by local authorities in England. Meltzer el al (2003) Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 29 of 62

257 For 2014, the proportion of school pupils with Special Educational Needs was 19.6% for Leicester City and 15.6% for Leicestershire County and Rutland. The England average was 17.9%. Children with a learning disability can often present with challenging and difficult behavior, which may also be associated with emotional distress. There is a specialist LD CAMHS service which provides and urgent, seven day a week service to reduce the risk of hospital admission or loss of residential care. This is linked to Transforming Care plans for all people with learning disabilities. The total number of Children and Young People who were a victim of a crime in 2014/15 across LLR was Of these the most prevalent crime types were assault, harassment, indecency and theft. It is well documented that young people are at a greater risk of becoming a victim of crime than the general population and that very few young victims go on to report their crime. The Office of the Leicestershire Police and Crime Commissioner has conducted qualitative research with young people and identified a need for therapeutic support for children and young people who are victims of crime and witnesses to crime 19. Leicestershire County Council s Public Health Department 20 carried out a mapping review of mental health and wellbeing support services for children in This report found high levels of anxiety, more anger, more challenging behavior including violence and more self-harming. Children raise issues of bullying, family separation, domestic abuse and academic pressure as causes of emotional and mental distress. There has also been a rise in issues relating to social media, including cyber-bullying, and internet sites or groups which promote self-harm or eating disorders. The report found examples of good early intervention and low level support services. These included counselling, self-esteem group work parental support, family mediation. However these are not universally available leading to a patchwork of provision. Such services may not always have links into statutory services such as educational psychology or CAMHS. 19 Children and young people victim service review. Office of the Leicestershire Police and Crime Commissioner / Baker Tilly (2015) 20 Mapping of children and young people s mental health and wellbeing support and services. Leicestershire County Council 2014 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 30 of 62

258 There has been significant pressure on local authority budgets which has led to a reduction of some early help services, either provided directly by the Councils or commissioned by them. 4.6 Role of Schools Schools have greater responsibility and autonomy for developing pastoral and educational support services. They can utilise pupil premium funding to provide additional emotional health and well-being support to enable those eligible for funding to access learning and improve outcomes. Young people in Rutland have recently stated that they want greater education and discussion about mental health issues at school, to help overcome stigma and discrimination. School teachers want opportunities to develop their skills and expertise in supporting their students, and in accessing specialist help at the right time. Schools have a very important role to play in supporting children and young people to be resilient and mentally healthy. A recent Chief Medical Officer s report 21 highlighted Promoting physical and mental health in schools creates a virtuous cycle reinforcing children s attainment and achievement that in turn improves their wellbeing, enabling children to thrive and achieve their full potential. In Leicestershire the Leicestershire Healthy Schools Programme provides a framework for a coordinated and effective approach to the planning and delivery of health and wellbeing improvement in schools. The programme operates a whole school approach to education and health improvement in schools ensuring that the whole community is involved in the process. 21 Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 31 of 62

259 4.7 Role of the Voluntary and Community Sector Voluntary Action Leicestershire (VAL) holds a database and public directory of voluntary and community sector (VCS) organisations for Leicester, Leicestershire & Rutland (LLR). These groups cover a range of services, and just over 450 groups help with emotional health and wellbeing with the main beneficiaries as children, young people and families (CYPF). These groups deliver a range of local community based activities, from, street based art, sport, drama and music, to more specialist support for conditions, such as Attention Deficit Hyperactivity Disorder (ADHD), for the whole family. VCS groups have a strong track record in building strong relationships with families, breaking down barriers, have direct access into families at a community level and have built trust with communities over a number of years. The VCS will have a pivotal role in delivering interventions and preventative projects and services working in consortia and/or in collaboration with statutory partners. There is currently a patchwork provision of commissioned VCS early help and support services that needs coordination and integration as part of a whole system wide local offer for families. This has the potential to reduce pressure on specialist CAMHS and waiting times for access to these services. 4.8 Redesign of Specialist CAHMS The specialist CAMHS Community Outpatient service has seen an increase in referrals of about 9% per year over the past four years. The main reasons for referral include conduct disorders, family problems, requests for assessment for neurodevelopmental conditions, low self-esteem, selfharm and eating disorders. This has led to significant pressure on the CAMHS teams with increased waiting times for assessment and treatment. Average waiting times for assessment are rising and are currently around 13 weeks. Some children and young people have to wait much longer. Around 30% of referrals are not accepted or redirected as they do not meet the thresholds for a CAMHS intervention. This indicates that work can be done to improve the understanding of the role of the specialist CAMHS service and promote other services that can provide appropriate support. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 32 of 62

260 The service provides a range of therapeutic interventions. Core interventions are Cognitive Behavioural Therapy (CBT), Systemic Family Therapy (SFT) and Psychodynamic Psychotherapy.. In 2014 the CCGs commissioned an independent review of the CAMHS community outpatient services to examine and address these issues 22. The review also considered concerns about joint working with other organisations such as GPs, schools and social care services. The key recommendations from this review centred on the referral and assessment process, clinical leadership, caseload management and advice, information and support for other practitioners and service users. These recommendations have been adopted into a Service Development Improvement Plan and a redesign of the specialist CAMHS 23. Key elements of the plan are to manage the current waiting lists to ensure that all children are safe, improve access, tackle low discharge rates, work to agreed quality standards as set by the Royal College of Psychiatrists, and improve engagement with stakeholders. CAMHS uses the following clinical and patient-centred outcome measures: Health of the Nation Outcome Scales for Children and Adolescents (HONOSCA) Friends and Family Test (FFT) Paediatric Index of Emotional Distress (PI-ED) Strengths and Difficulties Questionnaire (SDQ) 22 Review of NHS CAMHS Tier 3 services in Leicester, Leicestershire and Rutland. Tim Jones CAMHS Service Development and Improvement Plan 2015/16. Children and Families Commissioning Team, West Leics CCG Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 33 of 62

261 There has also been a recent Care Quality Commission inspection of children and families services provided by Leicestershire Partnership Trust (July 2015) This has recommended a number of areas of CAMHS community and in-patient services which require improvement. These include ensuring staff have regular supervision, training and appraisals; assessing and treating young people in a timely manner; the development of crisis response services; learning from serious incidents; and ensuring service users give consent to treatment and are informed of their rights. 4.9 Crisis and In-patient Care There have been seven serious incidents involving children known to the CAMHS service over the past two years who have been admitted to an adult in-patient ward or had an extended wait within the Emergency Department at the Royal Infirmary hospital. The CCGs commissioned an independent review into these cases which was conducted by Verita 26 and reported in July The key themes that were highlighted within this review were: Develop multi-agency care plans, risk assessments and crisis response plans for children and young people at risk of acute mental health or conduct difficulties There should be a clear place of safety for young people under the age of 18 Commission a crisis response service Ensure that there is a clear protocol and procedure for accessing in-patient services which is communicated to all relevant practitioners Leicester, Leicestershire and Rutland has been selected as one of only eight urgent and emergency care vanguard sites The Vanguard will create a new alliance-based urgent and emergency care system where all providers work as one network. This will bring together ambulance, NHS111, OOH 24 Leicestershire Partnership Trust: specialist community mental health services for children and young people. Care Quality Commission July Leicestershire Partnership Trust: child and adolescent mental health wards. Care Quality Commission July A thematic review of seven incidents involving Child and Adolescent Mental Health Services. Verita 2015 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 34 of 62

262 and Single Point of Access services to ensure that patients get the right care, first time. The Vanguard will also progress work to ensure that there is an all ages crisis response service including children and young people experiencing acute mental distress. A service model has been developed which will include a specialist CAMHs Consultant, nurse, psychologist, child social worker and a substance misuse worker as part of an all-ages liaison service. This service will focus on support for children and young people when they attend the Emergency Department and other acute hospital services. This will be a seven day service. Through the Future in Mind transformational fund we will commission multi-agency intensive community and home treatment services. These services will operate extended hours seven days a week, and will provide home visits and intensive work with the young person, their carers and other agencies such as school or social care. The aim will be to reduce and avoid admission to either ED or mental health in-patient units and also support planned discharge from in-patient units. Children in Leicester, Leicestershire and Rutland who require a period of time in a mental health hospital can access beds commissioned from NHS England. There is a 10-bedded unit within Leicestershire. Young people from LLR may be placed there or at another unit across the Midlands and East region. There are no specialist units in the region for young people with eating disorders or requiring a Psychiatric Intensive Care Unit (PICU). These young people may be placed anywhere in the country. This presents problems in continuity of care and education, difficulties for families and carers in visiting, and can damage the young person s links with friends and peers. We are keen to see a greater provision of general and specialist beds within the Midlands region. The data for June 2015 shows that 48 young people from LLR were placed in a hospital, 5 of these in eating disorder unit, 8 within a PICU and 4 in Low Secure setting. All 17 requiring a specialist unit are placed outside the East Midlands region. We are keen to work as part of regional collaborative commissioning arrangements to strengthen the provision of in-patient facilities within our region and ensure that there are good protocols for partnership working between Tier 3 and Tier 4 commissioners and providers. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 35 of 62

263 4.10 Eating Disorders The CAMHS service is presently not specified to provide a specialist eating disorder service. There has been a significant increase in referrals for this condition from around 40 to 100 per year. These children and young people are supported by the generic community CAMHS team. An eating disorder such as anorexia nervosa can be a particularly serious mental health condition with a risk of severe damage to physical health or mortality. There is a growing evidence base that early access to specialist community based eating disorder service operating to NICE guidelines can improve outcomes and be financially cost-effective by reducing reliance on long-term hospital placements. The CCGs have agreed to commission a specialist community based eating disorder service with the capacity to provide NICE concordat therapeutic interventions for 100 children and young people per year. This multidisciplinary service will consist of 11 staff and will serve an overall population of 1 million. The service will meet the national access standards by 2017/18. These are four weeks from referral to assessment and commencement of treatment for routine cases, and one week from referral to assessment and commencement of treatment for urgent cases. This development will potentially reduce pressure on generic CAMHs. It should also prevent the escalation of eating disorder conditions to critical levels where emergency admission to specialist or paediatric hospital wards is required Key findings impacting on the transformational plan Our region has a significant child ethnic minority population and all services will need to accessible and culturally appropriate. Peer and parental support groups for these communities may be particularly beneficial. There has been an increase in young people experiencing anxiety, anger and challenging behaviour and referrals to specialist CAMHS. Education services are very important in promoting resilience and good mental health and in commissioning specific pastoral support services Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 36 of 62

264 There are some excellent and innovative voluntary and community sector providers. There is a patchwork provision of early help and support services. These services need to be integrated within a care pathway and commissioned in a strategic way to ensure that there is consistent and equitable offer to children across the region. The CAMHS service must transform the assessment and treatment process so that help can be offered quicker. It can offer more advice, training and support to other organisations and practitioners. It can make better use of routine outcome measures. Specific community services for children and young people with eating disorders are required. A co-ordinated multi-agency response to children and young people experiencing a mental health crisis is required. There is a need for more generic and specialist hospital beds commissioned in the East Midlands. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 37 of 62

265 5 Transformational Plan for Promote good emotional health and resilience for all children, young people and their families Young people have said that they want to have the confidence to talk about emotional problems openly and without stigma. They want to be able to find information and support from the school, college or youth service, and also from websites and social media. Education services want to offer education and guidance for their pupils, provide pastoral support and know when to ask for specialist assistance. Parents, young people and schools are all concerned about the impact of cyber-bullying. Our partnership will commission and deliver a public health campaign on mental health and resilience. A key element of this will be to form partnership with education settings to develop and deliver age appropriate education on mental health problems. We will also review the current approaches and resources that are being used to address the misuse of social media, including cyber-bullying and sexual exploitation. The best practice approaches will then be shared across educational settings. Our partnership will develop a range of ways for children, young people and carers to find out about mental health and the range of services that can help this. This will be through utilising social media and more traditional communication methods. It will involve building on current best practice and innovation. The financial investment in this work will come initially from the transformational plan and from public health departments. The partnership will also engage with schools to release direct funding contribution. Indicative funding would be 200,000 from the transformation plan. This will be used to establish new school liaison posts and to commission a comprehensive health promotion campaign. The Standards for this work will include: Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 38 of 62

266 the number and proportion of schools which engage in the programme, a survey of young people about their attitudes, experience and awareness of mental health issues. 5.2 Development and delivery of co-ordinated, accessible and non-stigmatising early and targeted support for those experiencing emotional distress and the first signs of mental disorders Young people and carers have said that they want access to help and support quickly and locally, without being stigmatised. They want to have a choice about the kind of help they receive and be encouraged to become resilience and maintain their independence. They also want potentially serious problems to be recognised quickly, and no longer be told that they are not ill enough to get help. Organisations such as health, education, youth justice and social care want to work together to understand the needs of a young person and decide together with the young person and / or parent what support to offer. We know that a range of public, private and community organisations can provide effective support. They want their services to be part of a commissioned pathway of support, meeting high quality standards and linked to more specialist services. Our partnership will commission a multi-agency First Response service which will assess the level of distress and risk facing a child, young person or family, and co-ordinate the right intervention and support. The service will set thresholds using the Merton Risk Assessment Tool and Signs of Safety. It is important that there is quick local access to this first response, and that it benefits from the expertise and knowledge of practitioners from various agencies. The services will signpost the young person or family, escalate the case if required, or offer low intensity support and help. This will include offers such as counselling, group work and parental support. But it will also include direct access to specialist mental health services if required. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 39 of 62

267 There will be specific aspects of this work that will focus on services for children and young people from hard to reach communities. This will be achieved through building on and developing partnerships with local community groups such as the City of Sanctuary (refugees and asylum seekers), the Lesbian, Gay, Bi-sexual and Transgender. There will be financial contributions from local authorities, CCGs and the OPCC to supplement and support transformational plan investment in this approach. Indicative funding would be 460,000 from the transformational fund with matched funding (or work in kind) from local commissioning partners. The funding will be used to enhance early help capacity and to commission a range of community based short term interventions. The standards for the service will include The number of young people and / or carers who are assessed within four weeks of a referral. The number of children young people and carers who participate in programmes of early support. Improvements in Strengths and Difficulties Questionnaire rating for CYP participating in the programmes The proportion of CYP completing early help programmes who require further specialist CAMHS support. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 40 of 62

268 5.3 Single gateway to specialist CAMHS services with clear access standards Young people value the quality of care and support they receive from the specialist CAMHS service. They have said that they appreciate the therapeutic relationship they can develop with their practitioners and the support offered to their family and carers. However, it remains difficult to access the service quickly and there is a perception that a young person will be told that they are not ill enough to receive CAMHS help. The CAMHS service is experiencing a rising number of referrals (up about 9% per year) and increasing these are for complex or urgent situations. The CAMHS service will pilot establishing a single access team. This team will receive all referrals to the service and will make direct contact with the referrer, the young person and the carers (if appropriate) to understand the presenting issues. It will offer short term interventions or ensure that the young person can access the specialist CAMHS services if required. The pilot service will run during 2015/16 with the aim of commissioning a full service to operate from 2016/17 onwards. There will be locally agreed access waiting time standards There will be strong engagement with local authority social care access teams to share information (with consent) and to plan joint interventions. The service will also provide a set range of evidence based NICE concordat therapies. This will include Systemic Family Therapy, Cognitive Behavioural Therapy, Parenting Support and Interpersonal Psychotherapy. These will be specified clearly within contract documentation. The indicative financial commitment would be 50,000 from the transformational fund. There will also be support through the existing CCG funding of the CAMH Service. The standards for this service will be for all children and young people will receive an assessment within 13 weeks of referral. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 41 of 62

269 5.4 Specialist support for vulnerable children and young people with mental health problems The CCGs and local authorities will review and consider expanding the specialist therapeutic support that is available for children and young people who are particularly vulnerable. This includes looked after children, those at risk of offending, those with learning disabilities, those with a family of mental health problems, those who have been exposed to sexual exploitation and children who are refugees or asylum seekers. It is known that these children and young people are more likely to require psychological support and would benefit from swift access to services which are skilled and experienced in responding to their needs. Through Parity of Esteem we will focus on providing a dedicated and swift response to young people with a first episode of psychosis. This will ensure that we meet the national access standard that people with first episode psychosis will be assessed and commence treatment within two weeks of referral. The indicative financial commitment would be 50,000 from the transformational fund, and 288,000 from Parity of Esteem. This will be used to enhance clinical capacity within these specialist teams. The standard for this service will that all children and young people will receive specialist psychological support within 13 weeks of referral. 5.5 Systematic use of outcome measurement to drive clinical and service improvement Our partnership will strengthen the use of outcome measures. These will be used both to inform clinical practice for individuals, and also to improve the overall design of services. Measures will include HONOSCA, PI_ED, Friend and Family Tests, Outcome Star, Strengths and Difficulties Questionnaire, and Signs of Safety. A range of measures are set out in the guidance for the Children and Young People s Improving Access to Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 42 of 62

270 Psychological Therapies programme (CYP-IAPT) and the Child Outcomes Research Consortium (CORC). We will prepare for the Mental Health Service Minimum Data Set (MHSMDS). This work will involve ensuring that data systems are in place to record, analyse and report on the outcome measures. It will also involve developing information sharing protocols between organisations. The LLR CAMHS services are presently not part of the National CYP-IAPT programme. There is not a training provider for the Midlands region. However, the partnership is keen to support the Local Education and Training Board to develop provision locally. Non-recurrent transformational funding will be used to support this. The standards for this service All commissioned services will use both clinical and patient centred outcome measures. These measures will inform clinical practice and service planning All commissioned services will have data sharing agreements and protocols in place. 5.6 Specialist community services for children and young people with eating disorders Eating disorders such as anorexia nervosa and bulimia nervosa are debilitating mental disorders with high mortality rates 27. There has been an increasing prevalence of eating disorders amongst children and young people with the number of referrals to CAMHS increasing from an average of 40 a year in 2011 to over 100 in 2014/15. If untreated within the community, it is likely that a young person with an eating disorder will require a long 27 Guidance for commissioners of eating disorder services: Joint Commissioning Panel for Mental Health Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 43 of 62

271 period of hospitalisation to stabilise the medical condition and then treat the underlying psychological condition. NICE clinical guidance recommends family interventions for those with anorexia and cognitive behavioural therapy for children and adolescents with bulimia. 28 The Clinical Commissioning Groups have therefore decided to invest in the commissioning of a specialist multi-disciplinary community based eating disorders service for children and young people up to the age of 18. The service will deliver NICE concordant treatments for up to 100 new referrals per year. It will serve a general population of 1 million. It will operate to the national access and waiting time standards so that all routine cases will be assessed within 4 weeks and urgent cases within 1 week of referral. Over the period of this transformational plan there will be the opportunity to further enhance the service to meet all aspects of the national guidance (2015) 29 and respond to new NICE guidelines which are due in This will include developing pathways for self-referral and to ensure that the service can operate 7 days-a week. The potential benefits of this investment include reductions in admissions and length of stay in specialist hospital settings. It will also have the potential to reduce the number of crisis and acute cases. Indicative financial contribution: 440,000 from the transformational fund. This will be used to fund seven new posts within the service. These posts will have a role in outreach and advice to other practitioners as well as direct patient care. The Standards for this service will be All routine referrals will be seen within 4 weeks of referral All urgent referrals will be seen within 1 week of referral 28 Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders: National Institute for Clinical Excellence Access and Waiting time standards for child and young people s eating disorder services, NHS England 2015 Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 44 of 62

272 5.7 Co-ordinated support to prevent crisis and at time of crisis There is also a need to develop specific support for children and young people, and their carers experiencing a crisis situation due to significant behavioural or mental health disorders. This may include a young person being violent, using threatening behaviour towards themselves or others, or facing a life-threatening condition. In these situations, an urgent assessment or intervention may be required and the young person may need to be taken to a safe and calming environment where, in time, a full assessment can be undertaken. There is also a requirement to establish a designated Place of Safety as required under Section 136 of the Mental Health Act This Place of Safety should never be a police cell. The CCGs, in partnership with the local authorities, will commission an intensive community support service which will operate beyond normal office hours and offer home or community based assessments and interventions. The team will also liaise with NHS England and Tier 4 providers to facilitated planned admission and discharge. This team will consist of a CAMHS Consultant, CAMHS nurses and social workers. Through the Vanguard Programme, the CCGs will also commissioning enhanced all-age liaison psychiatry services. This will support children and young people with acute mental health or behavioural problems arriving at the emergency department. The team will include a CAMHS Consultant, CAMHS nurse, child psychologist, family social worker and specialist substance misuse worker. This is set out in the action plan for Leicester, Leicestershire and Rutland to deliver the Mental Health Crisis Care Concordat Crisis Care Concordat for Mental Health: Leicester, Leicestershire and Rutland action plan Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 45 of 62

273 Indicative funding would be 500,000 from the transformational plan and 250,000 from the Vanguard programme. This would be used to establish the new service teams. The standards for these services will be: No child or young person will wait more than 4 hours in the emergency department. No child or young person will be placed in a police cell as a place of safety The intensive community support service will operate 7 days-a-week 5.8 Workforce Development We have established a workforce development plan for the specialist CAMHS service. This focusses on succession plan and recruitment and the development of leadership and specific therapeutic skills. The plan recognised the need to develop skills and experience in therapies such as cognitive behavioural therapy, psychodynamic psychotherapy and family therapy. It is also important to have a workforce that is balanced in terms of age and gender and is ethnically diverse to reflect the profile of the children and families we work with. We will recommission a child mental health training and development programme. This will build on our successful approach of ensuring that local specialist practitioners deliver the training to other practitioners such as children s centre staff, social workers, police officers and school teachers. Indicative funding would be 70,000 from Future in Mind. This would be used to commission a programme of training. Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 46 of 62

274 6 Governance and Transparency This transformational plan presents a significant challenge to all partner organisations. But the vision is clear and the determination to make these changes now is set. The programme will require strong governance and management to ensure that it delivers against the objectives, and remains transparent and open to scrutiny and review. This is why we have decided to embed the Future in Mind Transformational Plan within the Better Care Together (BCT) Programme Framework. This approach offers the benefit of greater engagement with a wide range of stakeholders as well the potential to make links with other workstreams such as adult mental health and urgent care. The programme will be led by the BCT Delivery Board which is accountable to the Boards of the three CCGs and three Health and Wellbeing Boards for the area. It will be part of the Women and Children s Workstream, and be jointly led by the Director of Children s Services at Leicestershire County Council and the Director of Nursing at Leicester City CCG. A Steering Group 31 has already been established with representation from local authorities, voluntary sector, Healthwatch, the OPCC and health commissioners and providers. This steering group will have responsibility for joint commissioning of services, utilising Future in Mind and existing budget allocations. There is a programme lead officer, who will be supported by additional project officers responsible for delivering key aspects of the programme. Task groups are being established to manage each element of the programme. These task groups will be responsible for delivery and will receive regular reports against the key standards and Key Performance Indicators for their services. There will also be specific stakeholder reference groups for schools, GPs, parent/ carers, and young people. These groups will hold the overall programme to account, and ensure that it remains focussed on what local children, young people and carers have said that they want. The structure is set out in the diagram below. An easy read summary of the plan will be published on the websites for each CCG and Health and Wellbeing Board in December Better Care Together Mental health and wellbeing of children and young people steering group 2015: terms of reference Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 47 of 62

275 Governance Framework Mental Health & Wellbeing for Children and Young People Clinical Commissioning Groups Better Care Together Delivery Board via the Women s & Children s Work Stream Health & Wellbeing Boards Carers Young People Better Care Together Steering group Mental health & Wellbeing for CYP Co-commissioning Group Stakeholder reference groups Schools GPs Promoting resilience Early Help Access and Care Eating Disorders Intensive community Workforce Leicester, Leicestershire and Rutland: Mental Health and Wellbeing for Children and Young People Transformational Plan November 2015 Page 48 of 62