GOVERNING BODY ASSURANCE COMMITTEE

Transcription

1 GOVERNING BODY ASSURANCE COMMITTEE Monday 22 February pm 4:00pm Robert Robinson Room, Scarsdale, Chesterfield A G E N D A Enclosure Presenter 1. To receive apologies for absence: Verbal Ian Gibbard 2. Declaration of Interests: Ian Gibbard Governing Body Assurance Committee Members to declare interest in items on the Agenda To receive and note any changes to the Register of Governing Body Members interests 3. Minutes of the Governing Body Assurance Committee held on 25 th January 2016 To note 4. Matters arising from the Governing Body Assurance Committee of 25 th January 2016 For Assurance Action Log To note 5. Integrated Finance, Performance and Quality Improvement Report Paper A Paper B Paper B Paper C Paper D Ian Gibbard Ian Gibbard Darran Green Jayne Stringfellow 6. Governing Body Assurance Framework Principle Risk Three Paper E Ben Milton Beverley Smith 7. Transforming Care Learning Disabilities Paper F Beverley Smith

2 8. Proposal for establishing an East Paper G Mark Smith Midlands Affiliated Commissioning Committee 9. Primary Care Psychological Therapy Paper H Mark Smith (IAPT) Re-procurement Nephrectomy Report Paper I Ben Milton 11. Freedom of Information Policy Paper J Suzanne Pickering 12. Flexible Working Policy Paper K Mark Smith 13. Supported Learning Policy Paper L Suzanne Pickering 14. Corporate Incident Policy Paper M Suzanne Pickering 15. Pooled Budget For Children With Paper N Beverley Complex Needs Audit Assurance of Adult Safeguarding across NDCCG Paper O Smith Jayne Stringfellow For Information 17. IT Policy Highlight Report Paper P Suzanne Pickering 18. CSU Re-procurement Programme Board Paper Q Suzanne Pickering Reports from Sub Committees for discussion/action relating to key matters 19. Minutes of the 21 Century Plan Delivery Group meeting of 11 th January Minutes of the Primary Care Development Group meeting of 21 st December Minutes of System Resilience Group meeting of 8 th January Minutes of DCHS Quality Assurance Group meeting of 27 th October Minutes of DHU Quality Assurance Group meeting of 27 October Minutes of Patient Experience & Safety Committee of 20 October 2015 Paper R Paper S Paper T Paper U Paper V Paper W Mark Smith Jayne Stringfellow Jayne Stringfellow Jayne Stringfellow Jayne Stringfellow Jayne Stringfellow

3 25. Minutes of Prescribing Sub Group minutes of 6 January Minutes of Joint Area Prescribing Committee minutes of 12 January 2016 Paper X Paper Y Jayne Stringfellow Jayne Stringfellow 27. Minutes of Safeguarding Commissioning Group (Joint Adults and Children) held on 14 December 2015 Paper Z 28. Any Other Business All Jayne Stringfellow 29. Date and Time of Next Meeting: Monday 21 st March 2016, in the Robert Robinson Room, Scarsdale, Chesterfield, Derbyshire at 1:30pm

4 ND CCG Governing Body Assurance Committee 22nd February 2016 Paper A NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE MEETING 22nd February 2016 Report Title: Declaration of Interest Register Item No: 2 1. Background and context A Declaration of Interest Register is required under the Code of Accountability and the interests declared will be reported to the North Derbyshire CCG Governing Body and will be available for public inspection. 2. Key matters for consideration To provide a Declarations of Interest Register for North Derbyshire Clinical Commissioning Group (NDCCG). 3 Financial Impact None. 4. Analysis of risk Requirement to embed into the CCG to ensure sound corporate governance structures and transparent decision-making processes within NDCCG. 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all: None directly Improved patient access and experience: None directly Empowered, engaged and well-supported staff: None directly Inclusive leadership at all levels: None directly 6. Recommendations To review the Declaration of Interest for the Governing Body to ensure that it is correct and consistent Author: Suzanne Pickering, Head of Governance Sponsor: Mark Smith, Interim Chief Officer Date: 12th February 2016

5 North Derbyshire Clinical Commissioning Group Register of Interests Governing Body and Sub Committees February 2016 Governing Body Member Interests Mark Smith Spouse is an employee of Derbyshire Healthcare Services Foundation Trust Governor of Woodthorpe Community Primary School Sheffield. Ben Milton Partner at Darley Dale Medical Practice Director of Darley Private Healthcare Dr Smith and Partners are part of the Primary Research Network and are paid for engagement in their research projects Indigo Training is part of Darley Private Healthcare. Contract for service of Derbyshire Community Health Services NHS Foundation Trust. No spouse with relevant interests Darley Dale Medical Practice is a member of the North Derbyshire GP Federation Ian Gibbard No relevant interests No spouse with relevant interests David Collins Partner at Springs Health Centre, Clowne Spouse is a partner in Larwood Surgery Member via the practice in North Derbyshire GP Federation. Darran Green No relevant interests No spouse with relevant interests Jayne Stringfellow Governor Chesterfield Royal Hospital Foundation Trust Spouse is Trustee of Cross Roads Care East Midlands Andrew Milroy Assistant Director of Adult Care, Derbyshire County Council No spouse with relevant interests Bruce Braithwaite Director of Operations, Alliance Surgical Register of Interests Governing Body, CRG and Sub Committee February 2016

6 PLC Director BD Braithwaite Ltd Director Veincare Ltd Clinical Lead and Deputy Clinical Chair of Circle NHS Treatment Centre, Nottingham. No spouse with relevant interests Debbie Austin School Governor Taxal and Fernilee Primary School, Whaley Bridge Spouse is Employee of DCHS, Interim Associate Director of Transformation Gary Apsley No relevant interests No spouse with relevant interests Beverley Smith No relevant interests No spouse with relevant interests Joanne Winfield No relevant interests No spouse with relevant interests Anne-Marie Spooner GP Partner at Hasland Medical Centre Hasland Medical Centre is a member of the North Derbyshire GP Federation. No spouse with relevant interests Isabella Stone No relevant interests No spouse with relevant interests Governing Body Assurance Committee Interests Mark Smith Spouse is an employee of Derbyshire Healthcare Services Foundation Trust Governor of Woodthorpe Community Primary School Sheffield. Ben Milton Partner at Darley Dale Medical Practice Director of Darley Private Healthcare Dr Smith and Partners are part of the Primary Research Network and are paid for engagement in their research projects Indigo Training is part of Darley Private Healthcare. Contract for service of Derbyshire Community Health Services NHS Foundation Trust. No spouse with relevant interests Darley Dale Medical Practice is a member of the North Derbyshire GP Federation Register of Interests Governing Body, CRG and Sub Committee February 2016

7 Ian Gibbard No relevant interests No spouse with relevant interests Darran Green No relevant interests No spouse with relevant interests Jayne Stringfellow Governor Chesterfield Royal Hospital Foundation Trust Spouse is Trustee of Cross Roads Care East Midlands Gary Apsley No relevant interests No spouse with relevant interests Joanne Winfield No relevant interests No spouse with relevant interests Suzanne Pickering No relevant interests No spouse with relevant interests Isabella Stone No relevant interests No spouse with relevant interests Debbie Austin School Governor Taxal and Fernilee Primary School, Whaley Bridge Spouse is Employee of DCHS, Interim Associate Director of Transformation Anne-Marie Spooner GP Partner at Hasland Medical Centre Hasland Medical Centre is a member of the North Derbyshire GP Federation. No spouse with relevant interests Clinical Reference Group Interests Ian Hutchison Partner in Evelyn Medical Practice No spouse with relevant interests Sharon Dinham Work with Primary Care Research Network carrying out research projects with the GP Practice No Spouse with relevant interests Chris Harvey Partner in Stewart Medical Centre, Buxton Practice contract for provision of GP Services to Fenton Ward and Buxton MIU employed by DCHS Sessional GP (OOH) for Mastercall Ltd, Stockport No spouse with relevant interests Richard Butler GP Partner at Moss Valley Medical Practice and part of North Derbyshire GP Federation No spouse with relevant interests Register of Interests Governing Body, CRG and Sub Committee February 2016

8 Upendra Bhatia GP Partner in Newbold Surgery Care UK and Derbyshire Health United (DHU) sessional duties. Chesterfield Health Provider by proxy through Newbold Surgery. Research lead for practice for PCRN No spouse with relevant interests Philip Cox Vice Chair DHU No spouse with relevant interests Rick Meredith Clinical Director of Derbyshire Community Health Service Interim Medical Director Derbyshire Community Health Service No spouse with relevant interests Danny Connor Podiatric Surgery and Community Podiatry Services Buxton Outpatients and Theatre Services DCHS NHS Trust No spouse with relevant interests Ifti Majid Executive Director of Operations with Derbyshire Healthcare Foundation Trust. Spouse is Assistant Chief Transformation Officer at NHS North Derbyshire CCG. Steve Gillam Interim Clinical Director of Derbyshire Community Health Services No spouse with relevant interests Beverley Smith No relevant interests No spouse with relevant interests Audit Committee Interests Ian Gibbard No relevant interests No spouse with relevant interests Gary Apsley No relevant interests No spouse with relevant interests Mark Smith Spouse is an employee of Derbyshire Healthcare Services Foundation Trust Governor of Woodthorpe Community Primary School Sheffield. Suzanne Pickering No relevant interests No spouse with relevant interests Martin Colclough No relevant interests Spouse is employed as a Deputy Director of Public Health England Carl Twibey Partner is employed by Derbyshire Register of Interests Governing Body, CRG and Sub Committee February 2016

9 Community Health Services NHS Trust Andrew Milroy Assistant Director of Adult Care, Derbyshire County Council No spouse with relevant interests Joanne Winfield No relevant interests No spouse with relevant interests Primary Care Co-Commissioning Committee Interests Ian Gibbard No relevant interests No spouse with relevant interests Gary Apsley No relevant interests No spouse with relevant interests Joanne Winfield No relevant interests No spouse with relevant interests Isabella Stone No relevant interests No spouse with relevant interests Andrew Milroy Assistant Director of Adult Care, Derbyshire County Council No spouse with relevant interests Mark Smith Spouse is an employee of Derbyshire Healthcare Services Foundation Trust Governor of Woodthorpe Community Primary School Sheffield. Jayne Stringfellow Governor Chesterfield Royal Hospital Foundation Trust Spouse is Trustee of Cross Roads Care East Midlands Beverley Smith No relevant interests No spouse with relevant interests Ben Milton Partner at Darley Dale Medical Practice Director of Darley Private Healthcare Dr Smith and Partners are part of the Primary Research Network and are paid for engagement in their research projects Indigo Training is part of Darley Private Healthcare. Contract for service of Derbyshire Community Health Services NHS Foundation Trust. No spouse with relevant interests Darley Dale Medical Practice is a member of the North Derbyshire GP Federation Register of Interests Governing Body, CRG and Sub Committee February 2016

10 Debbie Austin School Governor Taxal and Fernilee Primary School, Whaley Bridge Spouse is Employee of DCHS, Interim Associate Director of Transformation Caroline Shearer Awaiting declaration Lisa Soultana Alexin Healthcare Ltd Non-Executive Director No spouse with relevant interests Johnathon Rycroft No relevant Interests No spouse with relevant interests Marie Scouse No relevant interests Elaine Michel Director in County Council with responsibility to advise all Derbyshire CCG s on Public Health Prescribing Sub Committee Interests Richard Clarey No relevant interests Sharon Dinham Nurse representative on ND CCG Clinical Reference Group Jean Richards No relevant interests Helen Gregory No relevant interests Jane Mellor No relevant interests Kate Needham Director/Secretary (10% Shareholder) of Hollowmoor Consultancy Ltd Maxine North No relevant interests Dr Tim Parkin Owner/Partner in Blackwell Pharmacy, Gloves Lane, Blackwell Derbyshire Partner Limes Medical Centre, Blackwell, Blackwell Medical Centre, Village Surgery (Pinxton & South Normanton) Member of Hardwick CCG Prescribing Lead, Learning Disabilities Lead and Research Lead Kelly Monck No relevant interests Dr Elizabeth Riches Partner of GP Practice at Chatsworth Road Medical Centre GP Partner ND CCG Chatsworth Road Medical Centre is part of North Derbyshire GP Federation Martin Shepherd No relevant interests Guillermo Sierra Area Manager for Lloyds Pharmacy and Register of Interests Governing Body, CRG and Sub Committee February 2016

11 a CCA rep for Derbyshire LPC Dr Lorraine Wooster Partner to be at Stubley MC Stubley Medical Centre is part of North Derbyshire GP Federation Dr Carolyn Emslie Practice member of ND CCG Partner at Springs HC Clowne Springs HC is part of North Derbyshire GP Federation Dr Diane Fitzsimons Director of Darley Private Healthcare Partner at Darley Dale Medical Centre Darley Dale Medical Practice is a member of the North Derbyshire GP Federation Denise Shaw No relevant interests Senior Leadership Team Interests Nicola Longson No relevant interests No spouse with interests Kate Needham Director/Secretary (10% Shareholder) of Hollowmoor Consultancy Ltd No spouse with relevant interests Adam Sutherst No relevant interests No spouse with relevant interests Marie Scouse No relevant interests No spouse with relevant interests Martin Colclough No relevant interests Spouse is employed as a Deputy Director of Public Health England Aaron Gillott Treasurer and Committee member of Derbyshire Alcohol Advice Service No spouse with relevant interests Laura Joy No relevant interests No spouse with relevant interests Simon Harris Non-remuneration Director at The South Wolds Academy Governor at Willow Brook Primary School Paramedic for St Johns Ambulance Service Paramedic for EMAS No spouse with relevant interests Non remuneratory Director for East Midlands Educational Trust. Katherine Majid Spouse is Acting CEO of DHCFT Register of Interests Governing Body, CRG and Sub Committee February 2016

12 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B NORTH DERBYSHIRE CCG GOVERNING BODY ASSURANCE COMMITTEE MEETING Robert Robinson Room, Scarsdale Monday 25 th January 2016 PUBLIC SESSION MINUTES Present Ian Gibbard Chair Lay Representative (Audit) Gary Apsley Lay Representative (Patient Experience) Darran Green Interim Chief Finance Officer Ben Milton Clinical Leader/Chair Suzanne Pickering Head of Governance Beverley Smith Chief Transformation Officer Mark Smith Interim Chief Officer Anne-Marie Spooner GP, Chesterfield Isabella Stone Lay Representative (Patient Experience) Jayne Stringfellow Chief Nurse and Quality Officer Joanne Winfield Lay Representative (Audit) In attendance Minute Taker Pauline Innes PA to Chief Officer Chair / Clinical Lead Kate Needham Head of Medicine Management Sally Baughen Head of Planned Care Adam Sutherst Head of Performance and Planning Simon Harris Assistant Chief Transformation Officer Jackie Jones Mr Wholley Director of Ambulance Commissioning Arden & GEM CSU Apologies Debbie Austin GP, High Peak Opening of Business/Standing Items GBAC Apologies for Absence Apologies for absence were received from Dr Austin in advance of the meeting. GBAC Declaration of Interests No declarations of interest were made with regard to today s agenda. No changes were requested to the Declaration of Interest Schedule. The Register of Declarations was agreed up to date. North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 1

13 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B GBAC Minutes of the North Derbyshire CCG Governing Body Assurance Committee of 21 st December 2015 The minutes of the meeting held on 21 st December 2015 were agreed as an accurate record subject to slight amendment. GBAC Integrated Quality Finance & Performance Improvement Report page 3 second line change period covering to November rather than October The Chairman signed the minutes. GBAC Matters Arising from the Minutes of the Governing Body Assurance Committee of 21 st December 2015 Judicial Review - Mrs Stringfellow provided an update relating to the Judicial Review informing the Committee that the Legal costs has come in at just under 3,000. The decision was upheld therefore Stepping Hill will remain to be the fourth specialist Site. Action Log The Committee reviewed the action log from the meeting held on 21 st December 2015 and a number of actions were closed: CGBAC Item 97 action on-going further education Mrs Pickering advised this is with the TU representatives, being amended and will be brought back to the February meeting. GBAC item 111 closed GBAC item 112 closed GBAC Integrated Quality Finance & Performance Improvement Finance Report Mr Green presented the finance report which covered the period of December 2015, the Committees attention was drawn to page 10 listing the CCGs financial positon. The Committees attention was drawn to the headline summary on page 9. Mr Green explained an amber RAG rating has appeared on the summary with regard to closing cash balance. This was due to the CCG applying for VAT back and the revenue office turning this round in 24hrs, therefore the CCG received this amount back in the bank on 31 st December 2015, which left a balance over and above what the CCG should have had. Summary Financial Position: Acute non NHS Providers there continues to be a lot of North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 2

14 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B activity still going to private providers. The CCG are working with the providers to look at how this can be contracted at a more favourable rate for next year. DCHS 188,000 favourable movement on the DCHS Mental Health line and corresponding adverse 190,000 on the DCHS community line which is a re-classification of some expenditure. Practice Prescribing still proving to be challenging, there is an increased overspend. The CCG remain confident of staying within control total for this year and of meeting the agreed underspend of just under 5m. The CCG still have sufficient reserves to take the CCG through to the end of the year and meet any challenges. Mr Gibbard indicated that the position relating to acute activity seems to suggest that areas of work undertaken is encouraging and suggested a bulletin be circulated encouraging staff to remain focused as developments are being seen. Mr Smith concurred that at 21C some high level metric information received was encouraging on non-elective activity which is going down against the plan. The Committee noted and received the financial report. Performance Report Mr Sutherst provided the Committee with an update from the exceptions highlighting salient areas: It was noted that overall the performance for the CCG is good, however, there remain to be a few areas of concern, nonetheless when looked at across the patch with the Area Team the CCG is a low risk. A&E waiting times North Derbyshire CCG failed to meet the national standard for A&E waits times, winter pressures now being seen. Reports are being received on breaches which is feedback to the Area Team. Stockport FT remains to be an issue, A&E still not recovered, Board to Board meeting has been arranged. Sheffield FT - a new path system in place, so unable to report on A&E at the moment performance is down to around 70%. Meetings have now been set up with Stockport and Sheffield CCGs to share information and performance a lot smarter CRHFT - meetings take place with Tony Campbell, Director of Strategy & Performance, CRHFT on a weekly basis.. Cancer 62 day waits North Derbyshire CCG met the 85% North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 3

15 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B target against the standard during November 2015, the first time since July. Whilst the CCG did hit the target, there were nine patients who were treated after day 62 and therefore breached the standard. This is a standard agenda item with Tony Campbell, not looking at putting a recovery action plan in. EMAS - major concern, performance continues to be low, need to ensure recovery action plan is put in place and how this performance managed. Care Programme Approach (CPA) - follows up within 7 days, the national reporting looks like the CCG are failing, however, the CCG are hitting the target of 95%, the Trust have been asked to re-submit the data Cancer 62 day waits First Treatment the national team have asked for a recovery plan from all organisations that are falling, one of these being Sheffield which the CCG have received. Mr Sutherst senses that there is an underlying issue at Sheffield and continues to work closely with Sheffield CCG to get further information. Mr Gibbard expressed his concerns relating to 62 day waits and felt that the CCG should be aiming for better standards. Mr Sutherst assured the Committee that he is trying to address this area of concern and meetings have been arranged with Sheffield Trust in relation to improving performance. Mrs Stringfellow queried information provided within the report on two Inter Patient Transfers by CRHFT which were received late, and enquired if there was an underlying reason for this. Mr Sutherst agreed to provide further information and the Committee with his findings. The Committee noted and received the performance report. Mr Sutherst Quality Report Mrs Stringfellow provided an overview of performance from the Quality Report highlighting salient areas for attention: Maternity Services - the CCG have had a challenge with CRHFT and maternity services on the back of the reports that came out of Morecambe Bay specifically around what lessons have been learnt and what has CRHFT taken on board in terms of learning and providing Maternity Care. The Patient Experience report through CQC is very positive for Maternity care at CRHFT. CQUINS currently negotiating CQUINS, awaiting national CQUINS guidance for 2016/17 whilst the CCG are trying to ensure that local CQUINS are kept to a minimum. Complaints the number of complaints that the CCG have North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 4

16 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B received are related to Continuing Healthcare and in particular related to retrospective claims that are historic periods of care. The Committee noted that a complaint was upheld relating to an IVF patient. The Committee noted and received the Quality report. Project Management Office Report Mrs Winfield enquired about schemes that are currently not showing on the system and queried if schemes are being captured and measured. Mr Green stated that Mr Sutherst has diarised time in with relevant people to sit and agree KPIs and advised where KPIs are in place the issue mainly focuses around information not being updated. Mr Green agreed to pick this issue up at the Executive Team Catch up Meeting taking place on Tuesday 26 th January Mrs Innes to look to identify a date for Mrs Winfield to chair a Senior Leadership Team Meeting in March GBAC Finance Resources 2016/17 Mrs Innes Mr Green provided a verbal update on the CCGs Financial Resources for 2016/17. It was noted that the CCG are still deemed to be overfunded by NHS England who have now introduced a new formula for calculating CCG new allocations. It was noted that North Derbyshire CCG received 1.8% growth which is the lowest possible allocation. Of the 209 CCGs in the country North Derbyshire CCG are judged 200 th on the list in terms of distance from equitable funding. National Events are attended by the CCG and feedback provided. Mr Apsley enquired if the CCG Governing Body should be writing to NHS England querying North Derbyshire being the 200 th out of 209 and shared his concerns that the CCG will be placed under even more financial pressure due to circumstances that the CCG are facing. Mr Smith clarified that he would want to understand the detail behind the calculation and on what basis the CCG have moved from 7.3% to 9.1% over target. Taking in to consideration that the CCG are aware that deprivation in Chesterfield is steadily getting worse. Ms Stone inquired if the figures provided are based on indicators of North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 5

17 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B deprivation. Mr Smith clarified that the key indicator within the formula is the proxy for deprivation; the calculation used focuses around mortality rate over 70+. Detailed discussions took place around the national indicators and areas of growth with certain communities. It was noted that Derbyshire County Council hold a Derbyshire observatory which provides an overview of Derbyshire through a range of social, health, economic, crime and environmental indicators. Mr Green advised the Committee of NHS England Business Rules which the CCG will meet and adhere to. It was noted that the CCG will fund budgets that are overspending this financial year and also any non-recurrent investments that have been made. Plans and schemes have been identified for 7.5m some of which is the hangover from this year s QIPP that did not commence on time, a paper will be presented at February s Governing Body Assurance Meeting demonstrating what schemes have been identified to delivery this target. The Committee noted: that NHS England allocations have been notified; that the CCG have minimal increases as a result of the position that the CCG are in specifically in terms of our distance from target which leaves a target of 11.5m QIPP as currently calculated; that the current positon is viewed as low risk; Mr Green to provide more detail next month for discussion how the CCG will achieve the 11.5m gap. Mr Green GBAC Governing Body Assurance Framework - Principal Risk Two Mrs Pickering presented an update to the Committee on the Governing Body Assurance Framework which provides a structure and process that enables the organisation to focus on the risks that might compromise the CCG in achieving its corporate objectives. The Committee noted the position for Principal Risk two in terms of 21c Transformation impacting on medium and long terms financial targets. Mr Green and Dr Milton have now updated the position to reflect for the CCG in terms of mitigation and addressing gaps in controls. The Committee noted and received the update with regard to the review of the Governing Body Assurance Framework. GBAC Information Governance Highlight Report update January 2016 Mrs Pickering presented the Committee with an update position as at the end of December 2015 beginning of January North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 6

18 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B Version 13 of the IG toolkit was released in May 2015 and subsequently reviewed by the Information Governance Team at Arden & GEM CSU (AGEM CSU). Confidentiality and Data Protection assurance requirements 232 and 235 have new requirement statements. It was noted that the CCG are on target working with Arden & GEM CSU to complete the information governance toolkit. In terms of training for the CCG this stands at 92%. With regard to the upload of toolkit information at the moment is standing at 19% which needs to be 70%. Once the CCG criteria and requirements evidence is uploaded i.e. specific data flow mapping minutes of meetings from January to March 2016 that require final completion it is expected this will then move up to 70%. An audit of the information governance toolkit will take place on the 8 th February 2016 by 360 Assurance and will be looking at specific requirements as indicated within the paper. The CCG will be on target and all information will be finalised and complete. To be submitted to April Audit Committee. The Committee noted that work continues on each of the requirements for the IG toolkit on a daily basis for final submission on 31 st March GBAC East Midlands Ambulance Service (EMAS) Mr Gibbard welcomed Mr Harris and Ms Jones to the meeting and introductions took place. Mr Harris provided a verbal update to the Committee from a local perspective informing of a Derbyshire EMAS Commissioning Meeting of which each of the four CCGs are represented and is chaired by Jackie Jones. EMAS colleagues are invited to this meeting and a pre meeting takes place to focus and discuss the items that need reviewing. Ms Jones provided a Performance and Financial update on East Midlands Ambulance Service. The Committee noted as from April 2015contract Regional meetings were put in place, these meetings sit alongside Partnership Board Meetings where Director leads from each county attend along with Clinicians and the EMAS Executive Team. CCG Congress meetings are also attended and updates are provided to Chief Officers highlighting any key issues. At the beginning of the year EMAS were on plan to increase their workforce in an attempt to reduce the amount of voluntary and North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 7

19 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B private ambulances used which has taken longer to achieve than originally set out. EMAS have reintroduced the role of technician to help offset some of the challenges in recruiting paramedics and keeping paramedics once recruited. Abstraction rates are looked at based on 28% EMAS are running at 35% abstraction rate therefore losing workforce that should be available for frontline duties for a variety of reasons i.e. sickness, training or alternative duties, which has had an impact financially and on resources. An Indicative activity plan was put in place at the beginning of the year based on the last 2/3 years. The areas of greatest growth are around hear and treat this is clinical advice that is given over the phone has increased; financially this has had a massive impact. The costings for a hear and treat are 20 and 200 for a see and treat. The number of calls classified as red has significantly increased which has further stretched an already stretched resource. Percentiles are monitored i.e. how long it takes to get to a Red one and Red two which is above 8 minutes therefore, is classed as a failure. It was noted the biggest factor remains to be around pre-clinical handover delays. EMAS are regularly losing 200hrs plus a day on waiting to handover patients, which equates to over 6,500 hours lost year to date. Further work needs to take place on sickness, resources and workforce and as commissioners work needs to continue with acute trusts to ensure handovers do not get delayed longer than necessary and that those patients are a priority to be handed over as soon as can be. Financial considerations: The Committee noted that EMAS s financial position has deteriorated month on month since the beginning of the year and are solely reliant financially on the Emergency Ambulance Contract. This triggered a Trust Development Authority Governance Review of their finances and EMAS contacted commissioners seeking support. A cash advance based on February invoices was made last June/July 2015 and as a consequence payment in February will not be available. EMAS, therefore, have applied to the DH for a loan which has not yet been approved. A fleet business case had been put forward with the Trust Development Authority (TDA) Finance and investment committee for capital support in order that they can bring forward their fleet replacement. The case was not supported by the TDA. North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 8

20 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B Mr Gibbard thanked Ms Jones for the summary position which provided the Committee with insight in relation to the ongoing concerns, and queried if there is a plan going forward. Ms Jones provided a view with regard to the Executive Team who has only been post a year, which may have some bearing on decisions that have been taken and not understanding the consequences of some of these decisions. The Committee noted and received Ms Jones views and detailed discussions were held. The Committee noted and received the verbal update however, do not feel assured but are better able to understand some of the issues that EMAS are facing and will be following progress with the Action Plan. GBAC Derbyshire Wide Information Sharing Agreement Mrs Pickering presented the Committee with an update on the Derbyshire Wide Information Sharing Protocol. The Committee noted that the purpose of this overarching Protocol is to set out a framework for partner organisations to manage and share information on a lawful and need to know basis with the purpose of enabling them to meet both their statutory obligations and the needs and expectations of the people they serve. This protocol is working collectively with 21C information governance workstream which includes the CCGs and Derbyshire Partner Organisations across Derbyshire. The protocol is built on the current Derbyshire Forum information sharing protocol, looking at how information is shared collectively and on a lawful basis and setting the principles. The protocol has been amended as part of the work stream so that collectively across the CCGs agree a protocol for sharing information within the 21C Programme. This will form the basis of the Derbyshire Partnership Forum information sharing agreement; once this has been approved by each of the Derbyshire CCGs it will then inform the final information sharing protocol which will then be signed up by all partner organisations including the police and fire. The Committee considered and approved the Information Sharing Protocol and consent model. Policies for approval GBAC Out of Hours Re-Procurement North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 9

21 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B Mr Green presented the Committee with an update relating to the Out of Hours Procurement. Derbyshire Health United (DHU) is the provider of NHS111 and primary care of Out of Hours (OOH) service. The Out of Hours contract was paused as per the request from NHS England and this gave the CCGs and providers across Derbyshire time to review what is required for the new contract for OOH taking into account 21C. The Committee was asked to agree that the Out of Hours contract with DHU is extended until June 2017 in order to mitigate the risks of an earlier reprocurement.. Mrs Smith stated this also fits with conversations had around 21c Clinical Hub pre consultation business case where some concerns were expressed regarding access to urgent care and advised the Committee that modifications have now been made which will allow more time for discussions within communities. The Committee agreed that the OOH contract currently with DHU be extended on the same terms until June GBAC North Derbyshire and Hardwick Clinical Guidelines Group Mrs Baughen introduced a proposal on the North Derbyshire and Hardwick Clinical Guidelines Group. In December 2014 Richard Bull (GP) presented a paper to GBAC requesting the establishment of a Clinical Guideline Group (a sister to Joint Area Prescribing Committee (JAPC) on a county-wide basis. This proposal was supported in principle by all four CCGs with the aim of commencing on 1 st April Approval is sought from the Committee for an establishment of a North Derbyshire and Hardwick Clinical Guidelines Group to take over from the work that the map of medicines group set in place in June Going forward, a robust process will need to be put in place, developing new guidelines and pathways. The Group is an operational group attended by one GP from each CCG, commissioning manager and quality lead. Other individuals are invited in to this group as required. The Draft Terms of Reference and flowchart for guidelines group were presented to the Committee for approval. Dr Milton enquired why a Pan-Derbyshire was not approved and stated that he is happy to support this proposal in the short-term however there is a caveat that somebody needs to take North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 10

22 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B responsibility to join with Southern Derbyshire. The Committee considered and approved: - the establishment of a North Derbyshire and Hardwick Clinical Guidelines Group in line with the draft terms of reference. - the proposed process for pathway approval. GBAC Adult Safeguarding Policy Mrs Stringfellow provided an update to the Committee on the revised Adult Safeguarding Policy. It was noted that a 360 audit review of Adult Safeguarding has taken place and will be presented to Audit Committee later this week. The new policy is Care Act 2014 Chapter 14 Safeguarding compliant and includes: The Making Safeguarding Personal agenda; The new categories of abuse; The six principles of Adult Safeguarding; Links to the Derby and Derbyshire adult safeguarding policy and new referral form; Information about PREVENT the Government Counter Terrorism Strategy. The Committee noted and approved the use of the policy and its availability on both the public and staff websites for those who wish to refer to or use the policy. GBAC CCG Equality Delivery System 2 (EDS2) Compliance Report 2015 Mr Wholley in attendance for this agenda item: Mrs Pickering introduced Mr Wholley and provided a brief overview on the CCG Equality Delivery System. Apologies were offered to the Committee for the lateness of circulating the compliance report. It was noted that the CCG are required to submit EDS2 compliance report which is to be publicised on the CCG website by 31 st January Mr Wholley provided a brief summary to the Committee, it was noted that the framework has been updated for reporting this year. The evidence portfolio provides detail around activity the CCG has been undertaking this year. There are some areas that have gone North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 11

23 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B really well, as well as to show levels of improvement when necessary. The narrative has back up documents when it is to be published on the website to give formal recognition. The Committee noted that one area of strength for the CCG focuses around communication and engagement with the communities that North Derbyshire is serving; there is a strong level of reaching certain groups that link to vulnerabilities which has been positive for North Derbyshire. When the report is approved and published it will highlight that the CCG is meeting the public sector equality duty and also in some areas is exceeding the expectations. Ms Stone has provided feedback to Mr Wholley and Mrs Pickering and felt overall this is a good piece of work where progress is being made. However, it was felt that there remains insufficient information around protected groups and how they are accessing specific services. Ms Stone to continue working with Mrs Pickering and Mr Woolley in assisting to help improve this area of work. The Committee noted and approved the paper to enable North Derbyshire CCG to publish the information to demonstrate compliance by the end of January GBAC Procurement Strategy Mr Gibbard informed the Committee that he has now met with Emily Armstrong, Arden & GEM CSU Procurement who was charged with developing the procurement strategy. When it was first published it was felt to be slightly high level in the sense it talked about vision and value. No information was available about contracts held and when they were due to terminate. It had been felt that it would be helpful if the document listed where the CCGs milestones were in terms of major contracts, which Ms Armstrong has now introduced. For future iterations of the strategy, Mr Gibbard suggested an approach to commissioning specific areas where we feel we could do better and where procuring a new service could help or not. The opportunity is less about the current document and much more about a process for the future. The Committee noted and endorsed the Procurement Strategy. GBAC Business Continuity Plan Mrs Pickering presented the Committee with an update on the Business Continuity Plan. It was noted that the Business Continuity Policy has been revised North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 12

24 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B and updated following a thorough review undertaken this year, looking at business impact assessments and risk assessments across all individual CCG departments. The Business Continuity plan will be presented to February 2016 GBAC meeting for approval. Mrs Pickering advised the Committee of a table top exercise that is scheduled to take place on Friday 5 th February 2016 with the CCG Senior leadership team and the Executives were information will be collated and pulled together in terms of Business Continuity for the CCG. The Committee considered and approved the revised Business Continuity Policy GBAC Clinical Engagement Dr Milton confirmed details of the clinical engagement meeting structure. From former conversations it was noted and agreed that CRG would disband with a view to getting greater clinical involvement in 21C Clinical and Professional Reference Group and in the Primary Care Development Group to be achieved on the basis on the communities recognised by the 21C workstreams rather than in localities. Support was sought from the Committee for the recommended changes in structure,the potential additional costs, and in particular in the proposed response to the loss of a Governing Body GP. The Committee noted and supported the proposals and requested the paper be presented to Governing Body on Thursday 28 th January 2016 for approval. Update from Sub Committees GBAC Minutes of the 21 Century Plan Delivery Group meeting of 14 th December 2015 The Committee noted and received the minutes of the 21 Century Plan Delivery Group meeting held on 14 th December GBAC Minutes of System Resilience Group meeting of 4 th December 2015 The Committee noted and received the minutes of the SRG group meeting held on 4 th December North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 13

25 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B GBAC Minutes of Prescribing Sub Group minutes of 2 nd December 2015 The Committee noted and received the minutes of the Prescribing group meeting held on 2 nd December GBAC Minutes of Joint Area Prescribing Committee minutes of 8 th December 2015 The Committee noted and received the minutes of the Joint Area Prescribing Committee meeting held on 8 th December GBAC Minutes of CRHFT QAG minutes of 26 th October 2015 The Committee noted and received the minutes of the CRHFT QAG meeting held on 26 th October GBAC Any other business Safer Staffing NHS111 Mrs Stringfellow provided an update to the Committee on the safer staffing of NHS111 Service. It was noted that the report was submitted on time, North Derbyshire was asked to lead and review all of the allegations made against DHU in the Daily Mail, both in the press and on-line. There were some 84 different allegations which were investigated within a number of themes. Mrs Stringfellow led the investigation on behalf of Mr Smith. DHU have also conducted a review and have completed a serious incident report. The main findings are available within the report along with recommendations that have been made. An Action Plan to address the recommendations has been developed and will be shared and progressed via the NHS111 Collaborative Commissioners meeting. The action plan will be monitored by NHS England via North Derbyshire CCG assurance meetings. Mr Smith thanked Mrs Stringfellow for the tremendous dedication and time undertaken on this piece of work which the Committee endorsed. The committee noted and received the report s findings and recommendations. GBAC Date and Time of Next Meeting: Monday 22 nd February pm in the Robert Robinson Room, Scarsdale, Chesterfield, S41 7PF. North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 14

26 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper B Signed by:. (Chairman) Dated: North Derbyshire CCG Public Governing Body Assurance Committee Meeting Minutes 25/01/16 15

27 ACTION LOG Paper C Action Log Public - current Closed issues are hidden Action Log Item Action Responsibility Target Date Completed Status 97 GBAC Further Education and Development Policy to be redrafted and brought back to a future meeting. 113 GBAC Integrated Finance Report - Mr Sutherst to provide further information on IPTS that wer received late. SP/MS Ongoing - Mrs Pickering advised this is with the TU representatives and is being amended to be presented to GBAC in February. AS

28 NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE MEETING 22 nd February 2016 Report Title: Integrated Finance, Performance and Quality Improvement Report Item No: 5 1. Background and context The purpose of this Integrated Quality, Finance and Performance Improvement Report is to provide Governing Body Assurance Committee members with strategic assurance and overview of the CCG s performance across a range of metrics. It is designed to facilitate the CCG assurance process and enable triangulation of quality, finance and operational performance across the CCG. 2. Key matters for consideration This report covers the period of December 2015 unless more current information is available at the time of writing the report and includes the following items: Executive Summary Finance Report 2015/16 CCG Assurance Framework Dashboard Exception Reports Local performance Indicators Project Management Office Report Quality Report Quality Premium 3 Financial Impact There is no direct financial impact on the CCG with regards this report, however it should be noted that should the CCG not achieve a number of the key performance indicators contained within the CCG Assurance Framework there will be a reduction in the Quality Premium available to the CCG in 2015/16. 1

29 4. Analysis of risk If the CCG fails to deliver against national and local standards it will have failed to deliver quality and outcomes for patients, which constitutes clinical risk. In addition, as described in section 3, if the CCG fails to achieve a number of the key performance indicators contained within the CCG Assurance Framework there will be a risk that the CCG will not attract the Quality Premium payment available to the CCG in 2015/16. This paper mitigates against these risks by ensuring that Governing Body Assurance Committee retain oversight of the CCG s performance against key national and local standards and are able to take remedial action as required and hold the organisation to account. 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all and improved patient access and experience: This report provides Governing Body Assurance Committee with an effective performance management mechanism that will ensure the CCG delivers national and local standards by commissioning safe, quality care for patients that improves outcomes, secures access and ensure an excellent patient experience. Empowered, engaged and well-supported staff/inclusive leadership at all levels: This report ensures that through effective performance management the CCG s staff will be empowered, engaged and supported to deliver. It will also ensure that the CCG commissions services from providers that demonstrate the values and behaviors encouraged within the CCG. 6. Recommendations Governing Body Assurance Committee is asked to: Note the January 16 CCG Financial Position (page 9). Note the CCG s position against the CCG Assurance Framework and identify any areas of concern that require information or analysis that the Governing Body feels necessary in the next report (page 28). Note the CCG QIPP red forecast as reported in the assurance framework (page 32). Note the CPA follow up actions; NDCCG have raised the discrepancies as a data quality issue with NHS Hardwick CCG (as lead commissioner for mental health), with the view for Derbyshire 2

30 Healthcare NHS Foundation Trust to re-submit their data. Providers can formally request a revision to the data and requests are visited every six months. If granted, Unify will be in contact with the provider to arrange for the new data to be uploaded. Review the Project Management Office report (page 45). Author: Carl Twibey, Senior Financial Accountant Laura Joy, Head of Clinical Quality Martin Colclough, Interim Assistant Chief Finance Officer Adam Sutherst, Head of Planning and Performance Amy Miles, Performance Manager / Senior Information Analyst Rebecca Manning, Performance Analyst Sponsor: Darran Green, Interim Chief Finance Officer Jayne Stringfellow, Chief Nurse and Quality Officer Date: 15 th February

31 Integrated Finance, Performance and Quality Improvement Report Governing Body Assurance Committee Date of Meeting: Monday 22 nd February

32 Integrated Finance, Performance and Quality Improvement Report Contents Table Executive Summary Finance Report ( to ) /16 CCG Assurance Framework Dashboard Exception Reports Local Performance Indicators Project Management Office Quality Report Quality Premium

33 Executive Summary Purpose The purpose of this summary report is to provide Governing Body Assurance Committee members with strategic assurance and overview of the Clinical Commissioning Group s performance across a range of metrics. The items highlighted within this summary covers the period of December 2015 unless more current information is available at the time of writing the report. Key Highlights North Derbyshire CCG saw an improvement in performance for diagnostic test waiting times during December 15 (page 28). North Derbyshire CCG performance against the national standards for two week cancer waits and 31 day cancer waits during December 15 remains above the standard, and performance against the 62 days standard for GP referrals has improved further during December 15 (page 29). North Derbyshire CCG remains on track to meet both national standards for IAPT; improving access to psychological therapies, and the percentage of patients moving towards recovery (page 30). North Derbyshire CCG reported no cases of MRSA December 15 (page 30). Key Risk Areas Whilst North Derbyshire CCG are currently hitting the target for waiting times from referral to treatment on incomplete pathways; should the problems in Ophthalmology continue, there is a risk bottom line performance will also dip below the target (page 28). Furthermore North Derbyshire CCG reported one patient waiting longer than 52 weeks from referral to treatment in Ophthalmology during December 15 (page 33). Accident & Emergency four hour waiting times for North Derbyshire CCG did not meet the 95% target during December 15 (91.9%), Chesterfield Royal Hospital NHS Foundation Trust and Stockport NHS Foundation Trust also failed on this target (92.6% and 73.7% respectively), (page 34). EMAS continue to fail against the three national ambulance response standards; Red 1, Red 2, and A19 (page 35). North Derbyshire CCG performance against the 62 day cancer screening referrals standard during December 15 failed at 76.9% (page 35). 6

34 North Derbyshire CCG performance for Care Programme Approach (CPA) follow ups within 7 days did not meet the target during Quarter Two or YTD, there has been 12 breaches YTD (page 30). Further review indicates there are some data discrepancies. North Derbyshire CCG performance against the dementia diagnosis rate during December 15 did not meet the target (64.5%). Further review indicates there were data collection errors which led to underperformance (page 37). The number of C-Diff cases reported by North Derbyshire CCG was above the monthly trajectory for December 15 (12 against a target of 9), and puts the CCG above the YTD trajectory (85 against a target of 81), (page 38). EMAS Handovers at both Chesterfield Royal Hospital NHS Foundation Trust and Stockport NHS Foundation Trust remain a problem (page 40). DHU 111 performance against the percentage of calls answered within 60 seconds measure failed at 93.4% during December 15 (page 41). Outcome of Assurance Meetings The 14/15 Quarter 4 assurance meeting took place on the 22nd June and the CCG remained fully assured. The assurance meeting due to take place on 4th February 2016 was cancelled due to planning round, however the area team still met with the Interim Chief Officer on the 12 th February As part of the new CCG assurance process, the CCG will receive an assurance rating at the end of the financial year. Recommendations Note the January 16 CCG Financial Position (page 9). Note the CCG s position against the CCG Assurance Framework and identify any areas of concern that require information or analysis that the Governing Body feels necessary in the next report (page 28). Note the CCG QIPP red forecast as reported in the assurance framework (page 32). Note the CPA follow up actions; NDCCG have raised the discrepancies as a data quality issue with NHS Hardwick CCG (as lead commissioner for mental health), with the view for Derbyshire Healthcare NHS Foundation Trust to re-submit their data. Providers can formally request a revision to the data and requests are visited every six months. If granted, Unify will be in contact with the provider to arrange for the new data to be uploaded. Review the Project Management Office report (page 45). 7

35 Finance Report Financial position for the period to

36 1.1 Finance Report ( to ) The purpose of this report is to inform the CCG Governing Body Assurance Committee of the financial performance and position of the CCG. 1.2 Summary Finance Headlines Table 2.1 North Derbyshire CCG Finance Performance as at 31 January 2016 Performance Measure/Duty Target YTD Actual YTD Achievement % RAG Rating Target for Year Forecast Achievement Forecast Achievement % RAG Rating Report Section Control Total ( '000) 4,162 4, G 4,994 4, G 4.3 Running Costs ( '000) 5,218 4, G 6,342 5, G 4.2 & 13 QIPP ( '000) 8,220 6, R 10,570 7, R 12 Expenditure Run Rate ( '000) 359, , G 431, , G 4.3 Cash Drawdown ( '000) 358, , G 429, , G 8 Closing Cash Balance (% of drawdown) A G 8 BPPC NHS Value (%) G G 10 BPPC NHS Volume (%) G G 10 BPPC Non NHS Value (%) G G 10 BPPC Non NHS Volume (%) G G 10 Table 2.1 above shows the financial performance highlights for the year to date as well as the forecast year end position. 1.3 CCG Financial Position The CCG receives regular updated confirmation of its Programme (commissioning of healthcare) resources and Admin resource which currently stand at 430,185,000 and 6,342,000 respectively. There have been three Programme resource movements in month. Tables 3.1 shows the allocation summaries split between Programme and Admin and the total resources available to the CCG. 9

37 Table 3.1 Resource Limit 000 Programme Resource Limit 1 st January ,398 Charge Exempt Overseas Visitors (CEOV) and non-rechargeable services (423) NUH Pacemakers 10 Inter CCG resource transfer 1 year rebasing 200 Total Programme Resource Limit 31 st January ,185 Admin Resource Limit 1 st January ,342 No change in month - Total Admin Resource Limit 31 st January ,342 Total CCG Resource Limit January , Summary Financial Position The CCG financial position has been analysed in accordance with the requirements of the ISFE (Integrated Single Financial Environment). This is a national financial system used by all CCGs and NHS England. It allows NHS England and the DoH to extract data direct from CCG ledgers as they are all on the same platform. Table 4.1 highlights the CCG Programme financial position at a summary level. 10

38 Table 4.1 Summary Financial Position North Derbyshire CCG (Programme Resources) Annual Budget YTD Budget YTD Actual YTD Variance Year End Forecast Variance Year End Var as % of Ann Bud Change in Year Forecast Variance Report Section '000 '000 '000 '000 '000 % '000 Acute Services Chesterfield Royal Hospital FT 123, , , Stockport FT 21,250 17,708 18,308 (600) (749) Sheffield Teaching Hospitals FT 19,261 16,051 15, EMAS 7,674 6,395 6, (29) East Cheshire NHS Trust 5,386 4,488 4, (57) Royal Derby Hospital FT 2,714 2,262 2, Central Manchester University Hospitals 1,808 1,507 1, Sheffield Children's Hospital FT 1,482 1,235 1, (85) 5.4 University Hospital of South Manchester 1,617 1,347 1,603 (256) (307) (157) 5.5 Other Acute Providers - NHS 6,154 5,125 5,445 (320) (436) 7.08 (11) Other Acute Providers - Non NHS 7,075 5,886 7,271 (1,385) (1,628) (26) 197, , ,827 (1,815) (2,817) 1.43 (265) Mental Health Services Derbyshire Healthcare FT 22,210 18,508 18,620 (112) (11) DCHS FT 14,115 11,763 11, Other Mental Health Providers 7,117 6,062 5, (325) 43,442 36,333 35, (185) 5.7 Community Services DCHS FT 38,543 32,111 32,416 (305) (151) Hospices 2,660 2,631 2,660 (29) (30) 1.13 (21) Oxygen Contract (49) Other Community Providers 2,564 1,891 2,038 (147) (252) 9.83 (80) Better Care Fund 11,599 9,666 9, ,815 46,673 47,203 (530) (433) Primary Care Local Enhanced Services 3,579 3,044 3,103 (59) (83) Basket of Services 3,745 3,121 3,125 (4) (13) 0.35 (3) Practice Prescribing 43,056 35,880 37,856 (1,976) (2,236) 5.19 (227) 5.8 Central Prescribing 1,775 1,479 1, Out of Hours 4,625 3,854 3,858 (4) Primary Care Other (43) (60) Co-Commissioning 37,225 30,668 30,712 (44) (101) Quality Premium ,424 78,693 80,823 (2,130) (2,353) 2 (97) Continuing Health Care Continuing Health Care 20,209 17,017 18,131 (1,114) (1,320) 6.53 (12) 5.10 Continuing Health Care Children 1,507 1,256 1, Funded Nursing Care 3,239 2,672 2, ,955 20,945 21,821 (876) (1,035) Operational Costs (Non-Running Costs) Transformation & Commissioning Nursing & Quality Property Services 0 0 (164) Management Team (433) (482) (61) 1,419 1,192 1,338 (146) (208) In-Year Contingencies and Reserves In-Year Contingency & Allocations 2,538 1, ,957 2, In-Year Risk Contingency 3,960 2, ,688 3, Control Total 4,994 4, ,162 4, ,492 8, ,807 10, Total Programme Resources 430, , ,946 3,709 4, (275) 11

39 Table 4.2 highlights the CCG Admin financial position at a summary level. Table 4.2 Summary Financial Position North Derbyshire CCG (Admin Resources) Annual Budget YTD Budget YTD Actual YTD Variance Year End Forecast Variance '000 '000 '000 '000 '000 Operational Costs (Running Costs) Board And Management Team 1,496 1,248 1, Transformation & Commissioning 1,620 1,282 1, Finance 1,570 1,309 1, IM&T (1) 0 Nursing & Quality GEM 1, NHS Property Services Total Admin Resources 6,342 5,219 4, Table 4.3 highlights the CCG Overall financial position at a summary level. Table 4.3 Summary Financial Position North Derbyshire CCG (Total Resources) Annual Budget YTD Budget YTD Actual YTD Variance Year End Forecast Variance '000 '000 '000 '000 '000 Total Programme Resources 430, , ,946 3,709 4,542 Total Admin Resources 6,342 5,219 4, Total CCG Resources 436, , ,712 4,162 4, Key Issues The CCG has a statutory obligation to not exceed its resource limit. The CCG has a planned underspend for of 4,994,000. The month 10 underspend stands at 4,162,000 and remains in line with the CCG s plan at this stage of the year. The information contained in table 4.1 is based on 9 month s healthcare activity information and 8 month s prescribing information. For the three largest acute contracts, activity and finance data tables have been included to show the performance by point of delivery (POD). 1.5.i Chesterfield Royal Hospital FT The Chesterfield Royal contract currently shows an underspend of 498,000. The forecast 12

40 outturn remains breakeven. This forecast is a prudent assessment using the profile of activity from previous years which show overperformance in the last part of the year. Discussions are still ongoing with the Trust regarding the QIPP plans. The outpatient project is currently focusing on dermatology before being rolled out across other specialties. It is expected that the initial planning and impact assessment stage will come to a close at the end of March and by this stage the CCG will have a better understanding of the likely impact and possible reduction in activity. Negotiations are also still ongoing with the Trust and DCHS with regards to the IV service and how savings will be released across organisations. Table Chesterfield Royal Activity and Costs To Date by Point of Delivery POD Activity Plan Cost Plan '000 Activity Actual Cost Actual '000 Activity to Date Variance Cost to Date Variance '000 Activity Variance % Cost Variance % A&E 36,392 4,137 36,993 4,203 (601) (66) (1.65%) (1.59%) Elective 15,086 15,101 15,424 14,985 (338) 116 (2.24%) 0.77% Non Elective 20,088 31,953 19,188 31, % 0.81% Outpatients First 31,626 4,886 27,824 4,250 3, % 13.03% Outpatients Follow Up 67,819 6,332 63,352 6,082 4, % 3.95% Outpatient Procedures 13,486 2,531 15,758 2,673 (2,272) (142) (16.85%) (5.61%) Non Tariff 620,442 24, ,663 25,090 (52,221) (517) (8.42%) (2.10%) Total 804,939 89, ,202 88,976 (46,264) 538 (5.75%) 0.60% 1.5.ii Stockport FT The Stockport FT contract forecast overspend remains at 749,000. Although the month 9 monitoring data shows a slight monthly improvement the activity levels are still in line with what has been previously forecast. As reported previously the overspend is predominantly due to an element of the contract which changed from block to cost per case. 13

41 Table Stockport Hospital Activity and Costs To Date by Point of Delivery POD Activity Plan Cost Plan '000 Activity Actual Cost Actual '000 Activity to Date Variance Cost to Date Variance '000 Activity Variance % Cost Variance % A&E 5, , (19) (18) (0.34%) (2.35%) Elective 3,274 3,631 3,235 3, % 4.59% Non Elective 3,454 5,820 3,352 5, (80) 2.96% (1.37%) Outpatients First 6,451 1,001 6,678 1,047 (227) (47) (3.51%) (4.65%) Outpatients Follow Up 14,061 1,044 14,868 1,079 (807) (35) (5.74%) (3.36%) Outpatient Procedures 1, , (230) (35) (12.29%) (9.12%) Non Tariff 177,192 3, ,252 3,839 (5,060) (427) (2.86%) (12.51%) Total 211,975 16, ,178 16,511 (6,203) (474) (2.93%) (2.95%) 1.5.iii Sheffield Teaching Hospitals FT At Sheffield Teaching Hospitals FT the month 9 monitoring data shows the CCG is currently underspending by 157,000. However, adjustments are continuing to be made as the implementation of Lorezno (the new patient administration system) is causing an issue with coding. The quarter 3 data will be frozen on 4 th March so any uncoded activity up to that period will not be charged. The forecast position has been updated to recognise an underspend of 100,000. With year end approaching the CCG considers it prudent to recognise an element of underspend now as it believes the contract is underperforming but cannot quantify the value of the underspend precisely due to the coding issues referred to above. Table Sheffield Teaching Hospital Activity and Costs To Date by Point of Delivery POD Activity Plan Cost Plan '000 Activity Actual Cost Actual '000 Activity to Date Variance Cost to Date Variance '000 Activity Variance % Cost Variance % A&E 2, , % 1.97% Elective 5,937 4,802 5,605 4, % 3.58% Non Elective 1,482 3,174 1,540 3,010 (57) 164 (3.87%) 5.18% Outpatients First 5, , (25) (11) (0.45%) (1.41%) Outpatients Follow Up 16,484 1,387 15,429 1,315 1, % 5.22% Outpatient Procedures 3, , (43) (6) (1.07%) (0.89%) Non Tariff 1,750 1,312 1,567 1, (124) 10.44% (9.43%) Cost and Volume Total 38,219 12,353 36,620 12,079 1, % 2.22% Cost Per Case 1,916 1,969 (53) Total 38,219 14,268 36,620 14,048 1, % 1.55% 14

42 1.5.iv Sheffield Children s Hospital The Sheffield Children s Hospital contract is now forecasting to underspend by 82,000 which is 85,000 worse than last month s forecast. The contract has not continued to underspend at the same rate as seen previously and applying the trend for the final quarter from previous years brings the forecast underspend down to 82, v University Hospital of South Manchester To date the contract with the University Hospital of South Manchester is overspent by 250,000. The majority of this overspend relates to emergency care. As the contract has continued to overspend for consecutive months the full year forecast has deteriorated by 157,000 to 307,000 overspent. 1.5.vi Derbyshire Community Health Services FT At Derbyshire Community Health Services FT the overall contract, shown under Community Services and Mental Health headings in table 4.1, has improved by 202,000. The CCG and Trust have agreed a non-recurrent reduction in bed days which reduces full year costs by 250,000 and could improve further in future months. The CCG has also reclassified further income from Community Services to Mental Health. There is an equal and opposite movement of 151,000 between the forecast positions on these lines vii Mental Health The overall mental health position has worsened in month by 185,000 to show a year end forecast underspend of 431,000. The main reasons behind this movement are the removal of the risk share which previously benefited the CCG by 214,000 and an increase in high cost patients during the month which are forecast to cost the CCG 130,000 between now and the end of the financial year. These increases are partially offset by the 151,000 income moved from the Community to Mental Health lines for DCHS (as detailed in 5.6 above). 15

43 1.5. viii Practice Prescribing The position at month 10 includes PPD prescribing data for April to November 2015, with estimates for December and January. Compared to the same period in 2014 the actual PPD costs have increased by 2,147,000. Expenditure on anticoagulants is up 110% due to increased prescribing of oral anticoagulants (NOACs) which equates to 522,000 of the increase. Other significant increases include diabetes drugs ( 269,000), analgesics ( 176,000), antidepressants ( 189,000) and thyroid/antithyroid drugs ( 115,000). Rebates have been received for the first 2 quarters and are expected to rise in line with NOAC spend ( 130,000 surplus to month 10). The year to date overspend is 1,976,000 and the full year forecast overspend is 2,236,000, which is 227,000 worse than reported last month. The main reason for the adverse movement is November s PPD costs, which were higher than anticipated when using the trend of previous years. There are also costs for the OptimiseRX software included in the forecast this month. OptimiseRX is a prescribing support tool that is integrated with practice s systems. This has been rolled out across practices in North Derbyshire although it s not compatible with some practices current software and some practices are choosing not to use it. 1.5.ix Central Prescribing Central Prescribing is showing a breakeven position year to date. The forecast outturn is an underspend of 140,000. At month 10 notification has been received that income is due from DCHS in respect of the prescribing costs incurred relating to the new sexual health services commissioning arrangements. This income has resulted in the underspend referred to above. The central prescribing charges from the PPD are continuing to increase and a communication has been sent out to non-medical prescribers highlighting the increasing levels of unidentified prescribing. The CCG is also investigating the reasons behind large increases in DCHS FP10 prescribing. This appears to be caused by increasing volumes of dressings being prescribed. However, there are other anomalies in the latest data and a disproportionate charge appears to be levied against North Derbyshire CCG. 16

44 1.5.x Continuing Healthcare The Adult full year forecast overspend has increased by 12,000 in month to 1,320,000. The CCG has seen a slight reduction in caseload during January, but has seen an increase in Retrospective and Personal Health Budget payments. The Arden and GEM CHC team have now received the quarter 3 recharge from Derbyshire County Council so will be working closely with the CCG finance team to check the data and costs to ensure that all parties agree that the caseload is accurate. 1.5.xi Funded Nursing Care Funded Nursing Care is showing an improved forecast position of 283,000 underspent. The 12,000 shift relates to a drop in caseload during January. 1.5.xii Co-Commissioning The co-commissioning position is showing a year to date overspend of 43,000 with an unchanged forecast overspend of 101,000 for the full year. The overspend relates to additional costs associated with the emergency caretaker APMS contract. Table 5.12 below shows the APMS split between baseline, caretaker costs and additional costs. The CCG had set aside 1,000,000 at the start of the year to cover any APMS additional costs. Table 5.12 Primary Care Co-Commissioning Detail Annual Budget YTD Budget YTD Actual YTD Variance Year End Forecast Variance '000 '000 '000 '000 '000 Premises Cost Reimbursement 5,153 3,865 3, Other Premises Costs (1) 0 Dispensing/Prescribing Doctors 1,405 1,054 1,090 (36) 0 Enhanced Services 2,095 1,571 1,577 (6) 0 General Practice - GMS 5,753 4,364 4,370 (6) 0 General Practice - PMS 15,142 11,330 11, Other GP Services (99) 0 QOF 4,136 3,102 3, Co-Commissioning Reserves General Practice - APMS baseline 1,732 1,163 1, APMS Caretaker Cost APMS Additional Cost APMS Other Delivery (101) (101) Total Primary Care Co Commissioning 37,225 27,642 27,695 (53) (101) 17

45 1.6 Risk pool The CCG is committed to mitigating financial risk as part of its financial planning strategy in order to achieve its statutory duty to breakeven. As part of this the CCG has looked to mitigate financial risk by making use of a Risk Sharing Policy across the Derbyshire CCG s. However, despite regular discussions an agreement has not yet been reached therefore no risk pool has been enacted. The CCG previously anticipated the risk pool would be applied to the mental health position but this has been removed as agreement now appears unlikely. The result of excluding the risk pool to the mental health position is a forecast increase in costs of 214, Contingencies and Reserves The CCG has a target underspend of 4,994,000 which has been agreed with NHS England. The CCG holds this as a separate reserve. The CCG also holds an in year risk contingency totalling 3,960,000 to mitigate financial risk within the financial plan and in year risk of adverse variances against budget. At month 10 3,289,000 (83.1%) of this has been be used to mitigate forecast overspends. Table 7.1 sets out the contingencies held by the CCG: Table 7.1 Contingencies and Reserves Held Uncommitted Planned underspend 4,994 4,994 In-Year Risk Contingency 3, ,954 5,665 Total as a % of Resource Limit 2.05% 1.30% Other Reserves 2,538 0 Total 2, CCG Cash Management In addition to the CCG having a resource limit it also has to operate within a maximum cash drawdown envelope. The maximum cash drawdown is the CCG s share of NHS England s cash limit. The CCG can drawdown up to this total into the CCG GBS (Government Banking System) account to pay its commitments, for example commissioned healthcare and staff costs. The estimated maximum cash drawdown amount currently stands at 429,866,

46 During the period April to January the CCG has drawn (including topsliced cash for prescribing and co-commissioning) 354,565,000 of its available cash limit which equates to 82.48% of the current available cash and remains in line with the CCG s cash plan. The CCG held a cash balance in its bank of 1.27% of the monthly drawdown as at 31 st January This was slightly over the NHS England s cash target of 1.25% due to a receipt received directly into the CCGs bank late on the last working day of January. 1.9 Statement of Financial Position As a statutory body the CCG has to adhere to International Financial Reporting Standards (IFRS) and best practice indicates that certain financial statements need to be reported to the Governing Body on a regular basis. Table 9.1 details the CCG Statement of Financial Position. Table 9.1 North Derbyshire CCG - Statement of Financial Position Non Current Assets Closing Balance 31st January 2016 Closing Balance 31st December 2015 Movement in Period `000 `000 `000 Plant, Property and Equipment Intangible Assets Total Non Current Assets Current Assets Inventories Receivables 7,154 3,301 3,853 Cash at Bank / OPG 3 6 (3) Total Current Assets 7,157 3,307 3,850 Current Liabilities (Due within 1 year) Payables (33,067) (26,874) (6,193) Provisions for Liabilities and Charges Borrowings Total Current Liabilities (33,067) (26,874) (6,193) Net Current Assets / (Liabilities) (25,910) (23,567) (2,343) Non Current Liabilities Payables Provisions for Liabilities and Charges Total Non Current Liabilities Total Assets / (Liabilities) (25,910) (23,567) (2,343) Tax Payers Equity General Fund (25,910) (23,567) (2,343) Revaluation Reserve Total Tax Payers Equity (25,910) (23,567) (2,343) 19

47 1.10 Better Payments Practice Code The CCG has a responsibility to meet the Better Payments Practice Code (BPPC). This focuses on the speed at which the CCG pays its invoices to the private sector and to other NHS organisations. The target is to pay 95% of invoices, in terms of value and volume, within 30 days. The CCG continues to meet all four cumulative targets and expects all four targets to be achieved for the full year Aged Debt Most of the outstanding Non NHS invoices relate to the regular charges made to Derbyshire County Council and are actively being chased. Table 10.1 shows the level of debt owed to the CCG and the length of time this debt has been outstanding. Table 11.1: Aged Debtors performance Non NHS NHS Not Yet Overdue Overdue 1-30 Days Overdue 31 Days + Not Yet Overdue Overdue 1-30 Days Overdue 31 Days + Volume Value 16,891 76, , ,253 1,605 22, QIPP The CCG set a QIPP challenge of 10,570,000 for although only 5,500,000 of this is needed to achieve a balanced financial position. At month 7 the QIPP forecast was revised to 7,517,000 due to a number of planned schemes that will not achieve savings as early as planned, but which will contribute to the QIPP challenge. The month 10 position shows that the CCG is on track to deliver the revised QIPP target. 20

48 Table 12.1: QIPP Plan Programme Original Planned Delivery '000 Updated Planned Delivery '000 Difference to Original Plan '000 Year to Date Original Planned Delivery '000 Actual Year to Date Delivery '000 Year to Date Variance Agaisnt Original Plan '000 Balance Forecast to be Delivered in Year '000 Acute 7,094 4,112 (2,982) 4,340 3,477 (863) 635 Continuing Care (630) (630) 0 Mental Health (217) (164) 54 Other Programme Services (30) Primary Care Co-Commissioning (34) 14 Primary Care Services 1,875 2, ,570 1, Running Costs Unidentified Schemes 30 0 (30) 1,060 0 (1,060) 0 Total 10,570 7,514 (3,056) 8,220 6,089 (2,131) 1, Running Costs The CCG has a Running Cost allocation in of 6,342,000 which is a 10% reduction from the previous year. The latest forecast expects this year s running cost spend to be broadly in line with the plan. Table 13.1 identifies the forecast CCG running costs and Table 12.2 shows the running cost and head count per directorate. Table 13.1: Running Costs CCG Population Running Costs / Head 000 Available Funds 292,426 6, Table 13.2: Running Costs by Directorate Annual Annual Actual FOT Plan Plan YTD / Head / Head WTE WTE Board and Management Team Transformation & Commissioning Finance Nursing & Quality NHS Property Services GEM Running Costs CCGs have been advised by NHS England that overall there will be no reduction in running cost ceilings in , slight variations may occur as a result of population share changes. 21

49 However, CCGs will be expected to absorb the additional cost pressures associated with salary uplifts and the 3% increase in National Insurance contributions within their existing allocation. A number of saving areas have already been identified including Property charges, classifying costs relating to service transformation as Programme spend and further reductions in travel and hospitality costs Underlying Position The underlying position is a measure to calculate the CCG s anticipated overall non recurrent spend from recurrent resources. It is reported monthly to NHS England and is expected to be at least 1% of the CCG s resource limit. The CCG s underlying position remains at 1.34% as shown below in table 14.1 Table 14.1: Current Underlying Position Recurrent funding used non recurrently '000 1% Transformational change 3,773 Contingency in excess of 0.5% 1,974 Total 5,747 Recurrent Resource Limit 427,947 Percentage used non Recurrently 1.34% 1.15 Financial Plan The CCG reported last month that it had received a lower than average growth in funding for its core programme services in of only 1.8% (3.7% growth nationally). Looking at the allocations for the CCG s allocation per head of population is still significantly higher than average which is the reason that its growth in funding for the next five years is low. Table 15.1 shows the allocation per head in , compared to target funding based on the NHS England allocation formula. 22

50 Table 15.1: allocation per head of population CCG/Area Baseline Allocation for (per head of Target Allocation for (per head of Distance from Target population) population) North Derbyshire CCG 1,336 1, Derbyshire Average 1,272 1, North Midlands 1,230 1,237 (7) Midlands and East Region 1,187 1,204 (17) England 1,221 1,221 0 Table 15.2 shows the planned QIPP requirement for which has increased to slightly over 12m. This is a result of aligning estimated activity growth with the latest NHS England guidance on data modelling. The level of QIPP required for next year may fluctuate as final agreement is reached with Providers on activity levels and contract values. A detailed paper on QIPP plans will be submitted to the Governing Body meeting in February. Table 15.2: Financial Plan Programme Budget Initial Summary January 2016 December 2015 Change m m m Anticipated Growth at 1.8% Inflation on contracts - net of efficiency 1.06% (3.3) (3.3) 0.0 Activity growth (5.2) (4.3) (0.9) Recurrent overspend (6.5) (6.5) 0.0 Funded non recurrently in (3.3) (3.3) 0.0 New Investments (1.0) (1.0) 0.0 QIPP required in Potential Risk and Mitigation In light of the CCG s tight financial position it has looked at how it can mitigate against further risk. The following areas of committed funding could be held if necessary to support the financial position: 23

51 Table 16.1: Mitigation of Future Risk Programme Area Committed Funds '000 Better Care Fund Performance 871 Quality Premium Allocation 644 Total 1, Virement Tables 17.1 to 17.3 show the budget virements for the period 1st November 2015 to 31st January Overall the CCG budget has increased by 901,000 during this period as a result of additional allocations and resource transfers. 24

52 Table 17.1: Annual Budget virements for the period 1st November 2015 to 31st January Programme Annual Annual Annual Explanation for Budget Movement Budget 31st Jan 2016 Budget 1st Nov 2015 Budget Movement '000 '000 '000 Acute Services Chesterfield Royal Hospital FT 123, ,687 1,530 Additional activity now in contract Stockport FT 21,250 21,250 0 Sheffield Teaching Hospitals FT 19,261 19,261 0 EMAS 7,674 7,674 0 East Cheshire NHS Trust 5,386 5,386 0 Royal Derby Hospital FT 2,714 2,714 0 Central Manchester University Hospitals 1,808 1, Transferred services Sheffield Children's Hospital FT 1,482 1,482 0 University Hospital of South Manchester 1,617 1,617 0 Other Acute Providers NHS 6,154 5, Transferred services Other Acute Providers Non NHS 7,075 7,075 0 Total Acute Services 197, ,767 1,871 Budget transfer from Reserves Mental Health Services Derbyshire Healthcare FT 22,210 22,210 0 DCHS NHS Trust 14,115 14,115 0 Other Mental Health Providers 7,117 7, CAMHS services Total Mental Health Services 43,442 43, Budget transfer from Reserves Community Services DCHS NHS Trust 38,543 38,553 (10) Transfers/Resilience Hospices 2,660 2, Transfer from DCHS Oxygen Other Community Providers & Better Care Fund 14,163 14,394 (231) BCF budget transfer Total Community Services 55,815 56,027 (212) Budget transfer to Reserves Primary Care Enhanced Services 3,579 3, Transfer from DCHS Basket of Services 3,745 3,745 0 Practice Prescribing 43,056 43,056 0 Central Prescribing 1,775 1, Revised budget Out of Hours 4,625 4,625 0 Primary Care other Co-Commissioning 37,225 37,225 0 Quality Premium Revised allocation Total Primary Care 95,424 94,197 1,227 Budget transfer from Reserves Continuing Health Care Continuing Health Care 20,209 20,209 0 Continuing Health Care - Children's 1,507 1,507 0 Funded Nursing Care 3,239 3,239 0 Total Continuing Health Care 24,955 24,955 0 Operational Costs (Non-Running Costs) Transformation & Commissioning Nursing & Quality GEM Integrated Care Programmes Total Operational Costs 1,419 1,419 0 Reserves & Allocations 6,498 8,590 (2,092) Net effect on Reserve transfers Control Total 4,994 4,994 0 Total Reserves 11,492 13,584 (2,092) Total Programme Resources 430, , Revised allocations 25

53 Table 17.2: Annual Budget virements for the period 1st November 2015 to 31st January Running Costs Annual Annual Annual Explanation for Budget Movement Budget 31st Jan 2016 Budget 1st Nov 2015 Budget Movement '000 '000 '000 Operational Costs (Running Costs) Board and Management Team 1,496 1,496 0 Transformation & Commissioning 1,620 1,620 0 Finance 1,570 1,570 0 IM&T Nursing and Quality GEM 1,129 1,129 0 NHS Property Services Total Admin Resources 6,342 6,342 0 No change in Running costs allocation Table 17.3: Annual Budget virements for the period 1st Novmber 2015 to 31st January Summary Annual Annual Annual Explanation for Budget Movement Budget 31st Jan 2016 Budget 1st Nov 2015 Budget Movement '000 '000 '000 Total Programme Resources 430, , Revised NHS England allocations Total Admin Resources 6,342 6,342 0 Total CCG Resources 436, , Revised NHS England allocations 1.18 Action Log Table 18.1 shows the issues identified along with an update on what actions are being taken. Previously reported items that have been assessed as complete by the Interim Chief Finance Officer have been removed. Table 18.1: Financial Position Action Log Area/Provider Issue Lead Officer Date first raised Finance and Activity Darran Green January Planning 2016 A series of Finance and Activity planning submissions has commenced. Action Initial Financial and Operational plans were submitted to NHS England on 8 February, in line with the national timetable. A second version of these plans are required on 2nd March 7th March, respectively. Status The Governing Body Assurance Committee will be updated on a monthly basis Recommendations The Governing Body Assurance Committee is asked to approve the virement report and to receive and approve the report. Darran Green Interim Chief Finance Officer 26

54 2015/16 CCG Assurance Framework Dashboard The CCG Assurance Framework is designed to give assurance that CCGs are delivering quality and outcomes for patients, both locally and as part of the national standards, as well as being the basis for assessing that they are continuously improving from the start point of authorisation. 27

55 2. CCG Assurance Framework Dashboard The delivery dashboard measures the overall performance of NHS North Derbyshire CCG and is fed by a series of indicators as outlined in the CCG Assurance Framework Report. The delivery dashboard results will inform the formal check point meetings with NHS England on a quarterly basis and informal monthly meetings. The assurance reporting format has been updated in line with the guidance from the NHS England 2015/15 Assurance Framework. 2.1 NHS Constitution NHS North Derbyshire CCG Chesterfield Royal Hospital Foundation Trust Stockport Foundation Trust Derbyshire Community Health Services NHS Trust Sheffield Teaching Hospitals Foundation Trust Exception Reported Indicator Name Period Standard / Plan Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Referral To Treatment Waiting Times (RTT) For Non-Urgent Consultant-Led Treatment Referrals To Treatment Incomplete Pathways - % Within 18 Weeks Number of 52 Week+ Referral To Treatment Pathways - Incomplete Pathways Dec-15 92% 92.7% 92.7% 93.6% 92.2% 92.2% 93.3% 92.1% 92.4% 92.8% 97.9% 97.7% 97.8% 92.8% 93.5% 93.8% Dec Diagnostic Test Waiting Times A&E Waiting Times Diagnostic Test Waiting Times - Proportion Over 6 Weeks A&E Waiting Time - Proportion With Total Time In A&E Under 4 Hours Dec-15 1% 0.8% 0.9% 1.5% 0.2% 0.5% 1.5% 0.1% 0.1% 0.3% 0.0% 0.0% 0.0% 6.0% 3.9% 2.1% No Data due to reporting Dec-15 95% 91.9% 93.8% 95.3% 92.6% 94.2% 95.1% 73.7% 80.6% 89.0% 100.0% 100.0% 100.0% #DIV/0! issues errors #DIV/0! as a result 94.8% of Lorenzo Number Of Trolley Waits In A&E Dec

56 NHS North Derbyshire CCG Chesterfield Royal Hospital Foundation Trust Stockport Foundation Trust Derbyshire Community Health Services NHS Trust Sheffield Teaching Hospitals Foundation Trust Exception Reported Indicator Name Period Standard / Plan Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Cancer Waits - 2 Week Waits (2WW) All Cancer Two Week Wait - Proportion Seen Within Two Weeks Of Referral Breast Symptoms Two Week Wait - Proportion Seen Within Two Weeks Of Referral Dec-15 93% 95.9% 96.5% 94.1% 96.9% 97.0% 92.8% 97.3% 96.7% 96.3% 94.3% 94.3% 93.4% Dec-15 93% 96.6% 97.0% 96.5% 96.6% 97.5% 96.6% 94.7% 94.5% 95.9% 98.4% 98.9% 97.3% Cancer Waits - 31 Days Cancer 31 Day Waits - First Treatment Administered Within 31 Days Of Diagnosis Cancer 31 Day Waits - Subsequent Surgery Within 31 Days Of Decision To Treat Cancer 31 Day Waits - Subsequent Drug Treatment Within 31 Days Of Decision To Treat Cancer 31 Day Waits - Subsequent Radiotherapy Within 31 Days Of Decision To Treat Dec-15 96% 96.9% 98.0% 98.7% 98.3% 98.7% 99.5% 97.5% 98.7% 98.7% 97.7% 97.9% 97.3% Dec-15 94% 100.0% 98.8% 98.7% 100.0% 100.0% 100.0% 100.0% Data currently 100.0% unavailable 100.0% 98.1% 97.2% 95.5% Dec-15 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Data currently 100.0% unavailable 100.0% 100.0% 100.0% 99.9% Dec-15 94% 96.7% 97.5% 98.3% 99.2% 99.2% 99.4% Cancer Waits - 62 Days Cancer 62 Day Waits - First Treatment Administered Within 62 Days Of Urgent GP Referral Cancer 62 Day Waits - First Treatment Administered Within 62 Days Of Screening Referral Cancer 62 Day Waits - First Treatment Administered Within 62 Days Of Consultant Upgrade Dec-15 85% 93.7% 87.7% 85.3% 91.6% 91.3% 89.0% 94.4% 87.5% 89.1% 80.7% 78.5% 81.4% Dec-15 90% 76.9% 81.8% 91.9% 100.0% Data currently #DIV/0! unavailable #DIV/0! 100.0% Data currently 75.0% unavailable #DIV/0! 100.0% Data currently 93.6% unavailable #DIV/0! Dec-15 N/A 66.7% 71.4% 78.4% 100.0% 100.0% 100.0% 79.4% Data currently 76.7% unavailable 80.8% 76.5% 82.3% 83.1% NHS North Derbyshire CCG East Midlands Ambulance Service Ambulance Response Ambulance Turnaround Exception Reported Indicator Name Ambulance - Proportion Of Category A (Red 1) Calls With Response Within 8 Minutes Ambulance - Proportion Of Category A (Red 2) Calls With Response Within 8 Minutes Ambulance - Proportion Of Category A Calls With Transport At Scene Within 19 Minutes Ambulance Handover Time - Ambulance Handover Delays Of Over 30 minutes Ambulance Handover Time - Ambulance Handover Delays Of Over 1 Hour Period Standard / Plan Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Jan-16 75% 66.7% 66.7% 71.2% 61.6% 61.6% 70.1% Jan-16 75% 56.6% 56.6% 67.7% 49.5% 49.5% 63.6% Jan-16 95% 84.0% 84.0% 90.2% 81.9% 81.9% 88.8% Dec-15 Reduction No CCG Level Measure Dec-15 Reduction Available For These Indicators

57 NHS North Derbyshire CCG Chesterfield Royal Hospital Foundation Trust Stockport Foundation Trust Derbyshire Community Health Services NHS Trust Sheffield Teaching Hospitals Foundation Trust Exception Reported Indicator Name Period Standard / Plan Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Mixed Sex Accommodation Cancelled Ops Mixed Sex Accommodation Dec Cancelled Ops for non-clinical reasons rebooked >28 days CPA follow up within 7 days Q3 95% 94.4% 93.9% Q Dementia diagnosis rate Dec-15 67% 64.5% 67.8% 67.9% Mental Health Plan 1.25% 3.75% 11.25% IAPT - Number Entering Treatment As Proportion Of Dec-15 Estimated Need In The Population Actual 1.3% 4.7% 15.9% IAPT - Proportion Completing Treatment That Are Moving To Recovery Dec-15 50% 53.0% 55.0% 55.4% 2.2 Health Outcomes NHS North Derbyshire CCG Chesterfield Royal Hospital Foundation Trust Stockport Foundation Trust Derbyshire Community Health Services NHS Trust Sheffield Teaching Hospitals Foundation Trust Exception Reported Indicator Name Period Standard / Plan Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Current Month Current Quarter Year To Date Safe environment and protecting from avoidable harm Healthcare Acquired Infection (HCAI) Measure: MRSA Infections Healthcare Acquired Infection (HCAI) Measure: C-Diff Dec-15 Infections % of adult hospital admissions, admitted within the month assessed for risk of VTE on admission Dec Plan Actual Q2 90% 97.9% 97.9% 95.9% 95.7% 99.9% 99.8% 95.1% 95.2% 30

58 2.3 Better Care Fund Better Care Fund Dashboard - Derbyshire County Council & North Derbyshire CCG Delayed Transfer of Care - Monthly Performance Delayed transfer of care from hospital per 100,000 (average number of days delayed per month) Exception Report Data Source Period Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Delayed Transfers Of Care data released monthly by NHS England - Part B - Days Delayed 2014/ / Trend Delayed Transfer of Care - Quarterly Performance Against Plan Delayed transfer of care from hospital per 100,000 (average number of days delayed per month) Exception Report Data Source Period 2014/15 Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2015/16 Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 Delayed Transfers Of Care data released monthly by NHS England - Part B - Days Delayed Actual BCF Plan Trend Exception Report Data Source Period Org Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Trend Non-Elective Admissions - Monthly Performance Non-Elective Admissions (General & Acute) - Number of episodes per 100,000 population Monthly Activity Return data released monthly by NHS England DCC NDCCG DCC NDCCG Exception Report Data Source Period 2014 Q Q Q Q Q Q Q Q4 Trend Non-Elective Admissions - Quarterly Performance Against Plan Non-Elective Admissions (General & Acute) - Number of episodes per 100,000 population Monthly Activity Return data Actual released monthly by NHS England Original Data / Plan Admissions to residential and nursing care homes Reablement/ rehabilitation services Permanent admissions of older people (aged 65 & over) to residential and nursing care homes per 100,000 population Proportion of Older People (65 & Over) Who Were Still At Home 91 Days After Discharge From Hospital Into Reablement / Rehabilitation Services Exception Report Data Source Period Q1 Q2 Q3 Q4 BCF Plan Adult Social Care Outcomes Framework Data Submitted Quarterly by Local Authorities Adult Social Care Outcomes Framework Data Submitted Quarterly by Local Authorities 2014/ / / % 86.6% 79.0% 87.1% 81.7% 2015/ % 84.4% 82.5% Trend Exception Report Data Source Period Org Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar BCF Plan Trend Dementia Rate of Dementia Diagnosis Dementia Prevalence Data from the Primary Care Webtool DCC 59.2% 59.4% 60.0% 58.8% 58.7% 59.2% 60.2% 61.4% 64.2% 64.5% 65.5% 67.3% 2014/15 67% NDCCG 59.0% 58.9% 59.6% 57.5% 57.4% 57.9% 59.5% 60.5% 63.0% 64.1% 64.9% 66.6% DCC 71.1% 69.2% 71.2% 72.0% 70.6% 72.0% 72.1% 72.0% 69.9% 2015/16 68% NDCCG 67.9% 64.5% 68.1% 69.3% 68.8% 69.6% 69.3% 69.5% 64.5% Patient Experience GP Patient Survey - Q32: In the last 6 months, have you had enough support from local services/organisations to help manage your longterm condition Exception Report Data Source GP Patient Survey Results Period Jan-Sept '13 Jan-Sept '14 Jul '14 - Mar '15 Jan-Sept '15 DCC 70.3% 70.8% 70.4% 70.5% NDCCG 71.3% 73.1% 72.4% 72.6% BCF Plan 65.9% 66.2% Jul '15 - Mar '16 Jan-Sept '16 Trend 31

59 2.4 Finance No Indicator Green Amber Red Performance at Month 10 1 Plan year to date (variance to plan and % of YTD allocation) Positive variance to plan or negative variance <=0.1% >0.1% <0.5% >=0.5% M10 plan = 4,162k, M10 actual = 4,162k. Month 10 Comments RAG Rating G Position in line with plan at month 10 2 Plan full year (variance to plan as % of allocation) Positive variance to plan or negative variance <=0.1% >0.1% <0.5% >=0.5% Full year plan = 4,994k which is 1.14% of allocation G 3 QIPP year to date delivery >= 95% >= 75% <95% <75% Plan YTD = 8,220k, delivered 6,089k to date which is 74.08% R Under plan year to date. The full year forecast has been revised downwards. See below. Primary Indicators 4 QIPP full year forecast >= 95% >= 75% <95% <75% Full year forecast now 7,510k against original plan 10,570k this is 71.05% of plan R 5.5m of the original QIPP plan was required to achieve a balanced financial position. Any QIPP in excess of 5.5m was planned to be re-invested in transformation. 5 Clear identification of risks against financial delivery and mitigations Mitigations equal to or greater than risks Risks not fully mitigated and if they were to materialise the CCG would not be in deficit or would be in deficit up to 1% of allocations Risks not fully mitigated and, if they were to materialise, the CCG would be in deficit greater than 1% of allocation Risk reserve of 3,960k held. Forecasting to use 3,289 of this at month 10 6 Running costs <=RCA N/A >RCA RCA = 6,342k. Forecasting to spend within this allocation G G Risks fully mitigated. Forecasting to use 83.06% of this at month 10 7 Underlying recurrent surplus on exit of 2015/16 >=1% <1.0% surplus Surplus >=0% 8 Financial position meets the 2015/16 surplus planning requirement >=1% surplus forecast >= breakeven and <1% surplus forecast <0% 1.34% reported at month 10 G Deficit Forecast Surplus is 1.14% of allocation G 9 Planned usage of non-recurrent headroom funds in line with business rules >= 1% >= 0.7% <1% <0.7% 1% G Supporting Indicators 10 BPPC performance invoices paid within Better Payment Practice Code >= 95% >= 75% <95% <75% All 4 cumulative measures >95% at month 10 G The monthly and cumulative performance for to date are all above 95% This target is expected to be achieved all year. 11 Cash utilisation <=1.25% >1.25% <2% >=2% CCG held a cash in bank balance of 1.27% of the monthly drawdown. A NHS England require CCG's to hold cash in bank of less than 1.25% of monthly drawdown. A debtor paid the CCG on the last working day of January which pushed the bank balance over 1.25% 32

60 3. Exception Reports Exception reports are provided where NHS North Derbyshire CCG is failing in the latest reporting month at CCG level (with the exception of ambulance performance which is at provider level). Exception 1 Number of 52 Week+ Referral To Treatment Pathways - Incomplete Pathways Target 0 CCG Lead Current Performance Adam Sutherst NHS North Derbyshire CCG (NDCCG) reported one patient waiting longer than 52 weeks on an incomplete pathway during December 15, taking the total for up to. The breach occurred at Chesterfield Royal Hospital Foundation Trust (CRHFT) in the Ophthalmology specialty. Issues A loss of clinical resource earlier in the year and an inability to recruit resulted in the trust being unable to deliver the adult squint service, as and results of this, a backlog built up. Actions Being Taken The patient was treated on 26th January NDCCG agreed with the trust to stop accepting new referrals July 15, and the service was taken off of the Choose and Book facility. The trust reviewed all of the patients who were on adult squint pathways and transferred them onto appropriate pathways. All patients are being treated in accordance with the Ophthalmology RTT Recovery Action Plan (RAP) which is currently in place. Recovery By Feb-16 33

61 Exception 2 A&E Waiting Time - Proportion With Total Time in A&E Under 4 Hours Target 95% CCG Lead Simon Harris Current Performance NDCCG failed to meet the national standard for A&E waits times during December (91.9%) for the second consecutive month. This is predominantly due to underperformance at CRHFT, 92.6% and is also impacted by underperformance at Stockport Foundation Trust (SFT), 73.7%. Please note that NDCCG A&E performance is calculated via apportioned provider performance, and is not an actual count of North Derbyshire CCG patients. North Derbyshire CCG Performance CRHFT Trust Performance SFT Trust Performance Issues CRH: Local data indicates that the trust also missed the ED target for January achieving 91.5% with the number of attendances at 6581, 2014 performance was 93.35% with 6011 attendances. In January 16 the DHU streaming service saw 664 patients, these are included in the overall attendances, the streaming services supported the ED target by 0.95%. During December 15 and continuing into January 16 there has been a high acuity of patients attending, as well as the continuation of existing flow issues within the trust. SFT: Performance has dropped significantly in November and December. The main contributor to patient flow continues to be delayed transfers of care leading to a lack of available beds. A&E performance is an ongoing issue for the trust and the lead CCG (Stockport CCG) issued a performance notice back in 2012/13. However, as the position has never fully recover, the performance notice was never closed. Monitor also issued an enforcement notice in 2013 regarding A&E which hasn t been withdrawn. Actions Being Taken CRH: Weekly teleconferences take place with colleagues across the Derbyshire health and social care system to understand what the issues are in order to maintain patient flow. In addition there is a SRG weekly teleconference at Director or CEO level, the following day to unblock and issues that may still exist. Additional beds were opened and maximised as required in order to deal with the increased demand. SFT: NDCCG are communicating with Stockport CCG (SCCG) around all performance issues at the trust. SCCG has a RAP in place with the SFT, in the form of the 90 day action plan, which is tracked at System Resilience Group (SRG). In order to increase bed capacity over the festive period the Trust cancelled non urgent operations for four weeks which freed up a surgical ward. The Trust is working closely with the Systems Resilience Group to look at additional actions to create capacity in the community to create flow in the hospital. Recovery By CRH: Significant pressure remains at the trust SFT: Ongoing 34

62 Red 1 Exception 3 Cancer 62 Day Waits - First Treatment Administered Within 62 Days Of Screening Referral Target 90% CCG Lead Michelle Anthony Current Performance North Derbyshire CCG missed the target during December 15 (76.9%) for the fourth consecutive month, which equates to three breaches, all of which were treated at Chesterfield Royal Hospital NHS Foundation Trust. 12 NDCCG patients in total were treated during December 15. Issues All three patients breached the 62 day standard due to medical reasons. One patient was seen in the breast specialty and surgery had to be cancelled due to a chest infection. Two patients were seen in the lower gastrointestinal specialty following bowel screening referrals, both patients were delayed as other possible cancers had to be ruled out before proceeding with treatment. Actions Being Taken Non-compliance is due to a combination of low numbers flowing through the service, which consequently means a handful of breaches can lead to underperformance, and medical complications. The trust continue to review pathways in order to reduce patients waiting longer than necessary for treatment. Due a further month of underperformance, NDCCG have requested that breach reports are sent through to NDCCG for all breaches at CRHFT. Recovery By This will continue to be a standing agenda item in the weekly meetings with the Director of Strategy and Performance at the trust for monitoring. Exception 4 Ambulance Proportion of Red 1 Calls With Response Within 8 Minutes Proportion of Red 2 Calls With Response Within 8 Minutes Proportion of A19 Calls With Transport At Scene Within 19 Minutes Target 75% 75% 95% CCG Lead Current Performance Simon Harris EMAS failed to achieve the performance standards for Red 1, Red 2 and A19 in the month of December; Red 1 (67.7%), Red 2 (56.5%), A19 (86.5%). Please note that at the time of reporting January data was not yet available, an update will be given in next month's report. By comparison, the previous year for the month of December was similar in terms of performance targets but the year to date at this point was significantly better. The response times by minute for December 15 are shown in the tables below. 35

63 A19 Red 2 Response times are getting longer and have become worse since the 2014/15 position. The graphs below compare the average time in which 75% of Red 1 and Red 2 calls are seen during (dotted lines) and (solid lines), and the average time in which 95% of A19 calls are seen during (dotted lines) and (solid lines). Issues EMAS continue to have very high levels of sickness and poor resourcing with little sign of recovery, these coupled with the financial challenges makes the situation increasingly difficulty. One issue EMAS is facing is the re-triaging of green calls that have been passed to them by NHS111 (categorised as a green call by the 111 pathways system). This occurs when EMAS enter their 'over capacity plan as a result of having no ambulance vehicles available to dispatch to patients. The over capacity plan reviews the current calls waiting with a view to prioritising the most urgent patients with limited ambulance availability. As a result of EMAS entering into over capacity NHS 111 green calls are re-triaged and due to the time delay for response in some cases, on top of the minute standard response time, a patient could have deteriorated resulting in escalation to red calls. Red calls require a much faster response and due to the increasing the number of red calls from the re triage of 111 calls performance is not met on an on-going basis. A further issue that of duplicate calls. Duplicate calls usually occur when several individuals call to report the same incident. EMAS are currently 41.7% up against plan and 47.9% up on this time last year in terms of duplicate calls. This can be attributed to individuals repeatedly calling back the ambulance is yet to turn up to the scene. It has recently been announced that Sue Noyes, the Chief Executive of EMAS, will be leaving in June 2016, there is was no update at the time of reporting to indicate when a replacement will be appointed. 36

64 Actions Being Taken EMAS have developed a revised Remedial Action Plan (RAP) that is currently with commissioners for review. The RAP will be discussed at contract meetings during w/c15th February 16 and will then be agreed at the EMAS partnership board, which now has a Derbyshire representative from South Derbyshire CCG. NDCCG are currently interpreting the RAP and will feed comments back to the Derbyshire representative. Recovery By There are currently no signs of recovery but commissioners are working with EMAS, Hardwick CCG are the lead commissioner for the whole contract and Southern Derbyshire are leading for Derbyshire. Exception 5 Dementia diagnosis rate Target 66.7% CCG Lead Current Performance Judy Derricott National Dementia Diagnostic Rates for December 15 indicate that North Derbyshire CCG is below the 66.7% target, at 64.5%. This is the first time North Derbyshire CCG have missed the target since May 15. Issues After reviewing the figures it appeared that, for a handful of practices, the data was not successfully collected by the GP Extraction Service (GPES) during December 15. After manually entering the data into our local information, it shows that NDCCG did meet the target, 71.0%. This shows an improvement on the November position (69.5%). Actions Being Taken NDCCG is working with HSCIC and the affected practices' IT systems to establish why this happened and how to rectify the figures. NDCCG have recently developed a dashboard which enables GP practices to see how they are performing against their peers in a more effective way, and is currently liaising with the Lead Mental Health GP to distribute amongst fellow GP practices with a view to encourage improved diagnosis rates. Recovery By Jan-16 37

65 Exception 6 Healthcare Acquired Infection (HCAI) Measure: C-Diff Infections Target 9 (Month) 85 (YTD) CCG Lead Sharon Lane Current Performance NHS England set the objective for NDCCG at 107 cases for 2015/16. As of December 2015 our total case number stands at 86, which puts us 6 cases over our objective for the period ending December This might be contrasted with the same period 14/15 when the CCG figure stood at 89 cases. Issues Stockport NHS Foundation Trust (SFT) has a Clostridium difficile target for 2015/16 of 17 cases with their figures already standing at 35 cases as of November This increase in numbers has been discussed with the infection control team at Stockport NHS FT. The increase is due to a change in procedure; more samples are being tested and in turn, this has led to more Clostridium difficile cases being identified. They have ruled out any issues relating to cross infection and only three cases have been identified where lapses in care have been noted. 6 cases attributed to NDCCG patients originate from SFT from the first 8 months of 2015/16 and again this could be contrasted with a Stockport figure of 2 cases for the same period in 2014/15. Although no direct cause and effect is demonstrated it does appear that higher than predicted/expected numbers of Clostridium difficile are being encountered in a neighbouring geographic area. Actions Being Taken Cases of Clostridium difficile isolated from community samples are being reviewed on a case by case basis and this includes a review with the patients' General Practitioner. A review of the cases carried out by the clinical quality team reveals that the majority of cases are of mild disease. The majority of cases do not show any lapses of care and were not, in the main, avoidable. From the 86 NHS North Derbyshire CCG cases to date 5 patients suffered symptoms of severe Clostridium difficile infection. Reviewing these cases does not reveal any significant causes for concern in relation to lapses of care or avoidability. The Clinical Quality Team will continue to monitor the situation regarding Clostridium difficile cases as they are reported and will continue to review the RCA reports on each case. Recovery By Given the nature of infectious diseases it is not possible to predict a recovery point. As Chesterfield Royal FT are currently performing well against their objective this hopefully will have a positive impact on our CCG cases. 38

66 Local Performance Indicators A number of local performance indicators have been identified by the CCG as key in achieving the CCG priorities. These are presented here to enable ongoing monitoring. 39

67 4. Local Performance Indicators The measures identified in the table below have been shown separately to the CCG Assurance Framework report as they are not part of the nationally defined framework. Measure 1 Delayed Transfers of Care Delayed Transfers of care CRHFT DCHS Standard Year April May June July August September October November December January February March YTD <3.5% <=12.5% (Local Target as community hospital) % 4.4% 3.5% 2.8% 2.0% 3.5% 1.7% 1.4% 0.8% 1.5% 1.4% 1.5% 2.4% % 1.2% 1.2% 1.2% 1.0% 1.2% 0.7% 0.1% 1.8% 1.1% % 9.2% 8.2% 7.9% 8.1% 7.9% 9.7% 6.2% 7.9% 6.9% 6.6% 4.9% 7.9% % 7.8% 7.5% 8.2% 6.9% 8.9% 6.8% 5.3% 7.1% 7.6% Delayed transfers of Care at Chesterfield Royal Hospital NHS Foundation Trust performed below the maximum threshold in December 15 (1.8%). The CCG continues to receive regular information regarding Delayed Transfers of Care from the trust. Further work is underway to review the reasons for delayed discharges during winter. A recent Delayed Transfer of Care Roadshow held by NHSE, TDA, Monitor and the DoH acknowledged that, from last year s winter pressures work, there is a correlation between ED waits and bed occupancy. This led to work looking at beds in delay and reasons for these delays. One of the main points was that a whole system approach to the issue is important, and that all partners work together to deliver better outcomes in this key area. An estimated discharge date CQUIN is currently in place at CRHFT which aims to understand where the blockages are and how these can be unblocked to prevent delays and maximise flow in the acute trust. A set of metrics will be put in place to collate key information which will report monthly into the System Resilience Group (SRG), which has all providers across the SRG footprint present. These metrics include items from the safer bundle (for example the percentage of emergency admissions for those aged over 75 with a length of stay of 7 days or more), and items from the CQUIN (for example percentage of patients with a documented treatment plan within 24 hours of admission). Measure 2 EMAS Handovers Average EMAS Handover Time Standard < 15mins CRHFT Stockport FT April May June July August September October November December January February March :29 20:40 19:29 19:52 20:02 20:32 19:27 19:25 20:42 20:45 20:40 20: :11 20:24 20:22 20:35 22:30 21:40 21:56 21:23 20:38 18:18 21:34 19:07 18:11 18:07 18:15 18:04 19:17 26:54 23:36 21:41 20: :18 18:08 19:01 20:28 20:28 21:36 21:50 25:39 25:46 EMAS handovers, which measures the average time it takes from when the ambulance arrives at the hospital to when the patient is handed over to clinical staff, continue to be above the 15 minute standard at both Chesterfield Royal Hospital NHS FT and Stockport NHS FT. EMAS and CRH have regular meetings and discussions regarding handover delays including improvement processes and pathways, given the heightened visibility about handovers a discussion has now taken place at SRG and it was agreed that a joint action plan should be developed by EMAS and CRH, the action plan is still being drafted and has not yet been shared with commissioners. 40

68 Measure 3 NHS Derbyshire Monthly Update % of calls abandoned after 30 seconds % of calls answered in 60 seconds Dec-15 Nov-15 Dec-14 Dec-15 Nov-15 Dec % 1.4% 7.3% 93.4% 90.9% 73.9% A contract notice was originally raised in May 15 with a Recovery Action Plan (RAP) stating performance would hit the 95% standard for calls answered within 60 seconds by September 15. DHU did not meet this deadline and the CCG agreed with DHU that fines would be imposed should the standard be missed during two, four week periods throughout October and November 15. DHU narrowly missed the target during both these periods and penalties were applied. A further RAP is now in place which states that DHU are to hit performance during two of three remaining months in (Jan - Mar 16). Local data indicates that DHU achieved 86.1% for the month of January for calls answered within 60 seconds. Activity is above plan for the year by 4.8%, and 8.9% from the previous year. Sickness also remains high for health advisors and nurse advisors at 8% and 2.5% respectively. DHU have had a draft report back from the CQC, which is being reviewed by DHU. Early indications are good (see below). 41

69 Measure 4 NHS North Derbyshire CCG and Provider Workforce Indicator Dashboard Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Number of Staff ND CCG (WTE) DCHS DHU ND CCG (in month) DCHS 1.6% 0.0% 0.0% 0.8% 2.5% 3.3% 1.6% 0.8% 0.8% 10.3% 10.2% 10.5% 9.7% 9.8% 9.8% 9.1% 10.0% 9.0% Staff Turnover DHU total 2.8% 1.9% 1.9% 2.0% 1.7% 2.7% 1.2% 0.8% 0.9% 111 Total 4.5% 2.4% 3.2% 3.5% 3.0% 3.7% 2.2% 0.8% 1.6% Call advisers 5.4% 2.8% 3.6% 3.5% 3.7% 3.7% 1.9% 0.7% 1.2% Nurse advisers 1.3% 1.2% 2.2% 2.2% 1.0% 3.1% 3.1% 1.0% 3.3% ND CCG 99.7% 99.7% 99.9% 98.2% 98.8% 99.9% 98.2% 98.7% 98.1% CCG National Average 97.8% 97.7% 96.6% 96.6% 98.0% 97.9% Not Yet Available due to a 3 month time lag on the national data CRHFT Stockport 95.3% 95.8% 95.8% 96.1% 95.4% 95.9% 96.2% 95.2% 94.6% 95.6% 95.6% 95.7% 95.7% 95.4% 95.4% 95.6% 95.5% 95.5% Staff Attendance Acute Trust National Average 96.2% 96.3% 96.3% 96.2% 96.3% 96.2% Not Yet Available due to a 3 month time lag on the national data DCHS 95.9% 95.6% 96.1% 96.1% 96.2% 95.8% 96.1% 95.3% 94.3% Community Provider National Average 95.7% 95.8% 95.7% 95.6% 95.8% 95.7% Not Yet Available due to a 3 month time lag on the national data DHU 92.4% 92.9% 95.3% 80.8% 93.4% 95.2% 94.6% 94.0% 94.1% 98.2% 94.2% Staff with appraisal completed (% compliance) CRHFT (rolling 12 months) DCHS Stockport 68% 70% 68% 67% 69% 70% 70% 72% 71% 93% 91% 89% 87% 87% 87% 87% 88% 90% 77% 72% 84% 82% 79% 79% 76% 76.1% 78.3% DHU 38% 38% 29% 50% 69% 90% 92% 91% 92% This data has been obtained direct from providers in order to illustrate performance against a range of workforce indicators. Whilst there are a number of outstanding items, data is currently being sourced with the aim that all measures will be monitored monthly. 42

70 Measure 5 GEM Performance The CCG receives a monthly KPI dashboard from Arden & GEM CSU detailing their performance. During December, Continuing Health Care failed at Overall Service level, and Health and Safety was identified as amber. KPI Level Performance is also reported below, on an exception basis. Overall Service Performance - December CHC IFR MCE Collaborative Contracting Equality, Inclusion & Human Rights Customer Contact and Complaints Health and Safety Business Continuity Finance HRBP and People Services Strategic IT Programmes Information Governance IT Information Services Clinical Procurement Transactional Procurement KPI Continuing Health Care New referrals will progress through CHC process as described by the National Framework within the spirit of the guidance (28 days). New CHC referrals will have a review undertaken within 3 months or at agreed specific intervals. Annual review of current cases or more frequently as necessary. Target RAG Score 90% 63% 85% 4% 85% 25% FNC referrals will have a review within 3 months or at agreed specific interval. 85% 0% FNC referrals will have a review within 12 months or at agreed specific interval. 85% 0% Issues/ Actions Performance continues to be poor, the backlog trajectory will not be addressed until staffing is in place in March with a completion date of June A paper went to the governing body/governing body assurance group last month, in which the four Chief Nurses in Derbyshire made a recommendation to continue with the current provider, with an increased level of scrutiny and expedite procurement. The CCGs have now moved to 2 weekly performance meetings, set up a new contract a management meeting and have a separate reprocurement group. Kath Henderson will continue to work with us to ensure that patients are clinically safe until reprocurment is complete. Health & Safety Continued compliance with statutory law (enforcement actions, recommendations from Regulatory Authorities) KPI RAG Score Completion of statutory training requirements (fire warden training) Issues/ Actions There are eight fire wardens in place, but they have had no training, First Aider/ Fire Warden/Evacuation chair training requirements to be be reviewed and then training will progress. The CSU has replaced the specialist contractor to support the CCG service delivery. 43

71 Overall Service Status KPI RAG Score Recovery Capacbility Issues/ Actions To be demonstrated by CCG, CSU will support CCG through the mutual aid agreement process. Information Services KPI RAG Score SUS / SLAM reconciliation process delivered to agreed delivery date Delivery of scheduled reporting to agreed delivery dates (appendix to SLA) Issues/ Actions Issues with Chesterfield Royal Hospital SUS submissions for months 1-7 are due to the provider allocating activity to CCGs based on CCG of residence rather than the patient s registered GP Practice. A re-submission was made and is now available. Arden & GEM have met with the information team at Chesterfield Royal and have agreed to develop closer working relationships and how to progress the reconcilaition. CRH have supplied known business rules and AGEM is now working to implement the business rules. 44

72 Project Management Office Report 45

73 Schemes not delivering but are being updated on Epmo Schemes delivering 5.1 Project Management Summary The CCG currently have 49 schemes monitored through the PMO office, of these 10 schemes are delivering, 21 schemes are not delivering but are being updated regularly on Epmo and 18 schemes that are not being updated on epmo. GBAC to approve and consider the following approach: Any scheme that is not identified as either QIPP or 21st C to be reviewed to understand the benefits and how they link to the CCGs aims and objectives. Schemes not delivering but are being updated on epmo, to be challenged at the monthly project management meetings to gain an understanding around non delivery and to evaluate the future of these schemes. Schemes not currently being updated on epmo will be given a deadline by which to update the epmo system, any schemes not updated after this date to be discussed at the Senior Leadership Team meetings. Schemes delivering Running Cost Reductions Prescribing Switches and Practice Level Support Rebates Ashgate Hospice - Specialist Palliative Care Consultant Anticoagulation BOS Blueteq Ashgate Hospice - Additional Beds Helens Trust - Night Sitting Optimise RX QIPP Project 21C Project Schemes not delivering but are being updated on epmo QIPP Project 21C Project Stroke Early Supported Discharge Generic Drug Savings & Patent Expiries Other Prescribing Airedale Telehealth Project (WS3) FLO Simple Telehealth Vasectomy (KPIs don t start until June 2016) Diabetes Better Blood Sugars (KPIs don't start until June 2016) Diabetes Type 1 Structured Education (KPIs don't start until June 2016) 46

74 Schemes not delivering and late/never been updated on epmo Contract Levers High Cost Patients Falls Partnership Service (WS6) (New KPIs start March 2016) FIRST Service (WS6) (New KPIs start March 2016) Additional Patient Flow Team Additional Pharmacy Cover for ED - weekends Additional Resource for the Rapid Response Team Triage of all ED & GP Referrals Mon-Fri on EMU Map of Medicine (KPIs don t start until December 2016) Care Co-ordination Case Management (WS3) IV Therapy Phase 1 Discharge Lounge Increased Capacity Enhanced Senior Surgical Consultant Review To Support Patient Flow Schemes not delivering are late updates/never been updated QIPP Project 21C Project Increase Bed Utilisation (WS6) Discharge to Access and Manage DCC Intermediate Care Bed in High Peak First to Follow Ups Non weight Bearing Dementia Support Worker/Primary Care Mental Health Worker Pilot (WS6) Additional Mental Health Crisis & Step Down Beds Ashgate Hospice Additional Resource to Support Patient Flow Voluntary Sector Funding to Support Patient Flow COPD Zero Length Stay Referrals Invoice validation Senior Clinical Input into Integrated Care Services Continuing Health Care GP Seniority Reductions GP Premises Glaucoma 47

75 Quality Report This report provides an overview of performance against key quality standards, ensuring that the CCG meets its corporate objective to put quality at the heart of all services we commission. 48

76 6.1 Quality News 2015 Patients Association Peer Review Results The final report regarding the 2015 Patient Association Peer Review panels with both Derbyshire Community Health Services Foundation Trust (DCHSFT) and Chesterfield Royal Hospital Foundation Trust (CRHFT) has now been published and shared with Providers. Over a period of two days, peer review panels looked at six complaints (per provider) and how they were handled by the providers. Complaints were measured against the nationally recognised Patients Association Complaints Management Scorecard. There were four panels with a mixture of clinicians, magistrates, lay people, complaints staff and a Patients Association Lay Expert as Chair. Each panel had a mix of staff from both Trusts to promote learning and sharing of good practice. The main objectives were To enable the participating organisations to understand the principles and practice of good complaints handling; To identify, through using a number of closed anonymised complaint files, where the organisation s current practice falls short of these good practice standards; To help the organisation to identify how it can work towards consistent good practice in complaints handling e.g. by providing access to best practice and assisting the organisation to develop clear action plans. This was the second of these events, with the previous one being held in December It was clear that there had been significant improvements made by the Providers, which has resulted in more timely higher quality handling of complaints and therefore improved responses to patients/complainants. The scoring system used ranges from 1-5 with 1 being poor practice and 5 being excellent practice. The table below shows the improvements in scores for both providers compared to

77 Overall across both organisations, communication with the person complaining is good, putting the person at the centre of the process, assessing the complaint is good in some parts, and the final letter has a large number of good/excellent scores. On-going improvements for both organisations need to be focused on thoroughness of the investigations, and the way the investigator reviews, organises and evaluates the findings. The Clinical Quality Team will be working with providers via the Quality Schedule to ensure that these areas are addressed. 6.2 Chesterfield Royal Hospital (CRHFT) 2015/16 Quarter 2 Commissioning for Quality and Innovation (CQUIN) and Quality Schedule Work continues with CRHFT to gain all of the required information to agree and sign off quarter 2 CQUIN and Quality Schedule data submissions. The Expected Date of Discharge (EDD) CQUIN has been an area of concern discussed with the Provider as there has been a lack of communication within the Trust of their discharge policies and limited information has been available against the agreed Key Performance Indicators (KPIs) to understand the current position. This has been escalated to the Medical Director and it is hoped that more data will be made available by mid-february. However it is recognised that the Provider has not achieved all of the quarter 2 CQUIN requirements. 50

78 2016/17 CQUINs The Clinical Quality Team has commenced work in collaboration with CRHFT to agree the 2016/17 CQUIN programmes and it is likely that these will focus on frailty specifically around delirium, maternity and compassionate care relating to carers. Work will continue around patient complaints as part of the quality schedule. National CQUIN guidance is expected to be published at any time detailing the national CQUIN programmes to be delivered, however this has not yet been published. Quality Visit to Ashover Ashover is a care of the elderly ward staffed by the nursing team who were previously on Pearson Ward. This was an announced visit with the Trust Deputy Director of Nursing and Head of Infection Prevention and Control to visit the ward as part of an agreed Serious Incident (SI) action plan following concerns about quality of care on the ward. The CCG visiting team included the Chief Nurse, Senior Quality Manager, Deputy Chief Nurse and a Lay Representative. The visiting team were welcomed to the ward by an enthusiastic matron who had a clear passion and drive to make improvements for her patients; this was evidenced with the current finger buffet pilot and the variety of dementia friendly resources and features on the ward. The ward was busy but welcoming and orderly and some very good feedback was received from patients and their families. The visiting team focused on pressure ulcer prevention and management and were pleased to have the opportunity to witness an internal pressure ulcer timeline meeting. Specific areas of good practice identified included Innovative finger buffet trial which is encouraging increased nutritional input Multi-Disciplinary Team (MDT) huddles with a focus on harms and nutrition Discharge Coordinator post Good patient feedback and communications observed Dementia friendly environment Student felt supported Good senior staff presence Reduction in falls and patients feeling reassured by levels of observation at night 51

79 Pressure ulcer timeline meeting process, challenges between staff and ownership of the issues was good A couple of areas of concern were also highlighted The patient s assessment booklet had not been completed on EMU, this had not been identified by staff on Ashover Ward therefore it remained incomplete Named Nurse Information and pressure ulcer champion information was blank and not completed Families were unaware of patient moves and assessment information didn t seem to have followed the patient EDD leaflets are not yet in use Overall the visiting team were pleased that clear actions had been undertaken as a result of the SI findings and action plan and assurance was gained that patients and their families were happy with the quality of care being delivered on the ward at the time of the visit. Safer Sharps Notification of Contravention In October 2015 following an inspection by the Health and Safety Executive the Trust was issued with a notification of contravention in relation to the Safer Sharps Regulations that were introduced in Following this notification the Trust has implemented actions to correct the contraventions to demonstrate compliance. They have responded to the Health and Safety Executive in January 2016 as requested outlining the actions they have taken. Safe staffing The table below demonstrates the fill rates for the Trust by both day and night shift staffing levels split by registered and non-registered nursing staff. 52

80 Monthly trend December January YTD YTD For December 2015 CRHFT reported an overall staff shortfall of 5.30% which equates to 582 shifts from a required The number of patient falls has increased from 97 November to 105. No falls were recorded which met the severe harm (or death) criteria although one patient sustained a fractured Humerus which was classified as moderate harm. Incidents reported onto DATIX by staff which were directly related to staffing issues rose to 47 in December 2015 from 28 in November There was also a rise in the number of red flags reported, which rose from 19 to 40. The Trust reported that the rise is red flags is related to patient acuity/dependency, staff sickness and also that staff may be more aware of reporting mechanisms following recent training. It is also notable that the cases reported onto DATIX may have then be raised as red flags therefore there is a probability of some duplication in reporting. Serious Incident Standards The CCG s Clinical Quality Team continue to work closely with Providers to support improvements in timeliness of reporting and closure of serious incidents and the quality of investigation reports received. Further detail is outlined in the report below. Number of serious incidents Number of incidents reported within 2 days No of incidents reported breaching 2 day deadline Number of incidents closed Number of extensions requested Number of reports overdue 0 Serious Incidents (SIs) Year to date, the Trust have reported a total of 78 serious incidents. The Trust continue to be on track with no incidents overdue and with only 20 incidents live, which is the lowest figure 53

81 since the CCG has been lead commissioner in The Trust s patient safety team are providing report writing training which has noticeably improved the standard of the reports submitted to the CCG. CRHFT 2015/16 Serious Incidents YTD Incident Type Nov-15 Dec-15 Jan-16 Apparent/actual/suspected self-inflicted harm meeting SI criteria Maternity/Obstetric incident meeting SI criteria: baby only (this include foetus. neonate and infant) Medication incident meeting SI criteria Pressure ulcer meeting SI criteria Slips/trips/falls meeting SI criteria Treatment delay meeting SI criteria HCAI/Infection control incident meeting SI criteria Radiation incident (including exposure when scanning) meeting SI criteria Pressure Ulcer Incidents Number of pressure ulcers developed/deteriorated which have been reported onto the Trust DATIX system. 54

82 Incident Type November 15 December 15 Pressure Ulcer Grade Pressure Ulcer Grade Pressure Ulcer Grade Nine pressure ulcers were reported during December Seven were classified as grade three with the remaining being grade two. The average number of pressure ulcers reported for quarter three 2015/16 stands at 10.3 compared with 18.6 in quarter two. Discussions have taken place with CRHFT with a view to developing a system to review pressure ulcers, in line with NHS England s Serious Incident framework, focussing on the level of harm to the patient and identifying any possible lapses in care. Healthcare Acquired Infections HCAI November 15 December 15 YTD 15/16 MRSA(post 48 ) MSSA (post 48 hr.) E-coli (all cases) C difficile(post 72 hr) One patient receiving care at the trust developed a Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia in December, four days after being admitted to the Trust. The Trust is in the process of completing a post infection review and is due to submit the final report to the CCG in March The infection control team at the Trust carry out monthly compliance audits on MRSA screening and treatment. In December 252 patient s records were audited. The results showed that 93.5% of patients across the Trust that were deemed to require MRSA 55

83 screening were screened appropriately. This is a slight improvement on the previous two months results. The Trust continues to perform well against the Clostridium Difficile objective with only one case in December Safety Thermometer The Safety Thermometer records the prevalence of harm on a particular day each month and should be used alongside other data such as incident data to measure the quality of care. The measures included are pressure ulcers, falls and urinary tract infections in patients with a catheter in situ. Please see the tables below for the 2014/15 Safety thermometer data. CAUTI The numbers of CAUTI remain low across the trust. Audit figures are produced monthly on compliance with good catheter management. The overall trust figure fell slightly in December 2015 (76% in November falling to 68.2% in December). 56

84 Falls There were no falls resulting in severe harm or death during the reporting period. Whilst the total number of falls increased in December 2015 (105), the Safety Thermometer shows a decrease in the number of patients suffering a fall and being harmed. 6.3 Derbyshire Community Health Services (DCHSFT) 2015/16 Quarter 2 CQUIN and Quality schedule Quarter two CQUIN and Quality Schedule data has all been received and agreed by commissioners. DCHSFT have raised concerns over their achievement of one aspect of the national dementia CQUIN where they are struggling with data collection and feel they may not achieve the required end of year position. Commissioners are working to gain clarity nationally around this CQUIN currently. 2016/17 CQUINs The Clinical Quality Team has commenced work in collaboration with DCHSFT to agree the 2016/17 CQUIN programmes and it is likely that these will focus on frailty specifically around delirium, admission avoidance work with Stockport FT and tissue viability work with nursing homes. National CQUIN guidance is expected to be published at any time detailing the national CQUIN programmes to be delivered. Falls Prevention Strategy 2016 DCHSFT have launched a falls prevention strategy following a deep dive piece of work by the new falls lead and 360 internal audit. The findings indicate that there has been a lot of activity around falls prevention and some good improvements, however there has been no coordination or robust governance embedded to demonstrate significant assurance particularly in the community based services. The new strategy provides a robust plan to reduce falls and their impact, it details how DCHSFT will work to identify and reduce the number of patients falling and resulting injuries in the home, commencing with the collection and collation of baseline data. A new multi-disciplinary falls working group will be a key facilitator in delivery of this work. 57

85 Monthly trend December January YTD YTD To date, numerous pieces of work have commenced and results of evaluations are awaited for example use of coloured wristbands to facilitate easy identification of those at risk and a review of movement sensors. The Clinical Quality Team will monitor the progress of this work through attendance at the Quality Service Committee and this will facilitate joined working and feedback both to and from the CCG falls lead and other provider falls programmes. Safe Staffing Ashgreen (Hillside and Valley View) and Walton Hospital (Linacre and Melbourne Wards) reported shortfalls, at times, in qualified staff. In order to ensure patient safety, staff have been asked to flex across services. DCHSFT report that recruitment is on-going but that some posts are difficult to fill. Serious Incident Standards The CCG Clinical Quality Team continue to work closely with Providers to support improvements in the timeliness of reporting and the closure of serious incidents and the quality of investigation reports received. Further detail is outlined in the report below. Number of serious incidents Number of incidents reported within 2 days No of incidents reported breaching 2 day deadline Number of incidents closed Number of extensions requested Number of reports overdue 0 58

86 Serious Incidents (SI) Year to date the trust have reported a total of 121 serious incidents. During January 2016, the Trust made a 100% improvement reporting all SIs within the two working day deadline. DCHS Serious Incidents 2015/16 YTD Incident Type Nov-15 Dec-15 Jan-16 Pressure ulcer meeting SI criteria Slips/trips/falls meeting SI criteria Pressure Ulcer Incidents Number of pressure ulcers developed/deteriorated which have been reported onto the Trust DATIX system. Incident Type November 15 December 15 Pressure Ulcer Grade Pressure Ulcer Grade Pressure Ulcer Grade NB: These figures may differentiate from the previous month s data due to the data excluding Derby City. Safety Thermometer The Safety Thermometer records the prevalence of harm on a particular day each month and should be used alongside other data such as incident data to measure the quality of 59

87 care. The measures included are pressure ulcers, falls and urinary tract infections in patients with a catheter in situ. Please see the tables below for the 2014/15 Safety thermometer data. The harm free score for the Trust rehabilitation wards was 94.33% for December 2015 which was the best result for the calendar year 2015, and above the internal target of 94% for the first time for these wards. Pressure Ulcers The pilot motivational interviewing workshops for community staff have been completed. This project aims to ensure staff are adequately skilled to motivate patients and relatives in order to change behaviours. A patient story regarding a pressure ulcer will be presented to the DCHSFT board in January Discussions have taken place with DCHSFT with a view to developing a system to review pressure ulcers, in line with NHS England s Serious Incident framework, focussing on the level of harm to the patient and identifying any possible lapses in care. The Trust Patient Safety Lead is developing a matrix which will assist staff in decision making regarding the level of harm (to the patient) and the threshold for reporting as a serious incident. 60

88 Monthly trend December January YTD YTD The trust has begun to roll out a network of Safe Care Champions who will be monitoring standards within clinical areas focussing on key standards in relation to care planning and the skin bundle. Falls In November DCHSFT reported five falls in the above category, this dropped to zero in December Falls data is analysed by the Trust s falls prevention lead and will inform the Trust s falls prevention strategy. 6.4 Derbyshire Health United (DHU) Serious Incident Standards The Clinical Commissioning Group Clinical Quality Team continue to work closely with Providers to support improvements in timeliness of reporting and closure of serious incidents and the quality of investigation reports received. Further detail is outlined in the report below. During the last quarter the incidents have significantly reduced. The Assistant Chief Nurse and Head of Primary Care Quality regularly provide feedback on the reports which are reviewed and these have greatly improved to a high standard. Number of serious incidents Number of incidents reported within 2 days No of incidents reported breaching 2 day deadline Number of incidents closed Number of extensions requested Number of reports overdue 3 Year to date, the Trust have reported a total of 15 serious incidents. There were no SIs reported during January. 61

89 Monthly trend December January Care Quality Commission (CQC) DHU have received the draft report from CQC report detailing the outcome of the inspection on 10 th November The report is being checked for factual accuracy and the outcome of the inspection is expected to be published shortly. 6.5 Primary Care Serious Incident Standards The Clinical Commissioning Group Clinical Quality Team continue to work closely with Providers to support improvements in timeliness of reporting and closure of serious incidents and the quality of investigation reports received. This was a new responsibility for the CCG from 1 April 2015 as this was previously managed by NHS England. Further detail is outlined in the report below. Number of serious incidents 2 0 Number of incidents reported within 2 days No of incidents reported breaching 2 day deadline Number of incidents closed 1 0 Number of extensions requested 1 0 Number of reports overdue 1 62

90 Developments in Primary Care Chronic Kidney Disease Nurse Facilitator Jane Tyler has now been in post for five months working two days per week, covering both Hardwick and North Derbyshire Clinical Commissioning Groups. Jane is employed to roll-out the use of Improving Patient care and Awareness of Kidney disease Together (IMPAKT) Chronic Kidney Disease (CKD) tool by General Practice to improve CKD diagnosis and management in line with National Institute of Health and Clinical Excellence (NICE) guidelines. Also to support the implementation of an improvement programme aimed at improving the prevention of Acute Kidney Injury (AKI) and the detection and management of patients with AKI. Funding was awarded through the East Midlands Strategic Clinical Network in recognition of the lack of capacity and capability in Primary Care to focus in CKD patients, resulting in large variance in quality outcomes, with planned Quality Outcomes Framework (QOF) changes predicted this will make this even more difficult. Jane uses the IMPAKT software to identify and provide information to support practices to manage patients with CKD. The software is applied to the practices with the greatest need i.e. lowest quality outcomes. The IMPAKT tool analyses the practice patient list focusing on: Accuracy of existing coding of CKD Identifies un-coded patients Identifies high risk of progression and Cardiovascular Disease (CVD) Jane will provide guidance on the review of patients with high blood pressure, patients with proteinuria, review patients on nonsteroidal anti-inflammatory drugs (NSAIDs) and priorities as identified by the practice. Jane has visited 18 practices so far with additional visits arranged as appropriate. Care Quality Commission Update Two further practice reports have been published following visits by the Care Quality Commission (CQC) this quarter; summary of key findings include: 63

91 Killamarsh Medical Practice The surgery has received an overall rating of Good. Summary of key findings include: The practice had an open and transparent approach to safety and an effective system in place for reporting, recording significant events, and applied learning from events. Staff assessed patients needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment, and clinicians had lead areas of responsibility. Feedback from patients about their care was consistently and strongly positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Patients said they found it easy to make an appointment with a GP, and usually this was with a GP of their choice. Routine appointments could often be booked on the day and if not, they were available within two days. Urgent appointments were available the same day, and the practice offered additional appointments on a sit and wait basis at the end of each morning surgery. The practice offered a minor injuries service and data demonstrated that 28 of 30 patients who had accessed the service since April 2015, had been treated without the need for referral to another unit such as the Accident and Emergency (A&E) department. The practice used clinical audits to review patient care and took action to improve services as a result. The practice had good facilities and was well equipped to treat patients and meet their needs. This was to be enhanced by an extension, including seven new consulting rooms, which was under construction at the time of our inspection. The practice worked well with the wider multi-disciplinary team to plan and deliver effective and responsive care to keep vulnerable patients safe. This approach had impacted on unplanned hospital admissions and attendance at A&E. 64

92 There was a clear leadership structure and staff felt supported by management. Areas of outstanding practice highlighted: A community pharmacist visited weekly and worked with the practice and the CCG medicine management technician on a variety of prescribing matters. The pharmacist reviewed spirometry results and reviewed patients with diagnosed lung disease for advice and medication reviews. The pharmacist had also audited patients with atrial fibrillation to determine if anticoagulation therapy was required in line with recognised guidance. Approximately patients were seen by the pharmacist each month. The practice employed their own community matron and care co-ordinator who managed patients by developing individualised care plans involving the wider health and social care team. This helped to keep patients safe in their own home (and in care homes), and also facilitated earlier hospital discharges. Alongside the practice s proactive approach in providing good access to GP appointments, a measurable impact was seen in the lower attendance at out of hours and A&E services, and the lower rates of unplanned hospital admissions for this practice. Stubley Medical Centre The surgery has received an overall rating of Good. A summary of key findings include: The practice had been one of the lowest users of the out of hours service within the CCG over the last three years, and hospital admissions were also amongst the lowest despite the demographics of their patient profile (higher number of older patients and higher disease prevalence rates). Patients said they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment. There was a clear leadership structure and staff felt supported by management. There was evidence that staff worked together well as a team and proactively engaged with the wider multi-disciplinary team to improve patient care. 65

93 Patients needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and further training needs had been identified. Staff were supported to develop their skills and knowledge. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, there was not a consistent approach in how incidents were reported, although learning points were shared with the wider practice team. Risks to patients were generally assessed and well managed, with the exception of those relating to recruitment checks. Urgent appointments were available on the day they were requested. However, patients told the CQC that they sometimes had to wait a long time for non-urgent appointments. Information on making a complaint was not readily available, and verbal complaints were not always reviewed. However, we did see evidence that learning had been applied from written complaints. Areas of outstanding practice Highlighted: The practice had a designated champion for frail and older people. The role ensured patients could access help and care rapidly to meet their needs, allowing them to remain in their own home. This was achieved via a co-ordinated multi-disciplinary approach focussed upon a holistic and caring patient-centred approach. The proactive approach to more complex patients had reduced the number of hospital admissions and A&E attendances. The practice also had the lowest rate of emergency admissions for patients experiencing poor mental health. 6.6 Never Events and Grade 2 Serious Incidents Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented that have been laid down by the Department of Health. Grade 2 incidents are considered to be high risk and require a comprehensive investigation report and action plan. These must be monitored by the Quality Assurance Group to full completion. 66

94 A Never Event occurred at Nottingham University Hospitals (NUH) related to wrong administration of medication involving a patient of North Derbyshire. The investigation is being managed by Nottingham North and East, Nottingham West and Rushcliffe CCG and the full report will be shared with North Derbyshire CCG for comments. 6.7 Stockport FT The Safety Thermometer records the prevalence of harm on a particular day each month and should be used alongside other data such as incident data to measure the quality of care. The measures included are pressure ulcers, falls and urinary tract infections in patients with a catheter in situ. Please see the tables below for the 2015/16 Safety thermometer data. 6.8 Medicines Optimisation Electronic Frailty Index audit across NDCGG for SystmOne practices The Medicines Management Team have run the electronic Frailty Index audit in all SystmOne practices in the CCG. Frailty is a state of vulnerability to adverse outcomes; older people with frailty are at an increased risk of falls, disability, hospitalisation, care home admission and death. The electronic Frailty Index (efi) has been developed and validated using the ResearchOne database. It is based on the cumulative deficit model of frailty and uses existing electronic health record data to calculate a Frailty Index score. The approach used differs from an 67

95 admission prediction algorithm since many frail patients have not yet required admission, and some recently admitted patients may require readmission as part of their care. The pharmacists within the Medicines Management Team often use the efi to help prioritise patients for medication reviews. The results of the audit show that on average 12% of the SystmOne practices list size (practice range 8% to 15%) have an efi that is mild, 4% (practice range 2% to 6%) have an efi that is moderate, 2% (practice range 1% to 3%) have an efi that is severe, and overall 17% of the CCG list size is on the efi (practice range 11% to 24%). Post Splenectomy Audit The Medicines Management Team have audited in conjunction with CRHFT, patients that have had a splenectomy in the past year to ensure that they have received the follow up treatment and care that is recommended. Vaccinations Pneumococcal Vaccine (Pneumovax II) No. of patients administered by CRH 6 - Of these given by hospital, number Read coded on GP clinical system 5 No. of patients with a recall on GP clinical system for revaccination 1 (recommended every 5 yrs) H.influenzae type b vaccine/meningococcal Group C (Hib/MenC Menitorix ) No. of patients administered by CRH 6 - Of these given by the hospital, number Read coded on GP clinical system 5 Meningococcal Group B vaccine (Bexsero ) No. of patients administered by CRH 3 - Of these given by hospital, number Read coded on GP clinical system 3 No. given by GP surgery 0 Influenza vaccine No. of patients administered by CRH 1 - Of these given by hospital, number Read coded on GP clinical system 1 No. given by GP surgery 5 No. of patients with a recall on GP clinical system for revaccination 1 (recommended every yr) Meningococcal ACWY Conjugate vaccine (Menveo ) No. of patients administered by CRH 2 Of these given by hospital, number Read coded on GP clinical system 1 No. given by GP surgery 3 Meningococcal Group B vaccine (Bexsero ) No. of patients administered by CRH 0 Of these given by hospital, number Read coded on GP clinical system NA No. given by GP surgery 3 68

96 The vaccination results highlight that practices may need to consider processes to remind patients that they require an annual flu vaccine and a 5-yearly pneumococcal vaccine. Only half of the patients had received the Meningococcal Group B vaccine however this was newly introduced mid-year. Antibiotics: No. of patients prescribed the recommended prophylactic antibiotics : (Phenoxymethylpenicillin 250mg BD, if penicillin allergic: Clarithromycin 250mg BD) No. patients regularly ordering prophylactic antibiotic from GP practice? 6 No. of patients given a supply of rescue antibiotics: 5 (Amoxicillin 500mg 1g TDS, if penicillin allergic clarithromycin 500mg BD) No. of patients who, since the splenectomy, have had an infection requiring antibiotics? (Looking back through the consultations) If the rescue antibiotics have been used have they been issued with a new supply? 6 (2 patients with pen v 500mg BD) 4 1 (other 3 didn t use rescue all came straight to GP for antibiotics) The antibiotics audit highlighted that some patients continued to receive the previously recommended higher dose of phenoxymethlypenicillin, which have now been reduced as a result of this work. Many patients were over ordering prophylactic antibiotics, the relevant practices are now reviewing their processes to reduce inappropriate antibiotic prescriptions. Additionally the Medicines Management Team contacted the patients to confirm that the patient s rescue antibiotics were still in date, and that they had a splenectomy alert card (for one patient this was printed and sent to them). PINCER intervention roll-out across North Derbyshire and Hardwick CCGs The PINCER trial was developed to study whether a pharmacist-led IT-based intervention could reduce medication error rates in the primary care setting. Results, published in the Lancet in 2012, showed that the PINCER intervention is an effective and cost effective method for reducing a range of clinically important and commonly made medication errors. The Medicines Management Team is currently working with the East Midlands PINCER project to roll out the intervention across North Derbyshire and Hardwick CCG GP practices and evaluate outcomes over the following 18 months. 69

97 During February and March 2016, the Medicines Management Team technicians will run the PINCER searches on the GP clinical systems to identify patients who may be at risk of a range of common and important prescribing and drug monitoring errors. The Medicines Management Team will then meet with each GP practice to discuss the results of the searches and agree an action plan to correct the errors identified as well as reviewing the systems and processes within the practice to help minimise the errors occurring in the future. The PINCER searches will be run periodically until the end of 2017 to assess outcomes and progress with the aim of reducing prescribing errors, reducing admissions due to medications, improving patient safety and providing cost savings to the NHS. 6.9 Patient Experience Lay Reference Group (LRG) On 22 nd January 2016 the LRG had two presentations. Below is a summary of each presentation with the LRG action/outcome. Positive Outcomes: 1. Louise Swain presented the pre-consultation programme Commissioners Working Together where NHS commissioners working across South and Mid Yorkshire, Bassetlaw and North Derbyshire are working to improve services for Children s surgery and anaesthesia and in Critical Care for people who have had a stroke. Lay Members were asked for their views on the approach to transform these services across a wider geographical area using a hub and spoke approach over North Derbyshire, Yorkshire and Humberside. It was highlighted that further information would follow at the beginning of June 2016 at which point the consultation proposals would be detailed. Lay Rep Outcome: The outlined approach to transformation was welcomed and the Lay Members were very pleased to have been included in the pre-consultation stage. They wait 70

98 with anticipation as to the proposals and how this might impact on North Derbyshire patients. They felt that the views of parents should be canvassed separately. 2. Adam Sutherst presented the North Derbyshire CCG weekly Performance Brief highlighting performance figures for referrals to treatment, diagnostics, cancer, 111, East Midlands Ambulance Service (EMAS), A&E, Colstridium Difficile, contract penalties, transforming care, continuing healthcare, dementia and CPA Follow ups. Lay Rep Outcome: The information was very much welcomed by the Lay Members and they asked that they be sent a copy of the brief once a month, two weeks before the next Lay Reference Group so that they could have time to digest and reflect on the insight ready for discussion at the Lay Reference Group. In addition the Lay Members also raised concerns around the following areas: Area for improvements: 1. Lay Members did not feel assured or felt that they had seen robust evidence to explain the continued poor performance of EMAS. Lay Rep Outcome: Lay Members will receive comparison data across other ambulance operators across the Country to see if it s a national problem. 2. Lay Members raised concern over the lack of patient and staff understanding of patient records what is available to whom; how and where do you access the information from? Lay Rep Outcome: A Lay member agreed to consider and summarise the NHS Choices information on patient records. Further discussions have been arranged and are on the February 2016 agenda for the Lay Reference Group. The North Derbyshire CCG communication officer will be invited to attend. 3. Lay Members raised difficulties experienced in accessing the Healthwatch website. It was also noted that it was confusing to members of the public when trying to find the right mechanism to feedback about the NHS. Lay Rep Outcome: Louise Swain is reviewing the mechanisms currently available for the public to leave feedback about ND NHS. This will involve: the development of a new 71

99 feedback logging tool called DATIX used within the CCG; information about PALs and complaints services in the CCG and provider organisation; as well as within NHSE and; and information about the role of Healthwatch. On completion of the review, an awareness raising campaign will be launched in April 2016 to help the public navigate the range of mechanisms. 4. A Lay Member questioned the policy of patients not being able to pay for flu vaccinations at their own practice whilst being allowed to purchase and have the vaccination at a neighbouring practice. Lay Rep Outcome: This query has been passed to the Primary Care Co-commissioning Team. PPG Network Meetings Four PPG Network meetings we held in January 2016 including North East, Chesterfield, Dronfield and North Dales. The High Peak meeting was cancelled due to illness. Common themes being discussed across the network included patient experience stories about poor communication in hospital and the discharge process from acute hospital and discharge pathways into the community and how communication between agencies could be improved. It was acknowledged that ophthalmology had seen improvements along with urology diagnostics. Also there was a lot of debate about the 21c proposals and how the PPG Network structure of meetings would fit with the emerging 21c communities. In particular the Nth East and Dronfield Networks were very keen to have clarification over the transformation of the locality groups into the new community group arrangements and how this would impact on them. (The proposed structure would mean that 3 practices currently sitting in the NEL5 Network would, under the new arrangements, sit in the NE and Hardwick Community Group with the 2 other practices currently sitting with the NEL5 network moving to the Dronfield Community Group.) PPG Network Outcome: A meeting has been arranged on 2 nd March 2016 for all chairs and vice-chairs of the five PPG Network groups and a range of Lay Members to meet. The main purpose will be to start to develop a better patient experience approach across the wider NHS system. Outcomes from this meeting will be shared in the March 2016 Quality Report. 72

100 6.11 Mental Health A Mental Health stakeholder event was held in the High Peak 3 rd February The event was very well attended by GPs, providers and representatives across the voluntary sector. The focus was on the High Peak Vision for Mental Health and provided an opportunity to share broad commission intentions, identify specific priorities for the High Peak population and start the conversation to what works well and what we can work together to deliver differently. An action from this year s event has been to create a distribution list to share ideas, projects and innovation across all stakeholders as it was clear that much is being done to support meeting the needs for this population group but there are gaps in people s knowledge regarding what is available where. Also in the High Peak in February two Dementia Support Workers have commenced in post. These two staff are based within the Stewart Medical Practice and are employed by Derbyshire Healthcare Foundation Trust (DHcFT). The posts are funded through the East Midlands Innovation fund for just over 12 months. Key Performance Indicators are being identified to support the evaluation of these posts. Amongst other functions, these roles will aim to: Act as a single point of access for people with dementia and their carers, for support and advice Carry out effective signposting to a wide range of dementia support services in the local area Work within primary care, linked to the integrated care co-ordinators and linked CPN from the CMHT to allow a release in time for CPNs to support diagnosis, and integrated care MDT engagement Help with crisis care planning and provide some level of in-reach support into hospital for any people admitted to a hospital bed Establish close working links with the Older People s Mental Health Consultant Psychiatrist to allow seamless transition of care Support practices in managing the dementia database and provide support for the establishment of consistent recording within patient medical records Pre-screen patients with a concern about memory possibly using new technology (eg CANTAB mobile etc.) to support a reduction in worried but well referrals Liaise with the existing dementia support service major area of benefit for early diagnosis patients and carers 73

101 In addition to the posts described above the CCG is working with DHcFT and Thorn Brook Surgery to recruit a Primary Mental Health Support Worker to work with adults experiencing mental health difficulties. This post holder will be employed by DHcFT but work as part of the Primary Care Practice. 11 applications have been received and interviews are being coordinated. In North Derbyshire s Child and Adolescent Mental Health Services (CAMHS) the CCG and Local Authority is working with Chesterfield Royal Hospital Foundation Trust (CRHFT) to support the implementation of the Derbyshire Future in Minds (FiM) Plan. CAMHS has received instruction from the CCG to recruit to the Eating Disorder Team. Information about the FiM plan can be found here: Wait times within CAMHS remains a concern (currently at 12 weeks) and additional funding has been offered to the service to support an immediate reduction in wait times. The CCG will continue to work with the team to identify ways in which additional capacity can be realised. The Local Authority and CCG have commissioned Relate Derby and Southern Derbyshire s children and young people s counselling service (Safe Speak) to provide additional support for children from the age of 5 years upwards. Safe Speak enables access to services in the Chesterfield area for face to face and live chat counselling. The Safe Speak counsellors work with a wide range of issues covering self-esteem and emotional difficulties. E.g. bereavement and loss, self-identity, sexuality, feeling low, unusual feelings, abuse, relationship breakdown or difficulty, domestic violence, self-harm, mild to moderate depression, not coping, stress, academic stress and friendships. It is anticipated that this supplementary service will have a positive impact on wait time for CAMHS overall. One of the aims for CAMHS is that by 2018 they be fully compliant with the values and standards as laid out in the Children and Young Person (CYP) Improving Access to Psychological Therapy (IAPT) document Delivering With and Delivering Well. North Derbyshire CAMHS are committed to the further development of the service in line with the aspirations as described with the FiM Transformation Plans. The service has invested in accredited training for clinicians to deliver a range of evidence based 74

102 interventions including CBT, Family Therapy and IPT, which are all central to IAPT compliance. An important step towards this aim is joining the North West CYP IAPT Learning Collaborative in the summer of As members of an IAPT Collaborative, the service will benefit from access to further training in relevant evidence based interventions, supervision and transformational leadership. A significant challenge for CAMHS is the ability to collate data as is a requirement of becoming IAPT compliant. The Child Outcomes Research Consortium (CORC) has worked with CRHFT to identify a possible interim measure to support improvement in data collection; SystmOne however is the Trust s current Electronic Patient Record and work is underway to assess the feasibility of additional licenses being made available to support CAMHS data collection. The Trust is aware this is a service risk and is a high priority to provide adequate system. 75

103 Quality Premium 2015/16 The quality premium was introduced nationally in 2013/14 to reward CCG s for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reducing inequalities. This report provides a high level assessment of CCG performance year to date. It should be noted that payment is largely dependent on end of year achievement. As such, some data is not available at the present time and the report should therefore be viewed in this context. 76

104 The purpose of this dashboard is to give NHS North Derbyshire CCG an insight into their current progress against the Quality Premium requirements for 2015/16. The full potential value of the Quality Premium is 1,400,000 based on NHS North Derbyshire CCG's current registered population of 280,000 patients, though the actual amount awarded is dependent on fulfilling the criteria stated below. There are 2 sections, Quality Premium Measures, passing these makes up the initial value of the Quality Premium, and NHS Constitutional Rights & Pledges, failing these will result in a percentage reduction in the sub-totaled value of the Quality Premium Measures. These factored together create the total quality premium amount applicable. Quality Premium Measures Threshold for Achievement Period (E.A.1) Potential Years Of Life Lost (PYLL) From Causes Considered Amenable To Healthcare Reduction of 1.2% or greater from 2012 to (E.A.4) Composite Measure On Emergency Admissions Increase In The Number Of Patients Admitted For Non-Elective Reasons Who Are Discharged At Weekends & Bank Holidays No Change or a reduction from 2012/13 to 2015/16 or a rate below 1000 per 100,000 population 0.5% Increase from 2014/15 to 2015/16 or greater than 30% in 2015/16 Reduction in the number of patients attending an A&E department for a mental health-related needs 90% To Be Correctly Coded who wait more than four hours to be treated and discharged, or admitted, together with a defined Proportion of Patients in A&E less than 4 Hours improvement in the coding of patients attending A&E. to be 95% or Greater A reduction in the difference between the health Improvement in the health related quality of life for people with a long term mental health condition related quality of life for people with All LTCs and Mental Health LTCs Improving Antibiotic Prescribing: a) Reduction In The Number Of Antibiotics Prescribed In Primary Care Reduction of 1% or greater from 2013/14 to 2015/16 Improving Antibiotic Prescribing: b) Reduction In The Proportion Of Broad Spectrum Antibitoics Reduction of 10% or greater from 2013/14 to Prescribed In Primary care 2015/16 or below 11.3% (England Median) Improving Antibiotic Prescribing: c) Secondary Care Provider Validating Their Total Antibiotic Major Providers to CCG (10%+) Have Validated Prescription data Their Antibiotic Prescribing Data 2013/14 Target YTD 2012 FYO /13 FYO 2274 Current YTD Performance Forecast RAG Rating % Of QP Potential Value Forecast Value % 140, , % 210,000 15% 210,000 10% 140,000 C1.2 Under 75 mortality rate from cardiovascular disease To Be Defined 10% 140,000 C2.3 People with COPD and Medical Research Council (MRC) Dyspnoea Scale 3 referred to a pulmonary rehabilitation programme. To Be Defined 10% 140,000 Sub-Total 100% 1,400, ,000 NHS Constitution Rights & Pledges Threshold for Achievement Period Baseline data and collections to be defined. The report will be updated once these are available Target YTD Current YTD Performance Forecast RAG Rating % Of Deduction (E.B.3) Referrals To Treatment Incomplete Pathways - % Within 18 Weeks 92% or greater monthly average for 2015/16 Dec-15 92% 93.6% 30% 42,000 20% 10% 280, ,000 Potential Deduction Forecast Deduction Indicator currently achieving / has achieved the Quality Premium requirements Indicator currently not achieving Quality Premium requirements but in a position where achievement is still possible Indicator has failed to meet Quality Premium requirements or is in a position where it will be not be achieved RAG Rating Key: (E.B.5) A&E Waiting Time - Proportion With Total Time In A&E Under 4 Hours 95% or greater for 2015/16 Dec-15 95% 95.3% 30% 42,000 (E.B.6) All Cancer Two Week Wait - Proportion Seen Within Two Weeks Of Referral 93% or greater for 2014/15 Dec-15 93% 94.1% 20% 28,000 28,000 (E.B.15.i) Ambulance - Proportion Of Category A (Red 1) Calls With Response Within 8 Minutes 75% or greater for 2014/15 Jan-16 75% 71.2% 20% 28,000 28,000 Total Deduction (to be subtracted from Quality Premium Total 100% 140,000 56,000 Grand Total 84,000 77

105 ND CCG Governing Body Assurance Committee 22nd February 2016 Paper E NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE 22nd February 2016 Report Title: Governing Body Assurance Framework Update Item No: 6 1. Background and context The Governing Body Assurance Framework provides a structure and process that enables the organisation to focus on the risks that might compromise the CCG in achieving its corporate objectives. It also maps out both the key controls that should be in place to manage those objectives, and confirm that the Governing Body has sufficient assurance about the effectiveness of the controls. The Governing Body must be appropriately engaged in developing and maintaining the Governing Body Assurance Framework to probe, discuss and advise so that updates to action plans can be made as required. 2. Key matters for consideration The Governing Body are refreshing and reviewing its Assurance Framework for 2015/16 to reflect any changes/areas of key focus for the CCG. The CCG has 5 principle risks which are reviewed and reported to the Governing Body Assurance Committee each month. One of the principle risks will be reviewed and discussed/challenged further at each of the meetings. Principle risk 3 will be reviewed at the February 2016 Governing Body Assurance Committee. 3. Financial Impact There is no direct financial impact arising although effective risk management will enhance best use of limited resources and provide a focus for CCG activity. 4. Analysis of risk The Governing Body Assurance Framework will provide a process for the management of the principal risks to the CCG in achieving its strategic aims and objectives. 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all: risks that are not appropriately identified and managed can have a negative impact on the planning of healthcare systems, the equitable delivery of healthcare, and the CCG s ability to deliver its objectives across a wide range of outcomes Improved patient access and experience: the risk management process is designed to assist managers identify those issues that would negatively impact on 1

106 patient access and the patient experience. By identifying and resolving such risks before they have chance to manifest it inherently improves the chance of patients having good access and experience. Empowered, engaged and well-supported staff: the barriers preventing staff from being empowered, engaged and well-supported are all risks to the CCG s effective delivery of its objectives and duties and therefore should be identified and managed in line with the CCG s risk management strategy. Where such risks are recorded on the register they will be included in future reports to the committee Inclusive leadership at all levels: the CCG s risk management strategy and supporting processes are designed to secure buy-in and engagement from managers at all levels to look at any issue that would negatively impact on stakeholders and to resolve them. 6. Recommendations The Governing Body is asked to receive the update with regard to the review of the Governing Body Assurance Framework. Author: Suzanne Pickering, Head of Governance Sponsor: Suzanne Pickering, Head of Governance Date: 12 th February

107 North Derbyshire CCG: Summary of Governing Body Assurance Framework February 2016 Introduction The Governing Body Assurance Framework aims to identify the principal or strategic risks to the delivery of the CGG s strategic aims/objectives. It sets out the controls that are in place to manage the risks and the assurances that show if the controls are having the desired impact. It identifies the gaps in control and hence the key mitigating actions required to reduce the risks towards the target or appetite risk score. It also identifies any gaps in assurance and what actions can be taken to increase assurance to the CCG. The table below sets out the North Derbyshire CCG strategic aims lists the principle risks that relate to them, and highlights where gaps in control or assurance have been identified. Further details can be found on the extract pages for each of the Principle Risks. The Strategic Aims of North Derbyshire CCG are: 1: Transform Primary Care 2: Develop integrated models of care 3: Redesign urgent and emergency care 4: Improve the management of long term conditions 5: Focus on prevention/ self-management 6: Review the productivity of elective care Principle Risk(s) Risk Owner Initial Score Current Score Risk Appetite Gaps in control Gaps in assurance 1. If the CCG does not achieve financial balance there is the risk that it will impact on CCG achieving its statutory duty and maintaining its autonomy. Darran Green Hold GP s to account for clinical variation and QIPP Joint Commissioning assurance st Century Transformation impacts on the delivery of the CCG s medium and long term financial targets 3. The potential difficulties of working with partner organisations and the financial challenges they face impacts on the delivery and success of 21st Century Transformation Darran Green m QIPP gap Beverley Smith Organisational Capacity Programme Management Office Provider 5 year transformation financial plans 4. Increase in CCG workload resulting from NHS England requirements for the CCG s organisational capacity to deliver its objectives whilst remaining within the Management Running Cost Allowance of per head of population. Mark Smith Increase in Workload from NHS England Manage expectations of Providers 5. Financial pressures on the CCG s providers has an effect on the quality of services which ultimately affects the health outcomes of the North Derbyshire CCG population Jayne Stringfellow Lack of robust methodology to monitor > in clinical outcomes Information flow from contract leads by other CCG s

108 North Derbyshire CCG: Summary of Governing Body Assurance Framework

109 Principle Risk: (1) If the CCG does not achieve financial balance there is the risk that it will impact on the CCG achieving its statutory duty and maintain its autonomy. What would success look like? That the CCG achieves financial balance as well as remaining in current balance. Positive outcomes from quarterly review meetings with NHS England. Risk rating Likelihood Consequence Total Strategic Aim : 1, 2, 3, 4, 5, 6 Risk register: Extreme High Moderate Principle threat(s) to delivery of the strategic aim Providers are under pressure financially Increase in older patients accessing the services Demographics Changes to Tariff Changes to legislation e.g. Continuing Health Care Over Performance of contracts PR1 Risk Score Clinical / Lay Lead Ian Gibbard/Joanne Winfield Executive Lead Darran Green Committee Governing Body / GBAC Initial Rationale: M8 position indicates that FOT continues to show achievement of target Current surplus. Risks still in Acute care, CHC and GP PR1 Risk Score prescribing but quantified level of risk can be 0 fully mitigated by contingency and other reserves. Appetite Key controls to mitigate threat: Strong Governance Structure with Lead Contracts Contract Monitoring Board (CMB); Contract Monitoring Group (CMG) ; Quality Assurance Group (QAG) Governing Body Assurance Committee (GBAC) & Governing Body (GB) Contracts Coordination Group Robust Financial Planning and 2015/2016 Financial Plan April May June July Aug Sept Oct Nov Dec Jan Feb Mar Date reviewed February 2016 Sources of assurance Meeting Minutes of CMB, CMG and QAG standing agenda item for GBAC Meeting Minutes of GBAC and GB Meeting Minutes of Contracts Coordination Group Monthly Finance Report and Integrated Finance, Quality Improvement & Performance Report Meeting Minutes Significant Assurance received on Internal Audit Reviews Board to Board meetings with Lead Providers Internal Audit and External Audit Qualified Finance Department Commissioning Prioritisation Group Gaps in control Positive assurances received How the CCG will hold the GP s to account for referral patterns, clinical variation and QIPP Integrated Finance, Performance and Quality Improvement Report Quarterly Finance Report submitted to Area Team Significant assurance from Internal and External Audit Challenge from GB Lay Representatives and Governing Body Gaps in assurance Joint Commissioning assurance, the CCG does not have control over what we do not commission Actions being taken to address gaps in control / assurance Formal monitoring of agreed QIPP schemes with reports required monthly to NHS E external and Senior Leadership Team. Identifies underachievement early, allowing time for remedial action.

110 Principle Risk: (2) 21 st Century Transformation impacts on the delivery of the CCG s medium and long term financial targets Strategic Aim : 1, 2, 3, 4, 5, 6 Risk register: Extreme High Moderate Clinical / Lay Lead - Ben Milton Executive Lead Darran Green Committee GBAC, Governing Body, CPRG What would success look like? The CCG, Providers and Partner are successful deliver in the system transformation across North Derbyshire. Risk rating Likelihood Consequence Total Initial Principle threat(s) to delivery of the strategic aim Partners withdraw from the 5 year plan Failure to deliver the 5 year plan Providers deliver but fail to achieve financial balance Fall over even though achieve the system plan Achieve success but fail to deliver the system plan PR2 Risk Score PR2 Risk Score Date reviewed February 2016 Rationale: Current Appetite April May June July Aug Sept Oct Nov Dec Jan Feb Mar Key controls to mitigate threat: All Provider and Partner Chief Officers are signed up to the 5 year plan. GE Healthcare providing consultant advice on the leadership of the 5 year plan. Unit of Planning between North Derbyshire and Hardwick CCG to implement transformation across North Derbyshire Programme Governance Structure in place Clinical and Professional Reference Group established and in operation Prioritisation of cross system initiatives identified for immediate focus on the delivery of plan 21st Century Programme Board Programme Management Office in place to support system transformation Gaps in control Impact of Greater Manchester Transformation Impact of Organisational Capacity Gap of 11.5m QIPP Gaps in assurance All Provider organisations have now endorsed the system plan at Board level. All workstreams now have identified support from provider organisations at Exec/ Clinical Lead and Project Manager level. Both CCG Directors of Finance providing detailed analysis in relation to 5 year plan to allow providers to produce individual plans Sources of assurance Northern Derbyshire Unit of Planning 5 year system plan Financial waterfall plan established to identify disinvestments and investments Clinical and Prioritisation Reference Group minutes, 21 st Century Plan Delivery Group Minutes and action log. Community Hubs Strategic Outline Case now being delivered at geographic community level with all partners engaged including lay representation CPRG meets monthly and meeting actions produced. Geographical Community Operational weekly All work streams established and reporting to CPRG and PDG Sign up to system plan now embedded with all main provider organisations and governed by 21C Programme Delivery Group Plan Delivery Group Positive assurances received Community Hub Strategic Outline Case, Scoping of priority work streams complete, Consistent messages presented to all CCG and Provider Boards. Actions being taken to address gaps in control / assurance Generic Board papers being presented at each CCG and Provider Boards monthly giving consistent update. Programme structure and summary of initiatives finalised and responsible lead identified. Financial waterfall plans to be produced for all Provider organisations.

111 Principle Risk: (3) The potential difficulties of working with partner organisations and the financial challenges they face impacts on the delivery and success of 21 Century Transformation Strategic Aim : 3 Risk register: Extreme High Moderate Clinical / Lay Lead - Ben Milton Executive Lead Beverly Smith Committee GBAC, Governing Body, CPRG What would success look like? The CCG, Providers and Partner successfully deliver the system transformation plan across North Derbyshire. Principle threat(s) to delivery of the strategic aim Partners withdraw from the 5 year plan Failure to deliver the 5 year plan Providers deliver but fail to achieve financial balance Fall over even though achieve the system plan Risk rating Likelihood Consequence Total PR3 Risk Score Initial Rationale: 20 Current PR3 Risk Score Appetite April May June July Aug Sept Oct Nov Dec Jan Feb Mar Date Reviewed February 2016 Key controls to mitigate threat: All Provider and Partner Chief Officers are signed up to the 5 year plan. GE Healthcare providing consultant advice on the leadership of the 5 year plan. Unit of Planning between North Derbyshire and Hardwick CCG to implement transformation across North Derbyshire Programme Governance Structure in place Clinical and Professional Reference Group (CPRG) established and in operation Prioritisation of cross system initiatives identified for immediate focus on the delivery of plan 21st Century Programme planned Delivery Group (PDG) Programme Management Office in place to support system transformation Gaps in control Impact of Greater Manchester Transformation Impact of Organisational Capacity Gap of QIPP (currently ~ 12M for 2016/17) Gaps in assurance Sources of assurance Northern Derbyshire Unit of Planning 5 year system plan Financial waterfall plan established to identify disinvestments and investments Clinical and Prioritisation Reference Group minutes, 21 st Century Plan Delivery Group Minutes and action log. Community Hubs Strategic Outline Case now being delivered at community level with all partners engaged including lay representation CPRG meets monthly and meeting actions produced. Community Operational weekly All work streams established and reporting to CPRG and PDG Sign up to system plan now embedded with all main provider organisations and governed by 21C Programme Delivery Group Plan Delivery Group Positive assurances received. Community Hub Strategic Outline Case, Scoping of priority work streams complete, Consistent messages presented to all CCG and Provider Boards. Actions being taken to address gaps in control / assurance Generic Board papers being presented at each CCG and Provider Boards monthly giving consistent update. Programme structure and summary of initiatives finalised and responsible lead identified. Financial waterfall plans to be produced for all Provider organisations.

112 Principle Risk: (4) Increase in CCG workload resulting from NHS England requirements for the CCG s organisational capacity to deliver its objectives whilst remaining within the 2015/2016 Management Running Cost Allowance of per head of population. Strategic Aim : 1, 2, 3, 4, 5, 6 Risk register: Extreme High Moderate Clinical / Lay Lead Ian Gibbard/Joanne Winfield Executive lead Mark Smith Committee GBAC What would success look like? CCG achieve its strategic aims and objectives Risk rating Likelihood Consequence Total Principle threat(s) to delivery of the strategic aim Need for continual development of staff team to adopt new ways of working and to manage ambiguity Restricted management cost allowance which is due to decrease further in future years Further restrictions now imposed on use of consultancy and interim staff Increased focus on delivery and activity at acute trusts has diverted financial and people resource Date reviewed February 16 Initial Rationale: Risk score has been increased as the workload Current pressures are currently high. CCG PR4 Risk Score is also reliant on a small number of Appetite external consultancy staff for 0 which we must find a succession plan. April May June July Aug Sept PR4 Risk Score Oct Nov Dec Jan Feb Mar Key controls to mitigate threat: Recruitment and selection process to attract the right talent and skills Succession planning and talent management plans in place to support capacity issues CCG commissioned leadership development programme and coaching Staff Engagement Group run by Chief Officer Business Continuity plans in place Joint working across the Northern Derbyshire Unit of Planning but could be increased Consultancy support commissioned to fill capacity and capability gaps Gaps in control Capacity is under constant review Succession plan for programme directors Sources of assurance Staff survey results, staff appraisals, vacancy levels, turnover rates, sickness and absence rates, grievance and disciplinary rates Numbers of people on talent management programme Number accessing EMLA or other development opportunities Notes of meetings Business Continuity Plan Joint working in roles across ND and HCCG to avoid duplication and create capacity Positive assurances received Part of 21c risk register and discussion at PDG. Discussions across all providers about how workload is shared Being discussed 21c programme, Capacity and capability requirements being scoped by end of June Primary care Co commissioning may create a capacity and capability issue 2015/2016 Organisational Development Programme in place to support 5 year plan. Gaps in assurance Actions being taken to address gaps in control / assurance 21c programme support not fully in place Scoping work on future requirements due by end of June 2015

113 Principle Risk: (5) Financial pressures on the CCG s providers has an effect on the quality of services which ultimately affects the health outcomes of the North Derbyshire CCG population What would success look like? The CCG can demonstrate that patients receive high quality, evidence based, person centered care from all providers of healthcare. Providers are providing and maintaining high quality of care. Risk rating Likelihood Consequence Total April Strategic Aim :1,2,3,4,5,6, Risk register: Extreme High Moderate Principal threat(s) to delivery of the strategic aim May Providers are not performance managed Providers do not follow best practice guidance to improve health outcomes Providers cannot recruit the required workforce Clinical / Lay Lead: David Collins, Gary Apsley Executive lead: Jayne Stringfellow Committee: GB, GBAC, HWB Increasing demands from non-elective admissions, increased acuity & complexity of patients & June July Aug Sept PR5 Risk Score Initial Rationale: Current Appetite Oct Nov Dec Jan Feb Mar PR5 Risk Score Date reviewed February 2016 Key controls to mitigate threat: Governance structure for Lead contracts including Contract Management Board, Quality Assurance Group, Contract Management Group Patient Experience and Safety Committee, External audit review of quality monitoring Clinical Reference Group Governing Body Assurance Committee & Governing Body Contract Co-ordination Group Robust quality monitoring systems and processes CQUIN schemes Board to Board meetings with lead providers Gaps in control Lack of robust methodology to monitor improvement in clinical outcomes. Gaps in assurance Information flow from contracts lead by other CCGS Sources of assurance Minutes of all meetings listed in key controls Monthly integrated finance, performance and quality report CQC intelligent Monitoring and ratings Significant assurance received on quality monitoring of secondary care contracts Quality visits National and local quality metrics and intelligence Basket of services review SQI visits Strengthening of quality schedule and reporting in the contracts process Schedule of review quality assurance by internal Audit in Q4 Positive assurances received Integrated Finance, Performance and Quality Report Significant assurance from external audit review of quality monitoring and patient and public involvement. Approved by external audit and changes to quality monitoring for 15/16. Actions being taken to address gaps in control / assurance Strengthening involvement across contracts led by other CCGs CCG involvement in older people s mental health and learning disability transformation programs Development of Clinical Policies and Guidelines Group led by GPs Identifying financial risks associated with CHC and system transformation External review of CHC. Primary Care Dashboard

114 Principle Risk: (3) The potential difficulties of working with partner organisations and the financial challenges they face impacts on the delivery and success of 21 Century Transformation Strategic Aim : 3 Risk register: Extreme High Moderate Clinical / Lay Lead - Ben Milton Executive Lead Beverly Smith Committee GBAC, Governing Body, CPRG What would success look like? The CCG, Providers and Partner successfully deliver the system transformation plan across North Derbyshire. Principle threat(s) to delivery of the strategic aim Partners withdraw from the 5 year plan Failure to deliver the 5 year plan Providers deliver but fail to achieve financial balance Fall over even though achieve the system plan Risk rating Likelihood Consequence Total PR3 Risk Score Initial Rationale: 20 Current PR3 Risk Score Appetite April May June July Aug Sept Oct Nov Dec Jan Feb Mar Date Reviewed February 2016 Key controls to mitigate threat: All Provider and Partner Chief Officers are signed up to the 5 year plan. GE Healthcare providing consultant advice on the leadership of the 5 year plan. Unit of Planning between North Derbyshire and Hardwick CCG to implement transformation across North Derbyshire Programme Governance Structure in place Clinical and Professional Reference Group (CPRG) established and in operation Prioritisation of cross system initiatives identified for immediate focus on the delivery of plan 21st Century Programme planned Delivery Group (PDG) Programme Management Office in place to support system transformation Gaps in control Impact of Greater Manchester Transformation Impact of Organisational Capacity Gap of QIPP (currently ~ 12M for 2016/17) Gaps in assurance Sources of assurance Northern Derbyshire Unit of Planning 5 year system plan Financial waterfall plan established to identify disinvestments and investments Clinical and Prioritisation Reference Group minutes, 21 st Century Plan Delivery Group Minutes and action log. Community Hubs Strategic Outline Case now being delivered at community level with all partners engaged including lay representation CPRG meets monthly and meeting actions produced. Community Operational weekly All work streams established and reporting to CPRG and PDG Sign up to system plan now embedded with all main provider organisations and governed by 21C Programme Delivery Group Plan Delivery Group Positive assurances received. Community Hub Strategic Outline Case, Scoping of priority work streams complete, Consistent messages presented to all CCG and Provider Boards. Actions being taken to address gaps in control / assurance Generic Board papers being presented at each CCG and Provider Boards monthly giving consistent update. Programme structure and summary of initiatives finalised and responsible lead identified. Financial waterfall plans to be produced for all Provider organisations.

115 Hardwick Clinical Commissioning Group TRANSFORMING CARE LEARNING DISABILITIES A PARTNERSHIP APPROACH IN DERBY CITY AND DERBYSHIRE COUNTY PURPOSE: FOR ASSURANCE KEY POINTS SUMMARY Across the country newly formed Transforming Care Partnership Boards are tasked with improving the outcomes for people, across all ages, with a learning disability and/or autism through the delivery of a robust and sustainable plan that: - o o o Reduces reliance on inpatient services (closing hospital services and strengthening support in the community) Improves quality of life for people in inpatient and community settings Improves quality of care for people in inpatient and community settings National guidance expects transforming care partnership boards to be established on large footprints of around 1 million populations. There has been effective and well established partnership working across health and social care in Derby City and Derbyshire County; undertaking care and treatment reviews; increasing the numbers of people who are supported in a non - hospital environment; planning the transformation of care. Existing effective partnerships have led to an agreed footprint of Derbyshire and Derby City. The Transforming Care Board is established with terms of reference and an agreed membership National and locally there is a recognition for programme resourcing. Funding is expected to be secured through BCFs. Recruitment is underway. There is also a need to identify additional clinical capacity from within the system to undertake care and treatment reviews. A plan to transform care for all ages will need to be developed by 8 th February Further national guidance is awaited and the Transforming Care Board will meet on the 28 th January 2016 to focus on the development of the plan, building on the excellent work undertaken in the city and north of the county. SRO for Transforming Care will be CO Hardwick CCG, who will also be Co - Chair of the Transforming Care Partnership Board along with Director of Adult Social Care, Derbyshire County Council Progress and assurance on the whole programme will be shared on a regular basis to Health and Well Being Boards, CCG Governing Bodies and partner organisations 1

116 Hardwick Clinical Commissioning Group TRANSFORMING CARE LEARNING DISABILITIES A PARTNERSHIP APPROACH IN DERBY CITY AND DERBYSHIRE COUNTY CONTEXT AND NATIONAL EXPECTATIONS Since the investigation into the abuse at Winterbourne View and other similar hospitals, there has been a cross-government commitment to transform care and support for people with a learning disability and/or autism who display behaviour that challenges, including behaviour that can lead to contact with the criminal justice system. The national focus and direction over the last 18 months has been on ensuring; individuals are enabled, supported and cared for in an appropriate environment, increased community capacity there is a reduction in inappropriate hospital admissions. In October 2015, NHS England, Local Government Association and ADASS reinforced the direction of travel and expectations by publishing, Building the Right Support and Supporting people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition - Service model for commissioners of health and social care services, this was followed by further planning guidance in December These documents place a clear expectation on both the NHS and Local Authorities to accelerate the delivery of a new model of care, locally and in partnership with a range of stakeholders, by March Across the country newly formed Transforming Care Partnership Boards are tasked with improving the outcomes for people, across all ages, with a learning disability and/or autism through the delivery of a robust and sustainable plan that: - Reduces reliance on inpatient services (closing hospital services and strengthening support in the community) Improves quality of life for people in inpatient and community settings Improves quality of care for people in inpatient and community settings Transforming Care Partnerships will be responsible for delivering a plan that improves outcomes and is sustainable. To support sustainable transformation there was a clear expectation of large planning footprints at a scale of around 1 million populations. Draft plans will be shared with NHS England on 8 th February for review. MEETING THE NATIONAL REQUIREMENTS LOCALLY Through the well-established Joint Commissioning Board (Derby City and Derbyshire County CCGs and Local Authorities) there has been a strong commitment and track record in proactively supporting people with a learning disability and / or autism to access care and support in the most appropriate environment. 2

117 Hardwick Clinical Commissioning Group With the introduction of person centred care and treatment reviews we have successfully discharged 20 people from our initial Transforming Care Cohort of 33 people from hospital to more appropriate settings for their needs. Across both the City and County there has been excellent work undertaken in understanding how we could develop a more community based offer of support and care which means we are well positioned to use the existing partnerships to transform care and support at the scale and pace required by the guidance. Given the strong partnership working, progress to date, the population scale required, it was agreed that the Derbyshire County and City footprint would be the basis on which we plan and transform services. The footprint will also enable learning disability services to be a key strand of the wider Sustainability and Transformation Plan (STP) which is expected to be on the same footprint. In order to deliver this change, a Transforming Care Partnership has been established across Derby City and Derbyshire County. The partnership brings together 4 CCGs, 2 Local Authorities (Adult and Children s services), NHS Specialised Commissioners, Service Providers, Health Education England, the police and the Police and Crime Commissioners office. The inaugural meeting took place on 12 th January 2016, at which we agreed leadership arrangements, governance, agreed to advertise for a Transforming Care Programme Manager, considered programme risks and mitigations and the development of the Transforming Care Plan by 8 th February A further meeting of the Transforming Care Partnership Board will be held on 28 th January 2016 to consider the first draft of the plan in light of partnership ambitions and further detailed guidance on the development of the plan. The plan will build on existing transformational work in the city and north of the county and will also need to align to the following priorities; Local Transformation Plans for Children and Young People s Health and Wellbeing Local action plans under the Mental Health Crisis Concordat The local offer for personal health budgets, and Integrated Personal Commissioning (combining health and social care) Work to implement the Autism Act 2009 and recently refreshed statutory guidance The roll out of education, health and care plans Local service transformation programmes (such as Joined Up care and 21C Wider system planning such as the Sustainability and Transformation Plan. The Board has identified the need for programme capacity to coordinate the development and implementation of the plan. The funding is expected to be secured through respective Better Care Funds. There is also a requirement for additional clinical capacity to undertake care and treatment reviews which can potentially be sourced through partner organisations. A further review of capacity will be undertaken as the Transforming Care Plan develops and begins to form part of the Sustainability and Transformational Plan. 3

118 Hardwick Clinical Commissioning Group MONITORING AND ASSURANCE The SRO and Co-Chair for the Transforming Care Partnership Board, Andy Gregory and Joy Hollister Co-Chair of the Transforming Care Partnership Board will ensure there is regular reporting and assurance on delivery to respective Health and Well Being Boards, CCG Governing Bodies (or appropriate committees). The delay in national guidance is likely to mean that plans submitted on 8 th February will require further iteration. This will allow sufficient time for review and consideration by the Transforming Care Board and partner organisations. 4

119 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper G NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING 28 th January 2016 Report Title: Proposal for establishing an East Midlands Affiliated Commissioning Committee Item No: 8 1. Background and context Since the NHS Reforms of 2012 the 20 East Midlands CCGs have not had a formal way of agreeing joint commissioning policies. The establishment of the Congress enabled CCGs to debate how commissioning can be strengthened collectively. External and Legal Support Recent changes to legislation allow for the establishment of joint committees between CCGs. The Congress has subsequently proposed that a joint committee could be established to develop common commissioning policies across the East Midlands. NHS Rushcliffe CCG commissioned legal support and external consultancy to assist in the development of the proposal and terms of reference. 2. Key matters for consideration This paper proposes the establishment of a number of processes to implement affiliated commissioning for 20 East Midlands (EM) Clinical Commissioning Groups (CCGs) and makes a number of recommendations for CCG Governing Body members to consider, note or agree. In the summer of 2015 CCG Chief Officers who are members of the Congress (referred to collectively as the Congress ) supported the development of affiliated commissioning arrangements. The rationale is that for a number of policy areas there are reduced people resources available to undertake policy development and review existing, and often out of date, policies (Annex 1); CCGs are facing significant financial challenges and need to prioritise available resource on transformative change and the postcode lottery discourse and perceived risks of legal challenge. Congress agreed that NHS Rushcliffe CCG should develop a proposal for affiliated commissioning for consideration. The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 1

120 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper G This paper presents the draft terms of reference and accompanying papers as part of establishing the arrangements. 3. Financial Impact 2015/16 Non Recurrent 20, /17 Recurrent 72, 232 Expected to be recovered and deliver efficiencies 4. Analysis of Risk 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all: Improved patient access and experience Empowered, engaged and well-supported staff: Inclusive leadership at all levels: 6. Recommendations Author: Sponsor: Governing Body are asked to: AGREE to recommend to each participating CCG that EMACC be established as a formal joint committee with delegated powers under section 14Z3 of the NHS Act 2006; AGREE to recommend which CCG will host EMACC; AGREE to recommend the appointment of an interim chair by the host CCG set out in Appendix 2; AGREE to recommend that each CCG approves the terms of reference by 1 st April 2016, set out at Appendix 1; AGREE to recommend that each CCG approves the funding of EMACC as set out in Appendix 3; NOTE the establishment of EMACC may require amendments to each CCG s Constitution by 1 st April 2016; NOTE the commencement date of EMACC of 1 st April 2016; NOTE that EMACC will be subject to an internal audit review after one year. Mark Smith, Interim Chief Officer Mark Smith Date: 10 th February 2016 The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 2

121 Proposal for East Midlands Clinical Commissioning Groups Affiliated Commissioning Executive Summary 1. There are a number of Clinical Commissioning Group (CCG) policies that are common across the East Midlands. Up until 2012 some of these policies used to be reviewed and updated by the former East Midlands Specialised Commissioning Group (EMSCG), supported by a Clinical Priorities Advisory Group (CPAG). Both these groups were established by the former Primary Care Trusts and disbanded as a result of the 2012 Health and Social Care Act. As a result of the Act a number of policies transferred to NHS England with others transferring to the CCGs. 2. With the demise of the above several CCG policies are now out of date and new policies are coming on line. At the current time every CCG needs to commit resource to update and/or produce policies. This is against a backdrop of competing priorities and limited resources both in manpower and finances. 3. Individual CCGs revising policies in isolation could result in a knock on effect to other CCGs in terms of quality, increased cost or equity of access. For example the In Vitro Fertilisation (IVF) policy limits the number of attempts a patient can have to access IVF. If a CCG agrees more or less than this number it could cause negative patient experience, a cost pressure, post code inequity and the potential for media and political interest. 4. The East Midlands CCG Accountable Officers are supportive of reinstating a revised structure to replicate the activities formerly undertaken by these groups with their powers. Therefore Governing Bodies (GB) are required to consider and ratify the establishment of the East Midlands Affiliated Commissioning Committee (EMACC) and a supporting Clinical Priorities Steering Group (CPSG). 5. The vision for EMACC is to: Maximise resources, reduce duplication and ensure clinical and cost effective policies that improve the quality of care for patients. 6. EMACC will have ways of working that will add value to CCG business. EMACC will approve policies that are worked up by CPSG described in the following scenario: a. If the In Vitro Fertilisation (IVF) policy didn t exist and one was required, CPSG would invite all CCGs to take part in the development. A workshop would be held with representatives from all the East Midlands CCGs. This would include CCG non-executives, patients/public, clinical and non-clinical experts and managers for example public health, health economists, finance and contracting. This workshop would agree the final draft IVF policy for EMACC to ratify. 7. This scenario above demonstrates that these groups will reduce the need for 20 CCG teams and five public health departments to all do the same policy and reduces the need for 20 GBs to ratify the policy. However it assures GBs that full involvement and inclusion of CCG members has taken place. 8. CCG GBs are asked to consider the attached cover paper and appendices which include a number of recommendations requiring review and ratification. EMACC Draft Proposal Page 1 of 27 EM CCGs

122 East Midlands NHS Clinical Commissioning Groups Proposal for establishing East Midlands Affiliated Commissioning Committee EMACC Draft Proposal Page 2 of 27 EM CCGs

123 Document filename: EMACC Organisation(s) East Midlands Clinical Commissioning Groups Document reference TM\ToR\EMACC v1.5 Project manager Tracy Madge Status Draft 1.5 Owner and SRO Vicky Bailey Author Tracy Madge Version issue date 10/12/2015 Amendment History Version Date Amendment History Shared with Lynn Sharp (LS), NHS Rushcliffe CCG Head of Governance Amended and issued to Vicky Bailey (VB) and LS for further comment and to discuss early legal advice Amended following workshop and issued to Craig Sharples (Governance), IFR leads - Jane Urquhart (JU), Andy Roylance (AR), Rose-Marie Usher (RM) Public Health (PH) - Jonathan Gribbin and legal - Browne Jacobson (BJ) for amend by Amended following Browne Jacobson and Jonathan Gribbin comments. For Vicky Bailey to review Amended and issued to BJ for final review before issue to Congress Amended following Congress, final IFR and PH review. BJ review and amends added. Issued by VB to CCG AOs for CCG Governing Body consideration Approval The following NHS Clinical Commissioning Group (CCG) Governing Bodies Leicester City CCG West Leicestershire CCG East Leicestershire & Rutland CCG South West Lincolnshire CCG Lincolnshire East CCG South Lincolnshire CCG Lincolnshire West CCG Southern Derbyshire CCG North Derbyshire CCG Erewash CCG Hardwick CCG Nottingham City CCG Nottingham West CCG Nottingham North & East CCG Rushcliffe CCG Newark & Sherwood CCG Mansfield & Ashfield CCG Nene CCG Corby CCG Milton Keynes CCG Date Version EMACC Draft Proposal Page 3 of 27 EM CCGs

124 East Midlands NHS Clinical Commissioning Groups Cover Paper Meeting Title Report Title Lead Director Report Author Purpose (tick only one) Executive Summary East Midlands Clinical Commissioning Group Governing Body Date: TBC Proposal for establishing an East Agenda Item: Midlands Affiliated Commissioning Committee Chief Officer Vicky Bailey, Chief Officer, NHS Rushcliffe CCG Approval Decision To note Information This paper proposes the establishment of a number of processes to implement affiliated commissioning for 20 East Midlands (EM) Clinical Commissioning Groups (CCGs) and makes a number of recommendations for CCG Governing Body members to consider, note or agree. In the summer of 2015 CCG Chief Officers who are members of the Congress (referred to collectively as the Congress ) supported the development of affiliated commissioning arrangements. The rationale is that for a number of policy areas there are reduced people resources available to undertake policy development and review existing, and often out of date, policies (Annex 1); CCGs are facing significant financial challenges and need to prioritise available resource on transformative change and the postcode lottery discourse and perceived risks of legal challenge. Congress agreed that NHS Rushcliffe CCG should develop a proposal for affiliated commissioning for consideration. Background This paper presents the draft terms of reference and accompanying papers as part of establishing the arrangements. Since the NHS Reforms of 2012 the 20 East Midlands CCGs have not had a formal way of agreeing joint commissioning policies. The establishment of the Congress enabled CCGs to debate how commissioning can be strengthened collectively. External and Legal Support Recent changes to legislation allow for the establishment of joint committees between CCGs. The Congress has subsequently proposed that a joint committee could be established to develop common commissioning policies across the East Midlands. Scope Proposal NHS Rushcliffe CCG commissioned legal support and external consultancy to assist in the development of the proposal and terms of reference. This proposal only covers the CCG areas of commissioning and excludes all NHS England commissioning responsibilities. Following a period of consultation with East Midlands CCG EMACC Draft Proposal Page 4 of 27 EM CCGs

125 representatives, lay representatives and public health the proposed arrangements are: Establishment of a formal decision making joint committee to be known as the East Midlands Affiliated Commissioning Committee (EMACC), operational from 1 st April Draft Terms of Reference attached at Appendix 1. EMACC s vision is to Maximise resources, reduce duplication and agree clinical and cost effective policies that improve the quality of care for patients ; EMACC should be a formal joint committee with delegated responsibilities with managerial and clinical representatives from the 20 EM CCGs or their nominated geographical lead i.e. one managerial and one nominated clinical representative for each of Nottinghamshire, Derbyshire, Northamptonshire, Lincolnshire and Leicestershire; Once CCGs have agreed to be part of EMACC and it has been formally established with delegated authority from each CCG they will be bound by EMACC s decisions; EMACC should have the authority to secure CCG resources from across the 20 CCGs on a fair shares basis; Decisions will be made by simple consensus, or where consensus cannot be reached, by simple majority vote of CCGs sitting on EMACC; EMACC and its supporting infrastructures will need to be hosted by one of the 20 CCGs; EMACCs Annual Work Programme should be ratified by all CCG Governing Bodies at the start of each financial year; Each CCG will need to review and amend their constitution to ensure that it appropriately references the new committee; The proposed start date for EMACC is 1 st April 2016; It is proposed that EMACC has a review by internal audit after year one of it becoming operational. EMACC will need to establish a Clinical Priorities Steering Group (CPSG) who will be responsible for developing, reviewing and scrutinising policies for ratification by EMACC, CPSG: Will not have any delegated powers and is an advisory and delivery group; Should have a standing membership which advises EMACC with the same Public Health and contract/commissioning managers and lay representation, linking to finance but it should also have the flexibility to engage additional individuals according to the policies being developed; Will prepare the Annual Work Programme for EMACC undertaking the detailed technical and clinical work required to develop the clinical policies within the programme; Should ensure that risks and mitigation, cost and clinical benefits of policies have been considered for every CCG member before recommending approval by EMACC; Should ensure that CCGs consult and communicate widely on changes and new policies; Will be proactive in calling on resources from all CCGs as required, allocating responsibilities, sharing out the Annual EMACC Draft Proposal Page 5 of 27 EM CCGs

126 Work Programme across the 20 CCGs to reduce duplication and draw on relevant expertise; Should be measured by approval of a policy by EMACC on first presentation; Will submit new and amended policies to CCGs for publication on their websites. Will support any other duties that EMACC require in order to discharge its responsibilities. Changes to constitutions It is anticipated that most of the CCGs will have amended their constitutions following the introduction of the power to create joint committees at the start of this year using the (non-mandatory) model wording released by NHS England (Appendix 4). However, each CCG will be required to review their constitution and confirm that it allows them to create joint committees before EMACC can be formally established. If CCG Governing Bodies ratify the terms of reference for EMACC they will also be giving delegated authority to EMACC to establish CPSG. The draft terms of reference have been through legal review and are compliant with legislation Hosting arrangements To agree the final arrangements it is proposed that Congress agrees to one CCG hosting the development of EMACC and that CCG appoints an interim, independent, lay chair from 1 st January 2016 to 31 st March This chair will be responsible for engaging all CCG Chairs and Clinical Leads to agree the final terms of reference and changes to constitutions by CCG Governing Bodies before 1 st April The draft job description for the chair is attached at Appendix 2. Consultation Costs The estimated costs in developing this proposal are in Appendix 3. It is recommended that costs are shared across the 20 CCGs which are expected to be off-set by the impact of EMACC in the increased efficiency of policy review and development. Local consultation A workshop was held to develop the proposal on the 4 November 2015, with attendees from all EM CCGs, Individual Funding Request (IFR) leads, public health leads, patient representative, commissioning GPs and legal experts. The case for change debated the policies covering non-specialised treatments which were originally developed by the former East Midlands Specialised Commissioning Group (EMSCG), which was disbanded following the reforms. Attendees agreed the need to secure consistency of thresholds across the whole region, using a do-once approach, for example in relation to policies such as cosmetic procedures, surrogacy and Gamete cryopreservation. These policies and others (Annex 2) are now out of date, beyond their review date or require amendment EMACC Draft Proposal Page 6 of 27 EM CCGs

127 Risks and benefits due to new evidence. The former EMSCG was successful in undertaking this function on behalf of East Midlands former Primary Care Trusts and with its demise the process in now undertaken by individual CCGs with the resulting risks highlighted below. The benefits of establishing formal arrangements for affiliated commissioning include maximising efficiencies, reducing duplication, removing the postcode allocation and maximising the commissioning of quality services. It was also agreed that EMACC would provide a collective, region wide voice that supports the evidence to change policies that may be subject to high profile challenge. All public health departments have confirmed their full support and input into this development and see if as fundamental to the review and development of robust policies. The risks to establishing these arrangements include the negative financial impact a decision may have on a local CCG and the alignment with current hosted arrangements for other areas, such as IFR. The workshop attendees felt that these risks could be mitigated by ensuring that the governance arrangements include no responsibility for financial limits and clear roles and responsibilities outlined in the voting arrangements. Subject to the above mitigation the recommendation from those who attended the workshop was that EMACC should be established. Recommendations The Congress is asked to: CONSIDER the draft terms of reference (Appendix 1) and if supported; AGREE to recommend to each participating CCG that EMACC be established as a formal joint committee with delegated powers under section 14Z3 of the NHS Act 2006; AGREE to recommend which CCG will host EMACC; AGREE to recommend the appointment of an interim chair by the host CCG set out in Appendix 2; AGREE to recommend that each CCG approves the terms of reference by 1 st April 2016, set out at Appendix 1; AGREE to recommend that each CCG approves the funding of EMACC as set out in Appendix 3; NOTE the establishment of EMACC may require amendments to each CCG s Constitution by 1 st April 2016; NOTE the commencement date of EMACC of 1 st April 2016; NOTE that EMACC will be subject to an internal audit review after one year. If the above recommendations are agreed each Chief Accountable Officer of the Congress is asked to: NOTIFY the Host accountable CCG when their CCG GB has: a) Approved the establishment of EMACC, including the host arrangements and appointment of the interim chair; b) Approved the terms of reference set out in Appendix 1 and funding in Appendix 3; c) Confirmed that any necessary amendments have been made to their constitution in order for EMACC to be EMACC Draft Proposal Page 7 of 27 EM CCGs

128 Financial Implications Appendices Report history established as a joint committee with delegated powers with effect from 1 st April /16 Non Recurrent 20,200 Signed off by: 2016/17 Recurrent 72, 232 Expected to be recovered and deliver efficiencies Appendix 1: EMACC Draft Terms of Reference Appendix 2: Draft Chair Job Description Appendix 3: Funding Appendix 4: NHS England Guidance on Constitution Changes None EMACC Draft Proposal Page 8 of 27 EM CCGs

129 Appendix 1 East Midlands Affiliated Commissioning Committee Draft Terms of Reference 1. Introduction 20 East Midlands Clinical Commissioning Groups (CCG) wish to establish a joint committee which enables the CCGs to work collaboratively on the development and maintenance of: Policies for services which CCGs have responsibility for commissioning; and New policies identified as being appropriate for identical implementation on a regional scale. Accordingly the East Midlands Affiliated Commissioning Committee ( EMACC ) has been established as a joint committee of the 20 East Midlands CCGs in accordance with section 14Z3 of the NHS Act 2006 and the constitutions of each of the CCGs listed in Annex 1 (the Participating CCGs ). The terms of reference set out the membership, remit, responsibilities and reporting arrangements of EMACC. 2. Vision The vision for EMACC is to: Maximise resources, reduce duplication and ensure clinical and cost effective policies that improve the quality of care for patients. 3. Principles The EMACC decisions will be based on the following principles: Optimise Health Outcomes: To agree policies that aim to achieve the greatest possible improvement in health outcomes for the East Midlands population within the resources that are available; Clinical Effectiveness: Ensure that the decisions are based on sound evidence of clinical effectiveness; Cost Effectiveness. Take into account cost-effectiveness analyses of healthcare interventions (where available) to assess which interventions yield the greatest benefits relative to the cost of providing them as part of agreeing policies; Equity. Operate within the context of each individual within the East Midlands population being of equal value; Access. Ensure that policy decisions reflect the need for care to be delivered as close to where patients live as possible; Patient Choice. Respect the right of individuals to determine the course of their own lives, including the right to be fully involved in decisions concerning their health care. However, this has to be balanced against the responsibility to ensure equitable and consistent access to appropriate quality healthcare for all the population; Affordability. Not agree policies that may not be able to afford all interventions supported by evidence of clinical and costeffectiveness within the available resources. Where this is the case, advise CCGs to undertake further prioritisation based on criteria including national and local policies and strategies, local assessment of the health needs of the population, to ensure that the CCGs do not exceed their available resources; EMACC Draft Proposal Page 9 of 27 EM CCGs

130 4. Host arrangements and funding Disinvestment. As well as agreeing new policies on the basis of the criteria above, EMACC will keep policies under constant review to ensure that they continue to deliver clinical and costeffective services at affordable cost; Quality: EMACC will aim to agree policies that offer high quality services as evidenced against national and international best practice. The Participating CCGs have agreed that [INSERT NAME] CCG will be the initial CCG Host of EMACC and that it will employ the chair and supply any other staff required to provide managerial and administrative support for EMACC (the Host CCG ). Hosting arrangements will be agreed annually as part of the Annual Work Programme (as defined below). The costs of the above employees, administrative support and audit and governance arrangements are funded by all of the Participating CCGs. The budget is agreed annually by the Participating CCGs as part of the Annual Work Programme and the agreed budget is then apportioned amongst the participating CCGs on a capitated basis. 5. Membership The members of EMACC shall be as follows: Voting members: Independent Chair. 1 x CCG clinical representative from each Participating CCG nominated by their respective Governing Bodies ( CCG Representative ). 1 x CCG non-clinical representative from each Participating CCG nominated by their respective Governing Bodies ( CCG Representative ). The CCG Representatives may appoint a deputy to attend on their behalf ( Nominated deputy ). The CCG Representatives may also agree to appoint 1 regional representative for each geographical area to attend and vote on behalf of all of the Participating CCGs provided that any such appointing CCG Representative is entitled to revoke this appointment and attend and vote at meetings themselves at any time should he or she wish to do so. Non-voting members Senior Officer of the Clinical Priorities Steering Group (as defined below). Public and Patient CCG representative. Co-optees The Chair may co-opt such other individuals as may be required from time to time including, for example, but not limited to: EMACC Commissioning Manager. Topic experts, clinical and non-clinical. Director of Commissioning. Director of Finance. Directors of Nursing/Quality. NHS England. EMACC Draft Proposal Page 10 of 27 EM CCGs

131 6. Chair and Vice Chair The Chair of EMACC will be an independent lay member and the Vice Chair will be a CCG Representative. They will be appointed by the Host CCG. In the event of the Chair being unable to attend all or part of the meeting the Vice Chair will deputise. 7. Quorum No business shall be transacted at any meeting unless a quorum is present. A quorum will be the Chair or Vice Chair and one clinical or nonclinical CCG Representative from each of the five geographical regions of Nottinghamshire, Derbyshire, Leicestershire, Lincolnshire and Northamptonshire 8. Attendees The Chair may invite representatives from the following areas to attend as may be required from time to time including (but not limited to): CCG Chief Accountable Officers/Chief Operating Officers. Patient/public leader/expert representatives. Directors of Public Health (local authority and/or Public Health England). Communications and Engagement. Representatives for an area of business under review or with experience or expertise pertinent to a particular topic. 9. Frequency and conduct of business EMACC will meet at least three times a year and meetings will be held in April, September and January. Meetings (including extraordinary meetings) shall be convened at the discretion of the Chair. Meetings will be organised and supported by the Host CCG. An agenda and supporting papers will be issued to Members not less than five working days before the meeting dates. 10. Authority The EMACC has delegated authority from each of the Participating CCGs in accordance with section 14Z3 of the NHS Act 2006 to: Undertake the responsibilities listed in paragraph 11 (below) Seek any information it requires in order to discharge its duties from any source; Seek information from any of the CCG s employees; Secure support from each Participating CCG to ensure they commit officers who are competent, available, authorised to represent and negotiate the CCG s position to input fully to the delivery of the Annual Work Programme; Call on the obligation of Local Authority Public Health to support delivery of the Annual Work Programme under the CCG Memorandum of Understanding with Public Health in Local Authorities; Establish and oversee a Clinical Priorities Steering Group (CPSG) which will support delivery of any EMACC s duties and responsibilities; Direct CPSG to adopt task and finish processes to deliver the Annual Work Programme calling on subject matter experts to develop, review and amend policies. For further details regarding CPSG please refer to paragraph 13 EMACC Draft Proposal Page 11 of 27 EM CCGs

132 below. 11. Responsibilities The principal duties of the EMACC are to: Recommend the Annual Work Programme (Annex 2) which will set out the policies to be developed by EMACC for approval by the governing bodies of the Participating CCGs by 31 st March every year ( Annual Work Programme ); Make binding decisions on clinical policies delegated by the Participating CCGs in the Annual Work Programme (which may include (without limitation) some or all of the policies listed in Annex 2 which were in place prior to the 2012 NHS reforms); Make binding decisions on clinical policies that are outside the Annual Work Programme in year where the EM CCGs determine that they fall within EMACC s remit (in the future these may include, but are not limited to, the policies set out in Parts 2 and 3 of Annex 2) Receive and/ consider recommendations from the CPSG; Agree decisions using a recognised and validated process for assessment based on evidence, quality, value for money, equality and inequality with due regard to the need to act transparently and ensure a robust decision making process; Take or arrange for all necessary steps to be taken to enable CCGs to comply with their statutory duties including (but not limited to)the quality and choice of health care provision, working to the NHS Constitution; Manage and update risk and conflict of interest registers; Ensure a shared commitment to improving quality, reducing inequalities and ensuring that collective resources secure a sustainable NHS that does not disadvantage or destabilise the resources required to discharge the functions; Promote partner organisations contribution to the production of robust policies; Engage patients and the public in the development and maintenance of the policies; Provide opportunity for shared learning and development across the local system that result in improved practice and better outcomes for the population; Provide the mechanism through which consensus can be built between the CCGs; Agree communications and ways of working as part the implementation of the decisions made; Establish and annually review the terms of reference for the CPSG; Publish meetings and minutes and an annual overview for inclusion in the Host CCG s public annual report; and Deliver the Annual Work Programme on time and within the annual budget set by the Participating CCG s as part of the Annual Work Programme. 12. Voting and decision making Decisions will normally be made by consensus of the CCG Representatives. Where this is not possible a vote of the CCGs Representatives will take place. The process is: One CCG Representative one vote; A simple majority vote of CCG Representatives present and eligible to vote; EMACC Draft Proposal Page 12 of 27 EM CCGs

133 Nominated Deputies shall have the same voting rights as the full CCG Representative; The presiding Chair will have the casting vote; CCG Representative s voting against a decision or abstaining but in the minority may request the minutes reflect their position. Other attendees are not entitled to vote. 13. Sub groups EMACC has established a delivery group to assist EMACC s delivery of the responsibilities listed in paragraph 11: The Clinical Priorities Steering Group ( CPSG ) will not have any delegated powers and is an advisory and delivery group. CPSG: Should have a standing membership which advises EMACC with the same Public Health and contract/commissioning managers and lay representation, linking to finance but it should also have the flexibility to engage additional individuals according to the policies being developed; Will prepare the Annual Work Programme for EMACC undertaking the detailed technical and clinical work required to develop the clinical policies within the programme; Should ensure that risks and mitigation, cost and clinical benefits of policies have been considered for every CCG member before recommending approval by EMACC; Should ensure that CCGs consult and communicate widely on changes and new policies; Will be proactive in calling on resources from all CCGs as required, allocating responsibilities, sharing out the work programme across the 20 CCGs to reduce duplication and draw on relevant expertise; Will submit new and amended policies to CCGs for publication on their websites Should be measured by approval of a policy by EMACC on first presentation; Will advise CCGs on publication of amended and new policies for their websites; Will support any other duties that EMACC require in order to discharge its responsibilities. 14. Reporting The EMACC will report to each CCG Governing Body following each meeting. Such reports will be prepared and circulated to all Participating CCGs by the Host CCG (following approval by the Chair) and will compromise the minutes of the meeting, summary of action taken since the last report, up to date risk register and an up to date conflicts of interest register. Minutes of the meeting will be available as requested and published publically on the Host CCG website. 15. Declaration of Interest and Register of Procurement Decisions The work of EMACC will be subject to regular monitoring by the Host CCG Audit Committee, which will undertake at least one formal review in the first year as part of its assurance function. The Host CCG will maintain and keep up to date a conflicts of interest register on behalf of EMACC. Members are required to declare any interests which relate to a particular issue under consideration as soon as they become aware of it and at the start of each meeting. Any such declaration will be formally recorded in the minutes (along EMACC Draft Proposal Page 13 of 27 EM CCGs

134 with details of the action taken to address the conflict) and declaration of interest forms completed for the Register of Interests. The Chair s decision regarding a Member s participation, or that of any attendee, in any meeting will be final. The Chair s decision regarding a Member s participation in a meeting (or part of a meeting) and, in the case of a CCG Representative, their entitlement to vote in a meeting will be final. If the Chair has a conflict of interest the Vice Chair shall make a decision regarding their participation and that decision shall be final. 16. Conduct Members and attendees will act in accordance with all applicable laws and guidance and relevant codes of conduct/good governance practice, and shall comply with the Host CCG s Conflict of Interest Policy. 17. Review of the Terms of Reference Final EM CCG Governing Body Approval Date: TBC Review Date: Ref: TM\ToR\EMACC v1.5: The EMACC Terms of Reference will be reviewed annually by the EM CCG Congress. Any changes to these Terms of Reference which are proposed by the EM CCG Congress must be approved by the Governing Bodies of the Participating CCGs before they are deemed to take effect. EMACC Draft Proposal Page 14 of 27 EM CCGs

135 Annex 1 Participating CCGs 1. NHS Leicester City CCG 2. NHS West Leicestershire CCG 3. NHS East Leicestershire & Rutland CCG 4. NHS South West Lincolnshire CCG 5. NHS Lincolnshire East CCG 6. NHS South Lincolnshire CCG 7. NHS Lincolnshire West CCG 8. NHS Southern Derbyshire CCG 9. NHS North Derbyshire CCG 10. NHS Erewash CCG 11. NHS Hardwick CCG 12. NHS Nottingham City CCG 13. NHS Nottingham West CCG 14. NHS Nottingham North & East CCG 15. NHS Rushcliffe CCG 16. NHS Newark & Sherwood CCG 17. NHS Mansfield & Ashfield CCG 18. NHS Nene CCG 19. NHS Corby CCG 20. NHS Milton Keynes CCG EMACC Draft Proposal Page 15 of 27 EM CCGs

136 Affiliated Policies Potential Areas for the Annual Work Programme Annex 2 Clinical Policies Sacral Nerve Stimulation (for CCG commissioned elements) Orthotic functional electrical stimulation for foot drop of neurological origin Hip Arthroscopy all pathologies East Midlands Regional Adult Cosmetics policy Individual Funding Requests Surrogacy Gastric Electrical Stimulation Gamete Cryopreservation Use of Bone Morphogenetic proteins In Vitro Fertilisation (IVF)/Intracytoplasmic Sperm Injection (ICSI) within Tertiary Infertility Services Non-Clinical Policies Frameworks for reviewing and agreeing policies at CPWG Orphan Drugs Experimental and Unproven treatments Defining the Boundaries between NHS and private treatments Patients changing responsible commissioner Ongoing access to treatment following a 'trial of treatment' which has not been sanctioned by the responsible CCG for a treatment not routinely funded or which has not been formally assessed and prioritised. Ongoing access to treatment following completion of non commercially funded trials, third party funded treatment Use of cost effectiveness, value for money and cost effectiveness thresholds Commissioning policy for guidance produced by the National Institute of Clinical Excellence. The role of commissioners in the evaluation of individual treatments and the funding of clinical research. Priority setting and decision making NHS pick-up of Drug Company sponsored treatments In year service developments and the CCG approach to treatments not yet assessed and prioritised Prior Approval Policy for Policies EMACC Draft Proposal Page 16 of 27 EM CCGs

137 Appendix 2 DRAFT JOB DESCRIPTION JOB TITLE: Independent Chair, East Midlands Affiliated Commissioning Committee. Host Organisation: NHS [insert name] Clinical Commissioning Group (CCG). Salary Grade: Starting from 500/day, negotiable depending on experience, excluding travel and sundry expenses. Accountable to: Accountable Officer, NHS [insert name] CCG. Hours of Duty: 10 days per annum (with a commitment to be flexible if significant tasks arise), to be appraised and reviewed on an annual basis. MAIN PURPOSE: 1. To provide independent leadership and strategic vision to the East Midlands CCGs on agreed affiliated policies. 2. To chair the East Midlands Affiliated Commissioning Committee (EMACC). 3. To deliver the vision for EMACC that is to maximise resources, reduce duplication and ensure clinical and cost effective policies that improve the quality of care for patients. KEY RESPONSIBILITIES: 1. Recommend the Annual Work Programme which will set out the policies to be developed by EMACC for approval by the governing bodies of the Participating CCGs by 31st March every year ( Annual Work Programme ); 2. Make binding decisions on clinical policies delegated by the Participating CCGs in the Annual Work Programme; 3. Make binding decisions on clinical policies that are outside the Annual Work Programme in year where the EM CCGs determine that they fall within EMACC s remit; 4. Establish and oversee a Clinical Priorities Steering Group (CPSG) which will support delivery of any EMACC s duties and responsibilities; 5. Annually review the terms of reference for the CPSG; 6. Direct CPSG to adopt task and finish processes to deliver the Annual Work Programme calling on subject matter experts to develop, review and amend policies. 7. Receive and/ consider recommendations from the CPSG; 8. Agree decisions using a recognised and validated process for assessment based on evidence, quality, value for money, equality and inequality with due regard to the need to act transparently and ensure a robust decision making process; 9. Take or arrange for all necessary steps to be taken to enable CCGs to comply with their statutory duties including (but not limited to) the quality and choice of health care provision, working to the NHS Constitution; 10. Manage and update risk and conflict of interest registers; 11. Ensure a shared commitment to improving quality, reducing inequalities and ensuring that collective resources secure a sustainable NHS that does not disadvantage or destabilise the resources required to discharge the functions; 12. Promote partner organisations contribution to the production of robust policies; 13. Engage patients and the public in the development and maintenance of the policies; EMACC Draft Proposal Page 17 of 27 EM CCGs

138 14. Provide opportunity for shared learning and development across the local system that result in improved practice and better outcomes for the population; 15. Provide the mechanism through which consensus can be built between the CCGs; 16. Agree communications and ways of working as part the implementation of the decisions made; 17. Publish meetings and minutes and an annual overview for inclusion in the Host CCG s public annual report; 18. Deliver the Annual Work Programme on time and within the annual budget set by the Participating CCG s as part of the Annual Work Programme. 19. Seek any information required in order to discharge duties from any source; 20. Seek information from any of the CCG s employees; 21. Secure support from each Participating CCG to ensure they commit officers who are competent, available, authorised to represent and negotiate the CCG s position to input fully to the delivery of the Annual Work Programme; 22. Call on the obligation of Local Authority Public Health to support delivery of the Annual Work Programme under the CCG Memorandum of Understanding with Public Health in Local Authorities; 23. Ensure the committee works collaboratively and effectively by encouraging and supporting the development of partnership working between the partner members its sub-groups. 24. Liaise with the appropriate managers to ensure the timely and effective management of committee business within agreed budgets. 25. Link nationally and regionally to ensure that the activities are aligned with national policy expectations and other developing practice. 26. To continually review membership and sub groups to ensure it is effective and representative. 27. To ensure that the work of the committee is managed in line with the principles of promoting equality and respecting diversity for all. 28. To comply with any other duties as may be jointly agreed from time to time as necessary and appropriate to the role. Job Description prepared by: Vicky Bailey, Accountable Officer, NHS Rushcliffe CCG Date: 25 November 2015 Agreed by Post holder: Date: EMACC Draft Proposal Page 18 of 27 EM CCGs

139 Job Specification: Independent Chair Note to Applicants: The Essential Criteria are the qualifications, experience, skills or knowledge you MUST SHOW YOU HAVE to be considered for the job. The How Identified column shows how the CCG will obtain the necessary information about you. If the How Identified column says the Application Form next to an Essential Criteria you MUST include in your application enough information to show how you meet this criteria. You should include examples from your paid or voluntary work. Experience Leading and managing in a large public or independent or voluntary organisation at a senior level to command respect within a multi-partner committee of agency senior representatives. Sufficient experience of the operational context of commissioning work to enable well- rounded contributions to policies Experience of chairing complex professional meetings at a senior level and ability to chair in an efficient manner. Experience of working across organisations and professional boundaries and collaborative and partnership working. Experience of working with members of the public in order to improve services. Essential (E) or Desirable (D) E E E E E A How Identified: A: Application Form; I: Interview, R: Reference P: Presentation A, I, R A, I, R A, I, R A, I, R A, I, R Experience of managing strategic and operational change. E A, I, R Experience of developing performance management across a E A, I, R complex organisational structure b) Training and Qualifications Relevant professional qualification of sufficient standing to command professional respect E A, R Clinical qualification D A c) Knowledge and Understanding Applicants should be able to demonstrate knowledge and understanding of the following areas relevant to the post Knowledge and understanding of developments in CCGs and their commissioning responsibilities E A, I, R Knowledge of appropriate corporate governance frameworks E A, I, R Knowledge of structure and functioning of large organisations E A, I, R, P An understanding of funding and accountability in the public E A, I, R, P sector Knowledge of performance management and quality assurance E A systems and operational environment Knowledge of the key drivers and influences on public services E A, I, R, P and partners Knowledge and understanding of administrative processes E A, I, R supporting CCG organisations. d) Personal Skills, Abilities and Competencies Applicants should be able to provide evidence that they have the necessary skills and abilities EMACC Draft Proposal Page 19 of 27 EM CCGs

140 required Chairing skills: ability to organise, coordinate and follow through on key decisions; manage competing or differing views and positively challenge to achieve the desired outcome. E A, I, R Ability to influence key stakeholders and decision makers E A, I, R, P Effective communication skills: interpersonal, presenting, media E A, I, R, P relations, maintaining a positive public and professional profile, sufficient to represent the CCGs effectively to the media & other forums as required. Effective problem solving skills: Able to identify issues and areas E A, I, R, P of risk and lead partners to effective resolution and decision. Skills in negotiating to assist in managing and resolving conflict E A, I, R Ability to generate and develop good working relations across E A, I, R member organisations Ability to influence senior personnel and liaise with political E A, I, R representatives Ability to recognise discrimination in its many forms and promote E A Equal Opportunities policies within the operation of the committee Ability to ensure high standards of confidentiality in terms of E A, I, R sensitive cross-organisational matters. The ability to be self-motivating and able to operate outside of E A, I, R single agency hierarchal structure. Assertive, clear thinking and able to negotiate. E A, I, R Conversant with and able to use information technology E A systems. e. Attitude/Motivation: Enthusiasm, commitment and a determination to carry forward a E A, I, R, P complex agenda. Commitment to improving outcomes for patients E A, I, R, P Ability to enthuse and gain the commitment of others. E A, I, R Commitment to principles of promoting equality and respecting E A, R diversity f. Availability: Have the flexibility to carry out the required tasks and duties, E A, R Be accessible to Members outside of committee meetings E A, I, R g. Physical Requirements: Where the applicant/post holder has a disability every effort will be made to make reasonable adjustments to enable them to carry out the duties of the post It may be necessary to travel within and outside the region in order to attend meetings, conferences, etc. E A, I EMACC Draft Proposal Page 20 of 27 EM CCGs

141 Appendix 3 Funding Forecast costing for developing affiliated commissioning across the East Midlands Non Item Costs Recurrent Recurrent External Support x ,200 Legal not inc. VAT 5, Interim Chair 10 days up to March 2016, 1,000/day 10,000 Chair 10 days/year, 1000/day 10,000 Management support 21,197 B7 WTE 0.5 A&C B4 WTE ,035 Topic experts ,000 Communication 3,000 To support communciation if policy changes are challenged Non Pay and overheads 15, /16 N/R Total 20,200 Assumes benefits realised offsets costs 2016/17 Recurrent total Assumes benefits 72,232 realised offsets costs EMACC Draft Proposal Page 21 of 27 EM CCGs

142 Appendix 4 Model wording for amendments to Clinical Commissioning Groups constitutions November 2014 Publications Gateway ref no EMACC Draft Proposal Page 22 of 27 EM CCGs

143 Model wording for amendments to clinical commissioning groups constitutions Note to accompany template document 1. The template documents have been developed to help minimise the work involved for CCGs. 2. When the nature of the co-commissioning required has been determined the use of the template documents will be considered. That could mean they are adapted or amended in light of your specific governance arrangements. Template constitution amendment 3. The template constitution amendment sets out three clauses that CCGs may wish to adopt. The clauses cover the following: Joint commissioning arrangements with other CCGs Joint commissioning arrangements with NHS England in relation to CCG functions Joint commissioning arrangements with NHS England in relation to NHS England functions 4. Some CCGs may already have a clause similar to the first template clause (joint commissioning arrangements with other CCGs). However, what is new is the provision for the establishment of a joint committee between CCGs. 5. The other two clauses provide for joint working with NHS England in two instances, as follows: a. The first is where the CCG wants NHS England to be involved in relation to the exercise of its (i.e. the CCG s) functions. b. The second is where NHS England and a CCG either jointly exercise NHS England functions or where a CCG is given delegated authority to exercise NHS England functions. 6. Where a CCG is working collaboratively, it is recommended that the detailed arrangements for that joint working are set out in a terms of reference document (see below). Where a delegation has been made by NHS England, there will also be a formal delegation document and a detailed agreement between the parties setting out the terms and conditions of the delegation. Template terms of reference 7. A template terms of reference document for joint commissioning arrangements has been developed for CCGs to use. This establishes a joint committee and sets out the things that would need to be considered and addressed when establishing such a committee. 8. We have also developed a template terms of reference document for the establishment of a CCG committee in the context of delegated commissioning. 9. As with the constitution amendment, these templates do not have to be adopted in their entirety and can be altered as appropriate to fit the specific requirements of the CCG(s) in question. 10. The template terms of reference and delegation documents will be included as annexes to Next Steps when it is published on 10 November EMACC Draft Proposal Page 23 of 27 EM CCGs

144 Template document [1] Joint commissioning arrangements with other Clinical Commissioning Groups [1.1] the clinical commissioning group (CCG) may wish to work together with other CCGs in the exercise of its commissioning functions. [1.2] The CCG may make arrangements with one or more CCG in respect of: [1.2.1] delegating any of the CCG s commissioning functions to another CCG; [1.2.2] exercising any of the commissioning functions of another CCG; or [1.2.3] exercising jointly the commissioning functions of the CCG and another CCG [1.3] for the purposes of the arrangements described at paragraph [1.2], the CCG may: [1.3.1] make payments to another CCG; [1.3.2] receive payments from another CCG; [1.3.3] make the services of its employees or any other resources available to another CCG; or [1.3.4] receive the services of the employees or the resources available to another CCG. [1.4] Where the CCG makes arrangements which involve all the CCGs exercising any of their commissioning functions jointly, a joint committee may be established to exercise those functions. [1.5] for the purposes of the arrangements described at paragraph [1.2] above, the CCG may establish and maintain a pooled fund made up of contributions by any of the CCGs working together pursuant to paragraph above. Any such pooled fund may be used to make payments towards expenditure incurred in the discharge of any of the commissioning functions in respect of which the arrangements are made. [1.6] Where the CCG makes arrangements with another CCG as described at paragraph [1.2] above, the CCG shall develop and agree with that CCG an agreement setting out the arrangements for joint working, including details of: How the parties will work together to carry out their commissioning functions; the duties and responsibilities of the parties; How risk will be managed and apportioned between the parties; Financial arrangements, including, if applicable, payments towards a pooled fund and management of that fund; Contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements. [1.7] The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph [1.2] above. [1.8] The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning. [1.9] Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the governing body. [1.10] The governing body of the CCG shall require, in all joint commissioning arrangements, that the lead clinician and lead manager of the lead CCG make a quarterly written report to the governing body and hold at least annual engagement events to EMACC Draft Proposal Page 24 of 27 EM CCGs

145 review aims, objectives, strategy and progress and publish an annual report on progress made against objectives. [1.11] Should a joint commissioning arrangement prove to be unsatisfactory the governing body of the CCG can decide to withdraw from the arrangement, but has to give six months notice to partners, with new arrangements starting from the beginning of the next new financial year. [2] Joint commissioning arrangements with NHS England for the exercise of CCG functions [2.1] The CCG may wish to work together with NHS England in the exercise of its commissioning functions. [2.2] The CCG and NHS England may make arrangements to exercise any of the CCG s commissioning functions jointly. [2.3] The arrangements referred to in paragraph [2.2] above may include other CCGs. [2.4] Where joint commissioning arrangements pursuant to [2.2] above are entered into, the parties may establish a joint committee to exercise the commissioning functions in question. [2.5] Arrangements made pursuant to [[2.2] above may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and the CCG. [2.6] Where the CCG makes arrangements with NHS England (and another CCG if relevant) as described at paragraph [2.2] above, the CCG shall develop and agree with NHS England a framework setting out the arrangements for joint working, including details of: How the parties will work together to carry out their commissioning functions; The duties and responsibilities of the parties; How risk will be managed and apportioned between the parties; Financial arrangements, including, if applicable, payments towards a pooled fund and management of that fund; Contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements; and [2.7] The liability of the CCG to carry out its functions will not be affected where the CCG enters into arrangements pursuant to paragraph [2.2] above. [2.8] The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning. [2.9] Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the governing body. [2.10] The governing body of the CCG shall require, in all joint commissioning arrangements that [insert who] of the CCG make a quarterly written report to the governing body and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives. EMACC Draft Proposal Page 25 of 27 EM CCGs

146 [2.11] Should a joint commissioning arrangement prove to be unsatisfactory the governing body of the CCG can decide to withdraw from the arrangement, but has to give six months notice to partners, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months notice period. [3] Joint commissioning arrangements with NHS England for the exercise of NHS England s functions [3.1] The CCG may wish to work with NHS England and, where applicable, other CCGs, to exercise specified NHS England functions. [3.2] The CCG may enter into arrangements with NHS England and, where applicable, other CCGs to: Exercise such functions as specified by NHS England under delegated arrangements; Jointly exercise such functions as specified with NHS England. [3.3] Where arrangements are made for the CCG and, where applicable, other CCGs to exercise functions jointly with NHS England a joint committee may be established to exercise the functions in question. [3.4] Arrangements made between NHS England and the CCG may be on such terms and conditions (including terms as to payment) as may be agreed between the parties. [3.5] For the purposes of the arrangements described at paragraph [3.2] above, NHS England and the CCG may establish and maintain a pooled fund made up of contributions by the parties working together. Any such pooled fund may be used to make payments towards expenditure incurred in the discharge of any of the commissioning functions in respect of which the arrangements are made. [3.6] Where the CCG enters into arrangements with NHS England as described at paragraph [3.2] above, the parties will develop and agree a framework setting out the arrangements for joint working, including details of: How the parties will work together to carry out their commissioning functions; The duties and responsibilities of the parties; How risk will be managed and apportioned between the parties; Financial arrangements, including payments towards a pooled fund and management of that fund; Contributions from the parties, including details around assets, employees and equipment to be used under the joint working arrangements. [3.7] The liability of NHS England to carry out its functions will not be affected where it and the CCG enter into arrangements pursuant to paragraph [3.2] above. [3.8] The CCG will act in accordance with any further guidance issued by NHS England on co-commissioning. [3.9] Only arrangements that are safe and in the interests of patients registered with member practices will be approved by the governing body. [3.10] The governing body of the CCG shall require, in all joint commissioning arrangements that the [insert who] of the CCG make a quarterly written report to the governing body and hold at least annual engagement events to review aims, objectives, strategy and progress and publish an annual report on progress made against objectives. EMACC Draft Proposal Page 26 of 27 EM CCGs

147 [3.11] Should a joint commissioning arrangement prove to be unsatisfactory the governing body of the CCG can decide to withdraw from the arrangement, but has to give six months notice to partners, with new arrangements starting from the beginning of the next new financial year after the expiration of the six months notice period. ---ENDS--- EMACC Draft Proposal Page 27 of 27 EM CCGs

148 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper H Report Title: Primary Care Psychological Therapy (IAPT) Re-procurement 2016 PURPOSE OF THE PAPER The CCG is asked to ratify the procurement process. PAPER PREVIOUSLY PRESENTED The CCG Governing Body and Clinical Commissioning Committees agreed the following; 1. Recommendation that services be re-procured under AQP January Revised service specification, local tariff and procurement timeline November 2015 RECOMMENDATION(S) The Clinical Commissioning Group are asked to approve the procurement process in order that the contracts can be negotiated and mobilisation can commence. The CCG are requested to approve award of contracts to the providers, with the new tariff arrangement set out within the procurement exercise. BACKGROUND AND CONTEXT PCPT (also known as IAPT) services have been delivered through a number of Any Qualified Provider (AQP) contracts under AQP since April In January 2015, the 4 Derbyshire CCG Governing Bodies agreed the re-procurement of PCPT under AQP and in November 2015 agreed the revised specification and local tariff for delivery from April 1st The service specification was developed following engagement with primary care, service receivers, public health, service providers and voluntary sector organisations. The key revisions to the specification and tariff include; The addition of a Step 3+ tariff to incentivise greater access and recovery rates for people with more complex needs, e.g. LTC, the deaf community, people whose first language is not English and to Extension of the inclusion criteria to include those aged 16 and 17 (previously 18 and over). This has been a joint process between Derbyshire CCGs (led by Hardwick CCG) and Nottinghamshire County and Nottingham City CCGs 10 in total. 28 provider organisations expressed an interest and attended a provider forum in September A total of 6 organisations formally applied to deliver services across Derbyshire CCGs. The evaluation panel consisted of representatives across the 3 localities including; 1

149 Arden GEM procurement lead, Commissioners, GPs, Service receiver representative, Quality leads, Communications lead and finance. Five organisations have successfully qualified to deliver services under AQP; Derbyshire Healthcare NHS Foundation Trust; Insight Healthcare; Nottinghamshire Healthcare Trust; Trent PTS and Turning Point. For Derbyshire this represents 1 additional new provider Turning Point. A summary of the procurement process can be found in Appendix 1 KEY MATTERS FOR CONSIDERATION The NHS England Mandate states that the IAPT waiting time and access standards must be achieved by 1 April percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent treated within 18 weeks. Providers have been asked to complete weekly patient tracking lists to enable providers and commissioners to target problem areas. The new contract includes substantial penalties for providers who fail to deliver the waiting time and access targets. IAPT service provider s recovery rates and overall access by the population are being met. IAPT referrals are continuing to rise county wide although there are some local variations and impact from the withdrawal of Steps to change in September EQUALITY IMPACT AND RISK ANALYSIS A deep dive into IAPT data was undertaken with Public Health in This revealed differences in access and outcomes. This information was used in the development of the new tariff for the 2016 contract. In particular we have incentivised support to people with a long term condition. In the life of the new contract period we intend to utilise CQUIN and other approaches to support improved access outcomes for disadvantaged groups. Authors David Gardner & Tracy McGonagle FEB

150 Appendix 1 Procurement Report for the Provision of: Any Qualified Provider for Primary Care Psychological Therapies (PCPT) Service / Improving Access to Psychological Therapies (IAPT) On behalf of: NHS Hardwick, North Derbyshire, Erewash, Southern Derbyshire, Nottingham City, Newark and Sherwood, Mansfield and Ashfield, Nottingham West, Nottingham North and East, Rushcliffe Clinical Commissioning Group (CCG) Reference Bravo Project 335 / itt_ Purpose The following report provides the NHS Hardwick, North Derbyshire, Erewash, Southern Derbyshire, Nottingham City, Newark and Sherwood, Mansfield and Ashfield, Nottingham West, Nottingham North and East, Rushcliffe CCG (the Commissioner), the Executive Team and CCG Governing Body with a summary of the any qualified provider tender process undertaken for the provision of primary care psychological therapies. 2. Background In 2015, the Commissioner recommended the initiation of a procurement process to procure primary care psychological therapies. It was agreed as any qualified provider procurement process. The Project Leads one for each locality so representing Derbyshire, Nottinghamshire and Nottingham City were agreed and the procurement process began. The contract of choice for the provision of the services will be from 01/04/ /03/2019, with an option to extend for a further 24 months subject to agreement by commissioners. 3. Procurement and Evaluation Process The Commissioners established a Project Delivery Group and Evaluation Panel to take the project forward. All members of the Project Delivery Groups and the Evaluation Panel were required to sign and agree to the Declaration of Conflict of Interest and Confidentiality for Tenders prior to their involvement at all stages of the process. Copies of all signed declarations have been kept as part of the project governance. The Evaluation Panel was multi-functional and multi-disciplinary, suitable to make the following decisions on behalf of the Commissioner: 1. Assessing and scoring (pass/fail) bids 2. A Recommendation of contract award on the basis of scoring (Pass/Fail) 1

151 The procurement process was conducted in accordance with the Commissioner Service Level Agreement with Arden and Greater East Midlands Commissioning Unit under the clinical procurement support service line. The lead procurement manager from Arden and GEM CSU was a member of the Evaluation in facilitative role. The procurement was conducted as an Any Qualified Provider (AQP) Process of the Public Contract Regulations The contract was publicly advertised on Official Journal of the European Union and Contracts Finder. The procurement was a one stage process termed as Any Qualified Provider. The award criteria used to assess and evaluate the ITT bids were approved by the Senior Responsible Officer. The tender submissions were judged against these pre-determined criteria. The procurement process was facilitated through the e-tendering portal Bravo Solution and the submissions were evaluated via an On-line system AWARD. In response to the advertisements, 28 potential providers expressed an interest and were given further information. All were requested to complete a questionnaire to establish their experience and suitability to perform the contract, 6 potential providers responded as requested. The ITT technical envelope had the finance, insurance, litigation questions. The qualification envelope had the service specific questions. Sections questions were either for information, pass/fail. The qualification section comprised a range of specific questions with associated evaluation criteria and scoring (pass/fail) guidance. The financial tariff was included in the tender documentation. The financial evaluation was based on the financial stability (last 3 years accounts). The ITT submissions were evaluated remotely using the AWARD e-procurement tool. The pre-moderation and moderation methodology was agreed with the Evaluation Panel. The evaluation team were Commissioner s representatives from a range of cross functional areas including finance, GP clinical, information governance and lay representative as part of its members. The moderation process reviewed all scores and evaluators comments including rationales. At the moderation meeting the Evaluation Panel then agreed a moderated panel score. The moderation meeting was held on 21 st January 2016 chaired by the Senior Procurement Manager. Clarification questions were raised during the evaluation period and at the moderation meeting, these questions were sent to providers for further response, and a further meeting was held on 28 th January 2016 to determine a final outcome. 4. Results Further to the on-line evaluation, moderation meeting, clarification of bid and the consensus meeting the panel have determined the following: Derbyshire Healthcare NHS Foundation Trust PASS Areas for focus / development: Linking of DIT, CBT, and EMDR with Short Term Psychodynamic approaches and other secondary services treatment and use of One day workshops for Step 3. Monitoring of contract to include focus this and on patient choice. Ensure governance is in place for use of multi-media assessments. 2

152 Insight Healthcare PASS Areas for focus / development: Use of affiliates and skill mix of workforce. Ensure governance is in place for use of multi-media assessments. Nottinghamshire Healthcare NHS Trust PASS Areas for focus / development: No base for the service in Derbyshire, provider has advised if deemed financially viable in the future would locate a Derbyshire premises, in the meantime would replicate the Nottingham (current) service. Nottingham Counselling Services FAIL Feedback of bid: Overall lack of continuity in response. Concerns included sufficient workforce to deliver the service with reference to counsellors delivering the service. Only one location used to deliver the service from. Unsure of ability to deliver the full range of treatments in order to fulfil the service. Lack of reference to risk and emergency protocols. Brief mobilisation plan, no mitigation of risks. Trent Psychological Therapies PASS Areas for focus / development: Premises locations to be confirmed. Turning Point PASS Areas for focus / development: Long stop date to be added to the contract, as provider cannot start the service until June Confirmation of premises locations and availability. Ensure staff will be available for service commencement of June All focus and development areas to be addressed where possible in the contract, other areas to be addressed within the contract review meetings for future service improvement. NHS Standard Contract Particulars - Conditions Precedent clause could be utilised for premises issues. 5. Next Steps The Commissioners have requested a final approval compliant with the CCG internal governance mechanisms. Once the recommendation has been approved by the Governing Body/Executive of NHS Hardwick, North Derbyshire, Erewash, Southern Derbyshire, Nottingham City, Nottingham West, Nottingham North and East and Rushcliffe CCG, Arden & GEM Commissioning Support Unit will notify the bidders of the outcome. Thus, it is expected that the successful bidder will be informed of the decision on 5 th February The unsuccessful bidder notification will also be published on the same day. The Commissioner will commence the implementation and mobilisation phase of the service with the new service starting on the 1 st April Report by Angela Deakin, Interim Senior Procurement Manager, Arden and Greater East Midlands Commissioning Support Unit 1 st February

153 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper I NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE MEETING Report Title: February 2016 Item No: 10 Chesterfield Royal Hospital NHS foundation Trust Laparoscopic nephrectomy 1. Background and context In 2005, NICE issued IPG136 on Laparoscopic Nephrectomy, which stated that if a Trust has in place the consent; audit and clinical governance, then there was adequate support to use this procedure. A laparoscopic nephrectomy has now been the standard curative treatment for kidney cancer for well over 10 years now. Presently, all patients that require this procedure at Chesterfield Royal FT are referred to Sheffield FT. 2. Key matters for consideration Chesterfield Royal FT has requested that laparoscopic nephrectomies (approx. 30 patients per annum) can now be delivered at the Trust. As this is an IPG, the CCG are required to give subsequent approval before this occurs. 3 Financial Impact The funding for these patients will transfer from Sheffield FT to Chesterfield FT. 4. Analysis of risk N/A. 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: All services described within the report are for all patients attending CRHFT, and therefore improvements in the quality of care will be for all. 1

154 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper I 6. Recommendations That the report and attached IPG136, is received and is approved for commissioning at Chesterfield Royal FT. Author: Michelle Anthony, Head of Acute Commissioning Sponsor: Ben Milton, Chair and Clinical Lead Date: 21st January

155 Laparoscopic nephrectomy (including nephroureterectomy) Interventional procedure guidance Published: 24 August 2005 nice.org.uk/guidance/ipg136 1 Guidance 1.1 Current evidence on the safety and efficacy of laparoscopic nephrectomy (including nephroureterectomy) appears adequate to support the use of this procedure provided that the normal arrangements are in place for consent, audit and clinical governance. 1.2 Patient selection is important when this procedure is being considered for the treatment of malignant disease. Long-term follow-up data are lacking, and clinicians are encouraged to collect data on rates of recurrence in patients with malignant disease. 2 The procedure 2.1 Indications Indications for nephrectomy (including nephroureterectomy) include renal cell or urethral cancer and benign conditions that lead to a poorly functioning or non-functioning kidney. These benign conditions may be due to or associated with symptomatic hydronephrosis, chronic infection, polycystic kidney disease, dysplastic kidney, hypertension and renal calculus. NICE All rights reserved. Page 1 of 5

156 Laparoscopic nephrectomy (including nephroureterectomy) (IPG136) The standard treatment for an irreversibly damaged kidney or localised kidney cancer is an open nephrectomy. Under general anaesthesia, the kidney is removed through an incision in the loin or the front of the abdomen. 2.2 Outline of the procedure A transperitoneal or retroperitoneal approach may be used for laparoscopic nephrectomy. In the transperitoneal approach, the abdomen is insufflated with carbon dioxide through a trocar and then three or four small abdominal incisions are made. In the retroperitoneal approach, a small incision is made in the back and a dissecting balloon is inserted to create a retroperitoneal space. After the balloon is removed, the space is insufflated with carbon dioxide and two or three additional small incisions are made in the back for the laparoscopic instruments. The kidney is freed by laparoscopic dissection, and is then enclosed in a bag and removed through an appropriate incision or placed in an impermeable sac, morcellated and removed through one of the port sites. The ureter is sometimes removed along with the kidney (laparoscopic radical nephroureterectomy) Hand-assisted laparoscopic nephrectomy allows the surgeon to place one hand in the abdomen while maintaining the pneumoperitoneum required for laparoscopy. An additional small incision is made which is just large enough for the surgeon's hand, and an airtight 'sleeve' device is used to form a seal around the incision. 2.3 Efficacy One non-randomised comparative study of 100 patients with renal cell carcinoma reported that there was no statistically significant difference in the estimated 5-year disease-free survival rate for laparoscopic and open nephrectomy (95.5% versus 97.5%, respectively). A case series of 157 patients with renal cell carcinoma who had the laparoscopic procedure reported an estimated 5-year disease-free survival rate of 91% Two non-randomised comparative studies, including 209 patients with upper urinary tract transitional cell carcinoma, reported no difference in recurrence rates between laparoscopic and open nephroureterectomy. NICE All rights reserved. Page 2 of 5

157 Laparoscopic nephrectomy (including nephroureterectomy) (IPG136) Two non-randomised comparative studies found that significantly less analgesia was required after laparoscopic nephrectomy than after open surgery. In a further two non-randomised comparative studies, the mean hospital stay ranged from 5.2 days to 8.9 days for open surgery, compared with 3.4 days to 6.8 days for laparoscopic surgery (p < 0.001). In one study, the mean convalescence period was also significantly shorter for laparoscopic surgery: 23 days compared with 57 days for open surgery (p < 0.001). For more details, refer to the Sources of evidence The Specialist Advisors did not express any concerns about the efficacy of this procedure when performed by trained operators. However, they noted that there was a lack of data from randomised controlled trials. 2.4 Safety Three non-randomised comparative studies reported complication rates for laparoscopic nephrectomy that were not significantly different from those for open nephrectomy. Six studies reported rates of conversion to open surgery: this occurred in 0% (0/54) to 10% (46/482) of procedures The complications reported in a large case series of 482 procedures (461 patients) included bleeding in 5% (22/482), re-intervention in 3% (15/482) and bowel injury in less than 1% (3/482). Other complications reported in the studies included paralytic ileus in 3% (2/60) of patients; injury to arteries in 3% (2/60), the spleen in 2% (1/60) and the adrenal gland in 2% (1/60); and urinary tract infection in 1% (2/157). Two case series reported mortality rates of less than 1% (2/263) and 1% (2/157). For more details, refer to the Sources of evidence The Specialist Advisors stated that potential adverse events included major haemorrhage from renal vessels, bowel injury and the need for conversion to open surgery. 2.5 Other comments It was noted that training and competence in laparoscopic techniques were important for surgeons undertaking this procedure. NICE All rights reserved. Page 3 of 5

158 Laparoscopic nephrectomy (including nephroureterectomy) (IPG136) 3 Further information 3.1 The Institute has produced guidance on laparoscopic live donor simple nephrectomy. Andrew Dillon Chief Executive August 2005 Sources of evidence The evidence considered by the Interventional Procedures Advisory Committee is described in the following document. 'Interventional procedure overview of laparoscopic nephrectomy (including nephroureterectomy)', March Information for patients NICE has produced information on this procedure for patients and carers. It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind. 4 About this guidance NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland. This guidance was developed using the NICE interventional procedure guidance process. It has been incorporated into the NICE pathway on chronic kidney disease, along with other related guidance and products. We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available. NICE All rights reserved. Page 4 of 5

159 Laparoscopic nephrectomy (including nephroureterectomy) (IPG136) Changes since publication 23 January 2012: minor maintenance. Your responsibility This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. Copyright National Institute for Health and Clinical Excellence All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE. Contact NICE National Institute for Health and Clinical Excellence Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT nice@nice.org.uk Endorsing organisation This guidance has been endorsed by Healthcare Improvement Scotland. NICE All rights reserved. Page 5 of 5

160 ND CCG Governing Body Assurance Committee Meeting 22nd February 2016 Paper J NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE MEETING 22nd February 2016 Report Title: Purpose: Information Governance Freedom of Information and Environmental Regulations Information Policy Review Item No: 11 The Governing Body is asked to approve the annual review of the Information Governance Freedom of Information and Environmental Regulations Information policy. 1. Background and context This following paper provides the Governing Body Assurance Committee with the key changes with regard to the Information Governance Freedom of Information and ERI policy which has been reviewed and updated by the Derbyshire Joint CCG Information Governance Committee in January IG07 IG Freedom of Information and ERI Policy 2. Key matters for consideration The policy has had its annual review and minor administrative changes have been made. The Information Governance policy has been developed by Arden and Greater East Midlands Commissioning Support Unit (Arden & GEM CSU) and has been approved at the Joint Derbyshire CCG Information Governance Committee on 26 th January Arden & GEM CSU are supporting and encouraging a consistent approach to Information Governance best practice within the Derbyshire CCG NHS organisations. Dissemination The Information Governance policy will be disseminated to all staff via the North Derbyshire CCG intranet. Staff are encouraged to raise their awareness of the policies and refresh their understanding on an annual basis. 3. Financial Impact There is no financial impact associated with this Information Governance Policy. 4. Analysis of Risk There is no direct risk associated with this Information Governance Policy. The Executive Team and Senior Leadership Team are responsible for ensuring that all policies are accessible to all staff and that all staff have read, understood and adhere to the policies. 1

161 ND CCG Governing Body Assurance Committee Meeting 22nd February 2016 Paper J 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all: Improved patient access and experience Empowered, engaged and well-supported staff: Inclusive leadership at all levels: This Information Governance Policy meets all requirements and include an Equality statement and Equality analysis. 6. Recommendations The Governing Body is asked to approve the Information Governance Freedom of Information and ERI policy to enable this to be implemented within the CCG. Author: Sponsor: Sam Robinson, Governance Officer Suzanne Pickering, Governance Lead Date: 12 th February

162 Freedom of Information & ERI Policy Document number: Issue/Approval Date: TBC Version Number: 2.4 Status: draft Next Review Date: June 2016 Page 1 of 19

163 Freedom of Information (FOI) and Environmental Regulations Information (ERI) Policy Document Reference: This document sets out what the Clinical Commissioning Group, its Commissioning Support Units and associated organisations will do Document Purpose: to comply with its obligations under the Freedom of Information Act 2000 (hereafter referred to as the Act) and includes the procedure to be followed when handling requests. Date Approved: 22 nd February 2016 Approving Committee: Governing Body Assurance Committee Version Number: 2.4 Status: Approved Next Revision Due: February 2017 Developed by: FOI Manager, Arden & GEM CSU Policy Sponsor: Derbyshire CCGs This policy applies to any person directly employed, contracted or Target Audience: volunteering to the CCG, including those working under an honorary contract and those authorised to undertake work on behalf of the CCG. Associated Documents: All Information Governance Policies and the Information Governance Toolkit Date Policy Circulated: 25 th February 2016 Page 2 of 19

164 Contents 1. Introduction 2. Scope 3. Purpose 4. Duties & Accountability 5. Environmental Information Regulations 6. Equality & Diversity 7. Freedom of Information Act 7.1 Main features of the Act 7.2 Publication Scheme 7.3 General Rights of Access 7.4 Charges and Fees 7.5 Time limits for Compliance with requests 7.6 Datasets and Re-use of Information 8. Provision for dealing with FOI requests 8.1 Service Management 8.2 Receipt of a request 8.3 Advice and Assistance 8.4 Circular or Round Robin requests 9. Complaints 10. Records Management 11. Monitoring Compliance 12. Due Regard 13. Training, Distributions and Implementation 14. Related Policies/Organisational Functions 15. Review 16. References Appendices A Freedom of Information Process Map B Detailed Procedure to process FOI requests C Exempt Information under Part II of The FOI Act 2000 D FOI Appeals (Internal Review) Procedure, Appeals Panel Terms of Reference E Fee s Page 3 of 19

165 Freedom of Information Policy 1. Introduction This policy applies to Derbyshire Clinical Commissioning Groups (CCGs), subsequently referred to in this policy as the CCGs. They include: 2. Scope NHS Erewash CCG NHS Hardwick CCG NHS North Derbyshire CCG CCGs are separate independent statutory organisations. This document sets out the Freedom of Information Policy for the Derbyshire Clinical Commissioning Groups. It explains what the organisation will do to comply with its obligations under the Freedom of Information Act 2000 (hereafter referred to as the Act). The Freedom of Information Act 2000 (FOIA) (Ref 1) came into effect for all public sector organisations on 1 January 2005 and gives the public a general right of access to information held by public authorities. Its key theme is that public authorities are accountable to the public and should be open and transparent in their decision-making. The policy is guided by the Lord Chancellor s Code of Practice on the Discharge of Public Authorities Functions under Part 1 of the Freedom of Information Act 2000 issued under Section 45 of the Act (Ref 2). This policy is supported by the procedures for responding to requests for information, as set out in Appendix A and B. This policy will be published on the intranet and internet. It is the duty of each NHS body to establish and maintain arrangements for the purpose of monitoring and improving the quality of healthcare provided by and for that body. The organisation is committed to this policy and its implementation. This policy applies to all contracted (permanent and temporary) staff employed by the organisation including lay members, students, trainees, researchers, trainers, volunteers, and staff of other organisations including consultants and contractors. The organisation supports the Government s commitment to greater openness in the public sector. The Act will further this aim of greater openness by enabling members of the public to be able to access key documents and as such scrutinise and question the decisions of public authorities more closely and ensure that the services provided are properly delivered. The organisation wishes to create a climate of openness and dialogue with all their stakeholders; improved access to information about the organisation will help to support this aim. The organisation will make such information available in a range of formats as required to meet the needs of the person requesting the information. The organisation recognises that individuals also have a right to privacy and confidentiality. This policy does not overturn the common law duty of confidence or the statutory provisions that prevent disclosure of personal identifiable information. The release of such information is covered by the Data Protection Act 1998 and is dealt with in the Personal Information Policy and associated procedures. Page 4 of 19

166 3. Purpose The policy will provide a framework within which the organisation will ensure compliance with the requirements of the Act and will underpin any operational procedures and activities connected with the implementation of the Act. 4. Duties and Accountability The Accountable Officer has the ultimate accountability for the organisation s compliance with the Act. The Accountable Officer will ensure that responsibility for bringing FOI issues to the Governing Body is delegated to an appropriate Director (or equivalent). The CCG has commissioned FOI services from Arden & GEM CSU who provide a locality FOI lead to liaise directly with the CCG. The FOI Lead is responsible for the operational management of FOI Service and ensures compliance with the Act through appropriate processes and procedures. The duties of the FOI Lead include: providing a centralised point of contact for handling all CCG related FOI enquiries, liaising with colleagues across the organisation to agree responses; providing advice and assistance to applicants requesting information under the Act production and maintenance of FOI policy and procedures (see Appendix A and B) promotion of FOI awareness across the organisation through training and the dissemination of the FOI procedures to all staff; ensuring that all staff and the general public are provided with information about their rights and responsibilities under FOI, in an accessible format; monitoring the Guide to Information required under the Publication Scheme (i.e. the CCG s FOI website); maintaining appropriate records of requests for information; production of monitoring reports; supporting the appeals/complaints procedure in respect of FOI. The FOI Lead will oversee the development and updating of FOI policies and procedures and ensure that awareness of FOI is maintained across the organisation. All staff including Governing Body members are obliged to adhere to this policy. They should be familiar with the requirements of the Act and be aware of their personal responsibilities under the Act. In certain circumstances, to support equality and diversity, line managers will need to consider individual requirements of staff to support good practice in complying with this policy. 5. Environmental Information Regulations 2004 The organisation recognises that, in addition to the Act, there is also an obligation on public authorities to respond to requests for environmental information under the Environmental Information Regulations (EIR) Page 5 of 19 The organisation will, as far as possible, respond to requests for environmental information using the same procedures as for responding to Freedom of Information (FOI) requests, while recognising that there are some differing regulations between EIR and FOI on the

167 provision of information. These include rules governing what environmental information may be disclosed (exceptions under EIR) and the requirement to respond to requests for environmental information whether the request is verbal or in writing. 6. Equality and Diversity The CCG aims to design and implement policy documents that meet the diverse needs of the services, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account current UK legislative requirements, including the Equality Act 2010 and the Human Rights Act 1998, and promotes equal opportunities for all. This document has been designed to ensure that no-one receives less favourable treatment due to their personal circumstances, i.e. the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Appropriate consideration has also been given to gender identity, socio-economic status, immigration status and the principles of the Human Rights Act. In carrying out its functions, the CCG must have due regard to the Public Sector Equality Duty (PSED). This applies to all the activities for which the organisation is responsible, including policy development, review and implementation. 7. Freedom of Information Act Main Features of the Act The main features of the Act are: a General Right of Access from 1 January 2005 to recorded information held by public authorities, subject to certain conditions and exemptions; a duty on public authorities to inform the applicant whether they hold the information requested and communicate the information to them, subject to certain conditions and exemptions; a duty on every public authority to adopt and maintain a Publication Scheme. This duty has been applicable to the NHS since 31 October 2003; the establishment of the office of Information Commissioner with wide powers to enforce the rights created by the Act and to promote good practice together with an Information Tribunal; a duty on the Lord Chancellor to establish Codes of Practice for guidance on specific issues, such as Records Management (Ref 3) 7.2 Publication Scheme and Guide to Information Section 19 of the Act makes it the duty of every public authority to adopt a Publication Scheme. The CCG has adopted the Model Publication Scheme issued by the Information Commissioner in 2008 (Ref 4) which gives an overview of the information that the organisation publishes and intends to publish in the future. It details the format in which the information is available and whether or not a charge will be made for the provision of that information. The Publication Scheme is available on the public website. The CCG s compliance with the requirement to publish information as set out Page 6 of 19

168 in the ICO Definition Document for Health Organisations will be regularly reviewed by the FOI Lead in accordance with ICO guidelines and the content of the website should be updated accordingly. Information in the Publication Scheme will be made automatically and proactively available. In most cases information which is made available via the Publication Scheme will be downloadable from the website. In the event that an enquirer is unable to download the information, applications for the information to be supplied in another format may be made verbally or in writing. 7.3 Requests for Information (General Right of Access) Section 1 of the Act gives a general right of access from 1 January 2005 to recorded information held by the CCG, subject to certain conditions and exemptions. Any person making a request for information to the organisation is entitled to: be informed in writing, or any other appropriate format on request, whether the organisation holds the information described in the request; and have that information communicated to them if it is held by the organisation and in an appropriate format on request. receive the information in a re-usable format The provisions are fully retrospective, meaning, that if the organisation holds the information when the request is received, it must be provided, subject to certain conditions and exemptions. The Act states that requests for information under the General Rights of Access must be received in writing and include the name of the applicant, an address for correspondence, and a clear description of the information requested. This includes , which is the preferred method of correspondence for the majority of FOI enquirers. 7.4 Charges and Fees Charges and fees will only be levied in exceptional circumstances, for example where large volumes of hard copy materials are requested, in which case the CCG will follow the Freedom of Information and Data Protection (Appropriate Limit and Fees) Regulations 2004 (see Appendix E). In general, no charge will be made. 7.5 Time Limits for Compliance with Requests The CCG will establish systems and procedures to ensure that the organisation complies with the duty to respond to requests within 20 working days of receipt of a request, in accordance with Section 10 of the Act. All staff will be required to comply with the requirements of these procedures; failure to do so may result in disciplinary action. 7.6 Datasets and Re-use of information Section 102 of the Protection of Freedoms Act 2012 adds new provisions to the FOIA regarding datasets. The new provisions are about how information is released and relate to information a CCG holds as a dataset, which is a defined term in the new provisions. Page 7 of 19

169 If a CCG is providing information that constitutes a dataset and the requester has expressed a preference to receive the information in electronic form, the CCG must provide it in a re-usable form as far as reasonable practicable. In accordance with the Re-use of Public Sector Information Regulations 2005 and 2015 a public authority has to make information and metadata available through standard licences and machine-readable formats wherever possible. The dataset provisions do not only create a duty under s 11(1A) for the CCG to provide datasets in a form that is technically capable of re-use, but also a duty under s11a (2) to provide datasets that are relevant copyright works under a license that permits reuse. However, those provisions do not remove those rights, third party rights need also be taken into consideration. In accordance with the s45 code of practice and the recommendation of the UK Government Licensing Framework the CCG will grant re-use under the Open Government License (OGL) for datasets that can be re-used without charge. It is also the default license for Crown Copyright works. 8. Provision for dealing with FOI Applications 8.1 Service Management The FOI Lead (Arden & GEM CSU) manages the provision of this service. 8.2 Receipt of a Request It is accepted that requests for information can come from many sources and it is important for all members of staff to be able to recognise an FOI request so it can be processed quickly and appropriately. All staff have a responsibility to ensure that all FOI applications are identified and reported. Not every application will clearly indicate the nature of the request as being FOI. For all requests for information, staff must follow the Requests for Information Flow Chart which can be found at Appendix A and the Procedure to Process Freedom of Information Requests Appendix B. 8.3 Provision of Advice and Assistance to Applicants The FOI Lead will act as a key contact point for Applicants for the CCG and will provide advice and assistance to potential and actual applicants for information under the Act. The FOI Lead will act as a source of advice and support for staff in regard to the Act. 8.4 Circular or Round Robin requests If circular or Round robin requests are received within the Arden & GEM CSU Area the FOI Lead will liaise with the CCGs across the area to ensure that a cohesive approach will be taken and a consistent response for all CCGs can be provided to the applicant. Page 8 of 19

170 9. Complaints/Internal Review Requests for review or complaints about handling of applications for information under the Act are specifically exempt from the NHS Complaints Regulations (NHS Complaint Regulations Part II, para 7(g)). A separate complaints/appeals process applies to such requests for review or complaints (see Appendix D). 10. Records Management The CCG and other organisations holding information on behalf of the CCG will have systems and processes in place for managing their corporate records in both electronic and paper format in order to respond effectively to requests for information. In line with NHS guidance on retention periods (Ref 12), electronic and paper records of FOI requests will be retained for three years and then destroyed, with the exception of requests where any information requested was refused and an exemption applied, in which case they should be retained for 10 years Monitoring Compliance The CCG will regularly review their Freedom of Information arrangements to ensure compliance with this policy. The FOI Lead (Arden & GEM CSU) will maintain records of all FOI requests to assess performance in meeting the standards and statutory timeframes set out in the Lord Chancellor s Code of Practice. The FOI Lead (Arden & GEM CSU) will produce monthly/quarterly reports to the CCG to assess performance in meeting the statutory timeframes and applicant satisfaction with the process. Review findings will also be used by the FOI Lead (Arden & GEM CSU) to inform measures for improvement, including identifying any communications and training needs and whether new or revised procedures are needed to comply with the policy. 12 Due Regard This policy has been reviewed in relation to having due regard to the Public Sector Equality Duty (PSED) of the Equality Act 2010 to eliminate discrimination, harassment, victimisation; to advance equality of opportunity; and foster good relations. 13. Training, Distribution and Implementation Training The Freedom of Information Officer (Arden & GEM CSU) will provide training to those managers tasked with handling FOI requests within the CCG and will consider specific training to identified groups as required or requested by the CCG. Distribution This policy will be published on the CCG website. All staff will be notified of this and any new or revised document via the policy alert system. Page 9 of 19

171 Implementation It is the responsibility of line managers to ensure that their staff are aware of this policy and procedure and how to deal with a Freedom of Information request should they receive one. 14. Related Policies/Organisational Functions A number of other policies are related to this Freedom of Information Act Policy and all employees should be aware of the full range: Records Management Policy Data Protection Policy (incorporating Access to Health Records Procedure) Complaints Management Policy and Claims Management Policy Access to Health Records Policy 15. Review The policy will be reviewed June Reference documents Data Protection Act 1998 Freedom of Information Act 2000 Secretary of State for Constitutional Affairs' Code of Practice on the discharge of public authorities' functions under Part I of the Freedom of Information Act 2000 Issued under section 45 of the Act.November 2004 Act, November Lord Chancellor s Code of Practice on the Management of Records under section 46 of the Freedom of Information Act 2000, November References 1. Freedom of Information Act Lord Chancellor s Code of Practice on the Discharge of Public Authorities Functions under Section 45 of the Freedom of Information Act Lord Chancellor s Code of Practice on the Management of Records under Section 46 of the Freedom of Information Act Model Publication Scheme me 5. Definition Document for the Model Publication Scheme for Health Bodies in England Page 10 of 19

172 reedom_of_information/detailed_specialist_guides/definition-document-health-bodiesin-england.pdf 6. Information Commissioner s Guide: Vexatious or repeated requests, Version 4 (December 2008) cation/awareness_guidance_22_vexatious_and_repeated_requests_final.pdf 7. Information Commissioner s Guide: When should names be disclosed? Version 1 (August 2008) cation/whenshouldnamesbedisclosed.pdf 8. Information Commissioner s Guide: The exemption for personal information, Version 3 (September 2008) edom_of_information/detailed_specialist_guides/personal-information-section-40-andregulation-13-foia-and-eir-guidance.ashx 9. Statutory Instrument : The Freedom of Information and Data Protection (Appropriate Limit and Fees) Regulations 2004) Information Commissioner s Awareness Guidance 2: Information provided in Confidence, Version 4 (September 2008) alist_guides/confidentialinformation_v4.pdf 11. Information Commissioner s Guide: Information provided in confidence related to contracts, Version 1 (October 2008) alist_guides/confidenceandcontracts.pdf 12. Records Management: NHS Code of Practice (April 2006) uidance/dh_ Information Commissioners Office Freedom of Information Act webpage: Secretary of State s Code of Practice (datasets) on the discharge of public authorities functions under Part 1 of the Freedom of Information Act, issued under section 45 of the FOIA UK Government Licensing Framework for public sector information Open Government License Information Commissioners Guidance on Datasets guides/datasets-foi-guidance.pdf Page 11 of 19

173 19. Contact for further Information: Debbie Parker Arden & GEM Commissioning Support Unit Cross O Cliff Bracebridge Heath Lincoln LN4 2HN Debbie.Parker@ardengemcsu.nhs.uk Tel: Page 12 of 19

174 Appendix A Page 13 of 19

175 APPENDIX B DETAILED PROCEDURE TO PROCESS FREEDOM OF INFORMATION ACT (FOI) REQUESTS Introduction The purpose of this procedure is to give staff a clear guide on how to manage incoming Freedom of Information Act 2000 (FOI) requests. The request must be made in writing (this includes s, letters, faxes). A request for information does not need to quote the FOIA. Legal Requirement The Organisation has 20 working days from the date of the request being received to comply with the legal requirements. This requires staff to act without delay on receiving a request following the guidance below: Steps to Follow: 1. Forward the document for processing Arden & GEM provides a central processing service and requests must be forwarded to the Arden & GEM FOI Team. NHS Northern Derbyshire CCG: NHS Hardwick CCG: NHS Erewash CCG: NDERCCG.FOIRequest@nhs.net foi.north@ardengemcsu.nhs.uk ECCG.FOIRequest@nhs.net The most appropriate transmission method must be considered in relation to the format of the original request (electronic or paper) and any delay will impact on the 20 working days. 2. Acknowledgement of Request Acknowledgement of the request should be made by the Arden & GEM FOI Team within twoworking days of receipt. 3. Providing the Information Requested The person who was identified holding the information will be notified of the details of the request and given a deadline date for supplying the information to the FOI Team. The FOI Team will then review the information and, if necessary, liaise with the person who provided the information in relation to further clarification or the potential application of exemptions. Where it is considered that an exemption applies to release information the FOI team will forward the draft response to the CCG for approval. Response Monitoring and Logging This will be carried out by Arden & GEM FOI Team who will liaise with the holder of the information and the person/agent who has lodged the request. 4. Collection of Costs If applicable the Arden & GEM FOI Team will request, collect and deposit any fees received with the Finance Department prior to the release of the records. Page 14 of 19

176 5. Information Release The information will be brought together and a response in form of a Decision Notice will be sent to the applicant by the Arden & GEM FOI Team. Page 15 of 19

177 APPENDIX C Exempt Information under Part II of the Freedom of Information Act 2000 FOI Absolute Exemptions s 21 s 23 s 32 s 34 s 36 s 40 s 41 s 44 Information reasonably accessible to the applicant by other means Information supplied by, or relating to, bodies dealing with security matters Court records Parliamentary privilege Prejudice to the effective conduct of public affairs (but only absolute in relation to information held by the Commons or House of Lords) Personal Information Information provided in confidence (but only if this would constitute an actionable breach of confidence) Prohibitions on disclosure FOI Qualified Exemptions subject to Public Interest test s 22 s 24 s 26 s 27 s 28 s 29 s 30 s 31 s 33 s 35 s 36 s 37 s 38 s 39 s 42 s 43 Information intended for future publication National Security Defence International relations Relations within the UK The Economy Investigations and proceedings conducted by public authorities Law enforcement Audit functions Formulation of government policy etc. Prejudice to effective conduct of public affairs Communications with Her Majesty etc. and honours Health and Safety Environmental information Legal professional privilege Commercial Interests Page 16 of 19

178 Public Interest Test The public interest will be considered in every case where a qualified exemption may apply. When applying the public interest test in the FOI context it means the public good, not what is of the interest to the public, and not the private interests of the requester. In carrying out the public interest test the organisation should consider the circumstances at the time of the request or within the normal time of compliance. Public interest arguments for the exemption must relate specifically to that exemption and the organisation must consider the balance of public interest in the circumstances of the request. When considering the public interest to reach a decision on a qualified exemption, the organisation will seek legal advice when necessary. The organisation will aim to use the qualified exemptions sparingly and will, in accordance with Section 17 of the Act, justify their use. Page 17 of 19

179 APPENDIX D 1. Introduction Freedom of Information (FOI) Appeals (Internal Review) Procedure and Appeals Panel Terms of Reference The right to appeal is a fundamental part of the Freedom of Information Act and the Environmental Information Regulations. This right can be exercised in two ways: by an internal review using the organisation s appeal procedures and by an external appeal to the regulatory the Information Commissioner s Office (ICO). The ICO will not usually investigate any appeal which has not been thoroughly investigated through the organisation s internal process. Dissatisfied applicants therefore have the opportunity for an initial review of how their request for information was handled. Having gone through this process, applicants who are still unhappy can complain to the ICO and will be dealt with in accordance with the ICO procedures. 2. Freedom of Information (FOI) Internal Review Procedure Appeals must be submitted in writing within 40 days after receiving the organisation s response. After this time period, the organisation will not hear appeals and applicants will be advised to contact the ICO directly. On receipt, the request for internal review will be acknowledged before it is assigned to one of a panel of reviewers, who are usually senior members of staff. The FOI Lead will provide the reviewer with a summary and details of the original handling of the request. The job of the internal reviewer is threefold: 1. To assess whether the authority has complied with its responsibilities under the FOIA, including timeliness and the duty to advise and assist. 2. To consider the information released against the information requested and make a full review of the papers associated with the original application, if appropriate, discussing the decisions with staff who dealt with the initial application. 3. To re-consider any public interest in disclosure and determine whether the information should be disclosed. The internal review constitutes a fresh inquiry into the request, rather than taking as a starting point the decision already reached and submitting it to a test of reasonableness. Reviews are also undertaken in the light of the general presumption in the FOIA in favour of release of information. Useful procedural guidance and advice on the application of the exemptions can be obtained from the Arden & GEM FOI Lead or the Information Commissioners Office. The ICO recommends that an internal review should take no longer than 20 working days. The internal reviewer sets out their decision in the form of a document outlining their conclusions and recommendations. Following management approval, the outcome of the review is communicated to the applicant. On completion of the review, records relating to the review are returned to the FOI Team. They are retained in order to assist in any investigation by the Information Commissioner. Page 18 of 19

180 APPENDIX E FEES FOR APPLICATIONS UNDER THE FREEDOM OF INFORMATION ACT 2000 The Freedom of Information and Data Protection (Appropriate Limit and Fees) Regulations 2004 indicate that the scheme set in place by the Act is not expected to be self-financing. These Regulations provide than an applicant would be charges the full cost of the authority s disbursements (such as costs for photocopying, printing and postage) The following charges may apply: Photocopies: A4 Black and White 10p per sheet A3 Black and White 20p per sheet A4 Colour 1.00 per sheet A3 Colour 1.50 per sheet Fax: To UK and Ireland 1.00 per page To Europe 1.75 per page To Rest of the World 2.00 per page Print-Outs from a Computer Black and White: 10p per page Colour 50p per page Photo Quality Paper Prints 1.00 per page Electronic Media: CD-R Disc in a Plastic 'Jewel' Case 1.00 Floppy Disc (1.44MB) 1.00 Scanning of A4 Paper Records 1.40 per image Scanning of A3 Paper Records 2.10 per image Attachment No Charge Page 19 of 19

181 ND CCG Governing Body Assurance Committee Meeting 22nd February 2016 Paper K NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE MEETING 22nd February 2016 Report Title: Flexible Working Policy Item No: Background and context This paper provides the Governing Body Assurance Committee with the revised and updated CCG s Flexible Working Policy. The policy has been reviewed by NDCCG Executive Team in conjunction with Arden & GEM HR and has been consulted with and accepted by Trade Union Representatives. 2. Key matters for consideration The following change has been made to the policy: Added an entire section on guidance for home working Added an entire section on how flexi-time operates including a template flexi sheet Added more into the Policy Statement in relation to the CCG s commitment to its staff Added the latest Equality and Diversity and Due Regard wording Emphasised the importance of working according to service need and varying hours in agreement with line managers Clarified the period of time when flexi-time can be accrued Limited flexi-time to agenda for change band 8b and below Clarified applications are not required if someone just wants to work flexi-time Clarified that evening work (which is after 19.00pm) should only be undertaken with the permission of the manager Inserted a link to the AFC section 3 on overtime Added a caveat that more than 15 hours can be carried across from one flexi period to the next in exceptional circumstances with the agreement of the relevant Chief Officer Confirmed that the right to request to work flexibly is available to all staff and the CCG actually extend that right from day one instead of after 26 weeks service 3 Financial Impact There is no impact financial impact associated with this policy. 4. Analysis of risk There is no direct risk associated with this policy. 1

182 ND CCG Governing Body Assurance Committee Meeting 22nd February 2016 Paper K 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: The strategic documents meet all requirements and include an Equality statement and Equality analysis. Better health outcomes for all: None Directly Improved patient access and experience: None Directly Empowered, engaged and well-supported staff: None Directly Inclusive leadership at all levels: None Directly 6. Recommendations The Governing Body Assurance Committee is asked to approve the Flexible Working Policy to enable the policy to be disseminated within the CCG. Author: Carole Whitton, Arden & GEM HR Business Partner Sponsor: Mark Smith, Chief Officer Date: 12 th February

183 Flexible Working Policy

184 ASSISTANCE WITH THE APPLICATION OF THIS POLICY AND UPDATES This policy has been prepared so as to reflect the law as at 1st December The policy will require periodic review to reflect subsequent changes to the law. Changes to employment law have generally been made on 1 February, 1 April and 1 October in any given year. For advice and assistance in relation to the application of this policy and to obtain updates please contact: Your line manager in the first instance, or Arden & GEM HR Business Partners. 2

185 Flexible Working Policy HR Policy: Date Issued: Date to be reviewed: HR09 Biannually or sooner if legislation changes Policy Title: Supersedes: Description of Amendment(s): This policy will impact on: Financial Implications: Flexible Working Policy All previous Flexible Working Policies Amended Policy for NHS North Derbyshire CCG employees All staff No change Policy Area: HR Version No: 2 Issued By: Governance Team Author: Document Reference: Effective Date: Review Date: February 2018 HR Services Arden & GEM and North Derbyshire CCG Executive Team APPROVAL RECORD Consultation: Approved by Committees: Committees / Groups / Individual Date Consultative Committee Trade Unions Dec 2015 Specialist Advice (if required) N/A Management / Staff Side Consultative Committee Governing Body 3

186 CONTENTS 1 POLICY STATEMENT 5 2 EQUALITY STATEMENT 5 3 PRINCIPLES 5 4 MONITORING AND REVIEW HOME WORKING ARRANGEMENTS FLEXI-TIME APPLICATION PROCEDURE APPEAL PROCEDURE 10 9 DUE REGARD 11 Appendix 1 Appendix 2 Appendix 3 APPLICATION FORM FLEXIBLE WORKING REQUEST ACKNOWLEDGEMENT FLEXI SHEET

187 1. POLICY STATEMENT 1.1 NHS North Derbyshire Clinical Commissioning Group (the CCG) is committed to being an employer of choice and to providing a range of flexible working options for employees. The purpose of this policy is to maintain a committed and skilled workforce and deliver high quality, cost effective services in an environment which maximises opportunities for employees to balance work and personal commitments. 1.2 The CCG is committed to the well-being of its workforce by providing flexible policies that comply with the Working Time Regulations and enable staff to maintain a healthy work life balance. 1.3 This policy sets out the flexible working arrangements that are available within the organisation. 1.4 This policy does not form part of any employee s contract of employment and it may be amended at any time. 1.5 This policy only applies to employees of North Derbyshire CCG. 2. EQUALITY STATEMENT 2.1 North Derbyshire CCG (NDCCG) aims to design and implement policy documents that meet the diverse needs of our services, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account current UK legislative requirements, including the Equality Act 2010 and the Human Rights Act 1998, and promotes equal opportunities for all. This document has been designed to ensure that no-one receives less favorable treatment due to their personal circumstances, i.e. the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Appropriate consideration has also been given to socioeconomic status, immigration status and the principles of the Human Rights Act. 2.2 In carrying out its function, NDCCG must have due regard to the Public Sector Equality Duty (PSED). This applies to all activities for which NDCCG is responsible, including policy development, review and implementation. 3. PRINCIPLES 3.1 NDCCG has an overriding responsibility to deliver timely services. It also has the right to seek ways of developing the capacity of its services, improving the capabilities of its employees and improving effectiveness. 3.2 It is the responsibility of each Head of Service to ensure that their team(s) has operational cover arrangements in place that are appropriate for that team. 3.3 All employees have the statutory right to request to work flexibly after 26 weeks continuous service. NDCCG has taken the decision to allow any employee, from their first day of employment onwards, the right to apply for a change in their contracted hours of work irrespective of their length of service. Please note that the right to apply to work flexibly does not guarantee a change will be made. 3.4 If an employee makes a request in relation to a reasonable adjustment under the Equality Act (2010) due to one of more the protected characteristics, this should be stated on the application form. 3.5 With the exception of flexi time, all flexible working requests must be made by completing and submitting a completed application form to the appropriate manager using the form at Appendix 1 of this policy. It is not necessary to complete an application form if an employee wishes to use flexi time. 5

188 3.6 All forms of flexible working are open to all employees with the exception of flexi time which is open only to members of staff on bands up to and including 8b. 3.7 All requests will be given full consideration and no reasonable request will be refused. However, in certain circumstances the needs of the business may not allow for the request to be granted. If a request is denied, a full and detailed reason for the refusal will be given in writing to the employee. 3.8 Managers will ensure that staff who request a flexible working arrangement are aware of the implications (if any) on their terms and conditions of employment e.g. salary, annual leave and pension. Managers should seek the assistance of an Arden and GEM Human Resources Representative where necessary. 3.9 As far as practicable, NDCCG may be able to offer flexible working arrangements in line with Agenda for Change such as: a) Part-Time Working - This is where an employee is contracted to a number of hours that are less than the normal hours of work of a comparable full-time employee. b) Job Share - This is normally where two people share the duties and responsibilities of one fulltime post in a partnership arrangement. c) Flexible Working (or flexi-time) Flexi-time allows employees to vary their actual working hours. This means that subject to service needs, employees can vary their start and finish times to better fit their domestic responsibilities, travel arrangements or for work purposes. Please refer to Section 6 for further information on flexi-time. Please note that flexi time is only available to employees on bands up to and including 8b. d) Annualised Hours This is where the hours that a person works are unevenly distributed throughout the year as opposed to working the same number of hours each week. So the person might work more hours at certain times of the year and less hours at other times, but across the whole year they will work an agreed, average number of hours per week. e) Flexible Rostering This is using periods of work of differing lengths within an agreed overall period. f) Term-Time Only Working This is where people work during the school term but not during school holidays and their pay is reduced accordingly. g) Home working This is where people work from home (or other remote locations) for all or part of their hours with a computer or telecommunication link to their organisation. Refer to Section 5 for further information on home working. h) Voluntarily reduced working time This is where people work reduced hours, by agreement, at a reduced salary. i) Fixed work patterns This is where, by agreement, days off can be irregular to enable, for example, access by separated parents to their children and flexible-rostering. j) Flexible Retirement This is defined as flexibility regarding the age at which an employee retires, the length of time an employee takes to retire or the nature and intensity of work in the lead up to final retirement. The NHS Pension Scheme offers a range of pension flexibilities to support both employers and members. The available options must be discussed and agreed between the employer and member Where a request for a permanent change to an employee s working arrangements is made, the CCG reserves the right to impose a trial period, the length of which will be at the line manager s discretion but will normally be between 3 and 6 months. The purpose of a trial is to establish whether or not the new working arrangements meet service needs. 6

189 3.11 Employees are able to request to work flexibly no more than once per rolling 12 months For details of arrangements covering emergency time off for the care of dependents and other situations, see the relevant HR policy Training and support will be available to all Line Managers in the implementation and application of this policy. 4. MONITORING & REVIEW 4.1 The policy and procedure will be reviewed periodically by the CCG with Arden & GEM HR support in conjunction with Trade Union representatives. Where review is necessary due to legislative change, this will happen immediately. 5. HOME WORKING ARRANGEMENTS 5.1 Working from home, or other remote locations, involves a more significant change in working arrangements than other forms of flexible working and this section provides detailed information specifically for home working. 5.2 There are a number of circumstances in which the ability to work from home on an occasional or temporary basis may assist an employee, for example when: despite being fit to work, travelling to the office is difficult (for example, due to recovery from an injury such as a broken leg); public transport has been disrupted (for example by inclement weather) and this affects travel arrangements; or a quiet, uninterrupted work environment will assist in dealing with a backlog of administrative tasks or in writing reports to a deadline. In these circumstances working at home can be authorised by the employee s manager without a formal flexible working request where the line manager believes that: the employee has work that can be undertaken at home; and working at home is cost-effective and any increase in work that may be passed to the employees colleagues as a result is kept to a manageable minimum. 5.3 Not all employees and not all jobs are suitable for homeworking. A request for homeworking is unlikely to be approved, on either an occasional or permanent basis if the employee: (a) (b) (c) needs to be present in the workplace to perform their job; is subject to performance capability proceedings or the employee needs supervision to deliver an acceptable quality and/or quantity of work; has an unexpired warning relating to conduct or performance. 5.4 It may assist an employee s application for homeworking if the employee first discusses their proposal with their line manager informally. This may identify potential problems with their application, such as a need to be in the workplace on occasions the employee had not considered, which the application can then address. 5.5 When a home working request is approved, the CCG will provide Information Technology (IT) equipment that the employee reasonably requires to work from home which will remain property of the CCG. Where equipment is provided, the employee must: (a) (b) use it only for the purposes for which it is provided; take reasonable care of it and use it only in accordance with any operating instructions and CCG policies and procedures; and 7

190 (c) make it available for collection by the CCG if requested. 5.6 It is the employee s responsibility to ensure that they have sufficient and appropriate equipment for working from home. The CCG are not responsible for the provision, maintenance, replacement, or repair in the event of loss or damage to any personal equipment used by the employee when working for the CCG. 5.7 The CCG are not responsible for associated costs of an employee working from home including the costs of heating, lighting, internet access, electricity or telephone calls. 5.8 All equipment and information must be kept securely. In particular, private and confidential material must be kept secure at all times. Employees must adhere to the CCG s Information Governance Policy and / or rules at all times 5.9 Employees must take reasonable care of their own health and safety and that of anyone else who might be affected by their actions and omissions. Employees must attend the usual office health and safety courses, read appropriate health and safety training material and undertake to use equipment safely. Any health concerns should be reported to the line manager The CCG retains the right to check home working areas for health and safety purposes. The need for such inspections will depend on whether work is undertaken at or from home and the nature of the work undertaken Employees working at home must not have meetings in their home with service users, patients or suppliers or clients of the CCG and must not give service users, patients, suppliers or clients of the CCG their home address or personal telephone number(s) Employees must ensure that their working patterns and levels of work both over time and during shorter periods are not detrimental to their health and wellbeing. Please refer to section 6.9 for information relating to the Working Time Regulations Employees working at or from home are advised to check the terms of their home insurance policy. Any accidents, incidents or near misses must be reported immediately in accordance with the CCG's Health and Safety Policy. 6. FLEXI-TIME 6.1 Flexi time enables employees to vary their start and finish times provided that they are available for work for a minimum of 4 hours per day. There are no fixed core hours where employees are obliged to be available for work. Availability for work should always be based upon service need to ensure continuity of service delivery. 6.2 Flexi-time gives employees the ability to manage their time according to workloads in agreement with their line manager and allows them to achieve a healthy work-life balance. Individuals using flexi-time must agree the parameters of their start and finish times with their line manager prior to commencing. Any variations from those parameters must be approved by their manager. 6.3 Flexi-time can be accrued between the hours of and Monday to Friday. Hours worked before or after or on a Saturday, Sunday or public holiday cannot be recorded on a flexi sheet. Evening work (defined as working after 19.00) is not encouraged as it is important that staff maintain a healthy work-life balance; however, the CCG accepts that there are occasions where occasional evening working is required due to service requirements, e.g. attending an evening meeting with stakeholders. Therefore, working during evenings (after 19.00) should only be undertaken with the prior permission of the manager. 6.4 If a member of staff is required to work on a Saturday, Sunday or public holiday, a separate agreement must be reached with the line manager beforehand which outlines how that time will be remunerated and recorded in line with Agenda for Change Section 3: Overtime Payments. 8

191 6.5 Employees are responsible for ensuring that their flexi-time arrangements do not adversely affect service delivery and business continuity. Notwithstanding section 7.5, Chief Officers have the right to withdraw an employees flexi-time working, or impose restrictions upon start and finish times, if an employees flexi-time arrangement adversely affects service delivery. 6.6 All employees wishing to use flexi-time must record the hours that they work using the flexi sheet template provided in Appendix 3 of this policy. Use of this sheet is not required for other staff. Flexi sheets should be kept fully up to date and must be made available to managers immediately upon request. 6.7 The maximum flexi credit balance that can be accrued is 15 hours for a full time employee (pro rata accordingly for a part time employee). The maximum deficit flexi balance that can be built up is 7.5 hours for a full time person (pro rata accordingly for a part time employee). 6.8 The maximum credit balance that can be carried across from one flexi period to the next is 15 hours and the maximum deficit that can be carried across to the next flexi period is 7.5 hours. Under exceptional circumstances a credit of more than 15 hours can be carried forward but prior permission must be obtained from the relevant Chief Officer. 6.9 Employees and their managers should be mindful of and adhere to the Working Time Regulations (1998) with respect to their Health and Safety and working patterns. For full details please contact your Arden and GEM HR Business Partner, but this includes: not exceeding 48 hours worked in a week averaged over 17 weeks (though employees can choose to opt out of this) taking rest breaks an uninterrupted rest break of at least 20 minutes for every six consecutive hours worked daily rest - 11 consecutive hours rest per 24 hour period weekly rest an uninterrupted rest break of 24 hours in each 7 day period 6.10 Requests to take time off for flexi leave should be made by submitting a current and fully updated flexi sheet directly to the line manager. Approval from the line manager must be sought in the same way as arranging annual leave. This includes providing reasonable notice of the intended time off. Line managers will refuse any flexi time-off requests that are made without current and fully updated flexi sheets. One full day off can be taken per 4 week flexi period Employees may not exchange a flexi credit for payment. Overtime payments can only be made in line with Agenda for Change Section 3: Overtime Payments. Follow this link to access AfC overtime rules: _service_handbook_fb.pdf 6.12 Flexi-time is available for all staff up to and including band 8b. 7 APPLICATION PROCEDURE 7.1 An employee has the right to be accompanied by their trade union representative or a work colleague at every stage of this procedure. 7.2 A request to change the contracted hours of work must be made by the employee in writing using the attached form (Appendix 1), to their line manager and must:- be dated and submitted allowing sufficient time between the submission of the request and the proposed start date for the application to be considered (minimum of 28 days); state whether a previous application has been made and, if so, the date on which it was made (only one application is allowed per rolling 12 months); include the reason the request is being made; 9

192 include details of the proposed change, proposed start date and an explanation of the employee s view of the effect on NHS North Derbyshire Clinical Commissioning Group business and how this may be dealt with; relate to hours, times or place of work. 7.3 The line manager will acknowledge the request and will arrange a meeting with the employee to discuss the application, to be held no later than 28 days after the date of application. 7.4 A decision will be made within 14 days of the meeting and the employee will be notified in writing. The notification will either:- accept the request and establish a start date and any other action or; confirm a compromise agreed at the meeting or; decline the request, detailing all of the facts and demonstrating the business rationale behind the decision and include details of the appeals process. 7.5 Should the application be approved, the change will be made on a permanent basis, unless all parties have agreed at the outset that the arrangement is time limited or subject to a periodic review (see also 6.5). 7.6 When considering flexible working requests, managers should take into account all relevant factors (including those listed in 7.7) to ensure that service delivery is not compromised by granting the request. In some circumstances, but not necessarily all, it may be appropriate to agree a trial period to gauge the impact of the new working arrangement. 7.7 Applications for flexible working arrangements will only be refused for one or more of the following reasons: the burden of additional costs; detrimental effect on ability to meet customer demand; inability to reorganise work among existing staff; inability to recruit additional staff; detrimental impact on quality; detrimental impact on performance; insufficiency of work during the periods the employee proposes to work; planned structural changes. 7.8 If the proposal is refused, the employee will be allowed 14 days in which to appeal. 8. APPEAL PROCEDURE 8.1 The employee must submit their appeal in writing within 14 days of them being informed of the decision. 8.2 The appeal will be acknowledged in writing and an appeal meeting arranged. 8.3 The appeal meeting must take place within 14 days of the notice of the appeal and will be heard by the line manager of the manager who made the original decision, or someone at an equivalent level. 8.4 The employee has the right to be accompanied by their trade union representative or a work colleague at this meeting 8.5 The decision on the appeal must be given within a further 14 days and is final. 10

193 9. DUE REGARD In carrying out its function, the CCG must have due regard to the Public Sector Equality Duty (PSED) of the Equality Act 2010 to eliminate discrimination; harassment; victimisation; to advance equality of opportunity; and foster good relations between the protected groups. This applies to all activities for which the CCG is responsible, including policy development, review and implementation. Due Regard is evidenced within this policy in sections 3.3, 3.4, 3.9 and

194 Appendix 1 Name: Manager: FLEXIBLE WORKING APPLICATION FORM Dept: Type of request: I wish to apply to work a flexible working arrangement that is different from my current working arrangement. I confirm that I have not made a flexible working request in the last 12 months. Is this request being made in relation to a reasonable adjustment under the Equality Act (2010) due to one of more the protected characteristics? (please circle) Yes / No If so, please provide further details in section 2. All sections must be completed 1. My current working arrangement is: 2. The arrangement I would like to work is: Please provide details of days/hours/times worked Please provide details of days/hours/times to be worked and if arrangement is temporary or permanent 3. I would like this working arrangement to commence from: Please also provide an end date if the arrangement is temporary 4. I think this change in my working arrangement will affect NHS North Derbyshire Clinical Commissioning Group and my colleagues as follows: Please include details of the potential benefits and drawbacks associated with the arrangement 5. I think the effect on NHS North Derbyshire Clinical Commissioning Group and my colleagues can be dealt with as follows: Please address any potential drawbacks associated with this arrangement 12

195 Homeworking applicants. When completing your application please consider: Health implications of your working station set up (display screen equipment) Personal security and safety Information governance Availability to come into the office as required by your manager (e.g. meetings, sickness cover, peak workloads, etc), Communication and supervision Insurance whilst working from home Signed: Date: Appendix 2 - (Line manager to complete and return to employee) 13

196 Scarsdale House Nightingale Close Off Newbold Street Chesterfield S41 7PF Dear Name Date Re Flexible working request I write to confirm that I received your request to change your existing work pattern on date. I will arrange a meeting with you to discuss your application within 28 calendar days. At this meeting I will consider your application, including any supporting information that you have provided, and I will inform you as to whether or not your request has been approved. If your request is approved we will agree a start date and in the event that it is not approved I will provide you with a full explanation outlining the reasons for my decision. You are welcome to bring a trade union / representative or a work colleague to this meeting. If you have any queries regarding the contents of this letter then you are welcome to contact me. Yours sincerely Name Job Title 14

197 Appendix 3 Flexi Sheet Flexi Sheet.xlsx 15

198 CCG Governing Body Assurance Committee Meeting 22nd February 2016 Paper L NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE MEETING 22nd February 2016 Report Title: Supported Learning Policy Item No: Background and context This paper provides the Governing Body Assurance Committee with a new North Derbyshire CCG Supported Learning Policy. This replaces the previous Further Education and Professional Development Policy. 2. Key matters for consideration The intention of this policy is to provide rigour, consistency and fairness across North Derbyshire CCG when considering supported learning requests from staff seeking financial assistance and/or time off work to pursue work-related further education or qualifications. 3 Financial Impact The financial impact will be to the relevant department and appropriate 75% funding for the supported learning. 4. Analysis of risk There is no direct risk associated with these documents. 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: The strategic documents meet all requirements and include an Equality statement and Equality analysis. Better health outcomes for all: None Directly Improved patient access and experience: None Directly Empowered, engaged and well-supported staff: None Directly Inclusive leadership at all levels: None Directly 6. Recommendations The Governing Body Assurance Committee is asked to approve the Supported Learning Policy to enable the policy to be disseminated within the CCG. 1

199 Author: CCG Governing Body Assurance Committee Meeting 22nd February 2016 Paper L Carole Whitton, Arden & GEM HR Business Partner Sponsor: Suzanne Pickering, Governance Lead Date: 12 th February

200 Supported Learning Policy 1

201 SUPPORTED LEARNING POLICY Policy Title: Description of Amendment(s): This policy will impact on: Financial Implications: Policy Area: Supported Learning Policy New Policy for NHS North Derbyshire CCG employees All CCG employees No change HR Version No: 1 Issued By: Author: Governance Team Arden and GEM HR Team Document Reference: Effective Date: January 2016 Review Date: January 2018 APPROVAL RECORD Committees / Groups / Individual Date Consultation: Partnership working forum 15/1/16 Approved by Committees: Governing Body Assurance Committee Revision History Version Revisions Date 1 Initial draft 15/12/2015 2

202 EQUALITY STATEMENT NHS North Derbyshire Clinical Commissioning Group (the CCG) aims to design and implement policy documents that meet the diverse needs of our services, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account current UK legislative requirements, including the Equality Action 2010 and the Human Rights Act 1998, and promotes equal opportunities for all. This document has been designed to ensure that no-one receives less favourable treatment due to their protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. Appropriate consideration has also been given to gender identity, socioeconomic status, immigration status and the principles of the Human Rights Act. In carrying out its functions, the CCG must have due regard to the Public Sector Equality Duty (PSED). This applies to all the activities for which the CCG is responsible, including policy development, review and implementation 3

203 Contents 1 POLICY STATEMENT 5 2 PRINCIPLES 5 3 CONDITIONS 5 4 DUE REGARD 7 5 MONITORING AND REVIEW 7 Part 2 PROCEDURE 8 Appendix A Appendix B APPLICATION FORM LEARNING CONTRACT AGREEMENT FORM

204 1. POLICY STATEMENT 1.1 North Derbyshire Clinical Commissioning Group recognises the benefits to the employee and the CCG of encouraging and supporting staff to undertake courses of additional learning, development or education, which are relevant to their current role and future development. 1.2 The types of learning, development and education covered by this policy are external, costed courses of further / higher education or continuing professional development which lead to a qualification or certificate of achievement (or similar) from a recognised educational establishment or professional body. This policy relates to externally run courses that have a cost attached to them and which take place over an extended period of time. 1.3 This policy does not cover any other forms of learning, development, training or continuous professional development. Excluded from the scope of this policy are (not an exhaustive list): internal training; free learning and development; any form of learning that is not related to an employees current or future role with the CCG; ad hoc conferences or development sessions; external briefings and updates; and so on. Please contact your line manager or Arden and GEM HR for further advice if required. 2. PRINCIPLES 2.1 All applications for funding and support will be considered equally on the basis of their merits and the funding available. 2.2 Support and assistance for employees encompasses a range of activities including financial assistance, time off for study and assessment, access to information and information technology. 2.3 Financial assistance and time off for study and assessment will be agreed by the Executive Team on a case-by-case basis. 2.4 Access to Information in order to support assessed work it may be necessary for employees to request organisational information. Such requests should be agreed to, provided that they are reasonable and conform to Information Governance rules on the release of such information. 2.5 Access to information technology in many cases it is necessary to access material and complete assessed work electronically. It is therefore important that wherever possible, employees are given reasonable access to information technology equipment in order to do this. Note however that software outside of the standard packages that are included on the organisations computers will not be installed. 2.6 Support will be available to all line managers in the implementation and application of this policy. 3. CONDITIONS 3.1 Normally an employee will be expected to remain in the CCG employment (or the successor organisation if the CCG is re-organised) for a period of at least two years from the date when the qualification is awarded. 3.2 An undertaking will be required from the employee to this effect and where the employee fails to honour the undertaking then the CCG may require the 5

205 repayment of all or part of the expenses paid (please see Appendix B). 3.3 The continuation of any such assistance granted will be dependent on satisfactory progress during the course of study. This may be judged by such factors such as regular attendance, the passing of examinations and by the receipt of favourable reports from the educational/professional institution involved. 3.4 Employees are responsible for providing evidence of their yearly, modular or exam results to their line managers. These will be retained with copies of relevant applications and placed on the employees personal file. 3.5 Employees must be made aware, before undertaking a course of study, that if they do not complete the course, or voluntarily leave the CCG, they may be required to repay costs in full if the reasons given are not deemed to be satisfactory. All such instances must be considered by the appropriate Chief Officer to ensure consistency. Situations where no repayment will be required are outlined in Appendix B. 3.6 All applications will be considered on their individual merit, which includes (not an exhaustive list): impact of approving the request upon service delivery; benefit to the CCG and the individual; cost; and time commitments. 3.7 Employees are expected to pay for any additional learning resources they require to undertake their learning such as text books, subscriptions to / membership of professional bodies and anything not included in the institutions course fees. 3.8 The CCG will not fund the cost of any re-sits incurred by an employee should they miss or fail any examination or assessment, unless the reason for missing the exam is deemed by the relevant Chief Officer to be satisfactory. 3.9 New starters to the CCG who are part-way through a course or study should discuss with their recruiting manager if and how they can be supported with their learning by the CCG Paid time off work will be granted for attendance at classes, seminars, conferences, tutorials and other occasions where face-to-face contact is required as part of the study. Time off / time off in lieu (TOIL) will not be granted for self-directed study or attendance at sessions outside an employee s normal working hours Paid time off work is allowed for examinations as follows: half a working day is allowed to prepare for each examination and half a working day time off is allowed to attend the examination itself. Should any examinations or assessments occur outside employees normal working hours, no time off / time off in lieu will be granted Employees are not required to re-pay or work back any agreed time off described in 3.10 and The CCG reserves the right to require employees to attend work under exceptional circumstances if service need demands it, even if that means the employee will miss classes, seminars, conferences, tutorials and other occasions of face-to-face contact related to their studies. If this results in any additional costs these costs will be met by the CCG and not the employee Some institutions may offer supplementary revision courses in addition to their 6

206 standard course content. If an employee wishes to attend a revision course as part of the supported learning, they must include full details in their initial application. Applications for revision courses after an application has been considered will not be accepted. 4. DUE REGARD This policy has been reviewed in relation to having due regard to the Public Sector Equality Duty (PSED) of the Equality Act 2010 to eliminate discrimination; harassment; victimisation; to advance equality of opportunity; and foster good relations. Due Regard has been demonstrated in the development of this policy in sections 3.2 and MONITORING & REVIEW The policy will be reviewed periodically by Arden and GEM Human Resources in conjunction with the CCG. Where review is necessary due to legislative change, this will happen immediately. 7

207 Part 2 1. PROCEDURE 1.1 All applications should be made on the appropriate application form (Appendix A). Employees are encouraged to discuss their application with their manager before submitting it. It is expected that applications will be discussed during appraisal / performance development review meetings and there will be a clear link between supported learning requests and employees performance management. 1.2 Employees should submit applications in sufficient time to allow the Executive Team to consider them within a reasonable period before the institutions enrolment deadline. 1.3 Applications for supported learning will be considered by the Executive Team on a fair and equal basis. A decision should be taken which considers the impact upon service delivery, the relevance to the applicant s current role and development and the benefits that it will bring to the business, time and cost commitments. 1.4 Applications should be sent to the relevant Chief Officer and the Executive Team will make the decision. 1.5 Funding decisions will be based upon suitability of course or programme and the availability of funds. 1.6 All applicants will be informed in writing of the outcome of their application whether it is successful or not. Applicants who are not satisfied with the decision will have recourse to the grievance procedure. 1.7 Successful employees must sign an undertaking to repay fees if the conditions contained within this policy are not fulfilled. A copy of this undertaking must be sent to the line manager to be kept in the employees personal file. 1.8 Where appropriate, a fees request letter should be sent to the education provider as soon as possible after an application has been approved. 1.9 If approved, the CCG will pay 100% of the course fees direct to the institution and the employee will reimburse their 25% contribution back to the CCG. Employees should not pay fees up front and then seek reimbursement from the CCG. The CCG will not make any payment direct to employees in respect of any course fees, all payments made by the CCG will be made directly to the institution Employees should keep their personal development plans up to date to include details of any supported learning activity. 8

208 APPENDIX A SECTION 1 Full name SUPPORTED LEARNING APPLICATION FORM TO BE COMPLETED BY THE APPLICANT Job title and Grade Telephone No/Ext. Service/Division Is your contract of employment: Permanent / Fixed Term What relevant qualifications do you currently hold? What is your proposed course? What qualification will you be awarded, if successful? What interim qualifications could you gain (if any)? e.g. A 3 year Master of Business Administration (MBA) course may offer CMS for success in Year 1, and DMS for success in year 2 Commencement date of the course What are the subjects that you will study and be examined upon during this coming year? Which year of the course are you starting? If fixed term state number of months How long will the full course last? For which years have you previously been funded? Name and address of University, College or other training provider? What study/course attendance Dates Additional Information time will you need to complete Full day release M T W T F the course?* Half day release M T W T F Evening only M T W T F * Please refer to sections 3.10 and 3.11 Self-directed study Weekend seminars Summer school Exam/study leave dates COSTS What are the estimated costs Full Amount Additional Information 9

209 associated with your attendance on this course? Course Registration Fees Tuition Fees Residential & Revision Fees (e.g. Summer Schools) Additional Examination Fees NB The omission of costs at this stage may restrict the level of reimbursement (Please turn over the page) COURSE SUITABILITY Please give your reasons why you feel this course is suitable for support from the CCG. e.g. What difference will the qualification make to the type of work that you could undertake? Why have you chosen this particular course provider? What relevance have the subjects to your current job or any job in the NHS that you may apply for in the near future? I have read and accept the conditions attached to any Further/Higher Education support included and have signed and included an Undertaking to Repay Costs form. Applicant s signature: Date: SECTION 2 TO BE COMPLETED BY THE APPLICANTS HEAD OF SERVICE (or Chief Officer if it is the Head of Service making the application) MANAGER S COMMENTS Please give your reasons why you feel the subjects covered in this course are relevant to the applicant s current job AND/OR to their potential career development How will the proposed attendance arrangements affect your section or Division? In your opinion, has the applicant the necessary ability and application to successfully complete the course? Please give any reasons (if any) why you feel that you cannot support this application Head of Service signature: Date: DECISION OF EXECUTIVE TEAM Approved Rejected Chief Officer Signature Date: ACTION REQUIRED Approval / Rejection letter sent Undertaking to Repay signed & returned Fees Request Letter sent Exam results received 10

210 Appendix B Learning Contract Agreement Form (TO BE COMPLETED BY THE APPLICANT IF THE APPLICATION IS APPROVED BY THE EXECUTIVE TEAM) Candidate s name: Job title: Location: Site / Location address: Contact telephone number: address: Details of course of study covered by this agreement: Candidate s line manager s name: Job title: Location: Site / Location address: Contact telephone number: address: Cost code: This document is the official learning agreement. By signing it the delegate and their line manager agree to the terms of the agreement. 11

211 Payment of course fees You agree to pay 25% of the course fees, revision fees and exam registration fees. The CCG will pay the remaining 75% of the fees. Unless included in your course fees, you will be required to pay for your own textbooks / additional resources and as such they will be your property and will not belong to the CCG. In signing up to this course you commit yourself in as much that if you do not complete the course, or you leave the employment of the CCG within 24 months of completing the course, for any reason (apart from redundancy, redeployment, retirement, ill health retirement or long term sickness) you will reimburse the CCG as outlined in the sliding scale below: Timescale Before completing the course of study and gaining the qualification Within 6 months after completion 6-12 months following completion months following completion months after completion More than 2 years after completion If you leave the CCG before completing the programme, or fail to complete the programme for any reason other than those given above, you will reimburse the CCG. If you complete the programme, and then leave the CCG within 6 months of completing the programme, you will reimburse the CCG. If you complete the programme, and then leave the CCG within 12 months (but more than 6 months) of completing the programme, you will reimburse the CCG. If you complete the programme, and then leave the CCG within 18 months (but more than 12 months) of completing the programme, you will reimburse the CCG. If you complete the programme, and then leave the CCG within 24 months (but more than 18 months) of completing the programme, you will reimburse the CCG. If you complete the programme, and leave the CCG more than 24 months after completing the programme, then there will be no charge. Payment due to the CCG 100% of any fees paid by the CCG 100% of any fees paid by the CCG 75% of any fees paid by the CCG 50% of any fees paid by the CCG 25% of the course fees paid by the CCG No payment due Any study leave has to be coordinated and agreed with your line manager and depends on the business needs, which take priority. Exceptions to this rule are exams or workshops that cannot be repeated or would delay the successful completion of the programme. 12

212 NHS North Derbyshire Clinical Commissioning Group Declaration of Payment for Corporate Sponsorship I, [insert name].., have read and understand the terms of sponsorship and agree to the following conditions: Sponsorship Repayment Scale Payment due to the CCG Before completing the programme of study Within 6 months following completion 6-12 months after completion months after completion months after completion More than 2 years after completion If I leave the CCG before completing the programme, or fail to complete the programme for any reason other than those outlined in this policy, I will reimburse the CCG. If I complete the programme, and then leave the CCG within 6 months of completing the programme, I will reimburse the CCG. If I complete the programme, and then leave the CCG within 12 months (but more than 6 months) after completing the programme, I will reimburse the CCG. If I complete the programme, and then leave the CCG within 18 months (but more than 12 months) after completing the programme, I will reimburse the CCG. If I complete the programme, and then leave the CCG within 24 months (but more than 18 months) after completing the programme, I will reimburse the CCG. If I complete the programme, and leave the CCG after 24 months of completing the programme, then there will be no charge. 100% of the any fees paid by the CCG 100% of any fees paid by the CCG 75% of the course fees paid by the CCG 50% of the course fees paid by the CCG 25% of the course fees paid by the CCG No payment due I understand and agree that any study leave has to be coordinated and agreed with my line manager and depends on the business needs, which take priority. Exceptions to this rule are exams or workshops that cannot be repeated or would delay the successful completion of the education. By signing this document, I also agree and understand that if, on leaving the CCG, I become responsible for the repayment of any fees as per the repayment schedule outlined above, such money will be paid to the CCG promptly. I also agree that such sums can be deducted from my final salary or other sums then owed to me by the CCG. The total sponsorship granted under this agreement by the CCG is [insert amount]. Candidate s name: Candidate s signature: Line manager s name: Line manager s signature: Date: Date: Once complete, please return this form to the line manager so a copy can be kept on the employees personal file. 13

213 ND CCG Governing Body Assurance Committee Meeting 22nd February 2016 Paper M NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE MEETING 22nd February 2016 Report Title: Corporate Incident Policy Annual Review. Item No: Background and context This paper provides the Governing Body Assurance Committee with the annual review and update for the CCG s Corporate Incident Policy. 2. Key matters for consideration The following changes have been made to the strategy and policy. Corporate Incident Policy Minor administrative changes Addition to the IG Incident procedure to include cyber security incident and relevant cyber security form. The policy can be accessed in the supporting documents attached to the Governing Body Assurance Committee papers on the NDCCG website. The policy will be available on the NHS North Derbyshire CCG intranet following approval and disseminated to the Executives and Senior Managers. 3 Financial Impact There is no impact financial impact associated with these documents. 4. Analysis of risk There is no direct risk associated with these documents. 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: The strategic documents meet all requirements and include an Equality statement and Equality analysis. Better health outcomes for all: None Directly Improved patient access and experience: None Directly Empowered, engaged and well-supported staff: None Directly 1

214 ND CCG Governing Body Assurance Committee Meeting 22nd February 2016 Paper M Inclusive leadership at all levels: None Directly 6. Recommendations The Governing Body Assurance Committee is to approve the reviewed Corporate Incident Policy to enable the policy to be disseminated within the CCG. Author: Suzanne Pickering, Head of Governance Sponsor: Suzanne Picking, Head of Governance Date: 12 th February

215 Corporate Incident Reporting Policy 1

216 Corporate Incident Reporting Policy 2

217 Policy Title: Supersedes: Description of Amendment(s): This policy will impact on: Financial Implications: Policy Area: Corporate Incident Reporting Policy All previous Corporate Incident Reporting Policies Review of Policy for NHS North Derbyshire CCG employees All staff No change Corporate Version No: 2 Issued By: Author: Governance Team Suzanne Pickering Document Reference: CIRP 01 Effective Date: March 2015 Review Date: February 2018 Impact Assessment Date: APPROVAL RECORD Committees / Groups / Individual Date Consultative Committee Specialist Advice (if required) N/A Approved by Committees: Management / Staff Side Governing Body Governing Body Assurance Committee Governing Body Assurance Committee February 2014 March

218 Contents page Introduction..... Page 5 Purpose and Scope..... Page 5 Definitions Page 6 Key Responsibilities.... Page 7 Information Governance Incidents..... Page 8 Health and Safety.... Page 11 Risk Assessments..... Page 12 Levels of Investigation.... Page 13 Sharing of Lessons Learnt Page 13 Reporting to external agencies..... Page 13 Monitoring and Reviewing... Page 16 Accident/Incident Report.. Page 16 Appendix A. Information Governance Incident Report Form..... Page 17 Appendix B. Accident and Incident Form..... Page 19 Appendix C. Cyber Security Incident Form. Page 21 4

219 1. Introduction This policy and procedures document applies to all staff directly employed by North Derbyshire Clinical Commissioning Group. The policy is designed to ensure that all staff have a clear understanding of their responsibilities and respond effectively to non-clinical incidents. Incidents occurring in an NHS provider organisations should be reported and investigated internally in accordance with that provider organisation s policy and procedures. Provider incidents should not be reported to the CCG with the exception of serious incidents which should be reported under schedule 12 of their contract. Independent Contractors are responsible in the same way as other contracted NHS providers, in reporting and investigating incidents occurring in their services. This policy is available to them as a framework to assist in developing their own robust local reporting systems. Where the incident is IG related, the HSCIC: Checklist Guidance for Reporting, Managing and Investigating Information Governance Serious Incidents Requiring Investigation, must be followed. 2. Purpose and Scope The purpose of the policy is to outline the arrangements for identifying, managing, investigating and reporting Information Governance, Business Contingency and Health and Safety incidents and near misses within North Derbyshire Clinical Commissioning Group. All Employees of the CCG have a duty to ensure incidents and near misses are reported as soon as possible and their manager notified so that the event can be investigated and measures taken to minimise the risk of recurrence of the situation. The incident reporting form should be used in all CCG areas to report and investigate incidents. It is the responsibility of all staff to report an incident within 48 hours (or 24 hours if serious). The incident form should be used to report the facts of the incident, not opinion, as comprehensively as possible using further sheets appended and secured to the form if required. The reporting of all incidents, prevented incidents (near-misses) is designed to ensure the following: A culture of openness in reporting incidents or prevented incidents (near misses). Prompt and precise gathering of information. Prompt communication with staff. Minimisation of distress to those affected by an incident. Identification of patterns and trends in the occurrence of incidents and prevented incidents (near-misses). Minimise, so far as is reasonably practicable, future risk by taking prompt and appropriate preventive action and ongoing monitoring. 5

220 Early warning of potential litigation and cost impact. Local managers are able to review local safety procedures. Fulfillment of the CCG s legal duties under statutory regulations including RIDDOR 1995, The Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations This policy applies to directly employed staff and others including visitors to CCG premises such as contractors/workmen, students on placement and volunteers. Only NDCCG staff will do the actual incident reporting and handling. 3. Aims The aims of the document are: To describe the process for reporting and recording incidents; To ensure the process conforms to NHS requirements; To encourage the prompt and consistent reporting of all incidents, and near misses; To ensure investigation of incidents and near misses; To provide a feedback mechanism and organisational learning from incidents and near misses. 4. Definitions Incident/Accident An unexpected or unplanned event that caused harm, or had the potential to cause harm, to a patient, member of staff, visitor, contractor or the CCG. Personal Accident Personal accidents are accidental incidents which affect and/or involve a person or persons and resulted or could have resulted in injury. Ill health, work or environmental related incidents. Illness which is related to work or the environment, unsafe environments, flooding, lighting/power/heating failure leading to of loss of services Fire Incident. Any incident which involves smoke, fire, suspected smoke or fire, or fire alarm whether it be actual or suspected. Adverse Incident: Any event which has given rise to potential or actual harm or injury, to patient dissatisfaction or to damage/loss of property (Ref: NHS Executive). This definition includes patient or client injury, fire, theft, vandalism, complaints, assault and employee accident and near misses. It includes incidents resulting from negligent acts, deliberate or unforeseen. Patient Safety Incident: Any unintended or unexpected incident that could have or did lead to harm for one or more persons 6

221 receiving or requesting NHS funded care i.e. patient. This was previously referred to as a Clinical Incident. Non-Clinical Incident: An unintended or unexpected event in which a member of staff or the public has been, or could have been, killed, injured or suffered ill health or mental trauma, or which has led to or could have led to, loss or damage to equipment or property, or other financial loss. There are a number of categories of non-clinical incident and these are described below. STEIS: The clinical risk management system adopted by the CCG in support of record keeping, management and analysis of incidents. Personal Accident: Any incident which affected an individual not directly related to clinical treatment for example back injuries related to manual handling. Vehicle Incident: Any incident involving a vehicle e.g. road traffic accident, excluding vandalism or theft which would be considered as a security incident. Violence, Abuse or Harassment: Any incident involving verbal abuse, unsociable behaviour, racial or sexual harassment or physical assault whether or not injury results. Health and Safety Incident: An event occurring by chance or arising from unknown causes resulting in injury, death or damage to people. Information Governance Incident: A near miss or incident relating to loss of information or compromise of information governance policy or systems. Security Incident. A security incident is one in which there is fraud, theft, deception, criminal damage, car crime, amongst other things involving staff, visitors to the CCG and its property. Clinical Incident. A clinical incident is one which arises in the context of the duty of care owed to patients by members of the healthcare professions, or consequences on decisions or judgments made by those professions in their professional capacity or relevant work. Near Miss An event that has the potential to cause harm or was prevented from causing harm to one or more individuals, damage to property, a security breach or confidentiality breach. Potential Risk An unexpected or unplanned event that caused harm or had the potential to cause harm to a member of staff, visitor or contractor and the situation/environment continues to pose a risk. Serious Incidents A serious incident requiring investigation is defined as an incident that occurred in relation to NHSfunded services and care resulting in one of the following. 7

222 For serious incidents refer to the ND CCG Serious Incident Policy 5. Key Responsibilities The Chief Officer is ultimately responsible for ensuring compliance with the Health & Safety at Work Act 1974 and associated legislation, and that this policy is implemented and effective within North Derbyshire Clinical Commissioning Group. The Chief Officer is responsible for the incident reporting system across the CCG and for the management of incidents to ensure risk to the CCG is minimised. The Head of Governance for North Derbyshire Clinical Commissioning Group is responsible for writing and implementing the policy and monitoring its effectiveness. They will ensure that the policy is adhered to including the internal and external reporting arrangements. The Caldicott Guardian is responsible for ensuring the protection and use of patient identifiable information, which may be used during the incident reporting process. The Chief Finance Officer is the CCG s main contact with the NHSLA in the event of a likely claim and to handle any claims in accordance with the CCG s Claims Management Procedure. They will ensure that any complaints arising from incidents are managed in accordance with the CCG s Complaints Policy. The Governing Body will receive and review incident reports to ensure that risk management issues have been addressed and to ensure that recommendations for improvements are implemented to reduce risk. 6. Information Governance Incidents 6.1 Introduction The Information Governance procedure is to be used in conjunction with the Checklist Guidance for Reporting, Managing and Investigating Information Governance and Cyber Security Serious Incidents Requiring Investigation.1 The CCG recognises that on occasions, IG incidents and near misses may occur that result in failure to meet the requirements of the Data Protection Act or the Common Law of Confidentiality. This document sets out the processes and clearly identifies the responsibility between the CCG and Arden & GEM CSU for managing incidents Roles & Responsibilities All CCG Employees All Employees of the CCG have a duty to ensure incidents and near misses are reported as soon as possible and their manager notified so that the event can be investigated and measures taken to 1 8

223 minimise the risk of a recurrence of the situation. CCG Managers Managers have a responsibility for ensuring that incidents and near misses are graded and investigated as soon as possible after the event and that measures are taken to minimise the risk of a recurrence of the situation. CCG IG Lead The CCG Information Governance Lead is responsible for ensuring that IG incidents are graded according to the HSCIC: Checklist Guidance for Reporting, Managing and Investigating Information Governance and Cyber Security Serious Incidents Requiring Investigation and that the appropriate reporting route is taken depending on the level of incident. For level 1 and below incidents, the IG Lead will also ensure that appropriate investigation is undertaken. For level 2 and above incidents, the IG Lead will ensure the incident is reported via the CCG s IG Toolkit. Arden & GEM Commissioning Support Unit (CSU) Arden & GEM CSU provides expert advice through the Information Governance Services and will support the CCG to assess and report any potential IG incidents. 6.3 Incident Definitions Information Governance Incident There is no simple definition of an IG incident. What may at first appear to be of minor importance may, on further investigation, be found to be serious and vice versa. As a guide: Any incident which involves actual or potential failure to meet the requirements of the Data Protection Act 1998 and/or the Common Law of Confidentiality; This includes unlawful disclosure or misuse of confidential data, recording or sharing of inaccurate data, information security breaches and inappropriate invasion of people s privacy; Such personal data breaches which could lead to identity fraud or have other significant impact on individuals; Applies irrespective of the media involved and includes both electronic media and paper records. Incidents may be caused through, for example: Information being lost in transit: Information being lost or stolen; Information being disclosed in error through mis-directed s and letters; Unauthorised access to systems. Cyber Security Incident There are many possible definitions of what a Cyber incident is, for the purposes of reporting a Cyber incident is defined as:- A Cyber-related incident is anything that could (or has) compromised 9

224 information assets within Cyberspace. Cyberspace is an interactive domain made up of digital networks that is used to store, modify and communicate information. It includes the internet, but also the other information systems that support our businesses, infrastructure and services. Source: UK Cyber Security Strategy, 2011 It is expected that the type of incidents reported would be of a serious enough nature to require investigation by the organisation. These types of incidents could include: Denial of Service attacks Phishing s Social Media Disclosures Web site defacement Malicious Internal damage Spoof website Cyber Bullying 6.4 Incident Management Reporting an Incident All IG incidents and near misses e.g. sensitive data such as sexual health information is sent to the wrong person, data on >100 people lost etc. must be reported to the CCG IG Lead using the form in Appendix A for Information Governance Incidents and Appendix C for Cyber Security Incidents. Wherever possible the Incident Report form should be completed and submitted within 24 hours of the incident occurring. Assessing an Incident Arden & GEM CSU will support the assessment of the incident in conjunction with CCG using the guidance in Checklist Guidance for Reporting, Managing and Investigating Information Governance and Cyber Security Serious Incidents Requiring Investigation by establishing the scale of the incident and applying the sensitivity characteristics to determine the level of incident. Incidents graded as level 1 or below are to be managed locally. Suspected incidents and near misses can still be recorded on the IG Toolkit, as lessons can often be learnt from them and they can be closed or withdrawn when all the facts are known. These incidents can be recorded on the IG Toolkit, but will not generate a report to the Department of Health (DH). In addition, CCGs may use a local incident reporting system in which case the IG incidents should be logged on this system to ensure they are captured and reported internally as any other incident type (eg through Quality and Risk Committee). Incidents classed as level 1 should be aggregated and reported in the annual report in the format 10

225 contained in the Checklist Guidance. Incidents rated as level 0 need not be reflected in annual reports. Incidents graded as level 2 and above must be reported via the IG Toolkit, which will generate reports to the DH and Information Commissioners Office (ICO) for IG SIRI and for Cyber SIRI reports will be generated to the DH and Health and Social Care Information Centre (HSCIC) only. ( ) The Incident Reporting Tool embedded within the IG Toolkit will also produce reports of closed incidents that will be made publically available. Local clinical and corporate incident management and reporting tools (including STEIS) can continue to be used for local purposes - but notifications of IG & Cyber SIRI for the attention of the DH,ICO and HSCIC must be communicated using the IG Incident Reporting Tool. The local IG team at Arden & GEM CSU will support assessment, investigation and reporting of IG incidents on behalf of the CCG and will agree the escalation procedure with the CCG to notify relevant Officers and Stakeholders (normally the SIRO). 6.5 Incident Report Plan The CCG IG Lead will be responsible for leading the incident response plan, adopting the checkpoints outlined in the HSCIC guidance. Arden & GEM CSU s responsibility is to support and advise a CCG of the appropriate response to an incident. Accountability for incident management rests with the CCG, e.g. decisions to write to patients would be taken by CCG and the final content of communications will require approval by the CCG before the communication is issued. 6.6 Incident Investigation and Reporting Arden & GEM CSU will support the CCG with the investigation into the incident and update the incident reporting tool accordingly. Arden & GEM CSU will support this process where access to the CCG IG Toolkit has been given in order to report IG incidents. The incident will be investigated as outlined in section 4.3 of the identified guidance. The scale of the investigation and the degree of reporting will be commensurate with the nature of the incident. A near miss may have the actions and learned fields on the reporting tool updated whereas a reportable level 2 SIRI would be subject to a root cause analysis exercise and formal report. 6.7 Incident Close Down After the investigation the SIRO within the CCG will close the incident on the reporting tool once they are satisfied that the incident has been fully investigated, that appropriate actions have been undertaken or a realistic action plan is in place, and a mechanism for disseminating any learning from the incident has been determined. Arden & GEM CSU will support this process where access to the CCG IG Toolkit has been given in order to report IG incidents. 7. Health and Safety Incidents 7.1 Members of Staff 11

226 The member of staff involved in the incident, or someone who notices it, should complete the form. Only one form should be completed. It should then be passed to the line manager within 48 hours for any further action, comment and signature. Any remedial action that is undertaken or planned should be noted on the form. The immediate priority for all staff in the case of an incident is to take steps necessary to secure the safety of the staff member and other people involved. Prompt action must be initiated to prevent a reoccurrence of any incident or to minimise the risk of a near miss or potential incident from materialising into an actual incident. The type of immediate action required varies according to the nature of the occurrence. Action may include: Administering first-aid Taking a faulty piece of equipment out of action Closing a workplace until repairs can be effected Changing a working practice to prevent re-occurrence. Serious incidents must be reported in accordance with the CCG s Serious Incident Policy. This includes completing an incident form and reporting to the Chief Nursing Officer by the fastest means telephone or Line Manager The Incident form must be signed off by the appropriate Line Manger and it is the responsibility of this manager to ensure a suitable investigation and corrective action is taken. The manager must also ensure that adequate feedback has been given to the person reporting the incident. The Manager should sign their section of the form and it should then be copied and the original forwarded to the Chief Nursing Officer within 3 working days. Any further follow up corrective actions taken by the line manager must be reported to the Quality Team for entry onto the incident database (DATIX). 8. Risk Assessment All incidents should be risk assessed by the line manager using the matrix set out below (table 1) A step by step guide on how to complete the risk matrix can be found in the CCG Risk Management Strategy - Table 1. Risk Matrix. Consequence Likelihood 1 Rare 2 Unlikely 3 Possible 4 Likely 5 Almost certain 5 Catastrophic Major Moderate Minor Negligible

227 The basic principle is to multiply the consequence by the likelihood. The resulting number is the risk grade. The risk grade obtained from the risk matrix is assigned levels and investigations as set out in the table below 1-3 Low risk Local manager investigates and includes findings on incident reporting form 4-6 Moderate risk 8-12 High risk Extreme risk Local manager to investigate using RCA and reports to Director Possible Serious Incident Follow SI Policy and procedure Risks calculated as 15 and above should be considered for escalation to a Serious Incident (SI). All individual incidents that lead to catastrophic outcomes must be escalated immediately as a Serious Incident. 9. Levels of Investigation Some incidents may not require immediate investigation but most will require immediate management actions urgently to prevent any further harm or damage. It is the responsibility of the local manager to investigate the incident and record their findings and action taken on the incident report form, or separately if necessary. 10. Sharing of Lessons Learnt All Teams/Executives will ensure incident outcomes are shared at local level. Through the analysis of Incidents all associated risks will be reported directly to the appropriate Executives and where necessary added to the local risk register. Learning from incidents will be shared at an organisational level through an incident report received by the Governing Body. 11. Reporting to External Agencies 11.1 Health and Safety Executive - RIDDOR The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 came into force on 1st April The CCG must report deaths, major injuries, and accidents resulting in over 7 day injury, diseases, dangerous occurrences and gas incidents. The law changed on 6 April If a worker sustains an occupational injury resulting from an accident, 13

228 their injury should be reported if they are incapacitated for more than seven days. There is no longer a requirement to report occupational injuries that result in more than three days of incapacitation, but you must still keep a record of such injuries The CCG is responsible for RIDDOR reporting to the HSE. When an incident has been identified as RIDDOR-reportable, the Head of Governance should be notified as soon as possible.. In serious incidents resulting in major injury or death, the Health and Safety Executive need to be alerted immediately ( Outside of normal working hours an appropriate Executive on-call should do this. If there is an accident connected with work (including an act of physical violence) resulting in an employee suffering an over-seven-day injury it must be reported in compliance with the above regulations within 15 days. An over-7-day injury is one which is not major but results in the injured person being away from work OR unable to do their full range of their normal duties for more than seven days. It is the manager s responsibility to ensure that the Chief Nursing Officer is contacted within 24 hours. The Health and Safety Executive will require the following information: - Date and time of incident Location of incident Name, home address, gender and status of persons involved / affected Details of any injuries Confirmation as to whether the situation is under control or whether assistance is required Brief outline of the circumstances of the incident Details of any witnesses Estates and facilities All urgent health and safety estates issues for CCG should be reported by the Line Manager to NHS Property Services (phone and ask switchboard to connect you to the on-call engineer). Out of normal hours, the senior manager on-call should be notified on National Reporting and Learning System (NRLS) All patient incidents for ND CCG will be reported electronically to the NRLS by the Corporate Office. This contributes to national learning about patient safety. The transfer of the operational delivery of the NRLS from the National Patient Safety Agency to the Imperial College Healthcare NHS Trust 14

229 occurred in May Medicines and Healthcare Products Regulatory Agency (MHRA) Any adverse incident involving a medical device should be reported as soon as possible. Electronic reporting using the online form on the NHRA website ( is the preferred method. The Medicines Management Team will report adverse reactions to medication to the NHRA. 12. The Accident/Incident Report Suitable information and training must be given to all employees regarding accident reporting and the location and completion of the Accident/Incident Report Form. Certain details about all accidents and near-miss incidents must be recorded - the method of recording in use at North Derbyshire CCG is the Accident/Incident Report Form Appendix B. All the information requested on the form must be provided or the reason that it is unavailable noted in the relevant area. Completed forms must be reviewed as soon as possible by a responsible person, usually a line manager, and any action taken as a result of the accident/incident must be noted on the form. Once the details and any actions have been recorded on the form, it must be given to the staff member s Line Manager, who in turn, will inform the nominated Health and Safety Professional within North Derbyshire CCG. If the accident/incident is serious, the details must be communicated immediately to the nominated Health and Safety Professional within North Derbyshire CCG either by telephone, mobile or . Either the injured person or their Line Manager can complete this. The forms require comment from a line manager regarding investigation, circumstances, and action taken these fields must be completed and the form signed before it is forwarded. In order to comply with the Data Protection Act, the original completed forms will be filed in a secure place. Reporting of Diseases and Dangerous Occurrences Regulations (RIDDOR) If an accident occurs during work for North Derbyshire CCG which results in over 7 consecutive days of incapacity for work (or normal activities) it is reportable under the Reporting of Diseases and Dangerous Occurrences Regulations (RIDDOR) and must be reported to the Recording Centre by telephone, internet, or by using the appropriate form (F2508) within 10 days. A copy of the completed form should be kept with other records including documents relating to the accident investigation, and to advise the insurers of a potential claim. All RIDDOR cases will be officially investigated to ensure best practice rules. Any person required to alert the authorities to either an over-seven-day injury at work, or a dangerous occurrence, must first contact their line manager and ensure that the details are forwarded immediately to the nominated Health and Safety Professional within North Derbyshire CCG 15

230 The person reporting must keep records of any developments to the injured person's health, up to and including a return to normal activities. Recording Centre - reports can be made in the following ways: - Telephone No Website Fax a completed form to Address Incident Contact Centre Caerphilly Business Park Caerphilly CF83 3GG 13. Monitoring and Reviewing This policy will be monitored for compliance with reporting to external agencies. Should internal audit undertake a review of risk management procedures including 16

231 17 Appendix A - Incident form Name of Person Injured: Department: Date of Accident: Time of Accident: Location of Accident: Please Circle one of the following: Accident Near-Miss Disease/Infection Address: Nature of Injury Signature of Person Completing form: Date Form Completed: Position of Person Completing form: Copies of report forwarded to: Date copies sent: Line Manager

232 18 Health and Safety Professional Occupational Health RIDDOR Paperwork reviewed to minimise reoccurrence: Witness Statement: [use additional sheets if required] Description of Events: [use additional sheet if necessary] Signature: Recommendations: Actions Taken: Name of H&S Professional:.. Signature:. Date:. Accident Number:..

233 19 Appendix B : Information Governance Incident Report Form (To be completed for all Information Governance (IG) Information security incidents or near misses. See Appendix 3 for Cyber Security Incidents) General Information Reported By: Department: Job Role: Phone: Address: Postal Address: Date/Time Detected: Date/Time Reported: Mobile: Fax: Additional Information: Incident Details Type of Incident: Confidentiality / Integrity / Availability Impacts on the Department (total failure, business as usual etc.): Type of affected System: Patient information, finance, administration etc. What is the information? Please list the data fields (eg name; address, clinical data) What security controls were in place? (Was the information encrypted?) Scale of Incident: How many individuals is the information about? If the scale of the incident is not known please estimate the maximum potential scale point. Less than 11 individuals, 11-50, , , , , , , , Incident Summary: Incident Details

234 20 Site Details: Site Point of Contact: Actions Taken: IG SIRI Level :

235 21 Appendix C : Cyber Security Incident Report Form General Information Reported By: Department: Job Role: Phone: Address: Postal Address: Date/Time Detected: Date/Time Reported: Mobile: Fax: Additional Information: Incident Details Cyber incident type: Tick Cyber Bullying Denial of Service Hacking Malicious Internal Damage Phishing s Social Medical Disclosures Spoof Website Website Defacement Other please specify How did the cyber incident come to light: Tick Anti-malware Audit External Notification Firewall Intrusion Detection System System Logs Other please specify Location(s) of the Cyber Incident Internet Facing? Tick Internet facing service Internet channel

236 22 Impact of cyber incident Cyber baseline scale Cyber sensitivity factors Tick at least one Administrative Availability Clinical Confidentiality Environmental Financial Integrity Personal harm or distress Reputational Tick No impact: attack(s) blocked False alarm Individual, internal group(s), team or department affected Multiple departments or entire organisation affected Tick all that apply Low A tertiary system affected which is hosted on infrastructure outside health and social care networks High Aware that other organisations have been affected Confidential information release (non-personal) or 100+ personal confidential records Critical business system unavailable for over 4 hours Likely to attract media interest Multiple attacks detected and blocked over a period of 1 month Repeat incident (previous incident within last 3 months) Require advice on additional controls to put in place to reduce reoccurrence

237 ND CCG Governing Assurance Committee 22 February 2016 Paper N NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE 22 February 2016 Report Title: POOLED BUDGET FOR CHILDREN WITH COMPLEX NEEDS Purpose: To seek Governing Body Assurance Committee approval for an agreement to continue a pooled budget arrangement between the North Derbyshire CCG and the Council and South Derbyshire, Hardwick and Erewash CCGs to provide and fund support packages for children and young people with complex needs. Item No: 15 Objective: Agreement to continue the section 75 pooled budget arrangements across Derbyshire. 1. Background and context Children and young people under the age of 19 with complex needs require input from a number of different agencies to meet those needs including all, or a combination of health care, social care, and support for educational special needs. In order to secure the individual arrangements that are required to support children and young people with complex needs, an agreement with a pooled budget arrangement between the Council and the CCGs, pursuant to Section 75 of the National Health Service (NHS) Act 2006 has been in operation since April Historically a pooled budget arrangement with Health Partners - Derbyshire County Primary Care Trust has existed since July Key matters for consideration The Section 75 agreement with a pooled budget arrangement has enabled funding allocations for complex cases to be managed in an efficient way in accordance with decisions made by a multi-agency monthly Complex Needs Panel (Children s Services, Adult Care, Virtual School and Health representatives). The agreement was due to be renewed from 1 st October Approval of a rolling 3 year Section 75 agreement with a pooled budget arrangement from 1 October 2015 to 30 September 2018 will ensure consistency and efficiency in associated processes. An annual review will be undertaken to consider development work proposals, a budget review and any changes that may be required to take account of new legislation. Agreement in principle has been obtained from the Council and from the other three CCGs for a 3 year formal agreement and pooled budget arrangement from October 2015 to The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 1

238 ND CCG Governing Assurance Committee 22 February 2016 Paper N September Formal approval is now being sought from each Governing Body. 3. Financial Impact The total annual budget is currently set at 5.2m per annum and it is proposed that this continues for the next three years. NDCCG contribution is 13% of the total budget and remains as follows: 2015/ / / /19 338, , , , Analysis of Risk The total budget has never been over spent. Any under-spend of the pooled budget will be borne by the Council and the CCGs in proportion to their contribution for the financial year in question, with any additional charges or refunds made in the same financial year. 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all: This will fund provision for children with the most complex needs. Improved patient access and experience: This enables the purchase of the most appropriate provision for each child. Empowered, engaged and well-supported staff: A joint Complex Case Panel will make the decision on each individual case. Inclusive leadership at all levels: A joint Complex Case Panel will make the decision on each individual case. 6. Recommendations That the Governing Body Assurance Committee agree the contribution from NDCCG as outlined in this paper. Author: Sponsor: Your Name & Job Title: Naomi Compton Senior Commissioning Manager Name & Job Title: Beverley Smith Chief Transformation Officer Date: January 2016 The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 2

239 Paper N POOLED BUDGET FOR CHILDREN WITH COMPLEX NEEDS 1. Purpose of the Report To seek Governing Body approval for an agreement to continue a pooled budget arrangement between the North Derbyshire CCG and the Council and South Derbyshire, Hardwick and Erewash CCGs to provide and fund support packages for children and young people with complex needs. 2. Information and Analysis Children and young people under the age of 19 with complex needs require input from a number of different agencies to meet those needs including all, or a combination of health care, social care, and support for educational special needs. In order to secure the individual arrangements that are required to support children and young people with complex needs, an agreement with a pooled budget arrangement between the Council and the CCGs, pursuant to Section 75 of the National Health Service (NHS) Act 2006 has been in operation since April Historically a pooled budget arrangement with Health Partners - Derbyshire County Primary Care Trust has existed since July The Section 75 agreement with a pooled budget arrangement has enabled funding allocations for complex cases to be managed in an efficient way in accordance with decisions made by a multi-agency monthly Complex Needs Panel (Children s Services, Adult Care, Virtual School and Health representatives). The agreement was due to be renewed from 1 st October Approval of a rolling 3 year Section 75 agreement with a pooled budget arrangement from 1 October 2015 to 30 September 2018 will ensure consistency and efficiency in associated processes. An annual review will be undertaken to consider development work proposals, a budget review and any changes that may be required to take account of new legislation. Agreement in principle has been obtained from the Council and from the other three CCGs for a 3 year formal agreement and pooled budget arrangement from October 2015 to September Formal approval is now being sought from each Governing Body. 3. Financial Considerations The pooled budget contributions will be detailed in the agreement. The total combined annual budget is 5,200,000 of which the Council s annual contribution will be 3,484,000. The total annual contributions from the CCGs will be 1,716,000. For the period covered by this agreement, assuming partners agree to set the budget at the current level, the proposed contributions are as follows:

240 Paper N Organisation % contribution 2015/ / / /19 CCGs 33% All ages 858,000 1,716,000 1,716, ,000 DCC 67% All ages 1,742,000 3,484,000 3,484,000 1,742,000 Total 100% 2,600,000 5,200,000 5,200,000 2,600,000 This is broken down as:- NDCCG 13% 338, , , ,000 Hardwick CCG 5.4% 140, , , ,400 Erewash CCG 4.6% 119, , , ,600 South Derbyshire 10% 260, , , ,000 Any under-spend of the pooled budget will be borne by the Council and the CCGs in proportion to their contribution for the financial year in question, with any additional charges or refunds made in the same financial year. 4. Legal and Human Rights Considerations An agreement made pursuant to Section 75 of the National Health Service (NHS) Act 2006 allows arrangements for pooling resources and delegating certain NHS and local authority health-related functions. Arrangements made by virtue of Section 75 do not affect the liability of CCG bodies or local authorities in relation to the exercise of any of their functions. 5. Recommendation That the Governing Body gives approval for North Derbyshire CCG to enter into a Section 75 agreement with pooled budget arrangement with Derbyshire County Council and Hardwick, Erewash and South Derbyshire Clinical Commissioning Groups for a 3 year period, in order to provide and fund support packages for children and young people with complex needs. Beverley Smith Chief Transformation Officer

241 ND CCG Governing Body Assurance Committee 22 February 2016 Paper O NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE 22 nd February 2016 Report Title: Purpose: Objective: 1. Background and context 360 Audit Assurance of Adult Safeguarding across NDCCG To inform the Governing Body Assurance Committee of the audit findings and action plan For Governing Body Assurance Committee to agree the action plan Item No: 16 At the end of Audit Assurance was invited to review the processes in place within NDCCG to deliver the Adult Safeguarding functions required of the CCG. 2. Key matters for consideration The audit concluded that it could give significant assurance that the NDCCG had the necessary structures in place to deliver the Adult Safeguarding agenda. The attached action plan sets out the findings with risk gradings for each section and the steps necessary to address recommended actions with lead responsible officer and time scales for completion. 3. Financial Impact None 4. Analysis of Risk On completion of the action plan the risk to the CCG of non-compliance with statutory obligations will be mitigated against. 5. Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 1

242 ND CCG Governing Body Assurance Committee 22 February 2016 Paper O 6. Recommendations That Governing Body Assurance Committee approve the audit findings and action plan. Author: Michelle Grant Sponsor: Bill Nicol Date: Date 15 TH February 2016 The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 2

243 Internal Audit North Derbyshire CCG Safeguarding Adults Final Report January 2016 Reference: 1516/NDCCG/02/R

244 Table of Contents Heading Page Executive Summary 1 Findings & Recommendations 4 Appendix A Risk Matrix & Opinion Levels 17 Distribution Name For Action For Information Mark Smith, Acting Chief Officer Darran Green, Acting Chief Finance Officer Jayne Stringfellow, Chief Nurse Bill Nicol, Head of Safeguarding Adults Ed Roynane, Safeguarding Adults Manager (South) Michelle Grant, Safeguarding Adults Manager (North) Key Dates Report Stage Date Discussion Draft Issued: 18 th December 2015 Exit Meeting: 9 th December 2015 Final Draft Issued: 11 th January 2016 Client Approval Received: 12 th January 2016 Final Report Issued: 13 th January 2016 Contact Information Name / Role Telephone / Tim Thomas, Director 360 Assurance Tim.Thomas@360Assurance.nhs.uk Annette Tudor, Associate Director Annette.Tudor@360Assurance.nhs.uk Sarah MacGillivray, Specialist Assurance Manager Clinical Quality Ruby Deo, Assistant Specialist Assurance Manager Clinical Quality Sarah.MacGillivray@360Assurance.nhs.uk Ruby.Deo@360Assurance.nhs.uk Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training

245 Executive Summary Information and Background A review has recently been completed in respect of the Safeguarding Adults arrangements in place at the CCG. The review examined the effectiveness of controls in place and was undertaken in accordance with the Public Sector Internal Audit Standards. The review has, therefore, been performed in such a manner as to provide an objective and unbiased opinion. Lessons from inquiries such as Mid Staffordshire NHS Foundation Trust and Winterbourne View have highlighted the need to make safeguarding integral to care. Prosecutions by the courts, enforcement measures by regulators and adverse media attention all demonstrate the high costs to services, staff and patients where there are failures in safeguarding patients and the public. Commissioners have responsibility for commissioning high quality health care for all patients in their area, including those patients who are less able to protect themselves from harm, neglect or abuse (as set out in Safeguarding Vulnerable People in the reformed NHS - Accountability and Assurance Framework, published in March 2013). Prevention of, and effective responses to, neglect, harm and abuse need to be addressed in all aspects of commissioning. Commissioners must work with providers, regulators and multi-agency partners to address concerns in services. An increasing number of patients with conditions such as dementia, the plurality of service providers and the broader range of settings in which care is provided present new challenges for commissioners in assessing and ensuring the safety of patients. Additionally, the amount of legislation being enacted and guidance being issued on the subject of safeguarding has increased significantly in recent years and CCGs need to be able to ensure that they comply with this legislation. Emphasis is being placed on the need for all organisations involved in safeguarding adults to demonstrate how they are working together to prevent abuse and neglect. Most recently the Safeguarding Vulnerable People in the NHS Accountability and Assurance guidance was revised and published by NHS England in July This guidance recognised the additional adult safeguarding duties introduced by the Care Act There is one Safeguarding Adults team for the four Derbyshire CCG s which is hosted by Southern Derbyshire CCG. There is a Head of Safeguarding Adults supported by two designated Safeguarding Adults Managers with one covering north Derbyshire (Hardwick and North Derbyshire CCG s) and one covering South Derbyshire (Southern Derbyshire and Erewash CCGs). Audit Objectives and Scope The objective of the review was to evaluate systems the CCG had in place for ensuring that adult safeguarding needs were identified & commissioned and that responsibilities placed upon commissioning organisations for safeguarding adults as set out within legislation and relevant guidance were being complied with. In order to achieve this objective, controls were evaluated and tested in the following areas: i. Commissioning Strategies for safeguarding adults; together with supporting safeguarding procedures; ii. Governance arrangements, including the CCG s arrangements for ensuring that roles as specified in legislation/guidance are in place and that it has appropriate resources in place to respond to the safeguarding agenda (this aspect of the review also covered safeguarding awareness training); iii. Systems which ensure that safeguarding is incorporated into contracting & procurement processes, as well as the processes for receiving assurance that providers are complying with safeguarding legislation; Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 1

246 Executive Summary iv. Processes in place for engaging with patients and the public on safeguarding, including the CCG s involvement in any specific adult safeguarding initiatives in the local community; and v. Procedures for identifying, reporting and escalating adult safeguarding risks through the CCG s standard risk management process. Partnership working with a variety of public sector bodies most notably the Local Authority is a critical success factor in many of the areas examined during the review. We have therefore commented on partnership arrangements where appropriate, for both local authorities Safeguarding Adults Boards for whom the CCG is a member. The control arrangements outlined above considered requirements from the following legislation and guidance: Safeguarding Adults Assessment and Assurance Framework (DH, 2012) Safeguarding Adults: the Role of NHS Commissioners (DH, 2011) Safeguarding Adults: An Aide Memoire for Clinical Commissioning groups (Sylvia Manson, 2013) Safeguarding Vulnerable People in the Reformed NHS: Accountability & Assurance Framework (NHS Commissioning Board, 2013) and not the 2015 one? The Care Act 2014 Summary Findings Areas of Good Practice A brief summary of the areas of good practice identified during the course of the review is provided below, and more detailed findings can be found within the full report. Safeguarding is referenced as part of the overall governance processes overseeing the delivery of the CCG s strategic plan. There is a dedicated Safeguarding Adults team which includes a Head of Safeguarding Adults, two Safeguarding Adults Managers and a named doctor for safeguarding adults. Safeguarding adults standards have been included in the provider contracts and information to support achievement / monitoring of the standards has been provided to the CCG. Initiatives have been undertaken to engage with patients and the wider general public. The CCG is a member of a number of regional safeguarding adults forums. Areas for improvement Partnership working is critical to the CCG s successful delivery of its safeguarding responsibilities, particularly with the local authority, who under legislation have the primary responsibility for safeguarding including the statutory duty for establishing Safeguarding Adults Boards (SAB s). More effective partnership working has been a common theme across recent legislation and guidance and the CCG should, therefore have an effective and prominent role in Local Safeguarding Adults Boards. Whilst we are raising no major concerns in respect of the CCG s efforts to engage with one of its key partners Derbyshire County Council, it is evident that systems the CCG is placing reliance on have been weak. Specific concerns include the lack of a strategic plan / strategy for Safeguarding Adults in Derbyshire and the lack of an up to date terms of reference for the Local Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 2

247 Executive Summary Safeguarding Adults Board. During the course of the review we have been unable to confirm that progress is being made to develop either key document. Audit Opinion We are providing Significant Assurance in respect of the CCG s own arrangements for Safeguarding Adults. Nevertheless, we consider it necessary to draw specific attention to weaknesses that have been present within one of the CCG s main partners, Derbyshire County Council in respect of the lack of a strategic plan and strategy for Safeguarding Adults in Derbyshire. Whilst we have no remit to audit their arrangements (and our opinion must, therefore, exclude them) it is evident in our work that improvements are required. Until these are delivered there is some limitation in the extent of positive assurance that the Governing Body can receive that overall processes the CCG is part of are operating efficiently. Summary of Recommendations High Medium Low Total Proposed Actions Agreed Follow Up A follow-up exercise will be undertaken during July 2016 to evaluate progress made in respect of issues raised. This will include obtaining documentary evidence to demonstrate that actions agreed as part of this review have been implemented. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 3

248 Findings & Recommendations The following sections of the report summarise the findings of our review. Each section highlights areas of good practice identified. Where relevant, any control weaknesses identified are outlined, including actions that have been agreed in order to address the associated risks. The matrix used for scoring risks is compliant with the ISO principles and generic guidelines on risk management. This risk matrix, along with definitions of different opinion levels, is provided at Appendix A. 1. Commissioning Strategy for Safeguarding Adults CCG North Derbyshire CCG and Hardwick CCG have a joint Strategic Plan 2014/15 to 2018/19. This includes five system objectives to be delivered by nine stated actions, safeguarding is referenced as part of the overall governance processes overseeing the delivery of the strategic plan. The CCG s Commissioning Intentions 2015/16 includes safeguarding with the Safeguarding Adult Asessment Framework review for all providers and ensuring that all healthcare providers can demonstrate that the learning from serious case reviews has been disseminated to all staff and that recommendations have been considered by providers and implemented as appropriate. The CCG s Annual Report for 2014/15 made reference to safeguarding in terms of monitoring safeguarding processes within provider contracts and was identified in the key priorities for 2015/16, as maintaining robust arrangements for safeguarding adults and children and playing a role in implementing the statutory requirements of the Safeguarding Adults Board. The Safeguarding Adults Policy has recently been revised to reflect the latest legislation and guidance. This policy has been developed for all four Derbyshire CCG s. The draft policy is due to be approved by the Joint Commissioning Meeting (attended by the four CCG s Chief Nurses and Head of Safeguarding Adults at its meeting in December The CCG s revised policy is in alignment with the Derbyshire wide Safeguarding Adults Policy and Procedures (see below). Additional policies which cover Derbyshire include the Derbyshire Prevent Plan 2015/16 which supports the Derbyshire Prevent Strategy and the Domestic Abuse Policy, Deprivation of Liberty Safeguards (DoLS) policy refreshed and issued in September 2015 to support CCG s compliance with legislation. Partnership Arrangements We sought to confirm the extent to which the CCG s strategy and policy was aligned to those developed by the Local Safeguarding Adults Boards (LSAB s). Joint Derby and Derbyshire Safeguarding Adults Policy and Procedures have been revised to reflect the latest guidance and legislation and have been formally approved by both local safeguarding adults boards. The policies are publically available from each board s website. The Derbyshire Local Safeguarding Adults Board (DCCLSAB) latest available strategic plan is dated Review of minutes of the Board provided between March and September 2015 did not identify any progress being made towards the development of a new strategic plan for the Board. Discussions with the Head of Safeguarding Adults identified that the development of a strategic plan had not been included on the agenda at the most recent Board meeting in December Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 4

249 Findings & Recommendations No. Findings 1. The Derbyshire Safeguarding Adults Board does not have an up to date strategic plan setting out the strategic direction or key priorities for the Board. The Strategic Plan is a critical public facing document setting out the aims and objectives for the Board and its partners over a future period. There a number of reasons for the lack of development of a strategic plan including the appointment of a new Board Chair 12 months ago, the lack of stated administrative support and funding contribution for the Board. There is an ongoing debate between the local authority and the CCG s in respect funding for the Board which has yet to be resolved. We acknowledge that the Board has lacked administrative support and this has begun to be addressed with the recent appointment of Project Support Officer who commenced in post in November The strategic plan should at least be developed with engagement from the Board members. Risk and Score (Impact x Likelihood) Lack of defined strategic direction and key priorities for the Derbyshire Safeguarding Adults Board. Lack of defined strategic direction and key priorities for the Derbyshire Safeguarding Adults Board is a considerable risk to the reputation of the CCG. High 4 x 4 Agreed Action The CCG s Chief Nurses as members of the Derbyshire Safeguarding Adults Board and the Head of Safeguarding Adults as Vice Chair of the Board will raise this issue with the Independent Chair. All Board members should be engaged in the development of the strategic plan. Responsible officer: Jayne Stringfellow, Chief Nurse Bill Nicol, Head of Safeguarding Adults Implementation date: 30 th June 2016 Management Response: The Head of Adult Safeguarding for the 4 Derbyshire CCGs will meet with the Independent Chair to discuss the reports findings and agree a plan for the development of a strategic programme. 2. Governance arrangements 2.1 Governance Structure CCG The CCG s governance structure for safeguarding is as follows: Governing Body Chief Nurse has executive responsibility for safeguarding. The Governing Body Assurance Committee (GBAC) meets on a monthly basis, safeguarding adults updates are received by this committee with its minutes being reported to the Governing Body. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 5

250 Findings & Recommendations It has been agreed between the CCG and the Safeguarding Adults Team that reports would be provided on as and when basis rather than a quarterly update. Review of GBAC minutes from January to September confirmed that safeguarding adult s updates were received by the committee as follows: GBAC June 2015 safeguarding adults report update on Deprivation of Liberty Safeguards and implications following the Cheshire West legal Judgement. GBAC September 2015 safeguarding adults report included issues with the court of protection cases, implications from the introduction of the Care Act 2014, and implications from the Prevent strategy. The terms of reference for the Governing Body Quality Assurance Committee was reviewed and approved in May The terms of reference includes a responsibility to oversee safeguarding arrangements for children and vulnerable adults and a specific duty to seek assurance that NDCCG is discharging its statutory responsibilities appropriately including safeguarding children and young people, deprivation of liberty safeguards (Including adult safeguarding) the duty to consult, and the duty to continuously improve the quality of services. An Annual Safeguarding Adults Report was produced and submitted to the GBAC in September The GBAC minutes were subsequently reported to the Governing Body in November The report highlighted the achievements of the Safeguarding Adults Team in the last year. The CCG s Annual Report for 2014/15 identified three key priority areas for 2015/16, one of which was quality and made reference to safeguarding, in terms of maintaining robust arrangements for safeguarding adults and children, the CCG playing a role in implementing the statutory requirements of the Safeguarding Adults Board and monitoring of safeguarding processes in providers. Partnership Arrangements We sought to determine the effectiveness of the CCG as a member of the LSAB. Derbyshire County Safeguarding Adults Board (DCCSAB) The board meets on a quarterly basis and the CCG is represented by the Head of Safeguarding Adults (who also is the Vice Chair) at each meeting. The DCCSAB has recently appointed a Project Support Officer to support the board and its sub groups. The Board also has two sub groups in addition to two joint sub groups with the Derby City Safeguarding Adults Board identified below. We were provided with board minutes between March and September 2015 and identified issues considered by the board included, updates from the sub groups, Care Homes Escalation Policy, CQC information sharing meeting, board terms of reference, management support for the board and the establishment of a new sub group, Safeguarding Incident and Learning Process Sub Group. The Board lacks an up to date terms of reference which is compliant with the Care Act (2015). Review of minutes from the Board Meetings between March and September 2015 identified that the Board had considered the options of having a terms of reference or constitution and concluded having a terms of reference was more appropriate. Comments on the existing terms of reference were required to be submitted to the lead officer by the end of August for circulation. We have been advised that the recent Board meeting in December 2015 did not include any discussion on the development of the terms of reference. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 6

251 Findings & Recommendations No. Findings Risk and Score (Impact x Likelihood) Agreed Action 2. The terms of reference for the Derbyshire Safeguarding Adults Board should be reviewed as a matter of priority. This is a key public facing document and should reflect the implications of the latest legislation guidance. The terms of reference should also include the following items that we would usually to expect to be included in a terms of reference: Core membership of the board in line with the Care Act and arrangements; Meeting frequency of the board; Identify the Vice Chair of the Board; Forward reporting to an oversight committee, such as the Health and Well Being Board; and Date of approval or review date. Lack of clearly defined accountability and governance arrangements for the Derbyshire Local Safeguarding Adults Board. Medium 4 x 3 Management Response: The Head of Safeguarding Adults as Vice Chair of the Derbyshire County Safeguarding Adults Board will raise the issues associated with the terms of reference identified in this review to the Chair of the Board for consideration. Responsible officer: Bill Nicol, Head of Safeguarding Adults Implementation date: 30 th June 2016 The Head of Adult Safeguarding will meet with the Independent Chair of the SAB to discuss the recommendations at the earliest opportunity to ensure revision of the terms of reference. Learning and Development Group (joint with Derby City SAB) This group should meet on a bi-monthly basis and has not met since January We sought to confirm whether this issue had been highlighted both SAB s and determine the action agreed. The October 2015 DCCSAB Board minutes identified that both local authorities had met to discuss the future of the group and agreed to progress towards multi-agency training with the group being re-launched in December No. Findings 3. Given that the group has not met for almost a year, we recommend that the Head of Safeguarding Adults as Vice Chair of both local Safeguarding Adults Boards suggests that the terms of reference are reviewed to ensure they reflect the latest guidance and legislation and the agreement by both local authorities to work towards multi-agency training. Risk and Score (Impact x Likelihood) Lack of consistent approach for multi-agency safeguarding adults training across Derbyshire. Agreed Action The Vice Chair of the Safeguarding Adults Boards will raise the issue of the review of the terms of reference with the Learning and Development Sub Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 7

252 Findings & Recommendations Low 2 x 3 group chair. Responsible officer: Bill Nicol, Head of Safeguarding Adults Implementation date: 30 th June 2016 Management Response: A new Chair has been appointed to the group and the membership revised. The CCG s will be represented on the group and will be tasked with ensuring that the Terms of Reference are revised and a work programme developed. An initial meeting was held in December 2015 to update the terms of reference which was attended by both Safeguarding Adults Managers. Mental Capacity Act Forum (joint with Derby City SAB) This group meets on a quarterly basis and its key focus is to review issues arising in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). We were provided with minutes for meetings held in February, May and August 2015 and confirmed that meetings are attended by both Safeguarding Adults Managers (who represent the four Derbyshire CCGs). Operational and Leadership Group The purpose of this group is to review and address operational issues and meets on a quarterly basis. The CCG is represented by Safeguarding Adult Manager (North). Minutes were provided for meetings held between January and July 2015 with issues considered including safeguarding policy and procedures review and update, operational updates from each partner agency and tissue viability guidance. Performance and Quality Group This group meets on a quarterly basis and is chaired by the CCG s Head of Safeguarding Adults. The purpose of the group is to provide quality assurance on multi agency safeguarding practice and meets on a quarterly basis. Review of minutes for March and June 2015 identified that the following issues had been considered by the group; operational dashboard, draft work plan for the group, VARM, potential case file audit, and board self assessment in preparation for the Care Act It was identified that there were two joint groups covering Derbyshire but not direct sub groups of the safeguarding adults boards. Adults at Risk Community Health (ARCH). We were provided with the terms of reference for group which identified the objectives for the group but did not, however, identify the meeting frequency or forward reporting which we would usually expect to see included. We were provided with minutes for meetings held between February and August 2015 and key themes arising from the meetings included the CCG s peer review Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 8

253 Findings & Recommendations process with providers, the Safeguarding Adults Assurance Framework (SAAF), Prevent Strategy and plan and development of a Domestic Violence Strategy. The City and County Sexual Violence Governance Board meets on a quarterly basis and the terms of reference for the board which define its key duties. We were provided with the minutes for the meeting held in August 2015 and confirmed that issues discussed included the national rape plan, Sexual Assault Referral Centre (SARC) commissioning update and the groups risk register. The City and County Joint Domestic and Sexual Violence Operational Group is attended by the Safeguarding Manager for Hardwick and North Derbyshire CCGs. 2.2 Staffing arrangements CCG (including safeguarding training for staff) The Chief Nurse has executive responsibility for safeguarding. A safeguarding team is in place which includes both adults and children s safeguarding leads. The Chief Nurse is supported by the Head of Safeguarding Adults and a Safeguarding Adults Manager (covering both Hardwick and North Derbyshire CCGs). The Head of Safeguarding Adults and the Safeguarding Adults Manager are the Prevent leads and Mental Capacity Act leads for the CCG. We confirmed that the Safeguarding Adults team is up to date with training, and the team review their continuing professional development and we were provided with evidence to support continuous professional development including but not limited to Court of Protection Seminars, Prevent Workshops and leadership training programmes. The Head of Adult Safeguarding provides clinical supervision to the two Safeguarding Adults Managers every six weeks. The Head of Safeguarding Adults has established a mechanism whereby coaching and mentorship will be received from the Director of Multi Faith Centre in Derby with quarterly one to ones agreed during 2016/17. Wider CCG Staff A joint Adults and Children s Safeguarding Training Programme has been developed for 2015/16. The training programme defines the levels of training required by staff group, includes the outlines for the training courses that are available to staff. It was identified that training is delivered by the Safeguarding Adults and Children s teams and the Multi Agency Risk Assessment Conference (MARAC) supervisor (Derbyshire Constabulary). We were advised that the Safeguarding Adults team have developed a safeguarding adults e-learning training package which can be accessed via the CCG s intranet site. Summary guidance on the implications of Care Act 2014 were provided to all the CCG s member practices. A series of workshops on Mental Capacity Act and Deprivation of Liberty Safeguards has been delivered across the CCG and this has been supported with the development of a DVD for member practices and a mobile phone application to aid GP s. We were provided with a copy of the training workshop delivered. We confirmed that an e-learning package for MCA / DoLS had been developed by GEM CSU with contribution from the Safeguarding Team in the design and content of the programme. The e-learning package accessible to all staff via a web link. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 9

254 Findings & Recommendations A record of training attendance is held by the Safeguarding Adults Team for the CCG which identifies all members of staff that have attended training courses provided by the team. We sought the training matrix for the CCG to identify the extent to which CCG staff are up to date with safeguarding training and it was identified that 56% of staff were not up to date with Level 1 safeguarding training which is the minimum required. We sought to determine whether the CCG regularly received assurances on the extent to which relevant staff at the Commissioning Support Unit were up to date with safeguarding training. We would expect this information to be routinely provided to the CCG in management information received from the Commissioning Support Unit on a regular basis. Whilst this information may be received at the CCG, it is not being disseminated to Executive Directors such as the Chief Nurse for assurance purposes. No. Findings 4. We have requested information that staff working at a wider level are up to date with safeguarding training commensurate with their role. Whilst this information may be received by the CCG it is not being provided to the Chief Nurse for assurance purposes. Risk and Score (Impact x Likelihood) Staff with patient contact are not up to date with the required level of training and could result in a negative impact on the CCG s reputation. Staff are not aware of the latest guidance and best practice. Low 2 x 2 Agreed Action The Chief Nurse will seek assurance that staff who operate at the CCG and at a wider level with patient contact are up to date with the required level of training as a matter of priority. Responsible officer: Jayne Stringfellow, Chief Nurse Implementation date: 30 th June 2016 Management Response: The Safeguarding team acknowledges that 56% of staff may not have completed / attended training session however this figure does not reflect those attending training sessions delivered by the Safeguarding Team. The Safeguarding Team are currently revising the content and evaluation of training packages offered and will include a more robust system for the collation and dissemination of training statistics from April This work has been delayed pending the imminent release of the Inter Collegiate document for Adult Safeguarding from the Department of Health. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 10

255 Findings & Recommendations Partnership Arrangements Discussions with the Head of Adult Safeguarding identified that the Learning and Development sub group has not met to date in the current financial year, however it has been agreed to re-launch the group at a partnership event to be held in December The Derbyshire SAB has links to the Safer Derbyshire website which offers training courses in counter terrorism, hate crimes and MARAC and Multi Agency Public Protection Arrangements (MAPPA). 3. Safeguarding is incorporated into contracting and procurement processes CCG i) Main Secondary Care Providers Safeguarding standards have been incorporated into the 2015/16 contracts with both providers, Chesterfield Royal Hospital NHS Foundation Trust (CRHFT) and Derbyshire Community Healthcare NHS Foundation Trust (DCHS). We were provided with the quality schedule for CRHFT and confirmed that safeguarding had been included in the quality schedule which required the Trust to comply with the Safeguarding Self-Assessment Framework and provide an annual report to the CCG on compliance. Produce and submit quarterly reports to the CCG on MCA / DoLS referrals, comply with markers of good practice, and be an active member of the Local Safeguarding Adults Board. We were provided with the quality schedule for DCHS and it was confirmed that safeguarding adults had been included within the schedule and the Trust were required to produce annual report of compliance against the Self-Assessment Framework and provide this to the CCG, comply with markers of good practice and participate in the Local Safeguarding Adults Board. The evidence provided in support of both provider s quality schedules is discussed at the quarterly respective Quality Assurance Groups. We confirmed through the review of the DCCSAB minutes that the CRHFT had attended the three Board meetings examined between March and September and DCHS had attended one. Previously, providers were required to complete the Safeguarding Adults Assurance Framework (SAAF) and submit this to the Safeguarding Adults Team. A peer review process and toolkit was developed in 2014/15 which included seven areas; MCA / DoLS, staff training, Female Genital Mutilation, MARAC, Dignity and Partnership and Collaborative Working. It was confirmed that the peer review was completed by all the providers using the following parings: Chesterfield Royal Hospital NHS FT: Derby Teaching Hospitals NHS FT EMAS: Derbyshire Healthcare NHS FT (We were provided with a copy this peer review as an example) DCHS: DHU The peer review process required that action plans were developed where relevant, and six monthly updates against the action plan were to be requested by Safeguarding Adults Team. Review of ARC-H meetings between February and August 2015 identified that meetings had been attended regularly by the providers and the completion of the peer reviews discussed. It was identified that two of the reviews were delayed due to staff sickness and staff turnover but have now been completed. Actions identified as a result of the peer review will be considered as part of the completion of the revised peer review process. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 11

256 Findings & Recommendations The peer review process has been updated for 2015/16 and includes Partnership and Collaborative working, safeguarding adults at risk, training and staff development, patient safety initiatives, implementation of the MCA and DoLS, making safeguarding personal and associated work streams (which include providing a copy of the safeguarding adults annual report and three key priorities for the forthcoming year). The providers will be required to the complete the peer review process during the last quarter 2015/16. Subsequent discussions with the Head of Safeguarding Adults identified that the peer review process will not continue on an annual basis, the Safeguarding team are considering how to enhance the Safeguarding Adults Assurance Framework (SAAF) process beyond the completion of the document and considering the use of confirm and challenge sessions. The CCG has a programme of clinically led visits with each provider and members of the safeguarding team attend on a periodic basis. Review of provider quality visits reports did not specifically identify any safeguarding concerns ii) Care Homes There is a bi-monthly joint Care Home quality meeting between the CCG and Derby City Council to review quality aspects of care home providers. This meeting is attended by the CCG s Care Home Lead (Hardwick CCG) in addition to the CCG s safeguarding adult s team. We were provided with the minutes for the latest meeting held in September Quality visits undertaken at care homes by the Local Authority are also attended by the CCG s Care Home Lead. Any safeguarding concerns would be raised with the safeguarding adult s team. We were not provided with any evidence of the SGA team being involved in visits to care homes (HCCG is the lead for Care Homes for Derbyshire), we were provided with a professional observation checklist for care homes in Derbyshire. The checklist included the environment, residents, resident s room staff and care plans. There is a regular newsletter that goes out to all care homes in Derbyshire and the CCG have used this letter to publicise the new Safeguarding Policy. We were provided with copies of the local Nursing Times for January, March and September Training events have been held for nursing home managers to support the new policy and new legal requirements. We were provided with evidence of nursing home training events held in March and April iii) Primary Care The safeguarding adults team have been involved in obtaining resource packs for GP practices such as Working MCA (2005) and Application for Deprivation of Liberty Safeguards (DoLS) DVD has been circulated to all member practices across the CCG. Each member practice has identified a safeguarding lead that will be issued with the revised Safeguarding Adults Policy once it s formally approved. Each member practice was required to complete the Joint Safeguarding Assessment Framework which required practices to RAG their achievement against the criteria and provide supporting evidence. The Safeguarding Adults team are reviewing the evidence provided in support of the assessments and will enable the team to focus their resources to support those practices scoring red or amber. The team are unable to visit every member practice to validate the evidence provided and are currently considering approaches such as a cyclical programme of monitoring visits. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 12

257 Findings & Recommendations The CCG also facilitated a pilot study to examine communication issues between the member practices and the Derby City MARAC, the review was also designed to implement communication mechanisms to address the lack of information for case conferences, and the CCG is working with the Local Medical Council to improve communication with member practices and information requirements with the MARAC. An Adult Safeguarding Protocol has been developed for all member practices and includes the categories and severity of abuse and how to make a referral to the relevant body. A Frequently Asked Question guide has also been developed for practice staff to address questions around the Prevent agenda and is accessible via the CCG s intranet site. We were provided with examples whereby GP s have contacted the Safeguarding Adults team seeking advice and support in terms of safeguarding referrals. 4. Engagement with patients and the public and wider partnership working CCG A number of initiatives have been undertaken by the Safeguarding Adults team we were provided with evidence of the following: Booklet on safeguarding in easy read language for patients with learning disabilities; Safeguarding Adults Team providing safeguarding awareness through presentations to the Big Health Day facilitated by the Learning Disability Partnership Board across Derbyshire; Safeguarding Adults team providing presentations on safeguarding and Prevent to voluntary groups; and The Head of Safeguarding Adults provided a presentation on the implications of the Care Act to the LMC annual meeting. There are a number of local and regional safeguarding forums in place of which the CCG is a member: The NHS England Safeguarding Adults Leads Virtual Network Prevent and MCA Forum East Midlands Safeguarding Assurance Forum. Joint Improvement Partnership covering Derbyshire. No. Findings 5. We examined the CCG s website and identified an overarching safeguarding webpage. This is underpinned by separate web pages for both adults and children. Risk and Score (Impact x Likelihood) Public does not know how to raise a safeguarding concern or seek assistance in identifying a safeguarding Agreed Action The CCG will ensure that the information provision on the safeguarding adults webpage is expanded with the information Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 13

258 Findings & Recommendations The CCG s webpage for safeguarding adults identifies contacts for safeguarding advice in office hours and identifies the contact details for the Safeguarding Adults Manager. It does not provide contact information for out of hours, referral forms, links to the prevent agenda nor any links to relevant policies or procedures. This is one the key mechanisms by which the public can access information in respect of safeguarding. We would typically expect to see the CCG s website provide the public with useful information on safeguarding, including what to do and who to contact when reporting safeguarding concerns. It should also set out what its responsibilities are in respect of safeguarding in an easy to understand manner. concern. Low 2 x 2 Management Response: identified in our findings. Responsible officer: Jayne Stringfellow, Chief Nurse Implementation date: 31 st March 2016 The points are noted and will be actioned as detailed within the report. Information for the public facing website was forwarded by the Safeguarding Adults team to relevant individuals within the respective CCGs but has yet to be uploaded as each CCg operates different processes for communications. Partnership Arrangements We sought to establish the extent to which the CCG had been involved in any activities to engage with the public and the extent to which the outcomes of the engagement had been considered in developing the safeguarding strategy. Additionally we sought to identify whether the CCG had with its partners engaged with hard to reach groups on safeguarding issues such as female genital mutilation and spousal abuse. We were provided with evidence of the following: Presentation to the DCCSAB on safeguarding adults and links to Serious incident Reporting procedures in a health care setting. The Head of Safeguarding Adults supporting Derbyshire County Council with a tendering exercise for Domestic Abuse support services. The Head of Safeguarding Adults designed an audit tool and led the case note audit review for Derby City Council. Both the City and County safeguarding Adults Boards completed a self-assessment toolkit in preparation for the Care Act 2014 coming into effect. All board members were required to complete the toolkit and responses were analysed and considered by the Boards at meetings held in October Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 14

259 Findings & Recommendations 5. Risk Escalation Processes We reviewed the CCG s risk register dated August 2015 and identified two risks in relation to safeguarding: The first one was the maintenance of safeguarding arrangements in light of the Care Act. The initial risk was scored as red with a score of 16 and is currently rated as amber with a score of 9 assurances identified included a designated officer for Safeguarding Adults, and a pilot scheme for the provision of a named doctor for safeguarding adults. The second related to changes to the interpretation of Deprivation of Liberty (DoLs) safeguards may lead to a financial, clinical and reputational issues for the CCG. The initial risk was scored as amber with a score of 12 and the current risk rating remains the same, the mitigating actions include reviewing those cases that meet the acid test requirements and having progress meetings between the Arden GEM CSU, the Safeguarding Team and Browne Jacobson to review progress. The CCG has contributed to Serious Case Reviews (although none in 2015/16 to date) and contributed to Domestic Homicide Reviews (5 to date in 2015/16). The Safeguarding Adults Manager has completed Individual Management Reviews (IMR s) which contribute to Serious Case Reviews and Domestic Homicide Reviews. The Derbyshire CCG s receive the executive summary from such reviews and the commissioning CCG receives the full report. An information sharing protocol in place within each provider contract which highlights the information to be shared with the CCG as the commissioner of secondary care services. The CCG receives all Serious Incident Reports from each provider and these are discussed at the Serious Incident Review Group which meets on a bi-monthly basis. An information sharing card has been developed for GP s and other independent contractors across Derbyshire outlining the circumstances in which information can be shared with other relevant agencies. 6. Effective Collaborative Commissioning Arrangements A Memorandum of Understanding (MOU) is in place between the four Derbyshire CCG s for the provision of adults safeguarding. This includes the roles and responsibilities and accountability arrangements for the service. Reports are provided in a standardised format to each CCG on a quarterly basis, additionally an annual report is produced for each CCG. We were provided with a copy of the annual report for 2014/15 submitted to each CCG. Any issues in relation to the MOU or the service are discussed and agreed at the Joint Commissioning meeting between the four Chief Nurses, Head of Safeguarding Adults and Safeguarding Adults Managers. This meeting is chaired by the Chief Nurse for Southern Derbyshire CCG. This is the forum for the Head of Safeguarding Adults to agree key decisions in respect of Safeguarding with the four Chief Nurses. The meeting should be held bi-monthly and last met in July 2015, the October meeting has been cancelled due to the unavailability of two of the Chief Nurses and the next meeting is scheduled for December If a particular CCG requires additional information this is actioned by the safeguarding adults team. To date we have been advised that no additional requirements have been identified to the Safeguarding Adults team. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 15

260 Findings & Recommendations We were provided with minutes of the Chief Nurses joint commissioning meetings held in February, April and June 2015 (Adults meetings are followed by children s). Review of the minutes identified the following:- Feb 2015 MCA / Dols updates, Care Act requirements implications for the CCG s, training update with progress being made on e- learning packages and podcasts, SAAF Peer Review process with the provider specific SAAF being created. Twice yearly visits were due to be held in April and October. April MCA / DoLs update, the increase in advice and support required by primary care which identified a potential weakness in the coaching and mentoring of the Safeguarding Adults team and Prevent mandatory training. June 2015 New Care Act requirements and resulting Self-Assessment Assurance Framework for Safeguarding Adults and CHC and DoLS implications on the CCGs. No. Findings 6. The Joint Commissioning Meeting with the Chief Nurses and Head of Adults Safeguarding have not met since July with the October 2015 meeting being cancelled, this has resulted in the revised CCG s Safeguarding Adults Policy approval being delayed and other decisions being delayed for almost five months until the meeting in December Risk and Score (Impact x Likelihood) Delays in key decisions for the four Derbyshire CCGs may have negative impact on the reputation of the CCGs. Low 2 x 2 Management Response: Agreed. Agreed Action In circumstances where the joint Commissioning meeting is cancelled, consideration will be given to holding alternative meetings such as conference calls or allowing deputies to attend the commissioning meeting. Responsible officer: Jayne Stringfellow, Chief Nurse Implementation date: 31 st March 2016 Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 16

261 Likelihood Appendix A Risk Matrix & Opinion Levels Score Impact Likelihood Impact 1 Negligible Rare Low Unlikely 1 L L L L L 3 Medium Possible 2 L L L M M 4 Very High Likely 3 L L M M H 5 Extreme Almost Certain 4 L M M H H 5 L M H H H Audit Opinions Full Assurance can be provided that the system of internal control has been effectively designed to meet the system s objectives, and controls are consistently applied in all areas reviewed. Significant Assurance can be provided that there is a generally sound system of control designed to meet the system s objectives. However, some weakness in the design or inconsistent application of controls put the achievement of particular objectives at risk. Limited Assurance can be provided as weaknesses in the design or inconsistent application of controls put the achievement of the system s objectives at risk in the areas reviewed. No Assurance can be provided as weaknesses in control, or consistent non-compliance with key controls, could result [have resulted] in failure to achieve the system s objectives in the areas reviewed. Advisory Counter Fraud Internal Audit and Assurance IT Risk Management and Assurance PPV Security Management Services Training 17

262 NDCCG 360 Assurance Safeguarding Report Action Plan No Findings Risk & Score 1 The Derbyshire High Safeguarding Adults 4 x 4 Board does not have an up to date strategic plan setting out the strategic direction or key priorities for the Board. Action The CCG s Chief Nurses as members of the Derbyshire Safeguarding Adults Board and the Head of Safeguarding Adults as Vice Chair of the Board will raise this issue with the Independent Chair. All Board members should be engaged in the development of the strategic plan. Responsible officer Bill Nicol Head of Safeguarding Adults Implementation date 30th June 2016 Management Response: The Head of Adult Safeguarding for the 4 Derbyshire CCGs will meet with the Independent Chair to discuss the reports findings and agree a plan for the development of a strategic programme. Progress 2 The terms of reference for the Derby City & Derbyshire Safeguarding Adults Board should be reviewed as a matter of priority. Medium 4 x 3 The Head of Safeguarding Adults as Vice Chair of the Derbyshire county Safeguarding Adults Board will raise the issues associated with the terms of reference identified in this review to the Chair of the Board for consideration. Bill Nicol Head of Safeguarding Adults 30th June 2016 The Head of Adult Safeguarding will meet with the Independent Chair of the SAB to discuss the recommendations at the earliest opportunity to ensure revision of the terms of reference.

263 3 Given that the group has not met for almost a year, we recommend that the Head of Safeguarding Adults as Vice Chair of both local Safeguarding Adults Boards suggests that the terms of reference are reviewed to ensure they reflect the latest guidance and legislation and the agreement by both local authorities to work towards multi-agency training. Low 2 x 3 The Vice Chair of the Safeguarding Adults Boards will raise the issue of the review of the terms of reference for the Learning and Development Sub group chair in line with the group s re-launch in December Bill Nicol Head of Safeguarding Adults 30th June 2016 A new Chair has been appointed to the group and the membership revised. The CCG s will be represented on the group and will be tasked with ensuring that the Terms of Reference are revised and a work programme developed. An initial meeting was held in December 2015 to update the terms of reference which was attended by both Safeguarding Adults Managers. 4 We have requested information that staff working at a wider level are up to date with safeguarding training commensurate with their role. Whilst this information may be received by the CCG it is not being provided to the Chief Nurse for assurance purposes. Low 2 x 2 The Chief Nurse will seek assurance that staff who operate at the CCG and at a wider level with patient contact are up to date with the required level of training as a matter of priority. Jayne Stringfellow, Chief Nurse 31st March 2016 The Safeguarding team acknowledges that 52% of staff may not have completed / attended training session however this figure does not reflect those attending training sessions delivered by the Safeguarding Team. The Safeguarding Team are currently revising the content and evaluation of training packages

264 offered and will include a more robust system for the collation and dissemination of training statistics from April This work has been delayed pending the imminent release of the Inter Collegiate document for Adult Safeguarding from NHS England 5 Examination of the CCG s website identified a webpage for protecting others which included references to both adults and children, the Derbyshire wide children s safeguarding policies, the current CCG safeguarding adults policy but no references to the Derbyshire wide safeguarding adult s policies and procedures. Low 2 x 2 Public does not know how to raise a safeguarding concern or seek assistance in identifying a safeguarding concern Michelle Grant, Adult Safeguarding Manager 31st March 2016 The CCG will ensure that the information provision on the safeguarding adult s webpage is expanded with the information identified in our findings.

265 6 The Joint Commissioning Meeting with the Chief Nurses and Head of Adults Safeguarding have not met since July with the October 2015 meeting being cancelled, this has resulted in the revised CCG s Safeguarding Adults Policy approval being delayed and other decisions being delayed for almost five months until the meeting in December Low 2 x 2 Delays in key decisions for the four Derbyshire CCGs may have negative impact on the reputation of the CCGs. Jayne Stringfellow, Chief Nurse 31st March 2016 In circumstances where the joint Commissioning meeting is cancelled, consideration will be given to holding alternative meetings such as conference calls or allowing deputies to attend the commissioning meeting.

266 ND CCG Governing Body Assurance Committee 22nd February 2016 Paper P NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE 22nd February 2016 Report Title: Information Governance IT Policy Report Item No: Background and context Derbyshire Health Informatics Service (DHIS) are now part of the Arden and Greater East Midlands Commissioning Support Unit (Arden and GEM CSU) and provide the CCG with the network infrastructure, internet and systems under a Service Level Agreement. There are a number of technical information security policies that are required by the CCG in order to confirm compliance with the IG Toolkit and as assurance that the technical infrastructure operates securely and that there are access controls in place. The policies recommended by the Joint Information Governance Committee for final adoption by the CCG are: Network Access and Security Policy Business Continuity Policy Equipment Room Access Policy Anti-Virus Policy Data Back Up Policy Internet Filtering Policy Filtering Policy Arden & GEM IT Services Change Control Policy 2. Key matters for consideration Arden and GEM CSU has developed the IT policies across all the localities and these are approved internally at the Information Governance Steering Group (December 2015). The policies will therefore not require internal approval or ratification by the CCG. However, there will need to be some internal confirmation for the CCG of adoption of the policies. 1

267 ND CCG Governing Body Assurance Committee 22nd February 2016 Paper P 3 Financial Impact None identified. 4. Analysis of risk None identified. 5. Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all: None Directly Improved patient access and experience: None Directly Empowered, engaged and well-supported staff: None Directly Inclusive leadership at all levels: None Directly 6. Recommendations The Governing Body Assurance Committee is asked to formally adopt the above policies. Author: Sam Robinson, Governance Officer Sponsor: Suzanne Pickering, Head of Governance Date: 5 th February

268 Information Governance Committee Highlight Report January 2016 Arden & Greater East Midlands Commissioning Support Unit (Arden & GEM CSU) provides the CCGs with the network infrastructure, internet and systems under a Service Level Agreement. There are a number of technical information security policies that are required by the CCGs in order to confirm compliance with the IG Toolkit and as assurance that the technical infrastructure operates securely and that there are access controls in place. Arden & GEM CSU has developed IT policies across all the localities and these have been reviewed and approved internally at the Information Governance Steering Group (December 2015). The policies will therefore not require internal approval or ratification by the individual CCGs. However there will need to be some internal confirmation for each CCG of adoption of the policies. Recommended by the Joint Information Governance Committee for final adoption by the individual CCGs. Network Access & Security Policy - Approved at the IG Steering Group December 2015 This document defines the Network Access and security for the network services provided by Arden & GEM IT Services. The Network Access & Security Policy applies to all business functions and information contained on the Network, the physical environment and relevant people who support the Network. To maintain access control to the services provided, Arden & GEM IT Services will only grant proposed users access rights to systems and information that have been directly authorised by the systems Information Asset Owner (IAO) or their deputy, the Information Asset Administrator (IAA). This policy sets out the controls that apply to the network infrastructure. This policy has been amended to reflect that it supports access to network systems and not physical access to facilities. Business Continuity Policy This policy sets out the general principles and processes for the creation and revision of business continuity management (BCM) for Arden & GEMCSU IT Services. 1

269 Equipment Room Access Policy This document sets out Arden & GEM s policy with respect to physical access to areas designated by Arden and GEM as being cabinets; communication rooms; network hubs; server rooms or data centres. Anti virus Policy This document describes the measures taken by IT Services to protect client systems against viruses, trojans and other malware Data Back- up Policy This document details the data backup; retention and restore policy employed by Arden & GEM IT Operations Internet Filtering Policy This policy aims to provide the details of the internet filtering arrangements in place at on the network and outlines clients and provider responsibilities in this domain. The internet filtering system will be used to produce reports on internet browsing and trend information. Arden & GEM IT services will work with clients to agree when these reports will be produced and the type of report that is required Filtering Policy An automated filtering toolset is used to control and manage incoming and outgoing traffic which can intercept and quarantine s for risks or potential risks. This policy defines how system monitoring should be used to check the effectiveness of controls adopted and to verify conformity to the organisations access policy model. Arden & GEM IT Services Change Control Policy This change control policy covers modifications and enhancements to infrastructure systems and services. It is vital to the smooth operation of the services that these modifications are handled in a controlled manner using a standardised process Bronwyn Jackson Information Governance Manager Arden & Greater East Midlands Commissioning Support Unit January

270 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper Q NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASSURANCE COMMITTEE 22 nd February 2016 Report Title: CSU Re-Procurement Programme Board Item No: 18 Purpose: Objective: To ensure CCGs can deliver the best outcomes for patients and the best value for the taxpayer it is critical that CCGs have access to excellent, affordable, commissioning support. An open and transparent procurement exercise. 1. Background and context At present the majority of commissioning support services are delivered by Commissioning Support Units (CSUs) through service level agreements (SLAs) between the commissioner and the CSU. Nationally the SLAs were put in place as a temporary measure to ensure that CCGS had the support they needed following their establishment under the Health and Social Care Act. There was always recognition that, as commissioning support services are covered by UK Public Contracts Regulations, then when SLAs came to an end, CCGs requirements should be secured through an open and transparent procurement exercise 2. Key matters for consideration To make the procurement process as efficient as possible, and to minimise the cost and burden on the system, NHS England co-developed the Lead Provider Framework (LPF) for commissioning support services with CCGs to ensure that commissioners are able to source as quickly as possible a range of excellent and affordable services from quality assured providers, who are committed to providing volume based discounts. Although CCGs are not mandated to use the LPF as the only procurement methodology, they are encouraged and incentivised in the form of access to NHSE procurement resource and expertise when procuring services from the LPF. However for future commissioning support services, CCGs have the option of using the LPF (which was already created via an OJEU procurement), or running their own tendering process for requirements valued over 172,500. In practice, using a framework agreement like the LPF will be quicker and easier than running a separate procurement. However, CCGs are free to do this and might, for example, prefer this option if they wish to consider a provider which is not on the LPF. Furthermore consideration on what the collaborative opportunities might be, in order to maximise savings from suppliers (making the most of volume based discounts) and reduce unnecessary fragmentation is essential, irrespective of what type of procurement process is followed. The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 1

271 ND CCG Governing Body Assurance Committee 22 nd February 2016 Paper Q In-housing is still an option which should be considered where this is sensible to do so, but recognising the policy on stranded costs is still to be clarified nationally. It was agreed at the Derbyshire CCG Chief Officers meeting that SDCCG will take a lead to oversee the CSU reprocurement process, in partnership and collaboration with Derbyshire CCG colleagues. It was further agreed that the Director of Corporate Development will assume this role and Chair the CSU Reprocurement Programme Board, with the SDCCG Deputy Director as management lead. Chaired by the Director of Corporate Development for Southern Derbyshire CCG, the Derbyshire CCG GEM Contract Leads meet monthly and have developed an outline plan for the procurement of all services currently provided by Arden & GEM CSU, commencing with the CHC service. It is proposed that a Programme Board be convened to oversee the delivery of this programme of work, with membership consisting of CCG GEM Contract Leads and Chief Finance Officers from each of the four Derbyshire CCGs, together with representation from a Chief Nursing Officer. The Terms of Reference for that group are attached at Appendix 1. NHS England procurement specialists will continue to be kept informed of progress and are invited to the Programme Board in an advisory capacity. The Programme Board plans to appoint a fixed-term Programme Manager to co-ordinate and progress the programme of work. This paper will be submitted and discussed within all Derbyshire CCGs and the Terms of Reference approved through their governance processes. 3. Financial Impact There may be some financial risk around stranded costs but also some financial benefit through potential savings on contract costs. It is too early as yet to quantify these. CCG CFOs, together with CCG CSU Contract Leads, will be members of the CSU Reprocurement Programme Board. 4. Analysis of Risk A risk register will be maintained as part of the programme management of this work and significant risks reported to the Governing Body. 5. Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all: Best outcomes for patients and best value for tax payer to have access to excellent, affordable commissioning support. Improved patient access and experience: None directly Empowered, engaged and well-supported staff: None directly Inclusive leadership at all levels: None directly 6. Recommendations The Governing Body is requested to note the arrangements. Author: Suzanne Pickering, Governance Lead Sponsor: Darran Green, Interim Chief Finance Officer Date: 10 th February 2016 The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 2

272 21 st Century Plan Delivery Group Meeting Notes Decision, issues and actions Monday 11 th January 2016, ; Robert Robinson Room, Scarsdale Present In attendance Apologies Ben Milton, North Derbyshire CCG Chair (BM) Tracy Allen, DCHS (TA) Tom Diamond, Programme Director (TD) Andy Gregory, Hardwick CCG (AG) Andrew Milroy, Derbyshire County Council (AM) Linda Dale, Children s Services representing Isobel Fleming, Assistant Director & Childrens Commissioning DCC (LD) Simon Roberts, Programme Director (SR) Gavin Boyle, CRH (GB) Mark Smith, North Derbyshire CCG (MS) Ifti Majid, DCHFT (IM) Darren Green Acting Chief Finance Officer (DG) Eleanor Rutter, Public Health (ER) (Metrics) Beverley Smith, Chief Transformation Officer (BS) Sarah Darracott-Hawkins, North Derbyshire CCG (Notes) Judith Douglas, EMAS (JD) Adam Sutherst, North Derbyshire CCG (AS) Amy Miles, North Derbyshire CCG (AM) No Item Discussion and agreed action Who By When 1 Chairs Introduction / Apologies / Minutes BM welcomed all to the meeting and wished everyone a new year. He said that he would like to extend his thanks to LT for her guidance and leadership during her time as Chair. 2 Status Report Community Hubs Programme TA informed the group that a lot of work has continued over the Christmas period. PCBC1 and PCBC2 were taken through the boards. Commissioning Contracting & Finance Arrangements The feedback from stage 1 highlighted that work needs to be done on commissioning, finance and contracting arrangements. DG had put together a document about this which is under discussion with DOF. Issues raised by CRH Board Community Hubs Business Case challenges re. provision of Specialist Rehab Beds from CRH site. Feedback regarding Urgent Care How does Community Hubs fit with the rest of the programme? How do we secure the sustainability of Acute Care? 21C Plan Delivery Group (11 th January 2016) Page 1 of 7

273 A meeting has been set up between the Chair and Chief Exec s at CRH to discuss these issues and to work on the Additional Rehab Beds. GB informed the group about a Special Board meeting that took place on 23 rd December to discuss the PCBC. GB updated the group on the issues and actions that were taken away from that meeting. Community Hubs GB believes that his Board understand that Community Hubs is a component of the overall system transformation. Specialist Rehab Beds He stated that the issues that were raised around the rehabilitation beds were surrounding the ownership. Urgent Care CRH board is comfortable that Urgent Care will not feature in this round of the PCBC. GB informed the group that he believes the proposal in the PCBC regarding the development of a whole system Urgent and Emergency Care Strategy is the best way forward. GB informed the group the CRH would like the Urgent Care Centre to be co-located. Day Hospital Services TA informed the group that there are a couple of areas where more work has been identified due to the knock on implications of the proposals around OPMH. A lot of work has been undertaken to reshape these services but discussions have not yet taken place with the public and professionals/clinicians about a new care model. IM is leading on a piece of work outlining how we would provide the services in line with local and national Dementia Strategies to fit with the proposals for in-patient assessments and treatment. TA stated she would like discussions to be had in this meeting about if it is appropriate to build this service into the business case and consultation. CPRG may sign off on a new clinical model. An engagement with the broader stakeholders has not yet taken place which has happened on the other parts of the proposals. Intermediate Care Beds Issues raised: Has enough work been completed in regards to the how and where will the Community Based Intermediate Care beds maybe located? Local Intermediate Care Beds are not necessarily all located in the right places Other Services implications for Community Hospital Site Rationalisation Analysis and draft proposals are in the process of being developed and will be reviewed at the Cross System Review on 13 th January. Discussions will take place during the review about the impact to the Community Bed sites if the proposals for OPMH and Community beds are implemented. 21C Plan Delivery Group (11 th January 2016) Page 2 of 7

274 TA, MS and AG will be meeting after this meeting to review what needs to be done on the PCBC. We will be working towards a deadline of end of February. Issues have been raised around equality impact assessments. Proposals to consult Learning Disabilities AM stated that the Derbyshire Transforming Care Partnership is being formed to take this work forward on a cross County footprint. The plan that is currently outlined sets out clearly what needs to be consulted on. It maps the current changes. At the HWBB the leading members agreed the direction of travel. AG doesn t think the plan will change but it is to do with whether or not it will be a joint consultation with the local authorities. AG believes a dialogue needs to be had with the public if LD is not going into the consultation this round but to inform them it is coming. Simon Hobbs view was the nature of the proposed changes to short break services would by implication create the responsibility for a joint consultation because we are changing the way we collectively deliver. Further discussions will be held with Simon and Joy tomorrow about this and also about the different landscapes of the South and North. TA stated to the group a decision needs to be made at the meeting tomorrow with DCC if it is in or out. SR asked the group to confirm the benefit of linking them together? SR stated that one of the benefits of linking the two was because they both have a similar theme of moving away from bed based care. At a point where no one is in disagreement about the direction of travel. Is a dependency being created by linking the two together? TA agreed with SR that there are challenges of linking them together but the benefit is pace. Urgent Care Firm proposals on which to consult have not been agreed. AG stated to the group that as a minimum, dialogue with the public during the consultation will be necessary to address the issues they have raised. IM informed the group about his anxiousness of going out to public if only part of the system is transformed not a system wide transformation. TD stated that further work needs to be undertaken on the risks and mitigations. TD gave the group an overview of Jayne Stringfellow s view from the CPRG meeting. Her view was that the national direction is becoming clearer and will become a benefit to us other the coming months. TA advised the group of DCHS feedback. The proposals were not sufficiently developed and a bit too narrow to go in as they are. A dialogue needs to take place on how the rest of this system is going to be changing under the overarching programme to support the specific changes. It was highlighted that not enough work has been completed across the programme on General Practice. GB stated that parts of it are understood but a lot is unclear; such as the role of the Ambulance Service there is an opportunity to link that in. Not in a position to consult on specific proposals. 21C Plan Delivery Group (11 th January 2016) Page 3 of 7

275 BS stated to the group that we need dedicated resources on Urgent Care over the next 6 months. Day Hospital Services Do we go ahead with the new model? Do we include that in the BC consultation when it hasn t been coproduced? TA stated that we could include what we want to talk to the public about this in a separate exercise. Do we push ahead and complete in the timeline running up to the next consultation. IM advised the group that he believes there are clinical risks for not going at the same pace. He also stated that we can t consult just on the services that we commission. BS suggested using CRPG and the Workshop 8s to help with having the discussions that need to be held to develop the model of care on the run up to the revised deadline. BM stated to the group that he thinks if we put it in the BC and it hasn t been developed adequately enough if we would be a clinical risk and a significant organisation risk. Intermediate Care Beds TA informed the group that discussions will be held at the next Community Hubs Group meeting. 3. System Plan TD reported that the last PDG meeting 5 elements were presented to the group of what it will take to deliver the system plan. 1. Forecast vs current performance Metrics spend by care area QIPP/CIP tracking/delivery 2. Review existing change plans investments/benefits (QIPP/CIP) / alignment to system plan 14/15 schemes 15/16 schemes 16/17 schemes (emerging) Update system totaliser MS updated the group about the review of schemes. There are no schemes that appear to not be working that should be stopped where that money can be reinvested. There are a lot of schemes are the list that are right to do as it fits with 21C and follows the right direction of travel. But questions need to be raised whether these schemes are delivering what was initially forecasted. We need to revisit the investments. 3. Updating the system plan 5 years 15/16 baseline activity, beds, Revised 5 year challenge Impact of existing change plans 4. System Plan for 2016/17 System Priorities CCG Priorities Provider Priorities 5. Sustainability and Transformation Plan Activity Workforce 21C Plan Delivery Group (11 th January 2016) Page 4 of 7

276 4. System Metrics ER is confident all the data is consistent because it has been QA by NDCCG analyst AM. A&E attendees ER presented the graph to the group which displayed consistent data over the last 3 years for both CCGs and all providers. 13/14 and 14/15 showed a slow consistent growth of about 1% year on year. This year which is on only 8/9 months worth of data is showing a 7.5% increase. The winter months still need to be added in which will have an impact on the increase further. On all the other metrics an aim has been put in place apart from this one. ER informed the group that she isn t aware that any discussions have taken place regarding what the aim is for this metric and these discussions need to be held. CRH see 55% of North activity 13/14 and 14/15 had a 0% growth but 15/16 3%. The Minor Injury Units increase has been more dramatic than the type 1 s. ER and AM will be tasked with pulling the data apart to investigate further what is behind it. Need to all think about what we are aiming for. LD suggested that age should be analysed and linked with the Community Hub Plans. Emergency Admissions ER presented the graph to the group and explained the different lines. The blue line shows what is happening. 13/14 and 14/15 had a 4% decrease and 15/16 is showing a decrease of 7/8% decrease. This data doesn t include the winter figures so this figure is not accurate until they have been added in. ER asked the group are they confident that the programme is delivering what the graph is telling us. GB believes it is too early statistically to say. GB informed the group about the hot clinics and ambulatory care that is in place for both adults and Paediatrics. ER stated that the data needs to be defined by age to see who it is impacting on. IM suggested that some positive measures should be in against the negative ones. Length of Stay ER presented the graph to the group. There is a consistent trend. All providers are down to 5.5 days. CRH is down to 4.5 days. The impact of LOS has an impact on bed capacity. ER mentioned she would be interested in seeing what the data would look like if the Zero Length stay data was taken out. To also look ambulatory vs non-ambulatory. ER believes there are three factors to look that: Normal Stays Ambulatory/Non Ambulatory Complex Discharges AM stated that the one thing we don t do is to focus on outcomes. Where do people go? What s the cost of it? Bed Based Care ER presented the graph to the group. She informed the group the Bed Base was a mathematical product of Length of Stay and Emergency Admissions. Delay Transfers of Care The data for this metric hasn t been reviewed or QA by AM. A plan has been put in place to agree a year on year reduction of 50%. ER/ AM C Plan Delivery Group (11 th January 2016) Page 5 of 7

277 Need to combine no. of patients delayed and no. of days and to come back with the refreshed data and look deeper the difference between normal and complex discharges. ER AM is not a resource that can be used due to her being involved in the planning round and GEM cannot be relied on in regards to data. TD informed the group that he believes there is a risk of work being duplicated but with different outcomes. 5 System Priorities We have agreed to focus on metrics and system priorities over 16/17. They are linked in terms of scale of ambition and what we are trying to achieve. We need an agreed set of priorities between providers and commissioners for the 16/17 contract and planning round which will include defined investments and disinvestments, CIP and QIPP. We will also need to define and agree a set of performance metrics and indicators for 2016/17 that are aligned to the Priorities which can be used to hold the whole system to account. We also need a greater alignment of individual organisations planning and financial assumptions. All organisations need to: Deliver safe and effective care in line with key performance targets set by the health and care regulators Operate within the financial resources available now and in the future Deliver clinically safe services Implement changes which will improve the quality of care and sustainability of the health and care system by supporting people to remain safe and healthy, at home and independent. AM put together a few priorities from a Social Care point of view. There are three System Levers: 1. Keeping people safe & healthy: Avoiding episodes of care 2. Keeping people at home/closer to home: Right care, right time, right setting 3. Effective use of resources: Efficiency The objectives and key initiatives were discussed. IM and BS strongly believe that Children s and Mental Health is in this system plan. AG said we need to capture all the priorities here otherwise they will be noted down elsewhere but really need to work of one definitive list. We need to agree who will be responsible to lead on each of these. The prioritisation of this will help shape the direction of travel for the contracting and planning round. AG thinks we need a blue print for Primary Care. TA stated to the group that we need to add something in regarding Information Governance. A timescale and who is leading on what needs to be agreed. All All C Plan Delivery Group (11 th January 2016) Page 6 of 7

278 DG stated that if any of the investments are not supporting the priorities listed and if they are not delivering. Why would we continue with them? SR interjected that we need to understand the implications if we pulled the scheme out. DG said we need to look at it has a priority because it s not supporting the direction of travel. BS informed the group that work is currently taking place regarding the investments and Gareth is mapping this to the planning guidance. The PDG group agreed that they are using these priorities for 16/17 Contracting and Planning round but still need to do a bit of work ensuring everything is included. Gareth and other colleagues are to have a planning workshop to start populating names next to pieces of work and once complete to circulate the complete list. 6 Any Other Business Planning Footprint AG is tasked with writing a paper in regards to the City and Countywide Footprint. AG BM is happy to continue the chairing of the meeting until someone else is appointed. 7 Next Meeting Monday 8 th February, 9.30am 12 noon, Robert Robinson Room 21C Plan Delivery Group (11 th January 2016) Page 7 of 7

279 Primary Care Development Group Meeting Committee Room, Scarsdale Monday 21 st December 2015 MINUTES Present Sam Taylor (ST) (Chair) NDCCG, Primary Care Lead, GP, High Peak Locality David Hill (DH) Arden GEM CSU Gill Francis (GF) Practice Manager, Thornbrook Surgery Helen Foster (HF) Practice Manager, Oakhill Medical Practice Ian Mason (IM) Lay Representative Jayne Stringfellow (JS) NDCCG, Chief Nurse Jon Vinson (JV) NDCCG, Lead Medicines Management Pharmacist Judy Derricott (JDe) NDCCG, Head of Primary Care Quality Karl Rex (KR) Practice Manager, Darley Dale Medical Practice Kate Chilton (KC) Practice Manager, Chesterfield Medical Partnership Kathryn Wileman (KW) Practice Manager, Dronfield Medical Practice Lisa Soultana (LS) Derby & Derbyshire Local Medical Committee Martin Colclough (MC) Interim Chief Finance Officer Praveen Alla (PA) GP, Bolsover NEL 5 Santos D Souza (SDS) GP, Newbold Surgery Sharon Dinham (SD) Practice Nurse, Chesterfield Medical Partnership Apologies Ian Hutchinson (IH) Kate Needham (KN) Ken Heap (KH) Marie Scouse (MS) Mark Wood (MW) May McWilliams (MM) Stuart Saunders (SS) In Attendance Julie Barton (JB) GP, Evelyn Medical Practice NDCCG, Head of Medicines Management Lay Representative NDCCG, Deputy Chief Nurse (Primary Care) Derby & Derbyshire Local Medical Committee LAY Representative GP, Dronfield Locality NDCCG, Clinical Quality Administrator Item Item Action 1. Welcome, Introductions and Apologies In the absence of the chair, JDe welcomed the group, introductions were given and apologies recorded as above. ST (Chair) arrived at 2.40pm. 2. Declarations of Interest The GPs and Practice Managers at the meeting declared an interest in the following agenda items: Community Support Team Monitoring Phlebotomy Service Specification 1

280 Anti-Coagulation Service Specification 24 Hour BP Specification Nurse Indemnity Engagement Fund 3. Minutes of the last meeting (23/11/2015) KN requested a wording amendment to section 8, paragraph 9 & 10. KN gave a breakdown on the drug cost of NOAC at 800 and average drug and monitoring warfarin cost at 250 per patient per year. KN stated that the Medicines Management Team are happy to run adhoc practice GRASP-AF data and warfarin safety data for any practice that want to actively review their patients to optimise oral anticoagulation for patients with AF. With one amendment the minutes of the previous meeting held on Monday 23 rd November 2015 were agreed as accurate. 4. Action Log Inc. Matters Arising Action Log Item 56 DH is unable to confirm at this time whether the 6 practices not engaging in the use of SCRs were the same 6 not participating in the Bluestream Academy. DH to feedback at the February 2016 meeting. Action Log Item 57 DH is still working on seeking clarity on mobile devices and the N3 connection and costs of Wi-Fi in care homes. DH to feedback at the February 2016 meeting. Action Log Item 58 DH has spoken to Andrew Hall, CSU Team to discuss the potential use of the touchscreens in practices. DH confirmed that sadly it is not cost effective for an alternative use and advised the group that practices are able to use the touchscreens in anyway beneficial to them. DH will confirm the decommissioning process for the touchscreens at the February meeting should practices wish to hand the screens back to NDCCG. Action Log Item 62 JDe has received confirmation from James Cutler (PCDC) that PREVENT training will not be available on the Bluestream website. The training must be delivered by an accredited trainer. JDe stated that she will work closely with Kathy Webster (Safeguarding lead) to establish what the practices strategic obligations are as per the NHS Standard contract. Action Log Item 63 JDe is awaiting a response from Hardwick CCG for the clarity on nursing home equipment in relation to the Phlebotomy Service Spec. JDe advised the group that CRH are not interested in offering a Phlebotomy service for patients over 12 years old due to the potential 2

281 high uptake. JDe asked the group if they would be interested in looking in to setting up a local agreement in which practices could refer patients to another practice who they find difficult to take blood from. Following a lengthy discussion it was agreed by everyone for JDe to approach CRH and Stepping Hill to ask if paediatric blood bottles could be more widely used and capillary blood samples accepted. Action Log Item Anticoagulation Specification and 24hr Ambulatory BP review is an agenda item for discussion at today s meeting. These actions can now be removed from the action log. Action Log Item 66 & 68 Few comments were provided regarding the Engagement Fund. Later in the meeting JS reiterated the importance of practice feedback in preparation for the review of this fund. Action Log Item Action 67 All items are on the agenda for discussion at today s meeting. These can now be removed from the action log. Action Log Item 69 Members present confirmed that they have highlighted the rising costs of indemnity and the importance of ensuring they have the right cover within their localities. This item can now be removed from the action log. 5. IM & T Update PA provided a brief update on Wi-Fi access in practices. PA confirmed that practices should be set up by April A third party has been commissioned to manage and control the risk of Wi-Fi within practice. PA advised the group the electronic communications will be changing. It is apparent that GP s are receiving inconsistent communications from several sources relating to patient data. PA is liaising with the Derbyshire Health Informatics Board and will continue to provide updates to the group. 6. TOR Update & Agreement JV raised question on who the Prescribing sub group is to report to. At present KNs understanding is that she reports to GBAC. This will be discussed at the next meeting. BS suggested that paragraph 5 & 6 be removed from section 6. These statements are duplication from section 5 & 6. A short discussion took place regarding the importance of ensuring the most appropriate person to attend the PCDG and that there is a clear understanding of the voting process in decision making and when there is no consensus. 7. Ophthalmology JDe informed the group that she is working closely with CRH to alleviate the pressures in the Ophthalmology department. The CCG are looking to 3

282 Commission a primary care service (delivered by local opticians) for the treatment of minor eye conditions currently managed by CRH. Conditions have been agreed by CRH and the specification is in development. The CCG is also working with the local optical committee to identify what is happening elsewhere re: prescribing. The CCG has also reviewed the existing cataract toolkit in line with current guidance and will open a window of opportunity for opticians to apply to offer the service. This will include post-operative cataract assessment. The current Level 1 & Level 2 Glaucoma Enhanced Service awarded to opticians in April 2016 has only become active. CRH are beginning to assess patients who are stable for management of their condition through local opticians contracted to deliver the new service. 8. Anti-Coagulation Service Specification JDe informed the group that the specification had been approved by Medicines Management. At the previous PCDG meeting locality representatives were asked to gain feedback on the specification from practices. KC stated that she had received no comments and PA stated that he wished for more time to review. It was agreed for the specification to be finally reviewed at January s meeting and then be ratified for April Any further comments to be sent to Judy.derricott@northderbyshireccg.nhs.uk as soon as possible. KW raised the issue why the audit had been changed from 12 monthly to 6 monthly. The group agreed that the audit should be carried out every 12 months. JDe informed members that a funding application has been submitted to Health Education East Midlands to deliver accredited INR training for 2 years. The training will consist of a 2 day training course for new starters and half day for existing staff. The training will include an assessment. A short discussion took place regarding Healthcare Assistants attending the training and their role in prescribing. JDe to review HCAs attending the course and it was unanimously agreed that changing dosage was a prescribing role; this should not come under the remit of a HCAs work. 9. I.V. Antibiotics JDe summarised the Intravenous Therapy Step Up Community Service in North Derbyshire. The main focus of the service is to provide an IV service to patients across North Derbyshire. The Step Up team currently provides an IV service to patients to North Derbyshire excluding high Peak. During the period 2014/ patients were successfully treated at home as part of the Step Up pathway, this compares with 99 patients in 2013/14. The CCG is currently working with DCHS to develop a specification for the Step Up pathway (referrals from primary care) which clarifies clinical responsibility, acceptance criteria and care pathways. 4

283 Overall the opinion of the group was that this was an excellent service. A small number of the group said that they found the two Step Up case scenarios provided in Enclosure 5 unclear. The group stated that they would like clear direction of the service, clear pathways, where does responsibility lie and how will information on the service be disseminated. JDe confirmed that all pathways will go through JAPC hour BP Review The service specification for 24 Hour Blood Pressure monitoring in Primary Care was agreed by the group to be ratified. 11. BOS Update JDe reported to the group that every practice apart from one have received a support visit by the Primary Care Quality Team. The support visits have gone well and practices understand the importance of monitoring the BOS 4 million budget in North Derbyshire. One of the key outcomes of the visits was that of the coding issues and the effect on the data analysis. Bet Rudge, Arden GEM continues to support the NDCCG and practices in addressing this issue. Bet will be working with us until June If practices wish to request additional support from Bet Rudge please contact her via at betty.rudge@ardengemcsu.nhs.uk. JB to circulate Bet s to all practices. JB JDe announced that the April monitoring information will be collated and practices visited on request. The analysis of comparative data will assist NDCCG to provide support and guidance where required to practices. JS opened up discussion on the general opinion of the BOS contract. It has been brought to the attention of JS that some practices had concerns and reservations of the contract. Following a short discussion the general consensus was that most of the practices were happy with the BOS contract and that they understood NDCCG are accountable for the 4 million contract and that monitoring and the provision of support is required. 12. Any other business KC commented on the CQRS reporting that is required for completion by Practice Managers. KC explained that this process can now take around 4 working days to complete. All Practice Managers concurred with KC and all agreed that it seemed to be a pointless exercise. ST raised the issue of readcoding for the BOS and asked if there was any support with this process. JDe confirmed that Bet Rudge is currently reviewing the comments and will feed back to practices individually. PA stated that his practice administration staff is assisting with the readcoding. KC expressed her concern of the number of letters she is receiving from ST 5

284 secondary care requesting the practice to make patient appointments. The group agreed that this is passing responsibility back to primary care and for a period of time there is no control of the patient s well-being. ST mentioned that the wider issue of secondary care passing responsibility to primary care has been discussed in the High Peak. The High Peak is working on a unified template letter to secondary care and ST to bring it back to the group when complete. Engagement Fund JS emphasised the importance of considering the engagement fund with new contracts to be issued from 1 st April The group was requested to feedback at the January meeting. JS stated that the PCDG will be more involved in the shaping of localities in the future. Date, Time & Venue of Next Meeting Locality Rep Tuesday 19 th January 2016, 2.00pm, Committee Room, Scarsdale Please forward apologies and agenda items in advance to Julie.barton@northderbyshireccg.nhs.uk Tel:

285 PAPER A: Notes of the North Derbyshire CCG & Hardwick CCG System Resilience Group Meeting Date 8 th January 2016 Time Venue Chair 2.00pm Robert Robinson Room Scarsdale Jayne Stringfellow, Chief Nurse & Quality Officer, North Derbyshire CCG Present Tricia Baily (TB) Gillian Burrows (GB) Andrew Milroy (AM) Simon Harris (SH) Kath Markus (KM) Gail Collins (GC) John Wright (JW) Pete Newby (PN) Sue Jenkinson (SJ) Douglas Briggs (DB) Adam Sutherst (AS) Gareth Harry (GH) Steve Lloyd (SL) Vicki Johnson (VJ) Paul Tilson (PT) Craig Whyles (CW) Tanya Henson (TH) In attendance Sharon Baker (Minutes) Laura Joy (LJ) General Manager, Planned Care & Outpatients, DCHS Integrated Community Manager, DCHS Assistant Director (Adult Care), DCC Assistant Chief Transformation Officer, NDCCG GP, LMC Medical Director, CRH General Manager, EMAS VSPA Manager, NDVA Lay Representative, NDCCG Lay Representative, NDCCG Head of Planning & Performance, NDCCG Chief Commissioning Officer, HCCG GP Chair, HCCG Assurance & Performance Manager, NHSE Deputy Clinical Director, DHU Locality Manager, EMAS County Operational Lead, DCC System Resilience Administrator, NDCCG Deputy Chief Nurse, Patient Experience, NDCCG Action 1. Apologies Apologies were received from Stephen Bateman; Tony Campbell; Carolyn Gilby and William Jones 2. Declarations of Interest No interests were declared. 3. Minutes of the Previous Meeting The minutes of the meeting of 4 th December 2015 were approved as an accurate record, with the following amendments;- Item 9. Paragraph 5. Amendment to the wording it was observed that some practices were high users of the service while others were low users. Item9. Paragraph 9. For noting failure of the nurse led service at Chellaston. 4. Matters Arising (unless covered elsewhere on the agenda) JS noted that all action points were covered in the agenda or action log. The action log was reviewed. Item 1; GP Home Visits report awaited. SL Item 13: Cancer 2WW at CRH (the process to 'defer to provider' by fax) Update from TC Page 1 of 6

286 required, GC to chase. To remain on action log. GC Item 15: Ambulance Handovers agenda item. Regular agenda item close action. Item 23: Stockport Hospital agenda item. Regular agenda item under performance. Close action. Item 24: Breaking the Cycle and System resilience Strategy (DTOC) agenda item. Peak Flow 4 - Perfect Week Exercise (16 th 22 nd December) Post meeting note: Attached report circulated to the membership by following the meeting. Peak Flow Report GC reported a successful perfect week (16 th 22 nd December).Thanking all providers for their input and system leadership from the SRG group. Results show some excellent improvements in discharge and how discharges are managed across the Trust. The week focused on discharge before 13:00 across the Trust and a perfect theatre scheduling and productivity approach to surgery. Highlights Data collection and allocated ward liaison roles went well on the first few days with a real burst of activity on the Wednesday and Thursday. The Red Cross supported discharge across the days, came in on the weekend (Sunday) assisting 22 patients with their discharge. Surgical wards achieved 49% of their discharges by 13:00 and reviewed 69% of their discharged patients before 13:00. Medical teams carried out reviews on 75% of patients before 13:00. Discharges increased across the Trust. Discharge lounge usage increased during the week. For the week the Trust managed to discharge 26% of patients before 13:00 hours with Wednesday reaching 32%. Compared to a pre peak flow rate of 19%. Focus # home for lunch. Perfect theatre scheduling and productivity, involved careful list planning, orthopaedic list increased by 60%, although couldn t consistently be achieved. The Trust is looking at a proportion of lists going forward. TH reported that DCC had operated as they would be responding going into a Bank Holiday. Informing members that Nottingham University Hospitals are participating in a breaking the cycle week commencing11 th January and recommended looking at their formats. PN informed members that following the Red Cross discharge support (first three months), the VSPA service would conduct a further needs assessment to continue support in the Community. Members supported Easter perfect week (Wednesday to Wednesday). SRG to manage and support planning. Action: Planning for Easter Perfect Week SH to contact George Briggs at CRH. SH to make contact with NUH re breaking the cycle format. SH Item 25: Care Home Beds JS sought update from Jim Connolly. No block booked beds for winter 2015/16. Action complete. 5. Delayed Transfer of Care (DTOC) Paper C prepared by SH & LJ presented by LJ. Delays in discharge processes and the resulting effect on Emergency Department targets, flow and patient care remain an area of concern locally and Nationally. Page 2 of 6

287 A recent DTOC roadshow held by NHSE, TDA, Monitor and the DoH acknowledged that from last year s winter pressures work, they discovered a correlation between ED waits and bed occupancy, which led to looking at those in delay and why they were in delay. One of the main points was that this is about a whole system approach and that is important that all partners work together to deliver better outcomes in this key area. It was also acknowledged that the problem is not necessarily all about the DTOCS, there is a lot in the gift of the acute trusts to resolve this problem. In North Derbyshire the Peak Flow/Perfect week concept has produced some good results but these have not been sustained. An EDD CQUIN is in place and some data has started to be produced, however more needs to be done to understand where the blockages are and how these can be unblocked to prevent delays and maximise flow in the acute trust. With this in mind it was proposed that a set of metrics should be put in place to collate key information and report this to the SRG. Key matters for consideration;- There are 8 High impact changes for managing transfers of care the CCG should work with providers to go through the model and look at where their organisation is against these (appendix 1) The proposed metrics (appendix 3) cover key aspects of the SAFER bundle (appendix 2), EDD CQUIN and information from the road show. Regular data reporting will assist with the identification of key areas of concern to be addressed by the Trust aiding further improvements to be made in the discharge process. Recommendations:- Assessment against the 8 high impact changes will be led by the CCG discharge group (LJ leading), which it is hoped will have representatives from across the health and social care system. SRG should review and agree the proposed metrics and include them as an agenda item. CRHFT to be asked to provide data against the metrics and comment on data which is routinely available and on what basis i.e. monthly or quarterly. A reporting schedule for metrics to be agreed between the SRG and the trust. The CCG Discharge Group to be recognised as a working Group of the SRG and formally report to SRG. Members discussed the recommendations/options. Right metric? Incentivised or business as usual? CQUIN may not be within the provider s gift. Mechanism required for monitoring and reporting into SRG on a month to month basis. Number of mechanisms on discharge. Commissioner Leads discharge meeting has been arranged, invites have gone out. LJ leading, meeting about systems and discharges. DCHS & DAC raised concerns around discharge and flow rates into the Community and Social Care. Transformation Fund incentives/joint rewards. Action: Providers to consider options and provide a response to JS/SH for review at the SRG meeting in February. Action: LJ & GC to discuss outside of the meeting. Action: VJ informed the group that the, SRG high impact interventions no.7, daily review of patients, 80% of weekend discharges should be included in the metrics list. Action: Regular reports to SRG to be scheduled. ALL LJ/GC LJ LJ 14:37 AM joined the meeting. Page 3 of 6

288 6. Christmas Debrief SH provided Countywide update, a really busy period, the health care system had coped quite well in comparison to Southern and Eastern Counties. Reporting that DCHS had opened additional beds (staffed by Whitworth and off-framework agency staff) which had not been utilised, transport issues had been identified. Action: GC/GB to discuss outside of the meeting. DHU SH provided update. National telephony contingency evoked by South Central and YAS, relating to flooding in Yorkshire on the 27 th and 28 th December. NHS 111 performance target 95%, achieved 92%. DHU have written to Commissioners to request a Force Majeure and awaiting response. Out of hours target achieved. Post meeting note: Commissioners confirmed on January 12 th that Force Majeure would apply to the time period requested by DHU. Please see attached dated Tuesday 12 January. GC/GB Re Force Majeure.msg 7. System Resilience Dashboard Paper D attached, circulated with the agenda. AS presented the Dashboard and led the group through key points. Paper D SRG Dashboard Jan meetin CRH - A&E failed the December performance standard. Top five areas, issues and actions identified. Pressure on the service expected over the next two weeks. AS receives monitoring report at 08:00am daily. It was noted that Sheffield Teaching Hospitals had been unable to provide data owing to PAS/Lorenzo implementation; Monitor was aware of the difficulty. Action: AS to share report with GC. AS The meeting with Stockport had been cancelled but it was intended that an alternative should take place; AS would provide an update to the SRG when received. A number of RAP and financial action plans are in place for EMAS until the end of February, beginning of March. Board to Board meeting scheduled next week. Wider system issues, not related to the local trust. Actions from Commissioner and Provider side in place, to ensure sustainability of safe patient transportation, improve performance, reduce long waits, impact on patients and improve outcomes. EMAS receiving support from Commissioners to achieve. Locally North Derbyshire doing very well, extra car and ambulance available. Geography challenging. Action: KM informed that from a GP perspective, general practices were being asked to down grade urgent ambulance requests. SL to take forward and challenge. RTT improvement across the board. Sheffield RAP in place. SL CRH Ophthalmology. RAP in place until February. On track to achieve target. AS reported in respect of planned care that all 52ww patients at CRH had been cleared; this was linked to work on and the recovery plan in ophthalmology. Diagnostics, echocardiography and urodynamics are all delivering. Sheffield recovery action plan requested. Page 4 of 6

289 Sherwood Recovery in for February. GC raised the potential to fine other trusts as an associate to the contract, for under performance. Commissioners confirmed, action available, contract notices can be raised, preference to try and negotiate. C Diff Sheffield, below target. Stockport, further information requested. AS confirmed contract notices in place for CRH (echocardiography; urodynamics and ophthalmology). DHU (calls answered in sixty seconds) and EMAS. 8. Ambulance Handover Action Plan Paper E circulated with the agenda. GC drew attention to key highlights. It was noted that the paper did not address flow within the hospital, but was expected to improve handover. GC acknowledged that there had been some problems with data capture; the newly implemented (electronic) system is operational, monitoring patient arrival and movement through ED. The collection of data is not yet compliant, diagnostic data should be available mid-february. ED Receptionist collating demographic data when patient books into ED (not in place at the moment). Action: GC to report back at February meeting, with updated action plan addressing, data and flow through MAU and other wards. GC 9. 7 Day Services Paper F (attached) circulated to the membership following the meeting. GC presented the paper, drawing attention to the key highlights. Paper F seven day servicesv4a.docx Local vision for seven day thinking across the local health community driven and governed by the North Derbyshire 21 st Century Healthcare Board as the Programme Board for the 7DS agenda. Operational group convened to deliver on identifying key actions; performance indicators etc. Two options for going forward. 1) Reconvene and refresh the group with renewed commitment to work to timelines to deliver objectives. 2) Establish a virtual meeting structure with commitment from all stakeholders to agree and update actions to secure the compliance outcome on a matrix to be monitored by SRG. Action: Members agreed a mandate for option two. GC to collate action plan matrix, in-line with planning intentions document, specific expectations; five out of the ten standards to be agreed; bring back to February SRG meeting. 10. Winter Debrief Paper G circulated with the agenda, presented by SH. The ND SRG awarded 1,892, monies to providers in 2015/16 covering many different schemes that were all aimed at providing greater resilience during the winter period and beyond the urgent care system. More formal reviews will need to take place including lessons learned and consideration for future use of resilience monies. Action: To support sharing of lessons learned and enable providers to share the outcomes of their projects it is proposed that providers deliver as five minute presentation on their projects and then share any learning. Action: SH to organise learning event and discuss output and implications for 2016/17 with finance. GC All providers SH 11. Any Other Business Page 5 of 6

290 Junior Doctors Strike GC provided assurance to the group that CRH were prepared for the Junior Doctors strike scheduled to commence on Tuesday 12 th January (8am) through to Wednesday 13 th January (8am). Indicating low risk for patients presenting at A & E. Planned outpatient clinic capacity reduced and some elective procedures had been cancelled. Cohort of patients had been advised by telephone. Communication via website. Proposed 48 hour strike Second week of February, proposed full walk out of Junior Doctors. Consultant, Pharmacy and enhanced service staff to fulfill the roles. Larger impact on planned activity. Patient safety paramount. Seasonal Influenza Vaccine Uptake amongst frontline healthcare workers in England Paper H circulated for information and to aid flu planning in the future. It was recognised that CRH ranked fourth in the country for influenza vaccine uptake amongst healthcare workers. Action: Providers to discuss performance back within own organisation and report any plans to improve performance for 2016/17 to SRG in February. 12. Date and Time of Next Meeting The next meeting will take place on Friday 5 th February :00 in the Robert Robinson Room, Scarsdale. All providers All to note Page 6 of 6

291 DCHS QAG Meeting Tuesday 27 October 2015 DCHS Quality Assurance Group Meeting Committee Room, Scarsdale Tuesday 27 th October :00 15:00 MINUTES Present Steven Bramley (SB) Andrew Ebbage (AE) Laura Joy (LJ) Rick Meredith (RM) Melanie Parkin (MP) Kathy Webster Apologies Jim Connolly (JC) Anne-Marie Spooner (AmS) Jayne Stringfellow (JS) Julie Wheeldon (JW) Carolyn White (CW) Delores Williams (DW) In Attendance Sally-Ann Coope (SaC) Rachel Jeffery (RJ) Anna Long (AL) Denise Sanderson Adam Short (AS) Lay Representative NDCCG, Commissioning Manager NDCCG, Deputy Chief Nurse (Chair) DCHS, Medical Director attending on behalf of Carolyn White DCHS, Lead for CQUIN & Quality Consultant/Designated Nurse Safeguarding Children and Children in Care Derbyshire County Hardwick CCG, Lead Nurse NDCCG, GP Clinical Lead - Chair NDCCG, Chief Nurse DCHS, Interim AID, ICBS South DCHS, Chief Nurse (Rick Meredith in Attendance) Erewash CCG, Clinical Quality Facilitator DCHS, Clinical Lead, Quality Always NDCCG, Clinical Quality Administrator Minute Taker DCHS, Integrated Community Team Lead DCHS, Lead Clinical Nurse, Continence DCHS, Quality and Business Performance Manager Item Item Action 1. Welcome, Introductions and Apologies LJ welcomed attendees to the meeting. Introductions were given around the table and apologies were recorded as noted above. 2. Safeguarding Children s Assurance framework KW presented the safeguarding children s assurance framework and explained that it is used for tracking progress. KW stated that there were a couple of items which have not yet been received and KW is awaiting an update on serious case reviews and serious learning reviews on three cases. Quarterly Training Report KW explained that all training providers receive a quarterly training report 1

292 DCHS QAG Meeting Tuesday 27 October 2015 which helps to provide early warnings. KW reported that DCHS safeguarding training is currently 88%, which is good. Policy for female genital mutation (FGM), Forced Marriage and Trafficking KW asked to receive a copy of the FGM, forced marriage and traffic policy once it has been through the governance processes at DCHS. MP agreed to send the policy through once available. ACTION: MP to send KW FGM, forced marriage and traffic policy once available. MP Health Hub KW informed the group that there is a newly commissioned service named the health hub which is a 12 month concept. There are two specifications and two assurance frameworks, one for the North of Derbyshire and one for the South of Derbyshire which have been put together by KW and DCHS colleagues, as well as partner agencies. They are not yet agreed and they have been created to look at what is already in place, how we work together and what is needed to be commissioned in the future. KW will be working with Jo Hunter, Gill Levick, AE and LJ on the health hub. AE confirmed that a draft contract variation has been added due to the contract being split and is working with Linda Hunter at Southern Derbyshire CCG to ensure the CCGs are working in similar ways at similar times. MP asked where the information on the health hub will be reported. It was agreed there will be a quality sub-group and a working group arranged for the service and both will report into DCHS QAG. The group discussed the North and South commissioning split for DCHS. KW assured that she is leading on safeguarding children for the whole of the county. The group thanked KW for her update on safeguarding children. 13:25 KW left the room. 3. DCHS Patient Story MP delivered a patient story in relation to the continence team. The patient s daughter had contacted the continence team after her father passed away, to thank them for their support throughout his end of life care. They assessed his needs and comfort and from this assessment they had removed the patient s catheter as it was causing discomfort and the team managed his incontinence in other ways. MP noted that this supports the work which DS and the continence team are doing on the ward with ensuring patients are assessed by their needs. LJ stated the Commissioning for Quality and Innovation (CQUIN) for catheters has reduced infection rates by approximately 72% within CRHFT and this shows that the hard work is being carried out across the patient pathway. The patient story was well received and LJ thanked MP and DS 2

293 DCHS QAG Meeting Tuesday 27 October 2015 for bringing it to the DCHS QAG meeting. 4. Continence Issues The group welcomed DS and AS to the meeting. DS informed the group the current continence waiting list for an assessment is no longer than 5 weeks. On average it is two to three weeks. Waiting times are being kept on top of and the service is much faster than the previous service provided by district nurses. The continence team have an active case load of 1,500 patients and the team are monitoring this tightly in respect of keeping system one up to date and ensuring patients are followed up with communications and appointments. DS informed the group of work which has taken place with medicines management with Harriet Murch in Erewash CCG and Kate Needham in North Derbyshire CCG which has made great savings. This was originally commissioned as a pilot and the results should be available soon. DS noted that outcomes for patients in clinic are significantly better as patients at home are often frail, elderly and housebound. DS reported that Catheter Associated Urinary Tract Infection (CAUTI) rates are continually low as an organisation and this is monitored through Datix where the team provide feedback on each one. DS reported that the home delivery service has been in place for just over one year and the service has seen an 8% increase within that time. The average cost per day of products is 55p and the national average is around 87p however the service is providing the right products for the patients at the right time. DS addressed previous concerns around delays in receiving orders. DS explained that the first order is made by the continence team however for any orders after that, the patient, relative or carer must instigate repeat deliveries, this is to prevent overstocking however this can be overridden if necessary and there are a portion of patients who receive a regular delivery. DS recommended that if anyone has queries or issues to contact her to enable her to look into individual cases and resolve any issues. DS is also working on pressure ulcers as continence is often related to pressure ulcers. AS informed that the team are taking on continence clinics in Derby City as well, the difference is that Derby City is currently clinic base only. The future may be to replicate the Derby County model in Derby City. LJ asked if DS has previously had any issues with the delivery of continence supplies after discharge. DS explained the team are working with the hospitals to plan discharges however communications are sometimes lost with CRHFT and Derby discharges. LJ informed she is lead for CRHFT and also lead for discharge. LJ would like to work with DS on this to improve communications. DS expressed an interest in working with LJ on discharge. DS explained; another piece of work which has worked for the team which is to emphasise how important it is to assess the patient when at home as often the patient s needs are different when they are at home. 3

294 DCHS QAG Meeting Tuesday 27 October 2015 DS provided the group with a report on continence which will be circulated post meeting. 13:50 AS, AL and DS left the meeting. 5. DCHS Quality Always The group welcomed SaC to the meeting. SaC presented information on the DCHS Quality Always visits and explained that the visits were created and based on a model which Salford Foundation Trust implemented and in turn; have turned the trust around. DCHS have amended this model as the organisation provides services for both inpatients and outpatients. The visits have been running with inpatient services for over one year now and it is going well. The visits are based on the five Care Quality Commission (CQC) care domains; safe, caring, responsive, effective and well lead. The visits are unannounced and they are then red amber green (RAG) rated, this rating will determine when the area is reassessed. The team are looking to incorporate a new system for areas which receive two consecutive visits with a green rating and the area would be assessed within 12 months rather than eight. SaC gave positive feedback on the older peoples mental health (OPMH) wards and learning disability (LD) core units. SaC also stated that Whitworth attained a green status on their first visit. The Quality Always model will now be rolling out into localities and the first locality will be Chesterfield. SaC informed the group of future work which is due to take place; The team have provided training for clinical leaders to develop their personal qualities and help to provide excellent patient experience, the training will continue and a further six training dates have been scheduled for staff. LJ thanked SaC for the information presented on Quality Always and provided feedback from SL, who recently attended a visit and have said that Quality Always is a very robust and useful process. This feedback has also gone to North Derbyshire CCG s Governing Body. LJ informed that she has been working on the quality strategy for the CCG which is a three year document; the document has included information around assuring quality within community hubs and homes and would like to use the same principles by using applying the CQC care domains across them. AE agreed and asked what would happen if there were changes to an area such as staff turnover which had previously received a green rating. MP assured AE that DCHS triangulate data and regularly communicate between teams to share this information. DCHS are also developing a quality dashboard and a rapid response dashboard which will also hotspot areas to be quickly and easily identified. LJ thanked SaC for her presentation on Quality Always Visits. 14:20 SaC left the room. 4

295 DCHS QAG Meeting Tuesday 27 October Minutes from the Previous Meeting Held on 28 th July 2015 The minutes of the previous meeting held on 28 th July 2015 were agreed as an accurate record. 7. Matters Arising and Action Tracker from 28 th July 2015 Action Log Ref: 89 AE informed the group that the contract has been reawarded to MEDEQIPP. The new contract will begin on 1 st December and there are no expected transfer issues. The contract is to provide an 8am 8pm seven days per week service. The action was marked as CLOSED and AE was asked to update with any future issues and information. RM expressed concerns around delays in ways of wheelchair provision and the affect this can have on tissue viability. AE explained that the better care joint commissioning funding group were recently tasked to look at the wheelchair service and there was also a commissioning investment last year of 0.5m and there is work in progress with this. Action Log Ref: 103 LJ informed that Hardwick CCG had responded to the request and have apologised as they do not have anyone who would be able to attend. Dr Ben Milton is now working on getting a GP to attend the meetings. The action was marked as ONGOING. LJ Action Log Ref: 105 and 107 Unfortunately Marie Scouse was unable to attend the DCHS QAG meeting to discuss information sharing, however there is a Derbyshire wide information sharing group with representatives from all key health and social care stakeholders including DCHS. The DCHS representatives for the meeting are; Alvaro Pancisi and/or Jonathan Sanderson. It was agreed to take this forward through the Derbyshire Wide information sharing group and caldicott guardians will be working with GPs on this. Jo Hunter is also arranging for DCHS to work with the CCG on Summary Care Records. The action was marked as CLOSED. Action Log Ref: 108 AE was asked to check if Chris Rowland s has this information and issues between the quality agenda which sends patients to MIU and cost pressures needs clarification. It was agreed to be picked up with DCHS and the CCG via their monthly meetings. The action was marked as CLOSED. Action Log Ref: 109, 110 and 111 LJ confirmed the paper has gone to Anne Hayes and information has been received. The acupuncture work has not yet been progressed due to the Clinical Commissioning Policy Advisory Group (CCPAG) meeting not taking place, this is expected to move forward on 12 th November 2015 and LJ has asked for this to be communicated via as it was felt it would be too long to wait until the January DCHS QAG meeting. An update to be provided at the January meeting. RM noted there has also been one complaint received regarding the removal of the service. The action was marked as ONGOING. LJ was aware of this. LJ Action Log Ref: 112 The action was marked as CLOSED. 5

296 DCHS QAG Meeting Tuesday 27 October 2015 Action Log Ref: 113 The action was marked as CLOSED. Action Log Ref: 114 This was presented in item four of the minutes. The action was marked as CLOSED. 8. DCHS Quality Schedule and CQUINs Performance Report MP updated on the different CQUINS Dementia The dementia CQUIN is causing issues which are due to data collection. There are struggles with capturing the patient s assessment onward referral and discharging. Work has taken place with all wards and Paul Lund has been liaising with wards on a daily basis. This has caused quite a variation on data flow. Andy Cole has been asked to support the communication and wards now have a nominated advanced nurse practitioner for communication, teams are then working with TPP to prompt the data to be collected. This is noted as a risk on the risk register as it is expected not to be completed this year. The group had a discussion on how the data translates; AE and MP had agreed that the practical recommendations are that DCHS should mark it as an onward referral and that this would be the best thing for the patient. AE felt the number of care plans needed to be in line with the number of referrals made as they should only be counted once. This is a piece of work which GEM could potentially support. Delirium DCHS are looking to relaunch the pathway which supports the CQUIN work. The delirium training reports were low for last month and therefore managers have been asked to support the training. There were 62 staff who took up training in quarter two. There have been other training programmes, these were; end of life with advanced dementia and also dementia, delirium and depression in the trust clinical programme. DCHS have also worked with Derbyshire County Council to make a training DVD which is being used to support the roll out of the first contact form. Improving Urgent Care There have been two meetings between East Midlands Ambulance Service (EMAS) and DCHS in regards to triaging to Minor Injuries Unit (MIU) when clinically appropriate and it has been agreed go live with trauma triage tool on 02/11/15. MP felt the work will be changing the culture for paramedics turning up at MIU, we have asked staff to work through the triage tool when they arrive to ensure it is followed correctly. The numbers are likely to be low for this as they do already treat patients for minor injuries. There is also a promotional video on YouTube to show what DCHS services provide which has been useful to patients, staff and EMAS. Pressure Ulcers Dedicated teams have completed motivational interview training and a clinical evaluation of this has begun. The video of Gee which showed an example of equipment has been fed back into the dedicated teams and 6

297 DCHS QAG Meeting Tuesday 27 October 2015 there have been positive changes made for future interviews. Compassion and Culture MP is waiting for this information go to the patient experience and engagement group. MP will send this through to AE and LJ when available. End of Life The end of life training programme is rolling out and work is being done to look at uptake and gaps. At present, 46% of registered DCHS staff have undertaken the training. This information will be put against the end of life audit and the information and feedback will go directly to clinical leads. MP informed that in quarter one next year, there will be interviews to gain feedback from bereaved carers. Staffing for Quality Staffing for quality will be presented at the next executive meeting and will be shared with AE and LJ when available. Improving Transfer of Care and Patient Flow It was fed back that the monthly meeting are progressing well and an action plan is in place. Quality Schedule OPMH having had achieved zero delayed transfer of care, MP is working with them to learn how this was accomplished and establish if it is able to be replicated in other areas. Quality Assurance LJ announced that an audit is expected to be completed within quarter four, this is to ensure the new quality assurance processes which were put in place after the QAG meetings were altered to occur quarterly rather than monthly have been effective. The group discussed documenting the DCHS quality schedule and CQUINs performance report and it was agreed that RJ would compile an overarching document which would show what was reported in each quarter. ACTION: RJ to create overarching document for DCHS quality schedule and CQUINs. RJ 9. Safeguarding (Children s and Adults) Presented under item two of the minutes. 10. DCHS Quality Always Visit Presented under item five of the minutes. 11. Clinical Concerns and Service Update Serious Incidents There were no concerns raised. 7

298 DCHS QAG Meeting Tuesday 27 October 2015 Commissioning Concerns LJ and MP discussed commissioning concerns as it has been highlighted that some are inappropriate and need further information provided. LJ explained this was also discussed at the CRHFT QAG held on; 26/10/2015. It was agreed a meeting be arranged for Jo Lacey, Louise Swain, LJ and MP to discuss commissioning concerns. ACTION: RJ to arrange a meeting for Jo Lacey, Louise Swain, LJ and MP to discuss commissioning concerns. RJ Level 2 Reports There were no concerns raised. Bolsover Hospital Update LJ informed that a recent report on Bolsover Hospital reported a significant improvement and they are now showing as amber on the RAG rating for Quality Always. RM added that the contract for the clinical lead has been extended to 12 months. Dronfield LJ reported that Lenthall Primary School has had a meningitis C incident. There was one child who has now recovered and a second child who has just been confirmed and has died. The public health process to inform patients and vaccination plan was outlined briefly. RM stated he would like to participate in a debrief and for DCHS to work with Public Health on vaccinations and would also like to see a Patient Group Directive (PGD) in place as the whole process has felt quite disjointed. LJ added that teleconferences have been taking place to bring organisations together to work on the response to the outbreak, but the CCG would support a debrief. RCA MP informed the group that DCHS will be reviewing the RCA process to attempt to minimise the workload, it is currently estimated that each RCA takes approximately 35 hours to complete. LJ showed support for this work and informed that she will be doing a piece of work with CRHFT and DCHS on RCA s before the end of the year. 12. IPC LJ passed on SL s apologies as she had felt there were no issues to be raised at the meeting. 13. Patient Experience and Complaints LJ was assured by the information which was presented through the PESC meeting on 20/10/2015. LJ stated that it will not be necessary to bring this item to the DCHS QAG meeting unless there is a particular issue which needed to be raised. 8

299 DCHS QAG Meeting Tuesday 27 October Any Other Business There was no further business discussed. 15. Date and Time of the Next Meeting Tuesday 26 th January :00 15:00 at Room TBA, Scarsdale, Chesterfield, Derbyshire, DE7 5FH. Please forward apologies to; 9

300 Derbyshire Health United Quality Assurance Group FINAL Minutes Tuesday 27 th October 2015 Derbyshire Health United Quality Assurance Group Ashgate Manor, Chesterfield Tuesday 27 th October 2015 MINUTES Present Jayne Stringfellow (JS) (Chair) Aqib Bhatti (AB) Gill Bingham (GB) Ian Gerrard (IG) Jenny Doxey (JDo) John Vinson (JV) Marie Scouse (MS) Ros Kibble (RK) Steve Bateman (SB) Apologies Delores Williams (DW) Jenny Tilson (JT) Kate Needham (KN) Pauline Hand (PH) Rosemary Brown (RB) Simon Harris (SH) In Attendance Christy Herbert (CH) NDCCG, Chief Nurse & Quality Officer DHU, GP Lay Representative Lay Representative DHU, Deputy Clinical Director NDCCG, Medicines Management Team NDCCG, Assistant Chief Nurse (Primary Care) DHU, Head of Clinical Governance DHU, Chief Executive Erewash CCG, Clinical Quality Facilitator DHU, Director of Quality & Nursing NDCCG, Head of Medicines Management DHU, Programmes & Operations Director Lay Representative NDCCG, Head of System Resilience NDCCG, Clinical Quality Administrator Item Item Action 1. Welcome, Introductions and Apologies JS welcomed the group, introductions were given and apologies record as above. 2. Declarations of Interest The group had no interests to declare. 3. Minutes of the previous meeting The minutes of the previous meeting held on Tuesday July 21 st 2015 were agreed as an accurate record. Action Tracker Action log item 78 In relation to the progression of the Care Plans through the Care Planning Committee MS informed the group that both she and JDe have recently met with JDo and discussed the RightCare nurses staying in post until March Together they have been working on developing examples of good practice to share with Practitioners. 1

301 Derbyshire Health United Quality Assurance Group FINAL Minutes Tuesday 27 th October 2015 MS informed the group that training workshops have taken place throughout the County with each area varying in uptake of these opportunities. MS confirmed that the CCG are happy for DHU to continue rejecting incorrect plans and sending these back to practices. This action can now be removed from the action log. Action log item 79 JS confirmed that the Safer Staffing Review has been cross referenced against the new single service improvement plan. This action can now be removed from the action log. Action log item 80 The Service Improvement Action Plan is for discussion under agenda them 6. This action can now be removed from the action log. Action log item 81 AB informed the group of organisations now providing indemnity for out of hours (OOHs).DHU to reduce the risk of increasing costs have decided to introduce a 5 per hour expense payment to GPs per quarter towards the indemnity cost with the proviso that they work 150 hours per year. AB stated that this has been well received by the GPs and has been running since October 1 st DHU have a large cohort of GPs that work a large number of hours and they hope to retain these. This action can now be removed from the action log. Action log item 82 In relation to the CCG Patient Experience Team having capacity to jointly work with DHU to carry out a patient survey JS informed the group that the CCG are more than happy to put the resources in to help with this. MS provided JDo the details of the Patient Experience Team. Action log item 83 JS asked that each CCG are reminded of the importance of identifying how practices in each area use the DHU data that is fed back to them and what they do with this data. Action log item 84 OOHs data is for discussion under agenda item 9. This action can now be removed from the action log. Action log item 85 The 111 Commissioning Standards is down for discussion under agenda item 11. This action can now be removed from the action log. SB informed the group that DHU are currently reviewing the new NHS 111 Standards that have recently been released. 4. Quarter 2 Quality Report RK presented the group with the Q2 2015/16 Quality Report. DHU have 2

302 Derbyshire Health United Quality Assurance Group FINAL Minutes Tuesday 27 th October 2015 two CQUINs set for 2015/16 of which CQUIN 1 data on Prescribing of all Antibiotic Items is always one quarter behind. JDo apologised for not providing the Q1 data and agreed to share this with the group post meeting. The group noted that this CQUIN was not achieved however whilst this has not been achieved work is taking place to progress this and is moving in the right direction. It was suggested that for the next meeting DHU provide a run chart to compare this year and the previous year s antibiotic prescribing. AB agreed to liaise with NEMS and Sheffield in order to help build a comparison. JV informed the group that the Medicines Management Team is working with high prescribing practices and he is happy to do something similar with the OOHs. JV agreed to look for trends within general practice on antibiotic prescribing. JDo AB JV JS and MS acknowledged that from the C Difficile Root Cause Analysis identified within NDCCG very little stemmed back from the OOHs service. This is very positive and nationally this area is now one of the best performers. The group noted that CQUIN 2 Broad Spectrum Antibiotic Prescribing for Q2 has improved and has been achieved. JDo informed the group that there has been vast improvement in the antimicrobial prescribing. Particularly in the prescribing for UTI. Clinical Audit RK gave an overview of the call advisor, nurse advisor, nurse practitioner and GP audits. The group noted the major work done by DHU around safety netting and the very informative article written by the Clinical Director in the clinical update newsletter. MS highlighted that in relation to the safety alerts which are currently communicated to JT who then cascade this to other members of staff the process will change. As of October 31 st all employers will have to access a website and will have to check themselves for safety alerts. A web link will be sent through to DHU when an agreed date change is clarified. The group noted that it is down to the staff members who are employed to inform DHU of any involvement in performance issues or changes to registration status. MS agreed to send to DHU the web link for Safety Alerts. MS Compliments and Complaints The group noted the compliments and complaints received within Q2. The compliment extracts received were noted as positive and meaningful. RK explained that there was real trend found with the complaints received. Complaint details involving staff has been fed back. RK informed the group that in relation to the ongoing complaint SI 2574, copies of the voice recordings were provided to the daughter of the deceased. PH, JDo and RK met with the daughter and the meeting was 3

303 Derbyshire Health United Quality Assurance Group FINAL Minutes Tuesday 27 th October 2015 successful. Feedback was provided to NHS pathways and changes will be made as a result. JS requested that in future the CCG are informed of any serious incidents or complaints that are sent through to the ombudsmen. This allows the CCG as commissioners to ensure that providers carry out any actions required. RK informed the group that one staff member is now back from long term sick, agency support remains in place whilst a phased return to work continues. RK and SB highlighted that the agency staff member has proven to be an excellent member of staff and DHU are looking into employing her. AB highlighted that an apprentice has now started within DHU and is proving to be very effective in the governance team. Incidents The group noted that there were three red incidents within Q2. These incidents included one IT Issue and two unexpected deaths found to be of natural causes. Finally RK informed the group that DHU will be having a CQC inspection on November 10 th & 11 th /16 Monitoring Tool JDo presented the group with the Q2 Monitoring tool and evidence. 2.9 Staffing Ratios The group discussed the staffing ratios and it was agreed that the evidence provided should include the use of agency staff as originally included within the safer staffing review. JDo informed the group that appraisals are now at 86% and it is hoped all members of staff will have had an appraisal or demonstrate dates are in place for appraisals by the CQC inspection. 1.1 Patient consent The group were informed that for September the number of cases within Derbyshire where the patient refused to share information was Medicine Errors JDo summarised to the group the medication incidents reported on Datix. These incidents included one prescribing error, two process errors, one incident were the clinician cannot recall writing on the label of the medication issued, one issue reported and rejected were it was thought that diazepam was missing but was not, two staff administration errors and finally three issues involving other agencies and reported by DHU staff. JDo explained that JT is heavily involved in the Patient and Public Involvement work. 4

304 Derbyshire Health United Quality Assurance Group FINAL Minutes Tuesday 27 th October 2015 JDo informed the group that the following policies are in place, in date and available on DHU intranet DHU Patient Consent Policy DHU Confidentiality Policy DHU Data Protection Policy DHU Information Governance Policy DHU Network Security Policy DHU Records Management Policy DHU RightCare Policy JS highlighted the mandatory reporting flowchart and process to follow of the Female Genital Mutilation (FGM) Policy which comes into force from October 31 st This mandatory reporting must also be adopted by DHU. MS agreed to send JDo and JT the FGM information and resources. MS 6. Service Concerns and Areas of Good Practice DHU Service Improvement Plan AB explained to the group that the DHU OOHs Service Improvement Plan looks at how DHU can fundamentally improve its service including engaging with the clinical lead, engaging with staff and how the NQR12 data which looks at performance and productivity at individual level provides assurances. This data is reviewed at the Contract Management Group. The group discussed the frustrations with the Adastra update and IT Issues. JS highlighted that a number of items within the action plan will underpin some of the information used for the whistleblowing review. JS stated it would be worthwhile pulling together the CCG comments and the DHU comments to ensure they are both clear and demonstrate a concise well written report. The whistleblowing publication will be released on December 2 nd and the evidence base from both commissioner and provider needs to correlate. AB informed the group that David Geddes is informally visiting DHU on November 12 th with a particular interested in integrated service and indemnity.. JS stated that the CCG are happy to participate if required. MS informed the group that at a recent 111 Call Review Meeting the Regional Pathways author was in attendance and seemed really happy with how the service is run. 5

305 Derbyshire Health United Quality Assurance Group FINAL Minutes Tuesday 27 th October Feedback from CMB SB advised that the full CQC inspection of DHU has been scheduled for the week of 9th November, This would involve inspection of the OOH sites and the four NHS 111 services. The group discussed the telephone clinical assessments and the percentage of actual emergency dispositions (ED) triaged. The local KPI for this standard is 5% with DHU currently referring 6.5% through to A&E. The National average for referrals to ED from NHS Pathways is currently 8% and, as this is a local target, DHU have asked that this target be amended to reflect the National Average. There is a joint responsibility for this KPI with Commissioners as DHU can only refer patients through to the services that are available and mapped on the Directory of Services. JS informed the group that the CCG wish to work collaboratively with providers however they are facing pressures from NHS England to issue penalty notices as per the contract. 8. Terms of Reference MS informed the group that the DHU QAG Terms of Reference are now up for review. MS explained that a number of changes need to be made to the TOR including clarity on the clinical lead and amendments to the membership list. JDo highlighted the usefulness of having an in-hours GP attend the QAG Meetings. The group were actioned with providing TOR feedback to CH within 10 working days so that MS can make the amendments to the TOR and be ratified at the next meeting. All 9. Data and Access to OOHs Data AB provided the group with a breakdown of data activity for both the OOHs and the 111 Service. AB explained that at practices request the data can be broken down to practice level. SB explained that the data presented has been circulated out to all Practices and has been profiled to each practice for the period of September 2014 August The group looked at Welbeck Road practice purely as an example of the data collected by DHU. SB informed the group that DHU analysts can look at the data and pick out themes and trends from the data collected, this includes calls by age band, calls by day/month, frequent users and Right Care profile. Both JS and MS stated that the level of data is really valuable, how the data is presented is clear and moving forward will be used in conjunction with the Arden & GEM CSU GEMIMA system and future practice visits. 6

306 Derbyshire Health United Quality Assurance Group FINAL Minutes Tuesday 27 th October 2015 JS highlighted that the frequency of data Collection should involve and be discussed at the System Resilience Group Commissioning Standards SB presented the group with the most recent version of the NHS Pathways License Compliance Action Plan. SB explained that DHU now have only one amber issue, this remains in amber due to external information outside of DHUs control. JS confirmed that she is happy with the progress made in completing the action plan. 11. Any other business MS informed the group that the CCG are in the process of arranging a meeting with DHU in order to seek clarity on timescales of the whistleblowing review. JS confirmed that this review is crucial in drawing up the comparisons of both the CCG and DHU within the agreed timescale by NHS England. SB highlighted that the Independent investigators leading the investigation have advised that DHU should do everything possible to try and achieve the 45 day timescale for reporting however the internal investigation and full comprehensive review cannot be compromised and this make take longer than 45 days. JS stated that the CCG have not agreed a 60 day timescale for the report, DHU would therefore need to request a formal extension through to the CCG. Both JS and MS explained if the report is not delivered by December 2 nd 2015 this will leave DHU open to further scrutiny by NHS England and may further damage the services reputation. SB agreed with JS and MS that the planned investigation meetings need to continue as they are and drive towards the 45 day completion date. 12. Date, time & venue of the next meeting Tuesday 26 th January 2016, 2pm, Ashgate Manor, Chesterfield Please forward agenda items and apologies to christy.herbert@northderbyshireccg.nhs Tel:

307 Patient Experience Committee Patient Experience and Safety Committee Tuesday 20 th October :30-11:30 am Committee Room, Scarsdale MINUTES Present Isabella Stone (IS) Chair Governing Body Lay North Derbyshire CCG Member Jane Birch (JBi) Engagement Officer HealthWatch Derbyshire Amanda Brikmanis (AB) Patient Experience North Derbyshire CCG Manager Vikki Develin (VD) CQC lead Chesterfield Royal Hospital FT Linda Jameson (LJa) Clinical Quality North Derbyshire CCG Administrator Ian Mason (IM) Lay Representative North Derbyshire CCG Jan Roddison (JR) Patient Experience Chesterfield Royal Hospital FT Debbie Rutter (DR) Lay Representative North Derbyshire CCG Louise Swain (LS) Head of Patient Experience North Derbyshire CCG Barry Whittlestone (BW) Lay Representative North Derbyshire CCG Apologies Gary Apsley (GA) Governing Body Lay North Derbyshire CCG Member Laura Joy(LJ) Deputy Lead Nurse/ Head North Derbyshire CCG of Clinical Quality( Chair) James Barker (JB) Patient Safety Lead North Derbyshire CCG Simon Goldsmith Deputy Head of Integrated Derbyshire Health United Governance Lana-Lee Jackson (LLJ) Patient Experience Lead Derbyshire Community Health Services Helen Foster (HF) Practice Manager Oakhill Medical Practice Joanne Lacey (JL) Head of Quality Chesterfield Royal Hospital FT Governance Jo Rhodes (JRh) Commissioning Officer North Derbyshire CCG Kieren Done (KD) Complaints and Customer Service Team Manager Stepping Hill Hospital Item 1. Welcome All were welcomed to the meeting. Everyone introduced themselves and apologies were noted. Debbie Rutter was welcomed as the lay representative for the Chesterfield area Action 2. Minutes of the last meeting held on the 7 th July 2015 and 1

308 Patient Experience Committee matters arising. The minutes of the last meeting were agreed as an accurate record. Matters Arising IM said that the Terms of Reference are not fulfilling the nature of this committee and need to be redrafted. It was noted that this is part of the discussion in Item 3 on the agenda. DATIX update LS said that the system is still under testing in relation to live data and so cannot be displayed to the group until the January meeting. It was confirmed that our system will not be able to link directly to provider Datix systems but it will give greater consistency and there may in the future be a potential to link systems. Datix will provide a better way of recording intelligence on both positive and negative patient experience. It was noted that Simon Goldsmith had been unable to attend or to field a representative for this meeting. It was agreed that this should be followed up in order to establish who will attend from DHU in the future. LJ attended the meeting in July of the High Peak Maternity Services Liaison Committee but was not at this meeting to report. Healthwatch has done a large piece of work with children and a report has been compiled. A summary was then circulated. AB explained that though nationally there is a Children s Takeover Day in November, NDCCG is not inviting students to the Lay Reference Group this year. AB is however building links with Chesterfield College. JBi said that Healthwatch had had access to the extensive survey done by one of the schools who presented last year and is launching its own questionnaire this year. AB said that she had been made aware of this by Tanya Nolan and wished to submit a question. JBi will speak to Tanya about this. The item Sharing Strategies was raised by Laura Joy and was not added to this agenda as LJ could not attend. JBi 3. Focus and proposed change of name IS met with LS and LJ after the last PESC meeting for a discussion about the group. It was felt that as safety issues are raised in other meetings the focus of this group should be focussed on patient experience particularly the soft intelligence gathered from patients themselves. IM commented that patient safety is implicit in the patient experience and was happy for the group to go forward as the Patient Experience Committee. The notes from the meeting are taken to the Governing Body but there is no feedback and BW felt it should be a two-way communication. It was felt that if the meeting held more focused discussion it might result in that communication on those specific matters. JBi attends the Tameside and Glossop group and they 2

309 Patient Experience Committee have GPs and the communication team in attendance and look at new services and proposals. It was felt that this group is very like the NDCCG Lay Reference Group. LS said that with the 21c work being around integrated working there would be more co-operative working. It was agreed that the group be renamed the Patient Experience Committee and that the reports from providers should be a summary sheet and the highlights should be a series of bullet points. The provider reports at the meeting were a full report from Chesterfield hospital, four bullet points from Stockport about North Derbyshire patients experience and six bullet points from DCHS. BW said that there should be reports from EMAS and Primary Care. All agreed that three areas of patient experience be focused on at the January meeting. IS and LS will revise the Terms of Reference and liaise with providers before the next meeting. LJa IS/ LS 4. Report from CQC on Chesterfield Royal Hospitals Vikki Develin gave a verbal report on the themes from the recent CQC visit and report. Positive aspects were noted in all nine services. All were good for caring with staff being kind and treating patients with respect. Patients were complimentary about the care they received Nutrition and swallowing assessments were conducted There was a clear vision of a Dementia friendly environment Children attending the Den are able to watch films that promote calm patients receive care throughout the pathway Privacy is maintained Health Care Assistants attend those patients with dementia who have no family support the Alzheimer document is used across the trust VD also identified some areas for improvement that are in the Improvement plan need for monitoring of patients in High Dependency Unit and on the ward Improvement in patient flow Lack of capacity to be assessed in line with the Mental Capacity Act More checking of patients at night - this was raised by staff who said that there was insufficient staffing at night. Children s nurses available 24/7 Staff to be trained in End of Life Care Improvement in the storage of records Improvement in care of property following a patient s death Providing dignity and respect for patients having a termination of a pregnancy The items on the improvement plan are to be addressed by the end of the year. BW noted that CQC also go into GP practices and EMAS and 3

310 Patient Experience Committee asked if reports are available from these. It was noted that it is possible go onto the Practice or any provider website to see the CQC report. Where action is needed, the NDCCG pick up any themes from the CQC reports and monitor the action. IM outlined two recent visits to Chesterfield Hospital wards and said there was a stark contrast between the wards. He said on one ward the staff were compassionate and gave a high level of clinical care but on the other ward staff were indifferent. IM also noted that the patient was informed on several occasions of a date for discharge but then then this was changed. IM asked about the electronic records on trolleys on the ward and JR said these were only for medications not for keeping notes up to date. IM said that on visiting the hospital with an elderly relative they had been told that as the pharmacy was closed at the weekend and they did not have the appropriate dressing. It was noted that with the move to 7 day working this was likely to change. 5. Provider Patient Experience Reports Chesterfield Hospital Patient Experience Report. JR said that on the whole the patient experience is positive. The key areas for concern have been food, noise at night and discharge. These are being addressed. There have been complaints about waiting times but as the average wait is around 15 minutes it was felt that this was high patient expectation rather than concern at the level of service. The headline issues were reviewed. Derbyshire Community Health Services LS reported the following from LLJ Patient experience activity in August 2015 summary Patients and service users have continued to describe positive experiences of using DCHS services people gave feedback (patient experience data) 1782 FFT returns for August which remains under target of 2000 or more each month (however this target was reached in September 2015 with 2073 cards) Continue to maintain 98% FFT recommendation. This is positive assurance in relation to people s experiences in that they would be extremely likely or likely to recommend DCHS service to others 9 complaints have been received for investigation (in accordance with NHS regulations) 57% of complaints were closed under 40 working days and DCHS continue to focus our efforts on improving the timeliness of responses to complainants. The September monthly report and our Q2 report are currently going through the governance approval process and are due to be discussed at the Patient Experience and Engagement Group on 27 October The Q2 summary will be available for the next PESC meeting. Derbyshire Health United No report provided 4

311 Patient Experience Committee Stockport report about North Derbyshire patients Four complaints received in Q2 about North Derbyshire patients The three that have closed were upheld partially or fully The complaints were about o Do Not Resuscitate (DNR) was placed on patient without discussion with family o Patient discharged from ED without the treatment the patient expected o Cancelled appointment o Delay in diagnosis No informal complaints were received. The group noted that due to staffing levels a clinic at Chesterfield had been cancelled. There was concern about cancelling and rescheduling clinics and it was asked whether staffing levels could be compared with Stockport Arden and Gem NDCCG complaints and Patient Concerns Report LS explained that in addition to the complaints received by providers this report contains 8 complaints from NDCCG residents received by Arden& GEM CSU on behalf of North Derbyshire CCG. BW commented that staff need to be trained to deal with complaints so that there can be immediate action. 6. Patient Transport EMAS - Item Deferred speaker not able to attend. It was noted that there should be a representative from EMAS and from Patient Transport on this group. LS said that Commissioners for both forms of transport are coming to the Lay Reference Group on the 23 rd October 2015 and she agreed to update on the procurement process for patient Transport as a post meeting note. Post meeting note: The contract will be awarded to EMAS pending a 10 day standstill period as long as no challenges are received within this period. Therefore we will know for definite on the 11 th November Recommendations and themes for the next meeting It was agreed that the topic for the next PESC meeting should be around cancelled appointments. All providers who are unable to attend should be asked to field a representative. LS and AB felt it would be useful to meet with providers to describe this approach 8. AOB No other business was discussed Date of Next meeting The next meeting will be held on from Friday 12 th February am am in the Committee Room at Scarsdale Other dates agreed for 2016 Tuesday 12 th April venue to be advised Tuesday 12 th July in the Committee Room at Scarsdale Tuesday 18 th October in the Committee Room at Scarsdale LJa agenda LS Complete LJa agenda LS/AB 5

312 Patient Experience Committee Signed by:. Dated: (Chair) 6

313 ND CCG Governing Body Assurance Committee 22 February 2016 Paper v NORTH DERBYSHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY ASURANCE COMMITTEE 22 February 2016 Report Title: Prescribing Sub Group Notes January Item No: 25 Purpose: Objective: 1. Background and context To note minutes of the Prescribing Sub Group To note work undertaken by the Prescribing Sub Group to improve the quality and cost effectiveness of prescribing in North Derbyshire CCG. Full minutes enclosed for information. The prescribing sub group meets monthly to discuss any issues related to prescribing or medicines optimisation, it is a multiprofessional committee with GPs, medicines management staff, commissioners, finance, secondary care and Local Pharmaceutical Committee representation it also has links with social care when relevant items are discussed. 2. Key matters for consideration AF template and resources - the template is now finished and ready to be put onto sharepoint, for practices to upload. Medicines Management Practice survey a medicines management survey has been developed to get feedback from prescribers on the medicines management service that the team provide, results from the survey will be taken to the March Prescribing Sub Group and used to inform and develop the service. Draft Medicines Optimisation Strategy, work plan and NICE medicines optimisation baseline the CCG medicines optimisation strategy and work plan is currently in development. Feedback from JAPC - Haloperidol position statement has been published and is on the website, there are currently supply issues with diamorphine ampoules. Midodrine has been reclassified from red to brown after specialist initiation and dose titration. Ulipristal for uterine fibroids (Esmya) has had a licence extension for intermittent use but it will remain red until a The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 1

314 ND CCG Governing Body Assurance Committee 22 February 2016 Paper v suitable pathway/guideline is developed. Rivastigmine for behavioural problems and psychosis in patients with PDCC does not need shared care for this indication but shared care remains in place for other indications (i.e dementia). Draft NDCCG anticoagulant (warfarin) specification - NOACs have been completely removed from the specification and they are now just part of the AF guideline with a standalone sheet making it clear what monitoring is required. Justin Cooke will be delivering training at the joint quest in February and will reiterate the NOAC monitoring required and MMT will also highlight it at the prescribing leads meetings. Continence project evaluation - Helen Greaves has been undertaking a project working 1 day per week for 6 months with MMT reviewing patients on continence products looking at ongoing need, ordering levels and cost effective alternatives. She has completed the audit in two practices; Welbeck Road had annualised savings of 4,383 and Avenue House had 5876 but there are 18 patients whose savings have yet to be calculated. This equates to approximately 7% of their continence spend so if this was to be replicated across all practices it would make a saving of 73k across north Derbyshire. There have been significant quality improvements such as removing indwelling catheters, improving patient comfort and it is expected that the work would lead to reduced rates of infection. MMT will liaise with Helen Greaves to see which simple switches MMT could undertake to release Helen s time to look at the more complex cases that require clinical input. The group felt that this was a worthwhile piece of work, and await the full outcomes from the initial pilot. Medicines waste campaign and work All the posters and resources have been delivered to practices by MMT and the five banners will be rotated around practices. Medicines management team will be meeting with the LPC to discuss the next part of the campaign which will be aimed at community pharmacies and they will also contact the head offices of the large chains to ensure they are on board with the campaign. The focus of the campaign will be to encourage patients to talk to their community pharmacist about any medication issues and the pharmacist would then offer whichever services is the most appropriate for that patient such as a medicines use review (MUR) or new medicines service (NMS). Prescribing concerns and inappropriate requests - There has been a reduction in the number or inappropriate requests from 54 in to 28 in 2015 to There has been very positive feedback about the CRH portal from the practices that have used the portal. Grasp AF summary information - Of the AF patients identified through GRASP as not being on an anticoagulant, that have now received a review from a clinician only 25% are now anticoagulated leaving 75% still without anticoagulation for various reasons such as patient declined, near end of life. Medicines Optimisation dashboard and Indicators from the PPD - North Derbyshire are outliers in terms of number of three day courses of antibiotics, high on antibacterial items per STAR PU but better on broad spectrum, high on antidepressant and low on first line choices, high on minocycline, good on insulin analogues. Work is already in place regarding The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 2

315 ND CCG Governing Body Assurance Committee 22 February 2016 Paper v antibiotics but MMT will now look at the minocycline prescribing. 3. Financial Impact Finance report - finance have changed the way the forecast has been calculated this month. The category M changes are not realising the expected savings so this has been taken into account in this month s forecast making the financial position worse. NOAC prescribing has now plateaued in HCCG but is still growing in NDCCG. The actual figures for October show NDCCG with a 5% forecast overspend of 2,009,500 and HCCG with a 12.3% overspend of 1,846,000. October is always a high spend month due to flu jabs and NDCCG is expected to come back to a 4.7% overspend. There are a number of rebates coming to an end so based on current usage finance will make some predictions as to the financial impact of these. There has been a reduction in the list price of two of the NOACs (dabigatran and rivaroxaban) and Fortisip, and Fortisip Compact, but the reductions in price are not as great as the rebate so there will be a financial hit for both CCGs. There are a number of price increases and price concessions in place at the moment, the drugs affected are either not particularly common or there is no alternative. Prescribing impact for primary care medicines Unfortunately there will be no savings realised from patent expiries for this year and pregabalin is not expected to reduce its price until 2017 due to the ongoing patent expiry legal issues. This will put considerable pressure on the prescribing budget for If licensed e-cigarettes become available on prescription at a cost of 600 per year this could have a significant cost implication of up to 2.2m per 100,000 population. One product is now licensed, but we are awaiting NICE review of the product. NOACs spend are continuing to rise, increased use for AF, DVT and potentially ACS will further drive increased cost. Plus actual cost of rivaroxaban and dabigatran increased for due to loss of rebate despite list price reduction. Sacubitril valsartan has evidence to support extending life in heart failure patients. Awaiting NICE guidance. Estimated 40,000 per 100,000 population. i.e. 120,000 for NDCCG and 40,000 for HCCG. Diabetes drugs. This is an area of major financial risk depending on the rate of uptake of newer therapies and the anticipated rise in the number of cases. Review of NICE guidance on the management of type 2 diabetes in adults published in December A resource impact is anticipated to come from a shift from sulphonylureas to the more expensive DPP-4 inhibitors. Treatment with sulphonylureas is estimated to have an average cost of 84 per patients per year vs 431 for DPP-4 inhibitors. The people affected by the new recommendations each year are likely to be those newly diagnosed with type 2 diabetes and those having their treatment intensified. Therefore implementation is likely to occur over several years. The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 3

316 ND CCG Governing Body Assurance Committee 22 February 2016 Paper v Drugs with potentially high impact for the CCGs primary care budget 16-17: Drug In NICE timetable? Potential costs Expected Impact Potential costs NDCCG Potential costs HCCG Eluxadoline oral (viberzi) - Irritable bowel syndrome, diarrhoeapredominant NICE currently scoping clinical/cost effectiveness of eluxadoline for IBS. Because this drug is not scheduled for NICE appraisal, these cost may not be fully realised 2016/17 351k - 703k 117k - 234k Vorapaxar - New antiplatelet NICE have currently suspended appraisal with no anticipated date for publication. More expensive than current options, but these cost may not be fully realised 487k 162k NDCCG high impact drug impact for is between 838k 1,190k; HCCG is 279k 396k respectively. Drugs with potentially medium impact for the CCGs primary care budget 16-17: Drug In NICE timetable? Potential costs Expected Impact Potential costs NDCCG Potential costs HCCG Naltrexone/ Bupropion - Obesity drug Sacubitril/ valsartan oral (Entresto) - Chronic heart failure NYHA class II-IV and NICE currently looking at clinical/cost effectiveness of naltrexone/bupropion. No date for publication confirmed As a further treatment option it will be additional to current costs. Currently under NICE STA review, due May 2016 EAMS - Sacubitril/valsartan has been shown to reduce mortality and hospital admissions and the MHRA considered that it has the potential to offer significant benefits for patients with heart failure 195k 65k 120k 40k The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 4

317 ND CCG Governing Body Assurance Committee 22 February 2016 Paper v LVE Safinamide - Parkinson disease Insulin inhalation (afrezza) - Diabetes type 1 and 2 Anamorelin oral - Anorexia/ cachexia associated with NSCLC. Lesinurad oral - Gout 2 nd line over current treatments. Not currently in NICE timetable Low impact. Not currently in NICE timetable Low impact as uncertain of UK availability Not currently in NICE timetable for review Cost may not be fully realised Currently under NICE STA review, anticipated November 2016 As a further treatment option this will be additional to current costs. 38k 12k 37k 12k 75k 25K 23k 8k NDCCG medium impact drug impact for is 488k and HCCG is 162k. Drugs with potentially low impact for the CCGs primary care budget for 16-17: Drug In NICE timetable? Potential costs Expected Impact Potential costs NDCCG Potential costs HCCG Obeticholic acid oral - Primary biliary cirrhosis- 2 nd line. Currently under NICE STA review, due November As a further treatment option this will be additional to current cost, but may reduce the need for liver transplant. 9k 3k NDCCG low impact drug impact for is 9k and HCCG is 3k. Therefore the forecast impact for for NDCCG from new medicines is 1,335k to 1,687k and for HCCG is 444k to 561k. There is additional pressure from the NOACs, loss of rebates and new Type 2 diabetes guideline, increasingly elderly population, care shifting to primary care, volume growth. The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 5

318 ND CCG Governing Body Assurance Committee 22 February 2016 Paper v Secondary care cost impact for will be brought to February Prescribing Sub Group, nationally that has been growing at 15% per year, which is significantly higher than the primary care growth. NDCCG recorded savings April 15 to 21 December = 648, (however 32,140 is dietician reviews) HCCG recorded savings April 15 to 21 December = 287, (however 29,274 is dietician reviews) MMT have already achieved the QIPP target in year with a quarter left to go so well done and thank you to all the technicians and pharmacists for their hard work delivering this with practices. 4. Analysis of Risk There is significant risk on the prescribing budget for 16-17, the new medicines alone are predicted to cost the CCG new costs of between 1.3m and 1.7m, plus continued growth in volume, NOACs, diabetes medicines and shifting of care to primary care will put very significant pressure on the prescribing budget. Nationally prescribing growth is forecast to be approximately 5% which would mean an increase spend of 2.26m in vs Equality Impact Please describe how this report and/or the services described within it aid the CCG in achieving the objectives of the Equality Delivery system, namely: Better health outcomes for all: Improved patient access and experience Empowered, engaged and well-supported staff: Inclusive leadership at all levels: 6. Recommendations To note the minutes of the January Prescribing Sub Group Author: Kate Needham, Head of Medicines Management Sponsor: Jayne Stringfellow, Chief Nurse and Quality Officer Date: February 2016 The NDCCG values Patient-Focus, Integrity, Courage and Responsiveness inform our decision making and behaviours 6

319 North Derbyshire and Hardwick CCGs Group Prescribing Sub-Group Meeting Date 6th January 2016 Present: Dr Carolyn Emslie Richard Coates Dr Diane Fitzsimons Helen Gregory Apologies: In attendance Kate Needham Maxine North Dr Tim Parkin Martin Shepherd Guillermo Sierra Jon Vinson Scott Webster Bob Whitehouse Dr Lorraine Wooster Sharon Dinham Judith Town Dr Elizabeth Riches North Derbyshire Clinical Commissioning Group GP Sub-Group Member (Chair) Assistant Management Accountant GP sub-group Member NDCCG (North Dales Locality) Lead Medicines Management Technician (minute taker) Head of Medicines Management Lead Medicines Management Pharmacist GP Sub-Group Member Hardwick CCG Chief Pharmacist CRHFT LPC representative Lead Medicines Management Pharmacist Project Manager Hardwick CCG Medicines Management Pharmacist (HP and Dales locality) GP Sub-Group Member NDCCG (Dronfield Locality) Practice Nurse, Non-medical Prescriber, NDCCG CRG Head of Finance, Commissioning NDCCG GP Sub-Group Member NDCCG (Chesterfield Locality) Agenda Item Presented by Welcome 1. Declaratio ns of conflict of Interest Matters arising 2. Minutes of Last Meeting - Accuracy AF template and resources Medicines Managemen t Practice survey Procuremen t options spend None were declared. Decision Made / Action Required The minutes of the December 2nd 2015 subgroup were accepted as a true record. Jon reported that the template is now finished and ready to be put onto sharepoint, for practices to upload. There are no issues with Emis Web template, but it can be a little difficult to upload onto TPP if the user has not uploaded templates before. Liz Middleton is going to spend some time with Denise Shaw showing her how to do it so that both Liz and Denise will then be able to help any practices that require assistance. Once it is on sharepoint Jon will all prescribing leads and practice managers and will provide Liz and Denise s contact details in the . Jon has now put the survey onto survey monkey. Once finalised it will be sent out to all practice managers and prescribing leads. There is no limit to the number of responses so practice managers will be requested to forward it to all relevant members of staff within their practice. Discussed under item on agenda. By Whom Nefopam MMT have not received an update from HCCG so Maxine will MN Feb PSG JV JV By When End Jan Feb PSG Rele v To 1

320 Barlborough Treatment Centre Draft Medicines Optimisatio n Strategy, work plan and NICE medicines optimisation baseline Collaborativ e discharge/s afety audit 3. Finance reports 4. Community Pharmacy Update -LPC feedback -LPS feedback -LPN 5. Feedback from JAPC contact Mandy Simpson directly. Once Kate has finished this she will circulate to the group for comments. As part of the 21 century work streams MMT have been asked to run the electronic frailty index in all SystmOne practices and they are about to start the PINCER safety work in all practices so unfortunately there is not currently capacity in the team to undertake this audit. Richard explained that there has been a change in the way the forecast has been calculated this month. The category M changes are not realising the expected savings so this has been taken into account in this month s forecast making the financial position worse. NOAC prescribing has now plateaued in HCCG but is still growing in NDCCG. The actual figures for October show NDCCG with a 5% forecast overspend of 2,009,500 and HCCG with a 12.3% overspend of 1,846,000. October is always a high spend month due to flu jabs and NDCCG is expected to come back to a 4.7% overspend. There are a number of rebates coming to an end so based on current usage Richard is making some predictions as to the financial impact of these. There has been a reduction in the list price of two of the NOACs (dabigatran and rivaroxaban) and Fortisip, and Fortisip Compact, but the reductions in price are not as great as the rebate so there will be a financial hit for both CCGs. There are a number of price increases and price concessions in place at the moment, the drugs affected are either not particularly common or there is no alternative. Jon was asked to ensure that there is a message on OptimiseRx regarding the most cost effective iron preparation and Max will include information on the price increase on gentamicin HC, Locortenvioform and Fucithalmic in the next MMT newsletter. Jon to consider whether OptimiseRx messages should be added for these too. Information was noted. Kate and Debbie Bennett are attending the next LPC meeting to discuss the draft pharmacy waste campaign materials. The group thanked Diane for her valuable contribution to JAPC but unfortunately due to other commitments she is no longer able to continue with this. None of the other GPs present could regularly attend but, along with Diane, are happy to deputise when Carolyn in unable to attend. It was suggested that the place be opened up to other prescribing leads as this could be a KN JV MN Feb PSG Asap March newsle tter Pre 2

321 6. Draft NDCCG anticoagula nt (warfarin) specificatio n 7. Gonorrhoea and antimicrobia l resistance letter 8. PrescQIPP resources to agree any areas for local work good learning opportunity for them. Haloperidol position statement has been published and is on the website There are currently supply issues with diamorphine ampoules. Martin reported that it is unclear what the issue is and he has been told that there are sufficient stock levels for current demand. CRH are reviewing this on a weekly basis but currently have stock and are able to order further supplies. DHU have used up their stock and were unable to obtain further supplies from their usual supplier but have found an alternative supplier who can get the 5mg ampoules. Martin will keep the MMT updated with further information Midodrine has been reclassified from red to brown after specialist initiation and dose titration. Promixin is going to remain red due to the potential confusion of different formulations. Ulipristal for uterine fibroids (Esmya) has had a licence extension for intermittent use but it will remain red until a suitable pathway/guideline is developed. Chlamydia guideline is going to go back to JAPC for further discussion as to whether a guideline is actually needed. PGD from NHSE for tetanus/diptheria has been adopted for use. Rivastigmine for behavioural problems and psychosis in patients with PDCC does not need shared care for this indication but shared care remains in place for other indications. There have been some queries regarding auditing patients every six months so Judy is changing this to twelve months. Judy has also been asked to put together the criteria for what constitutes restarting warfarin as opposed to managing warfarin. Once these amendments have been made it will go to the Primary Care Development Group on the 19 th of January for final agreement. NOACs have been completely removed from the specification and they are now just part of the AF guideline with a standalone sheet making it clear what monitoring is required. Justin Cooke will be delivering training at the joint quest in February and will reiterate the NOAC monitoring required and MMT will also highlight it at the prescribing leads meetings. The current accredited training for warfarin management is to undertake the BMJ modules which the practice has to pay for. However, Judy is in the process of applying for funding to get a 1 to 2 day training course for new staff and a half day refresher course with the aim of this becoming accredited, which could then replace the need to do the BMJ modules. A letter from DH has gone to all GPs and online pharmacy services regarding the concern of antimicrobial resistance to gonorrhoea. Diane reported that one of her colleagues had already raised this issue at a practice meeting and was very concerned to see how easy it was to self-diagnose and get oral antibiotics via on-line pharmacies. The guidelines recommend both oral and IV antibiotics and there was no follow up provided or education regarding contact tracing with the online site. Kate explained that monitoring controlled drugs is a huge work load implication for MMT and it was hoped that that the PrescQIPP reports would replace a lot of the work MMT do and enable the team to reduce their workload. Unfortunately the reports do not provide enough information for MMT to give NHS KN MS Feb scri bing Lea ds 3

322 9. Prescribing impact for primary care medicines North Midlands adequate assurance so the current MMT system will remain in place. The group reviewed the proposed PrescQIPP work plan to prioritise those areas that would find most useful, Kate to return to PrescQIPP. KN Jan 8th Sadaf has put together a paper for prescribing growth predictions for 2016/17. Unfortunately there will be no savings realised for this year and pregabalin is not expected to reduce its price until 2017 due to the ongoing patent expiry legal issues. If licensed e-cigarettes become available on prescription at a cost of 600 per year this could have a significant cost implication of up to 2.2m per 100,000 population. One product is now licensed, but we are awaiting NICE review of the product. NOACs spend are continuing to rise, increased use for AF, DVT and potentially ACS will further drive increased cost. Plus actual cost of rivaroxaban and dabigatran increased for due to loss of rebate despite list price reduction. Sacubitril valsartan has evidence to support extending life in heart failure patients. Awaiting NICE guidance. Estimated 40,000 per 100,000 population. i.e. 120,000 for NDCCG and 40,000 for HCCG. Diabetes drugs. This is an area of major financial risk depending on the rate of uptake of newer therapies and the anticipated rise in the number of cases. Review of NICE guidance on the management of type 2 diabetes in adults published in December A resource impact is anticipated to come from a shift from sulphonylureas to the more expensive DPP-4 inhibitors. Treatment with sulphonylureas is estimated to have an average cost of 84 per patients per year vs 431 for DPP-4 inhibitors. The people affected by the new recommendations each year are likely to be those newly diagnosed with type 2 diabetes and those having their treatment intensified. Therefore implementation is likely to occur over several years. Drugs with potentially high impact for the CCGs primary care budget 16-17: Drug Eluxadoline oral (viberzi) - Irritable bowel syndrome, diarrhoeapredominant Vorapaxar - New antiplatelet In NICE timetable? Expected Impact NICE currently scoping clinical/cost effectiveness of eluxadoline for IBS. Because this drug is not scheduled for NICE appraisal, these cost may not be fully realised 2016/17 NICE have currently suspended appraisal with no anticipated date for publication. More expensive than current options, but these cost may not Potential costs Potential costs NDCCG 351k - 703k Potential costs HCCG 117k - 234k 487k 162k be fully realised NDCCG high impact drug impact for is between 838k 1,190k; HCCG is 279k 396k respectively. Drugs with potentially medium impact for the CCGs primary care budget 16-17: 4

323 Drug Naltrexone/ Bupropion - Obesity drug Sacubitril/ valsartan oral (Entresto) - Chronic heart failure NYHA class II-IV and LVE Safinamide - Parkinson disease Insulin inhalation (afrezza) - Diabetes type 1 and 2 Anamorelin oral - Anorexia/ cachexia associated with NSCLC. Lesinurad oral - Gout 2 nd line In NICE timetable? Expected Impact NICE currently looking at clinical/cost effectiveness of naltrexone/bupropion. No date for publication confirmed As a further treatment option it will be additional to current costs. Currently under NICE STA review, due May 2016 EAMS - Sacubitril/valsartan has been shown to reduce mortality and hospital admissions and the MHRA considered that it has the potential to offer significant benefits for patients with heart failure over current treatments. Not currently in NICE timetable Low impact. Not currently in NICE timetable Low impact as uncertain of UK availability Not currently in NICE timetable for review Cost may not be fully realised Currently under NICE STA review, anticipated November 2016 As a further treatment option this will be additional to current costs. Potential costs Potential costs NDCCG Potential costs HCCG 195k 65k 120k 40k 38k 12k 37k 12k 75k 25K 23k 8k NDCCG medium impact drug impact for is 488k and HCCG is 162k. Drugs with potentially low impact for the CCGs primary care budget for 16-17: Drug In NICE timetable? Potential costs Expected Impact Potential costs NDCCG Potential costs HCCG Obeticholic acid oral - Primary biliary cirrhosis- 2 nd line. Currently under NICE STA review, due November As a further treatment option this will be additional to current cost, but may reduce the need for liver transplant. 9k 3k NDCCG low impact drug impact for is 9k and HCCG is 3k. Therefore the forecast impact for for NDCCG from new medicines is 1,335k to 1,687k and for HCCG is 444k to 561k. There is additional pressure from the NOACs, loss of 5

324 rebates and new Type 2 diabetes guideline Prescribing impact for secondary care medicines Continence project evaluation Medicines safety and use resources Controlled drug LIN update Medicines waste campaign and work This is not yet finished and will come to February s meeting. Helen Greaves has been undertaking a project working 1 day per week for 6 months with MMT reviewing patients on continence products looking at ongoing need, ordering levels and cost effective alternatives. She has completed the audit in two practices; Welbeck Road had annualised savings of 4,383 and Avenue House had 5876 but there are 18 patients whose savings have yet to be calculated. This equates to approximately 7% of their continence spend so if this was to be replicated across all practices it would make a saving of 73k across north Derbyshire. Kate explained that whilst the savings were not as big as expected there were lots of quality improvements such as removing indwelling catheters, improving patient comfort and it is expected that the work would lead to reduced rates of infection. MMT will liaise with Helen Greaves to see which simple switches MMT could undertake to release Helen s time to look at the more complex cases that require clinical input. The group felt that this was a worthwhile piece of work, and await the full outcomes from the initial pilot. MMT will have a look at the de-prescribing resources to see if anything can be adopted. For information Prescribing concerns and inappropriat All the posters and resources have been delivered to practices by MMT and the five banners will be rotated around practices. Kate is meeting with the LPC to discuss the next part of the campaign which will be aimed at community pharmacies and she will also contact the head offices of the large chains to ensure they are on board with the campaign. The posters will be ready to go out early February and the focus will be to encourage patients to talk to their community pharmacist about any medication issues and the pharmacist would then offer whichever services is the most appropriate for that patient such as a medicines use review (MUR) or new medicines service (NMS). The Hardwick QIPP 8a Pharmacist and band 6 technician posts are currently out to advert with a closing date of January 15 th, these posts will have focused pieces of work in high priority practices and areas. Scott reported that the lean review at Creswell is currently underway and he will be undertaking the lean review at Staffa at the end of January, this one will be more complex due to the practice having five sites but he is working closely with the practice manager to organise this. There has been a reduction in the number or inappropriate requests from 54 in to 28 in 2015 to There has been very positive feedback about the CRH portal from the practices that have used the portal. 6

325 e requests Grasp AF summary information Medicines Optimisatio n dashboard updated information Indicators from the PPD Drug safety alert SABs alert NPSA alert MHRA bulletin Sponsorshi p request MMT activities Of the AF patients identified through GRASP as not being on an anticoagulant, that have now received a review from a clinician only 25% are now anticoagulated leaving 75% still without anticoagulation for various reasons such as patient declined, near end of life. Maxine will pull together the information to estimate how many strokes have been prevented as a result of this project and the potential cost-saving. For information - includes lots of bench marking data such as numbers of MURs, NMS. These indicators used to be the NICE QIPP indicators. North Derbyshire are outliers in terms of number of three day courses of antibiotics, high on antibacterial items per STAR PU but better on broad spectrum, high on antidepressant and low on first line choices, high on minocycline, good on insulin analogues. Work is already in place regarding antibiotics but MMT were asked to look at the minocycline prescribing. None None MMT Activities NDCCG recorded savings April 15 to 21 December = 648, (however 32,140 is dietician reviews) MO Feb PSG HCCG recorded savings April 15 to 21 December = 287, (however 29,274 is dietician reviews) Feedback from CRHFT Southern Derbyshire PSG Any other business MMT have already achieved the QIPP target in year with a quarter left to go so well done and thank you to all the technicians and pharmacists for their hard work delivering this with practices. Martin reported that that they have agreed to switch to Oramorph liquid for pain relief post day surgery. He will let Kate now when the change to practice will take place and Kate will inform prescribers that patients will be given a 100ml bottle on discharge and this would be sufficient for the majority of patients and very few patients would be expected to request a further supply. Maxine will also add to the next newsletter. For information. None. 7

326 Dates of future meetings: 3 rd Feb 2 nd March 6 th April 4 th May 1 st June 6 th July 3 rd Aug 7 th Sept 5 th Oct 2 nd Nov 7 th Dec KEY MESSAGES FOR CCGs Messages for Healthwatch For information. NDCCG recorded savings April 15 to 21 December = 648, (however 32,140 is dietician reviews) HCCG recorded savings April 15 to 21 December = 287, (however 29,274 is dietician reviews) Some initial work has been done to estimate the forecast impact for for NDCCG from new medicines which have been estimated to be in the range 1,335k to 1,687k and for HCCG is 444k to 561k. There is additional pressure from the NOACs, and sip feed loss of rebates, continued growth in NOAC prescribing and the new Type 2 diabetes guideline. None identified. Date of next meeting: Wednesday 3rd February 2016 Venue: Parish Centre, 91 Sheffield Road, Stonegravels, Chesterfield, S41 7JH Time of Meeting: pm (Please note that lunch will NOT be provided) 8

327 For agenda items contact Slakahan Dhadli Tel: DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE (JAPC) Minutes of the meeting held on Tuesday 12 January 2016 CONFIRMED MINUTES Summary Points Traffic lights Drug Nefopam Toujeo Oxybutynin patches Decision BROWN 3 rd line with exceptionalities BROWN after specialist/consultant initiation BROWN for patients unable to tolerate oral medication RED RED RED RED as per NICE TA369 BLI-800 bowel cleansing preparation Carfilzomib Ceftolozane + tazobactam Ciclosporin eye drops Bortezomib RED as per NICE TA 370 Trastuzumab RED as per NICE TA 371 Apremilast BLACK as per NICE TA 372 Abatacept, Adalimumab, Etanercept RED as per NICE TA 373 and Tocilizumab Erlotinib RED as per NICE TA 374 Gefitinib BLACK per NICE TA 374 Elosulfase alfa RED as per NICE HST2 All Homeopathy Treatments BLACK Clinical Guidelines (Updated) Dapoxetine position statement Derbyshire Nebuliser Guidelines for COPD Patients - Assessment and Initiation Primary Care Management of Overactive Bladder (OAB) Proton Pump Inhibitors - Advisory Guidance on when to initiate a PPI with a NSAID (or antiplatelet) Patient Group Directions Influenza, Fluenz Tetra and Intanza 1

328 For agenda items contact Slakahan Dhadli Tel: Present: Southern Derbyshire CCG Dr A Mott Mr S Dhadli Mrs L Hunter Mr S Hulme Mrs S Qureshi Dr M Watkins North Derbyshire CCG Dr C Emslie Mrs K Needham Mr J Town Hardwick CCG Dr T Parkin Erewash CCG Ms H Murch Derby City Council Dr R Dewis GP (Chair) Specialist Commissioning Pharmacist (Secretary) Assistant Chief Finance Officer Director of Medicines Management NICE Audit Pharmacist GP GP Head of Medicines Management North (also representing Hardwick CCG) Head of Finance GP Lead Pharmacist Consultant in Public Health Medicine Derbyshire County Council Derby Hospitals NHS Foundation Trust Derbyshire Healthcare NHS Foundation Trust Ms B Thompson Secretary - Drugs and Therapeutic Committee Chesterfield Royal Hospital NHS Foundation Trust Mr M Shepherd Chief Pharmacist Derbyshire Community Health Services NHS Trust Mr M Steward Head of Medicines Management In Attendance: Mr A Thorpe Derby City Council (minutes) It was noted that there was no representation from DTHFT because of the Junior Doctor s strike, but it had been agreed that post meeting ratification of the decisions would be made by the members of JAPC from the Trust. 2

329 For agenda items contact Slakahan Dhadli Tel: Item 1. APOLOGIES Ms D Bennett, Dr W Goddard, Dr M Henn and Mr C Newman. Action 2. DECLARATIONS OF CONFLICT OF INTEREST No declarations of interest were made. 3. DECLARATIONS OF ANY OTHER BUSINESS Diamorphine Shortage. Winterbourne Update. Patient Group Directions. 4. MINUTES OF JAPC MEETING HELD ON 8 DECEMBER 2015 The minutes of the meeting held on 8 th December 2015 were agreed as a correct record. 5. MATTERS ARISING a. Bridging Therapy for Low Weight Molecular Heparin (LWMH) Mr Dhadli advised that Dr Goddard had agreed to check whether Dr McKernan wished to comment on the draft LMWH bridging guidance. This had been added to the JAPC action tracker. b. Promixin Mr Shepherd commented that the proposed use of Promixin as a second line option to colomycin in the shared care guideline for the treatment of pseudomonas aeruginosa lung infections in adults with bronchiectasis who were non cystic fibrosis patients should remain unchanged. WG c. d. e. Ulipristal Acetate for Uterine Fibroids Mr Shepherd reported that a pathway for the use of ulipristal acetate in the treatment of uterine fibroids had been developed and sent to a consultant gynaecologist at DTHFT for comment. This pathway would be brought to the February JAPC meeting for discussion. Chlamydia Testing and Screening Management The amended guidelines would now be brought to the February JAPC meeting for further discussion. Guidance for Blood Glucose Lowering Therapy in Adults with Type 2 Diabetes Mr Dhadli reported that the diabetes guidance was being updated in light of NICE NG 28. Before presentation to JAPC both the consultants from DTHFT and CRHFT, and the Guideline Group, would need to agree the content. SD RD/SD SD 6. NEW DRUG ASSESSMENTS/TRAFFIC LIGHT ADDITIONS a. Update from DTB and SMC Reviews Mr Dhadli stated that it had been agreed that JAPC would review the drugs included in the horizon scan in the light of the publication of any peer reviews. Two Drug and Therapeutic Bulletin (DTB) reviews and one review from the Scottish Medicines Consortium (SMC) had been published on catephen for external genital warts, ciclosporin eye drops for dry eyes and naloxegol for opioid induced constipation. 3

330 For agenda items contact Slakahan Dhadli Tel: Item Green tea extract for external anogenital warts (Catephen): Mr Dhadli reported that catephen had been highlighted in the December 2015 horizon scan and assigned a traffic light classification of BLACK while a public health review was undertaken. Catephen is a herbal medicinal product consisting predominantly of catechins (sinecatechins) extracted from the green tea leaf formulated as a topical preparation for the treatment of external genital and perianal warts. Current drug treatment options included imiquimod 5% cream and podophyllotoxin 0.15% cream but these had limited efficacy and high recurrence rates and adverse effects. Evidence came from three randomised double-blind placebo-controlled studies which evaluated the efficacy and safety of topical sinecatechins for the treatment of external anogenital warts. The randomised controlled trials showed the licensed topical formulation of green tea extract resulted in complete clearance of external anogenital warts between 34 to 47% of patients compared to approximately 35% treated with placebo. The DTB had concluded that there was currently insufficient evidence to recommend catephen in preference to existing topical therapies. Mr Dhadli referred to the British Association for Sexual Health and HIV (BASHH) guidance on the treatment of external genital warts which included catephens as a treatment option although there was no reference to it in any algorithm of treatment. Podophyllotoxin was an option for initial treatment and there was a NICE Evidence Summary of New Medicines which referred to catephens as the most costly treatment option together with the lack of published comparisons with other active treatments for genital and perianal warts. Mr Dhadli reminded JAPC that referral to specialist genitourinary services is recommended for all people with anogenital warts. Agreed: The previously assigned classification of BLACK would remain unchanged due to lack of evidence and cost effectiveness compared with standard therapy. Ciclosporin Eye Drops: Mr Dhadli advised that NICE had published TA 369 which recommended ciclosporin eye drops (Ikervis) as an option for the treatment of severe keratitis in adult patients with dry eye disease that has not improved despite treatment with tear substitutes. The SMC review referred to the evidence which came from a pivotal phase III double-masked study (SANSIKA) which looked at the modified Oxford scale and the Ocular Surface Disease Index as a marker for improvement using the corneal fluorescent staining technique. Mr Dhadli highlighted that the primary outcomes had not been achieved in the pivotal study and for one co-primary outcome in the supportive study. Evidence of efficacy was derived from secondary outcomes, post-hoc and subgroup analyses. It was noted that the evidence from these types of analyses could be less robust in nature. Agreed: This supported the classification of RED as per NICE TA 369. Action 4

331 For agenda items contact Slakahan Dhadli Tel: Item b. Naloxegol: Mr Dhadli advised that naloxegol had a dual classification of BROWN for the treatment of opioid induced constipation in palliative care and RED for other specialities such as pain and gastro-intestinal conditions. Naloxegol was a peripherally acting mu-opioid receptor antagonist licensed for the treatment of opioid-induced constipation in adults who had an inadequate response to laxative treatment. The evidence was obtained from two identical doubleblind placebo-controlled studies which evaluated the efficacy of naloxegol. Patients with constipation arising from oral opioid therapy for chronic noncancer pain had received naloxegol 12.5mg, 25mg or placebo once daily for twelve weeks. The primary end point was response rate during the twelve week trial period with a defined response of three or more spontaneous bowel movements (SBM) per week and at least an increase of at least one SBM over the baseline for nine of the twelve weeks and three of the final four weeks. It was noted that the treatment responses were smaller than anticipated, as the trials expected a 60% response rate for the primary endpoint, but only 35 44% was achieved. The SPC had concluded that there was limited clinical experience with the use of naloxegol in opioid-induced constipation in patients with cancer-related pain and therefore caution should be used when prescribing naloxegol to such patients. Naloxegol was contraindicated in patients with underlying cancer who were at heightened risk of gastrointestinal perforation. Mr Dhadli added that the American Food and Drugs Administration had not agreed the use of naloxegol in malignant pain due to lack of evidence in this particular group of patients. Agreed: The previous classifications of BROWN for use in palliative care as per NICE TA 345 and RED for use in the pain and gastroenterology clinics would remain unchanged. Nefopam Mr Dhadli highlighted that the cost of nefopam had increased significantly since the previous classification by JAPC of GREEN 3rd line choice in step two of the non-malignant chronic pain in primary care guidance. Nefopam was licenced for the relief of acute and chronic pain, including post-operative pain, dental pain, musculo-skeletal pain, acute traumatic pain and cancer pain. Due to the price increase it had been decided to look at the evidence and cost effectiveness for the use of nefopam. SIGN guideline 136 concerning the management of chronic pain published in December 2013 had indicated that the evidence identified on the use of nefopam for chronic pain relief was not sufficient to support a recommendation. Two local pain consultants, Dr Faleiro (DTHFT) and Dr Makkison (CRHFT), did not recommend the use of nefopam in primary care. It was noted that DTHFT had classified nefopam as a third line option for patients who were contraindicated or intolerant to NSAIDs or opiates. During discussion Dr Parkin and Dr Watkins highlighted that nefopam was another option for pain relief. However it was considered that nefopam would rarely be used by GPs except in cases of intolerance to other drugs such as morphine. A classification of BROWN would highlight that its general use was not recommended alerting prescribers to the cost and exceptional circumstances. Action 5

332 For agenda items contact Slakahan Dhadli Tel: Item c. Agreed: Nefopam re-classified as a BROWN drug (from GREEN) for patients intolerant to, or contraindicated, to NSAIDs and opiates. Toujeo Mr Dhadli reported that Toujeo was a high-strength insulin glargine 300 units/ml for people with type 1 or type 2 diabetes who had large daily insulin requirements to reduce the number and volume of injections. In October 2015 JAPC had classified Toujeo as BLACK in the light of concerns raised by the MHRA (concerning high strength, fixed combination and biosimilar insulin products and the minimisation of the risk of medication error). A view from the consultant diabetologists about the use of Toujeo had therefore been requested and they had now indicated that they would wish to use Toujeo for the following groups: Patients on insulin degludec. Patients being considered for insulin pump therapy. Patients currently on high dose of insulin (>150units/day) who would otherwise have been started with Humulin R U-500 or degludec. The evidence from Toujeo came from two NICE evidence summaries of new medicines in both Type 1 and 2 diabetes which showed non-inferiority to insulin Lantus, similar safety and patient factors and was cost equivalent. It was noted that the percentage of adults with confirmed or severe nocturnal hypoglycaemia was lower with Toujeo than with Lantus in two of three studies. Mrs Needham commented that it may be necessary to change the position of degludec as this was an option for patients on Humulin R. It may also be necessary to determine whether patients on Humulin R would be suitable to switch to Toujeo. These points would be considered further by the Guideline Group. It was also noted that a similar request for the re-classification of Toujeo from BLACK had been made by Dr Robinson, CRHFT Consultant Diabetologist with agreement on similar positioning. Agreed: Toujeo re-classified as a BROWN drug after specialist initiation for the specific patients who were on insulin degludec or Humulin R; those being considered for insulin pump therapy and those currently on a high dose of insulin. Action SD SD SD 7. CLINICAL GUIDELINES a. Dapoxetine Mr Dhadli stated that JAPC had classified dapoxetine as a BLACK drug for the treatment of premature ejaculation. It was highlighted that the position statement still required updated prices. b. Agreed: JAPC ratified the dapoxetine position statement with a two year extension. Nebuliser Guidance Mr Dhadli reported that no changes had been made by the Guideline Group and the DTHFT Lead Respiratory Nurse had suggested a change to indicate that patients who required replacement consumables should contact the clinician who placed the initial order for further supplies. SD 6

333 For agenda items contact Slakahan Dhadli Tel: Item Action Agreed: JAPC ratified the Derbyshire Nebuliser Guidelines for COPD patients with the agreed amendment and a two year extension. SD c. Management of Overactive Bladder Mr Dhadli highlighted some of the changes which had been made to the Primary Care Management of Overactive Bladder (OAB) Guideline: The Guideline Group had proposed that the assessment sections for men and women be removed to leave conservative management with nonpharmacological treatment and then leading on to the treatment algorithm for OAB. A section had been included concerning consideration before starting OAB and caution in use of anti-muscarinics in the elderly. How anti-muscarinics should be initiated to include starting, maximum dose and incremental doses. Addition of a reference to indicate that there was currently very limited evidence for the use of mirabegron in combination with an antimuscarinic and that more evidence would be required to assess whether combination therapy was appropriate. Inclusion of a reference to the MHRA safety warning issued in October 2015 about the contraindication of mirabegron in patients with severe uncontrolled hypertension and that blood pressure should be measured before starting treatment and monitored regularly during treatment, particularly in patients with hypertension. Oxybutynin patches were referred to in the pharmacological treatment of overactive bladder section and required a traffic light classification. It was agreed that a traffic light classification of BROWN should be assigned for use due to exceptionality for those patients who were unable to take oral medication. Mrs Needham referred to the offer of pads or other containment device in the lifestyle advice section of the flowcharts and suggested that this should be done via the continence service. In addition, the reference in the third line agents section to branded generics should be amended to preferred brand. Agreed: JAPC ratified the Primary Care Management of Overactive Bladder Guideline with the inclusion of the agreed changes and amendments. SD SD SD d. Proton Pump Inhibitor Guidance Mr Dhadli reported that minor changes had been made to the existing guidance for Proton Pump Inhibitors to include references to rebound hypersecretion, tubulo-interstitial nephritis and the very low risk of subacute cutaneous lupus erythematosus highlighted in the MHRA Drug Safety Update of September Agreed: JAPC ratified the Proton Pump Inhibitors Guidance with the inclusion of the agreed amendments. SD 7

334 For agenda items contact Slakahan Dhadli Tel: Item 8. MONTHLY HORIZON SCAN Mr Dhadli advised JAPC of the following new drug launches, new drug formulations and drug discontinuations: Action New drug launches in the UK: Aviptadil + phentolamine (Invicorp) CCG commissioned line. To be left unclassified and await clinician request. BLI-800 (Eziclen) Classified as RED. Carfilzomib (Kyprolis) NHS England commissioned line. NICE TA expected in September Classified as RED. Ceftolozane + tazobactam (Zerbaxa) CCG commissioned line. Classified as RED. New formulation launches in the UK: Fluticasone propionate + salmeterol xinafoate (AirFluSal Forspiro) Combination inhaler containing a corticosteroid and long-acting beta 2 agonist for chronic obstructive pulmonary disease (COPD) in adults. This was cheaper than Seretide 500 accuhaler, but more expensive than current first line treatments, and would be included in the appendix section of the COPD guideline ahead of Seretide. Licence extensions: Aflibercept (Eylea) For visual impairment due to myopic choroidal neovascularisation in adults. No NICE TA was expected and was an alternative to ranibizumab (licensed), bevacizumab (off-license) or vertoporfin photodynamic therapy. This is not currently commissioned and would require a business case for consideration of its use. Secukinumab (Cosentyx) Ankylosing Spondylitis (AS)/Psoriatic arthritis (PsA) NICE TA for AS expected October 2016 and NICE TA for PsA expected in February This is not currently commissioned. 9. MISCELLANEOUS a. Dental Prescribing Letter Mrs Needham advised that a letter signed by Dr Mott on behalf of JAPC would be sent to the Clinical Director at Charles Clifford Dental Hospital in Sheffield to highlight that Derbyshire GPs should not be requested to prescribe fluoride products for patients. b. c. Early Access to Medicines (EAMs) Mr Dhadli reported that an EAMS notification had been received from the MHRA about Osimertinib for the treatment of adult patients with locally advanced or metastatic epidermal growth factor receptor T790M mutationpositive non-small-cell lung cancer who had progressed on or after EGFR TKI therapy. The EAMs notification was noted for information. Gonorrhoea and Antimicrobial Resistance Mr Dhadli reported that the Department of Health had issued guidance on gonorrhoea and antimicrobial resistance and the recommended therapy of injectable ceftriaxone and oral azithromycin. It was highlighted that suboptimal treatment did not happen and that, in the event that services lacked the facilities to provide injectable drugs, patients were referred to a Genitourinary Medicine (GUM) Clinic or sexual health service for management. 8

335 For agenda items contact Slakahan Dhadli Tel: Item d. e. Dr Dewis commented that this advice was also included in the chlamydia guideline and had been circulated via the specialist service. HRT Advice Mr Dhadli tabled 'NICE Bites' on menopause which summarised the prescribing recommendations from the NICE Clinical Guideline NG 23 which covered the diagnosis and management of menopause including women who had premature ovarian insufficiency. Dr Amanda Smith, a lead doctor from the Derbyshire Integrated Sexual Health Service had further shortened this to the key messages that she felt were important to prescribers Further more Dr Smith had commented that some of the HRT products in the JAPC formulary could not be recommended due to their equine content. It had been decided therefore to send the relevant chapter in the BNF formulary for comment by Dr Smith and any possible changes to be then further discussed by the Guideline Group. Dr Watkins queried the use of testosterone in menopause and it was agreed that this should also be considered by the Guideline Group. It was noted that the use of testosterone had been recommended as a treatment option in the NICE Clinical Guideline. Ms Town also agreed to look into access across the county to the HRT/Menopause service and update at the next meeting. Specialised Commissioning A document from NHS England 'Improving Value for Patients from Specialised Care' was tabled for information and Mr Dhadli highlighted some of the main points: The commissioning process would be strengthened. A Strategic Services Review Programme would be published to ensure cost effective treatments from the most capable providers. The clinically driven change agenda would be centred on working with partners to implement the findings of the national taskforces. The single operating model to be applied to all contracts in 2016/17. Contracting for Excluded Drugs and Devices measures introduced in recent years to help ensure that providers and commissioners could jointly deliver best value, including national changes to the tariff excluded high cost devices supply chain, would continue. The Reforming the Payment System process with providers would continue. Adult specialised severe and complex obesity services should no longer be commissioned by NHS England and should be reflected in CCG contracts from April The following services will no longer be commissioned by CCGs and would be reflected in NHS England contracts from April 2016: - Some highly specialist adult male urological procedures. - Primary ciliary dyskinesia management services for adults. - Some highly specialist adult haematology services. A mandatory collaborative process for resolving significant local service issues before any service expansion/development plans or service termination notices would be considered by the Commissioner. Action SD JT 9

336 For agenda items contact Slakahan Dhadli Tel: Item Mr Dhadli also highlighted the section in this document about contracting for excluded drugs and devices and that there would be a central repository of prices for excluded drugs with specific prices for each one to avoid regional variations. In addition notice would be given on some of the confidential agreements which some providers had with Pharma and the online clinical decision support tool (Blueteq) would subsequently be used for all high cost drugs. The paper based approval process would also be terminated and the online clinical decision support tool used instead by all providers of the identified devices and procedures. Mr Dhadli referred to the NHS England Specialised Commissioning Drugs Briefing for December 2015 and highlighted some points: The National Commissioning Pharmacists Network had been launched at the end of Principles determining the commissioning of drugs. Clarification that some of the chemotherapy supportive drugs were not considered chemotherapy supportive and therefore GP should prescribe. Biosimilars to be used if available at a significantly lower price and there is no reason not to. Alirocumab for hypercholesterolemia and evolocumab for hyperlipidaemia among the drugs to be added to the national excluded drugs list. Reference to Medicines Optimisation Clinical Reference Group and strengthening the links with CCGs. Providers should not initiate any specialised services before discussions were held with the CCGs. Mr Dhadli summarised the CCG key learnings and direction of travel for NHS England. Action 10. JAPC BULLETIN The following change in the bulletin was noted: NICE Diabetes Guidance 'NICE has finally published the long awaited type 2 diabetes in adult guideline. The guideline recommends some change in how we could manage diabetes locally. Until then existing local guidelines should be followed for existing and newly diagnosed patients.' The December JAPC bulletin was ratified with the agreed amendment. 11. MHRA DRUG SAFETY UPDATE The MHRA Drug Safety Update for December 2015 was noted. Mr Dhadli highlighted the following: Thalidomide: reduced starting dose in patients older than age 75 years. Mycophenolate mofetil, mycophenolic acid: new pregnancy-prevention advice for women and men. Bisphosphonates: very rare reports of osteonecrosis of the external auditory canal. This would be highlighted in the osteoporosis guidelines. Antiretroviral medicines: updated advice on body-fat changes and lactic acidosis. SD 10

337 For agenda items contact Slakahan Dhadli Tel: Item 12. NICE SUMMARY Mrs Qureshi informed JAPC of the comments for the CCGs which had been made for the following NICE guidance issued in December 2015: TA 369 Ciclosporin for treating dry eye disease that has not improved despite treatment with artificial tears - Ciclosporin was recommended as an option, within its marketing authorisation, for treating severe keratitis in adult patients with dry eye disease that had not improved despite treatment with tear substitutes. It is estimated that 2.28% of adults had dry eye disease and 6% of this population had severe dry eye disease and that 75% of this population would use ciclosporin. The number of people treated with optimmune and restasis would decrease and there would be an associated increase in the number of patients treated with ciclosporin eye drops. The total number of people treated would remain the same. Dr Parkin commented that it would be important to highlight in the guidance that this was not just for the treatment of dry eyes and was another treatment option instead of long-term corticosteroids for patients with keratitis due to dry eye disease. Classified as a RED drug. TA 370 Bortezomib for previously untreated mantle cell lymphoma Classified as a RED drug (NHS England drug). TA 371 Trastuzumab emtansine for treating HER2-positive, unresectable locally advanced or metastatic breast cancer after treatment with trastuzumab and a taxane Not recommended by NICE. Classified as a BLACK drug (NHS England drug). TA 372 Apremilast for treating active psoriatic arthritis Not recommended by NICE. Classified as a BLACK drug. TA 373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis All classified as RED drugs (NHS England drugs). TA 374 Erlotinib and gefitinib for treating non small-cell lung cancer that has progressed after prior chemotherapy - Erlotinib was recommended by NICE as an option for treating locally advanced or metastatic non-small-cell lung cancer. Classified as a RED drug (NHS England drug). Gefitinib was not recommended by NICE for the treatment of locally advanced or metastatic non-small-cell lung cancer that had progressed after non-targeted chemotherapy in people with tumours that were EGFR-TK mutation-positive. Gefitinib classified as a BLACK drug. HST2 Elosulfase alfa for treating mucopolysaccharidosis type Iva Classified as a RED drug (NHS England drug). Action SD SD SD SD SD SD SD 13. TRAFFIC LIGHTS ANY CHANGES? Classifications Nefopam BROWN with exceptionalities Toujeo BROWN after specialist initiation 11

338 For agenda items contact Slakahan Dhadli Tel: Item Oxybutynin patches BROWN for patients unable to take oral medication BLI-800 bowel cleansing preparation RED Carfilzomib RED Ceftolozane + tazobactam RED Bortezomib RED as per NICE TA 370 Trastuzumab RED as per NICE TA 371 Apremilast BLACK Abatacept RED as per NICE TA 373 Adalimumab - RED as per NICE TA 373 Etanercept RED as per NICE TA 373 Tocilizumab RED as per NICE TA 373 Erlotinib RED as per NICE TA 374 Gefitinib BLACK as per NICE TA 374 Elosulfase alfab RED as NICE HST 2 All Homeopathy BLACK Action 14. JAPC ACTION SUMMARY The action summary was noted by JAPC and amendments made: Grazax Decision to be made as to whether this would be brought to the June 2016 JAPC meeting or via another route. Immunomodulating drugs Consultant Rheumatologists to be asked for their views on the drugs on a rolling basis. Pain Guidance To be brought to the February 2016 JAPC meeting. Management of Overactive Bladder To be taken off the list. Chlamydia Guidance To be brought to the February 2016 JAPC meeting. LMWH Bridging Guidance To be brought to the February or March 2016 JAPC meeting. Ulipristal for uterine fibroids To be brought to the February or March 2016 JAPC meeting. Fluticasone propionate + salmeterol xinafoate To be brought to the February 2016 JAC meeting. SD SD SD SD SD SD SD SD 15. GUIDELINE GROUP The summary of key messages arising from the meeting held in December 2015 was noted. Mr Dhadli highlighted the following: Carbocisteine sachets had been added to the respiratory formulary as a cost-effective option. Lactulose sachets Classified as BLACK as less cost-effective than current standard therapy. Lucentis Classified as RED as per NICE TA 155 as not previously classified. 12

339 For agenda items contact Slakahan Dhadli Tel: Item Pegatinib Classified as RED as per NICE TA 155 as not previously classified. Action 16. MINUTES OF OTHER PRESCRIBING GROUPS Sheffield Area Prescribing Group 15/10/15 South Staffordshire Area Prescribing Committee 30/10/15 Chesterfield Drugs and Therapeutic Committee 17/11/15 Clinical Commissioning Policy Advisory Group 12/11/15 DTHFT Drugs and Therapeutic Committee 17/11/15 Mr Dhadli highlighted the following: Sheffield Area Prescribing Group: Toujeo classified as an amber drug. Paracetamol dosing in low weight adults. South Staffordshire Area Prescribing Committee: Agreed to adopt Derbyshire JAPC Medical Devices Policy. Magnaspartate (KoRa) oral powder added to their formulary as the licensed oral magnesium preparation. Chesterfield Drugs and Therapeutic Committee: Concern expressed about the initiation of NOAC therapy without adequate consideration of the potential place of alternative anticoagulants such as warfarin. Ongoing discussion about the use of Dymista for a defined cohort of patients. 17. ANY OTHER BUSINESS a. Diamorphine Mrs Needham reported that there was currently a national shortage of diamorphine and regular updates were therefore being received about supplies. CRHFT had decided not to change their current practice but DTHFT had moved to morphine injections apart from syringe drivers who were still given diamorphine. The out-of-hours service had found it difficult to obtain supplies of diamorphine. It was noted that Manor Pharmacy as suppliers of syringe drivers to Erewash had plenty of stock of diamorphine. b. Learning Difficulties - Winterbourne Medicines Programme Dr Parkin reported that Hardwick CCG, as the lead commissioner for learning disability services, had taken on the responsibility via the Learning Disabilities Clinical Reference Group to review and reduce the inappropriate use of medicines for this group of people. Three cohorts of patients had been identified within South Derbyshire Learning Disabilities Team, the North Derbyshire Learning Disabilities Team and also those under the care of GPs. It was noted that South Derbyshire Learning Disabilities Team had already undertaken an audit of all patients known to the service. The tool used in the City for the audit would be slightly adapted and rolled out to the North Derbyshire Learning Disabilities Team. In connection with the patients known to GPs, it was agreed that the first stage would involve the use of practice pharmacists to carry out some work to identify those patients who were on antipsychotics and then take them off antipsychotic prescribing. 13

340 For agenda items contact Slakahan Dhadli Tel: Item c. Patient Group Directions Mr Dhadli advised that NHS England had added FluMist to the Patient Group direction (PGD) for influenza. Action JAPC noted that Dr D Harris, Lead Antimicrobial Pharmacist across all the Derbyshire CCGs, had agreed that the Derby Urgent Care Centre should use the following PGDs: Amoxicillin to treat acute otitis media. Doxycycline to treat exacerbations of COPD and (doxycycline used along with metronidazole) for cat, dog and human bites in penicillin allergic patients. Erythromycin to treat acute otitis media and also sore throat/tonsillitis/pharyngitis in penicillin allergic patients. Nitrofurantoin MR to treat uncomplicated UTIs in women (non-pregnant, aged 16 to 65 years). Phenoxymethylpenicillin to treat sore throat/tonsillitis/pharyngitis. Trimethoprim to treat uncomplicated UTIs in women (non-pregnant, aged 16 to 65 years). All the above antibiotics were appropriate agents for the treatment of the above infections and included in the JAPC Antimicrobial Treatment Guidance. 18. DATE OF NEXT MEETING Tuesday, 9 th February 2015 at 1.30pm in the Post Mill Centre, South Normanton. 14

341 Paper Z Minutes of Safeguarding Commissioning Group (Joint Adults and Children) 14 December 2015 Board Room, Toll Bar House, Ilkeston Safeguarding Adults Meeting commenced at 1pm Present Jayne Stringfellow (Chair) (JS) Chief Nurse, North Derbyshire CCG Lynn Woods (LW) Chief Nurse, Southern Derbyshire CCG Bill Nicol (BN) Head of Safeguarding Adults Sally Goodwin (SG) MARAC, DCC Ed Ronayne (ER) Adult Safeguarding Manager Michelle Grant (MG) Adult Safeguarding Manager Phil Sugden (PS) Deputy Chief Nurse, Hardwick CCG Heidi Scott-Smith (HSS) Deputy Chief Nurse, Erewash CCG Michelina Racioppi (MR) Designated Nurse, Safeguarding Children Kathy Webster (KW) Consultant Designated Nurse, Safeguarding Children and Children in Care Tricia Field (TF) Designated Doctor, CRH Juanita Murray (JM) Assistant Designated Nurse for Children in Care Gill Kerry (minutes) (GK) Administrator for Safeguarding Children and Children in Care 1 Apologies and Introductions Action Apologies were received from Jim Connolly, Jenny Evennett and Lesley Smales 2 Declaration of Interest There were no declarations of interest to note in regards to the agenda 3 Minutes of previous meeting (Adults) and Action Log The minutes from the meeting dated the 8 June were agreed as a true and accurate record Action Log 8 June item 4 Update on Deprivation of Liberty cases identified in supported living. MG has produced a paper and shared it with all 4 CCG s action complete, remove from action log 8 June item 5 JS to draft a formal letter re uncertainty of DSAM role to local authority the Care Act has been re-written and the DASM has been removed. Remove from action log 8 June item 7 TOR update leave on action log pick up at next meeting 4 Matters arising from minutes not on the agenda No matters arising to discuss 5 JSAAF Audit Tool MR, KW and BN are planning to redesign a Joint Safeguarding Assurance Framework Tool for GP s to complete. It was also decided to carry out random sampling and potentially to visit GP s who did not respond to the Adult Joint Safeguarding Commissioning Group minutes for 14 December 2015

342 Paper Z sample. TF feels the Named Doctors should be included Action 1 4 Professionals to meet and discuss, include Named Doctors and bring back to the next meeting Action 2 MR will circulate the Nottinghamshire report 6 Iris Report Derbyshire WISH were successful in 2014 in securing a health and homelessness grant to deliver a pilot piece of work delivering domestic abuse awareness and interventions training and support to GP practices across a cluster group within Amber Valley. The pilot was to last for six months. The work started for the pilot in February Three GP practices were identified for the pilot after liaison with local partners, and assessing which practices had not previously attended domestic abuse awareness training. The training sessions were aimed at both clinical and non-clinical staff for the awareness training sessions and clinical staff only for the interventions training sessions. In order for the IRIS to be delivered successfully as a countywide approach there would need to be a drive from clinical leads and a sustained promotion within the CCG s seeing this as a priority for funding All of the training sessions have now finished and the CCG s are still keeping links with the practices about referrals. Derbyshire County Council are commissioning domestic violence services including a single referral point and there is also an e-learning package available to GP s Action Chief Nurses felt it would be a good idea to pick a theme when delivering training as GP s often feel bombarded. Safeguarding Adult Team to meet to map out themes for training for 3 yearly cycle. There are mandatory requirements however from Central Government which will need to be factored 7 Position paper Re DoL in supported living Browne Jacobson have provided 2 training sessions for continuing health care nurses (CHC). The first one was not well attended (3) but the second one attracted 13. Two cases are being taken to the Court of Protection, South Derbyshire Clinical Commissioning Group (SDCCG) case will take place on Friday 18 December and North Derbyshire Clinical Commissioning Group (NDCCG) goes to court in January. The adult safeguarding managers will work with CHC to develop a database for each CCG to record the numbers of DoL s applied for as well as authorised and review date. This will be shared with the Chief Nurse for each CCG. The CCG have asked Continuing Health Care to identify 4 potential cases in 2014 after the Cheshire West Judgement but paperwork has still not been provided. Action PS to check joint funding in place Adult Joint Safeguarding Commissioning Group minutes for 14 December 2015

343 Paper Z Progress on CHC service action plan meets every Wednesday, also need to bring the 4 identified cases to the meeting. 8 Draft DoL Policy Michelle presented the new DoL policy which will cover the 4 CCG s. The policy was accepted by the CN s. A separate policy is required for children which would be included in the same pack and referenced in the adult s policy. LW asked if algorithms and flowcharts could be included and explained it may have to be reviewed again after 360 assurances. Action once amendments have been made can be circulated to chief nurses 9 Memorandum of Understanding The document tabled is an updated memorandum of understanding detailing collaborative governance and operational arrangements for adult safeguarding across Derbyshire clinical commissioning groups. BN always attends the Adult Safeguarding Board to represent the four CCG s. The chief nurses have a rota of all meetings and will then decide whether going to attend or delegate to their assistants. The internal review will look at the MOU so may need to amend after results of Adult Safeguarding 360 audit 10 Adult Safeguarding Policy The adult safeguarding policy has been reviewed. Action JS, PS and HS-T will take to GBAC meeting as a revised policy 11 MARAC Pilot Report South Derbyshire CCG Adult Safeguarding Team agreed to lead and administer a pilot study which has taken place from January 2015-June 2015 to facilitate communication between general practitioners and the Derby City Multi-Agency Risk Assessment Conference (MARAC) and in so doing identify potential communication pathways to enhance information sharing. A letter from the Medical Director and Deputy Police and Crime Commissioner was drafted detailing the importance and purpose of the MARAC process. This was accompanied by a simple template requesting relevant information from the victims named GP. All GP s who were contacted were asked to complete the template even if a nil return. During the pilot study 151 information requests were made to GP s. Only 36 responses were returned. This represented a non-compliance rate of 76% and a completion rate of 24%. Of the 36 completed 21 were nil responses (58%) A recommendation from the Pilot report was for the 4 CCG s to contribute 3,750 towards a cost of an additional MARAC administrator resource within the MARAC Funding was agreed with details of contribution to be finalised and to commence Jan 2016 DCC hope to have someone in post from the 1 January 2016 Adult Joint Safeguarding Commissioning Group minutes for 14 December 2015

344 Paper Z 12 Updated SAAF (Safeguarding Adults Assurance Framework) The document tabled is in a new format it used to be a spreadsheet. BN wants it to be a working document and help NHS provider Adult Safeguarding leads when doing safeguarding work. Health providers have been given a return date of 13 May 2016 prior to 1:1 visits. If there are any problems with compliance then safeguarding team will go to the responsible commissioner for support. 13 Any Other Business No other business was discussed All Safeguarding Adult Team left the meeting Safeguarding Adults meeting closed at 2:50pm Adult Joint Safeguarding Commissioning Group minutes for 14 December 2015

345 Paper Z Minutes of Joint Safeguarding Commissioning Group (Adults and Children) 14 December 2015 Board Room, Toll Bar House, Ilkeston Meeting commenced at 2:55pm Present Jayne Stringfellow (Chair) (JS) Chief Nurse, North Derbyshire CCG Lynn Woods (LW) Chief Nurse, Southern Derbyshire CCG Heidi Scott-Smith (HSS) Deputy Chief Nurse, Erewash CCG Phil Sugden (PS) Deputy Chief Nurse, Hardwick CCG Tricia Field (TF) Designated Doctor, Derbyshire County Kathy Webster (KW) Consultant Designated Nurse, Safeguarding Children and Children in Care Michelina Racioppi (MR) Designated Nurse, Safeguarding Children Juanita Murray (JM) Assistant Designated Nurse, Children in Care Gill Kerry (GK) Administrator for Safeguarding Children and Children in Care Apologies were received from Jim Connolly, Jenny Evennett and Lesley Smales 1 Minutes of Safeguarding Children from previous meeting and action log The minutes from the meeting in June were agreed as a true record Action Log 8 June item 1 Named Doctor vacancies. SDCCG still have 3 safeguarding sessions which have not been filled. In the County there are 5 Doctors doing 8 sessions. Action SDCCG will have one more attempt to see if can recruit for at least 1 session. 8 June item 4 Starting Point KW gave a verbal update. Starting Point commenced on the 7 September, regular meetings are taking place to monitor progress. Starting Point is an extended Multi-Agency Safeguarding Hub (MASH) dealing with both child protection/safeguarding and lower level work. There is a debate at the moment around what part of Starting point should sit within the main 0-19 children service specification which is commissioned by Public Health and what needs to be continued to be commissioned by the CCGs. KW will get the first quarter figures to make a case as strong as possible and will share with the 4 CCG s. The health team are getting 200 referrals a week. KPI s within the Starting Point service specification will help the CCGs to see how much of the work is child protection/safeguarding. Action keep on the agenda The information sharing agreement for Starting Point has been signed off. KW does not think it is feasible for every GP practice to sign off individually. There are no issues with GPs sharing information with Starting Point Team. 8 June item 7 MARAC the information agreement has now been signed and can be removed from the action plan Adult Joint Safeguarding Commissioning Group minutes for 14 December 2015