Chair Attached Attached Attached. Chair and chief officer s & patient experience reports Chair s report Chief officer s report

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1 NHS Barking and Dagenham Clinical Commissioning Group Governing Body meeting 22 March pm Barking Learning Centre, 2 Town Square, Barking, IG11 7NB Item Time Lead director Attached, verbal or to follow Welcome, introductions and apologies Declaration of conflicts of interest Minutes of the meeting held on 26 January 2016 Matters/actions arising 1.30 Chair Attached Attached Attached Chair and chief officer s & patient experience reports Chair s report Chief officer s report Chair CB Attached Attached Governing body assurance Governing body risk assurance framework report BHRUT performance risks Delivery of IAPT operating plan standards Personal Medical services (PMS) review update SM CB RK SS Attached Attached Attached Attached Corporate strategy and planning Operational Planning 2016/17-update on submissions 2016/17 Financial Planning Report Primary care strategy update CCG strategic direction 2016/17 and onwards SM TT SS CB Attached Attached Attached Attached Service transformation and development Improving patient flow front of A&E and supporting discharge business case Response Car - London Ambulance Service and Community Treatment Team business case JJ JJ Attached Attached Quality and performance Patient experience report Finance and activity report Quality in commissioning report SW TT JH Attached Attached Attached Development/governance Revisions to committee Terms of Reference and establishment of an auditor panel Finance & delivery committee chair s report Audit & governance committee chair s report Minutes of sub committees and relevant fora: Executive committee Patient engagement forum Joint executive team committee Primary care committee Investment committee MP KP KP Attached Attached Attached

2 Item Time Lead director Attached, verbal or to follow 8.0 AOB Questions from the public Date of next meeting 24 May 2016

3 Glossary of terms and abbreviations Term Explanation AO ACO ADL APC ASH BCF BHR BHRUT BPPC CAPS CCG CCS CDOP CEO CFO CHC CHSCS CIL COB COO CQC CQRM CQUIN CSU CTT Accountable Officer Accountable Care Organisation Activities of Daily Living Area Prescribing Committee Accredited Safe Haven Better Care Fund Barking and Dagenham, Havering and Redbridge Barking, Havering and Redbridge University Trust Better Payment Practice Code Clinical Application Services Clinical Commissioning Group Complex Care Service Child Death Overview Panel Chief Operating Officer Chief Finance Officer Continuing Healthcare Community Health and Social Care Services Community Infrastructure Levies Corporate Objectives Chief Operating Officer Care Quality Commission Clinical Quality Review Meeting Commissioning for Quality and Innovation Commissioning Support Unit Community Treatment Team

4 CVS CYPP DI DOH DTOC ECG EHC EoI EOL FNP FT FYE GBAF GP H4NEL HCAIs HE NCEL HSC HWBB IAPT ICC ICM ICSG IFR IRS IST JAD JET JHWS JMT Council of Voluntary Services Children and Young Person Plan Discovery Interview Department of Health Delayed Transfer of Care Electrocardiogram Education, Health and Care Expression of Interest End of Life Care Family Nurse Partnership Foundation Trust Full Year Effect Governance Board Assurance Framework General Practitioner Health for North East London Healthcare Associated Infections Health Education North Central and East London Health Scrutiny Committee Health & Wellbeing Board Improving Access to Psychological Therapies Integrated Care Coalition Integrated Case Management Integrated Care Joint Health and Social Care Steering Group Individual Funding Request Intensive Rehabilitation Service Intensive Support Team Joint Assessment and Discharge Service Joint Executive Team Joint Health & Wellbeing Strategy Joint Management Team

5 JSNA KGH KPIs LAC LAS LETB LMCs LPC LSCB LTC MASH MLU MSRB NEL NELCSU NELFT NHS NHSE NICE OFSTED OD ONEL PALS PEFs PELC PMCF PMO POD POLCV PPGs PSED Joint Strategic Needs Assessment King George Hospital Key Performance Indicators Looked After Children London Ambulance Service Local Education and Training Boards Local Medical Committees Local Pharmaceutical Committee Local Safeguarding Children s Board Long Term Conditions Multiagency Safeguarding Assessment Hub Mid-wife Led Unit Maternity Systems Readiness Board North East London North East London Commissioning Support Unit North East London Foundation Trust National Health Service NHS England National Institute for Health and Care Excellence Office for Standards in Education, Children s Services and Skills Organisation Development Outer North East London Patient Advice and Liaison Service Patient Engagement Forums Partnership of East London Cooperatives Prime Minister s Challenge Fund Project Management Office Point of Delivery Procedures of Limited Clinical Value Patient Participation Groups Public Sector Equality Duty

6 PTL QIPP RAG RTT SAB SCN TDA TSCL TUGT UCC UCL UCLP VFM WELC WICs YTD Patient Tracking List Quality, Innovation, Productivity and Prevention Red. Amber, Green Referral To Treatment Safeguarding Adults Board Strategic Clinical Network Trust Development Agency The Transforming Services Changing Lives Timed Up and Go Test Urgent Care Centre University College London University College London Partners Value for Money Waltham Forest, East London and City Walk in Centres Year to Date

7 Register of interests 2015/16 Declaration of governing body members Last updated: January 2016 Name Role Organisation Nature of interest Amendment and date Dr Waseem Mohi Chair Markyate Surgery Salaried GP Together First Limited (from May 2014) Shareholder London Wellbeing Care Ltd Director Dr Chandra Mohan Clinical director Urswick Medical Centre Primary Care Partnership Limited Senior partner Director Together First Limited (from May 2014) Shareholder Dr Ravali Goriparthi Clinical director Tulasi Medical Centre Venkat Health Centre GP Partner GP Partner Together First shareholder removed 26/6/15 Health & Happiness Clinic Ltd Director Boerrhinger 1

8 Name Role Organisation Nature of interest Amendment and date Barking, Dagenham and Havering LMC Member Royal College of General Practitioners Member Ingelheim Principle investigator removed 26/6/15 Diabetes UK Primary Care Diabetes Society National Diabesity (Diabetes & Obesity) Forum Lilly Pharmaceutical Company Limited Dr Jagan John Clinical director King Edward Medical Group LMC (Barking, Dagenham & Havering) NHS England North East London Foundation Trust Together First Limited (from Member Member Member Member of the teaching panel GP Partner, other GPs are family members. Member London clinical senate member GPwSI in Cardiology BD CHS Shareholder 2

9 Name Role Organisation Nature of interest Amendment and date May 2014) Health 1000 (December 2014) Prime Minister s Challenge Dr Rami Hara Clinical director Urswick Medical Centre Pharmaceutical companies Together First Limited (from May 2014) Director Lead GP Principal Speaker fee - Chair and speaker at educational lectures/meetings Shareholder Dr Gurkirit Kalkat Clinical director Thames View Health Centre Primary Clinical Partnership Ltd GP Principal Director/owner or part owner/ Share holder Apex Healthcare Ltd Director/owner or part owner/ Share holder Queen Mary Medical School, London Honorary Lecturer Together First Limited (from May 2014) Shareholder 3

10 Name Role Organisation Nature of interest Amendment and date BHR CCGs Area Prescribing Chair Dr Anju Gupta Clinical director Abbey Medical Centre GP Principal Together First Limited Member NELFT GPwSI - Diabetes NHSE GP appraiser Wilson Mason PLC Spouse employed as an architect and company undertakes NHS work Barking, Dagenham & Havering LMC Member Sahdia Warraich Lay member The Forum for Health and Wellbeing The Forum for Health and Wellbeing Trading Ltd Director Company Director Member of Healthwatch Redbridge removed 14/3/16 Healthwatch Newham Company Director (from 28/3/13) Healthwatch Waltham Forest Company Director (from 8/2/13) London Borough of Redbridge Spouse is a Councillor 4

11 Name Role Organisation Nature of interest Amendment and date Kash Pandya Lay member - Governance Hillcroft College for women, Surbiton Essex Ministry of Justice Advisory Committee Council Member and Audit Chair Lay Member for appointment magistrates Health & Safety Executive Her Majesty s Inspector of Constabulary Brentwood Citizen s Advice Bureau Havering CCG Redbridge CCG PricewaterhouseCoopers Independent Audit Committee Member Associate Inspector Generalist advisor Lay Member Lay Member Kiren Pandya (son) Management consultant North Central London CCGs Out of hours and 111 procurement panel chair Added 25/8/15 Charles Associate North Essex Partnership Non-Executive Director 5

12 Name Role Organisation Nature of interest Amendment and date Beaumont Independent Lay Voting Member for Audit Committee and Individual Funding Request Panel Foundation Trust Steve Ryan Secondary Care Consultant Steve Ryan Healthcare UCL Partners Sole Trader Honorary contract CAMHS Transformation Healthy London Partnership Strategic Lead London Clinical Senate Council Member Conor Burke Accountable officer Your business works (not trading) Redbridge college Director Former Audit committee member Accenture UK Consultancy removed 9/7/15 Sharon Morrow Chief operating officer None None Tom Travers Chief financial Officer Royal Free Foundation Trust Wife works in finance department Jacqui Himbury Nurse director Nursing, Midwifery Council Nurse member Fitness to 6

13 Name Role Organisation Nature of interest Amendment and date Practice panels 7

14 Draft Barking & Dagenham Clinical Commissioning Group Governing Body Meeting 26 January pm Barking Learning Centre CHECK Present: Dr Waseem Mohi Clinical Director and Chair Dr Ramneek Hara (RH) Clinical Director Dr Thota Mohan (TM) Clinical Director Dr Gurkirit Kalkat (GK) Clinical Director Dr Jagan John (JJ) Clinical Director Dr Anju Gupta Clinical Director Sharon Morrow (SM) Chief Operating Officer Conor Burke (CB) Accountable Officer Kash Pandya (KP) Lay member - governance Tom Travers (TT) Chief Finance officer Jacqui Himbury (JH) Nursing director Steve Ryan (SR) Secondary care consultant In Attendance: Marie Price (MP) Anne-Marie Keliris Matthew Cole (MC) Dr Raj Kumar (RK) Ian Winning (IC) Director of Corporate Services Company secretary Public Health director Clinical Champion for mental health and GP (for item 3.3 & 5.2) CSU Apologies: Sahdia Warraich (SW) Dr Ravali Goriparthi (RG) Anne Bristow (AB) Lay member patient and public involvement Clinical Director Corporate director adult and community services Item 1.0 Welcome and apologies The Chair welcomed Steve Ryan to his first governing body meeting. Action Apologies for absence were received from Dr Goriparthi and Sahdia Warraich 1

15 1.2 Declarations of conflicts of interest There were no additional declarations of interest. 1.3 Minutes of the last meeting The minutes of the meeting held on 24 November 2015 were agreed as a correct record. 1.4 Matters/Actions arising The committee noted the actions taken since the last meeting. 2.0 Chair & Accountable Officer s Reports 2.1 Chair s report The Chair presented his report covering the following areas: Clinical director elections Kings Fund clinical leadership programme Secondary care consultant The governing body noted the report. 2.2 Chief Officer s report The chief officer presented his report covering the following areas: CCG assurance CCG development Devolution/Accountable Care Organisation (ACO) Urgent and emergency care vanguard Primary care transformation The governing body noted the report. 3.0 Governing body assurance 3.1 Governing body assurance framework SM presented a report which outlined the key risks to the clinical commissioning group in achieving its corporate objectives as identified in the governing body risk assurance framework. There are five risks on the GBAF:- 1. Barking Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance 2. BHRUT referral to treatment times (RTT) performance 3. BHRUT cancer performance for 2 weeks and 62 days 4. Improved access to psychological therapies (IAPT)

16 5. Quality, innovation, productivity and prevention (QIPP) delivery JH reported that there is a clinical harm review meeting with NHSE which demonstrates external challenge. KP reported the audit and governance committee had discussed risk appetite and a risk assurance map which will show how risks are managed within the CCG. AG questioned if there are any clinicians involved in the clinical harm process. JH confirmed that BHRUT have a robust process in place which had been evaluated by NHSE. She added that there is clinical input from the CCG together with a lay member and also clinicians from the Trust. AG questioned if details of RTT delays should be shared with practices and patients. SM responded that GP colleagues are asked to offer patients choice and there is a robust communication plan in place to deal with queries from practices and patients. SR questioned how easy it was for GPs with patients who have deteriorated after referral to be seen quickly. RH responded that there a direct line to the hospital with patients being seen on the same date. JH added that BHRUT have restructured their response system with a GP liaison manager now in place and reported there had been excellent feedback recently where concerns have been acted upon immediately. MC questioned how the GP alert system worked to pick up RTT delays. JH responded that the system is as reactive as we would like it to be, adding that the process to report has now been made easier after the recent relaunch. SM also reported that locality meetings have been restructured to ensure that GPs can raise concerns. The governing body noted the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken 3.2 BHRUT performance risks CB presented a report which provided a further update on the key actions that the CCG is taking to seek performance improvements at the Trust. It is doing this by both holding the Trust to account through its contract and other mechanisms, as well as providing overall support through wider system initiatives overseen by the Integrated Care Coalition and System Resilience Group (nee Urgent Care Board).

17 It was noted that there are still some major concerns around RTT, A&E and cancer. CB reported there had been a consistent improvement in A&E compared to last year and reported that there had been a director in A&E overnight recently which had made a significant difference and an area that needs exploring further. The Chair questioned how the urgent care vanguard will help improve A&E performance. CB responded that the urgent care vanguard is a project jointly owned by the health and social care system and a programme board has been established. He added that the focus of the vanguard will be to help the public access services in the right location for their needs. TT reported that vanguard funding had been confirmed at 1.3m for 2015/16. The Chair questioned how patient views are being gathered. TT reported that there are a number of workstreams within the vanguard project that include patient engagement. KP referred to RTT, an area of ongoing concern and questioned if there is confidence in achieving the recovery plan by March CB responded that until the plan has been received and reviewed it was difficult to confirm adding it will also depend on other factors ie resources available. The Governing Body noted the action being taken to date to mitigate the performance risks at BHRUT. 3.3 Delivery of IAPT operating plan standards RK presented a report which provided an update on actions that are being taken to improve performance against the Improving Access to Psychological Therapies (IAPT) standards. It was noted that data from October and November shows that Barking and Dagenham achieved the access target in those months. This has been as a result of a programme of practice visits and actions by general practice to increase referrals. JJ was pleased to note the improvements in access to the service and locally practice visits were appreciated by all GP colleagues which had proven effective. He suggested a long term plan for self referral would see sustained improvements. MC expressed a degree of frustration that uptake is not taken up quickly and questioned what other things can be done to ensure general practice are fully committed. RK responded that this has been discussed at a recent PTI and relaunched locality meetings which was welcomed.

18 GK welcomed the improvements in uptake and questioned how we are addressing reaching hard to reach groups. RK responded that the IAPT service are aware that improvements in this area are still needed and are actively liasing with religious leaders and promoting interpreting services. CB requested that Barking & Dagenham practices share their learning with Redbridge and Havering CCG colleagues. RK welcomed this and reported that he had met with colleagues who are co-ordinating Redbridge practice visits and would be happy to support further. The Chair questioned if there is a way to ensure that patients with anxiety and depression access the service as there can sometimes be a stigma attached to asking for help. RK responded that although this is a self referral service, contact is available for some patients and NELFT are actively encouraging self referral. It was suggested the use of practice based referral data could be used to target improvement in specific practices. RK MP reported that a marketing and communication plan had been commissioned to rebrand the service and local focus groups have taken place. JJ commented that a change in the service name could present problems. The governing body noted the improvement in performance seen in October and November. 3.4 Primary care update GK and JJ declared an interest in the item as PMS contracts holders. SS presented a report which updated and briefed on the development of the CCG s Primary Care Transformation Strategy, negotiations on the 2015/16 and 2016/17 Prime Minister s Challenge Fund GP hub contract, and delegated responsibilities for the commissioning of primary medical services, specifically in regard to: the proposed (voting) clinical membership of the CCG s Primary Care Commissioning Committee, and the mandated Personal Medical Services (PMS) Review. JJ highlighted the importance of a consistent message from the CCG and NHSE. GK questioned what the impact of the new contract will be locally. SS responded that an impact assessment is currently underway and this will inform communications to practices TM questioned if a GP practice can refuse to sign the new PMS contract. SS responded that GPs will have the right to request a

19 GMS national contract but it was hoped that this can be avoided. SR asked what the timeline is for implementation. SS responded that a three month extension had been approved and new contracts are due to be signed in July. JJ questioned what the timeframe is for moving forward the primary care landscape. SS responded that a virtual network will be in place 16/17. The Governing Body noted the update on the development of the Primary Care Transformation Strategy and the update on the negotiations for the Prime Minister s Challenge Fund GP hub contract for 2015/16 & 2016/ Corporate strategy and planning 4.1 Planning requirements and operational requirements SM presented a report which summarised the latest information received in respect of the planning round for 2016/17, and takes into account local developments around the Barking and Dagenham, Havering and Redbridge (BHR) Health Economy s successful bid to develop a business case for an Accountable Care Organisation (ACO). MC highlighted that it was important to bring together and be clear on communications around prevention. SM agreed, adding this was a high level report and would need to engage more widely with partners on this. TT reported that following local discussions around the ACO a different approach to 16/17 contracts is currently being explored. He added that the tariff is not expected to be released until March when contracts will need to be signed which is a risk. KP highlighted risks around timescale and engagement of the new assurance framework and questioned if the CCG can influence this. SM responded that this is nationally determined with the first assessment in quarter one. CB added that this is one level of complexity and challenge, highlighting the importance of sustaining good provision locally as on a national basis those who can lead and sustain change will have more opportunity for additional funding. SR commented that cost improvement programmes would be the biggest challenge and it would be helpful to explore what the CCG can do to help. The Chair commented that the STP timeline needs to be clear for the public. CB agreed it was important to engage with public and

20 added this was start of six month process and the first step will be a survey run by IPSOS Mori on how the system will work. The governing body: noted the described planning requirements and timescales from the newly-published NHS England 2016/17 planning guidance (both in the text below and the attached summary of the guidance) noted the emerging workstreams which will require additional consideration for 2016/ Service transformation and development 5.1 Healthy London Partnership 2016/17 and 2017/18 TT presented a report which updated on the the Healthy London Partnership (HLP) that has been in operation since May As programmes progress in line with the plans agreed by London CCGs and NHS England (London), the Interim London Transformation Group (ILTG) has requested that a longer term commitment is considered by accountable organisations for 2016/17 and 2017/18, i.e. a further two years. The majority of CCGs across London have agreed the proposals outlined. The maximum contribution is 0.15% per CCG and where the budget is not used against agreed programme priorities it is returned to CCGs. This is in line with 2015/16 contributions and arrangements. KP welcomed the report as it was good to learn from other areas in London and questioned if there are any tangible examples of benefits gained. CB reported that he chairs the urgent care pathway for London which has helped to change the 111 service in the last six months by using health analytics and starting to explore extending this to the ambulance service. SM reported on national transformation programme and the work to develop early diagnosis and crisis intervention and the set up of a commissioning network across London. The Governing Body: Noted the progress and achievements of the HLP to date Agreed to support the HLP in 2016/17 and 2017/18, including the proposed planning process and financial assumptions. Agreed to the proposed ongoing governance arrangements

21 5.2 Enhanced mental health liaison business case RK presented a report which provided a further review of the funding of the Enhanced Mental Health Liaison EMHL) night service, taking in account policy requirements as well as activity data from the service. The paper requested that recurrent funding for the EMHL night service be agreed. This will ensure that patients attending acute hospitals in Barking and Dagenham, Havering and Redbridge (BHR) with urgent mental health needs will have their needs met in a timely way. It will enable the health economy to manage pressures on acute beds. It will enable commissioners and providers to meet the expected minimum standards for liaison mental health services and will enable progression towards providing the appropriate service expected by The chair requested that performance measures are included in future reports and highlighted the importance of strengthen community services. RK responded that there are two main teams, IAPT and emergency team. He added that mental health services need a robust system for emergency treatment just like A&E for any other physical condition. RK/SM JJ agreed it is an essential service and was reassured to see positive patient feedback and staffing levels increased. He added that there are a range of community services via hubs for out of hours aswell as PELC and A&E based system if GP colleagues need urgent review and questioned if there is a way colleagues can contact the service directly. RK responded that there was and acknowledged it was a complex pathway. JH commented that mental health patients have emergency conditions just like a physical emergency and it is our duty of care to ensure right care is available with the right competencies. AG questioned if it would be possible to look at outcomes and diagnosis as part of a future performance audit. RK agreed to request this information from NELFT. RK/SM agreed to discuss a further assurance report for the governing body in six months. RK/SM RK/SM The Governing Body agreed recurrent funding of 67,646 for the EMHL night service, thus securing a 24/7 service on a recurrent basis. 6.0 Quality and performance 6.1 Patient experience report SW presented a report which provided a summary of the various feedback that has come through to the CCG from patients and

22 stakeholders highlighting the following areas: The last patient engagement forum (PEF) meeting and activities of PEF members. Work on strengthening relationships with the voluntary and community sector, including local meetings. Progress in developing our new engagement strategy NHS England (NHSE) assurance on engagement The Chair thanked members of the patient engagement forum for their important contribution to the work of the CCG. The governing body noted the report. 6.2 Finance and activity report TT presented the month 8 finance and activity report highlighting that as reported previously, the CCG has agreed a revised risk assessed forecast outturn of 3,352k with NHSE. This represents a 1.14% surplus rather than the original planned 2% surplus. The revision to the forecast was based on a risk assessed view of the underlying data driving the month 6 year to date and forecast positions. As at the end of November (Month 8) the position has remained stable and the CCG has maintained a 1.14% forecast surplus. At month 8 this represents year to date slippage of 1,299k against the original year to date planned surplus of 3,533k and 1,948k slippage against the original planned 2% surplus. The main driver behind the reported position is Barts Health, where a significant over performance is reported. The latest risk assessed forecast overspend is 2,097k or a 12% contract pressure. Barts Health - The Month 7 data before adjustments indicates a high level of year-end over performance. The Barts Health contract continues to present the largest financial risk to the CCG. The latest data received from the Trust highlights over performance reported across a range of points of delivery, including non-elective, critical care, elective care, maternity pathway, outpatient procedures, high cost drugs and treatments and unidentified QIPP schemes. A number of challenges have been made and the reported position includes assumptions that a number of challenges are successful, and that the worsening activity trends are mitigated. The CSU have carried out further analysis of the Barts position and are in the process of risk rating the issues identified, to further inform the reported outturn position. BHRUT A fixed price contract has been agreed with BHRUT for 2015/16, including non-recurrent funding to support the delivery of the QIPP schemes and the achievement of key performance indicators, ensuring system sustainability in the coming years. The

23 fixed price also includes funding to ensure operational resilience during winter and meet the targets set to address the RTT backlog at the Trust. The 2015/16 contract will still be managed under full PbR rules, as at Month 6 there were a number of issues with the Month 7 data and the finance and activity plans. These are being flagged for correction with the Trust through the TSG and SPR meetings. As highlighted in previous reports the CCG faces a number of risks that may further impact the financial position. These include: further acute activity growth above planned levels, QIPP delivery, continuing care growth and prescribing growth. A number of mitigations are in the place attempting to off-set these risks and include robust contract management, PMO QIPP process and ongoing review of investments. Month 8 QIPP delivery, based on Month 7 SUS data, has delivered a total of 599k actual savings against a target of 628k. This represents a year to date saving of 4,220k against a plan of 4,290k. KP referred to the BHHRUT RTT and that a number of GPs might be referring to other trusts and if the CCG were doing anything to stop this. TT responded that BHRUTs recovery plan includes reviewing patterns and budgets but recognises there will be a degree of pressure. He added that there is a volume of activity going through the independent sector and challenging some of the pricing for this activity which is seeing a positive outcome. The Chair questioned if there was an increase in spend at Barts Health last year. TT confirmed there was a 12% increase. KP noted the risk scenarios which were helpful and would discuss this in more details at the Finance and Delivery committee. He added that spend with associates has gone up but spend at acute had not gone down and what the latest position was. TT confirmed there has been growth in associate contracts rather than a shift of activity. KP questioned if there is any indication of what the QIPP will be in next years allocations. TT confirmed the allocation of 295m which is a 3.15% uplift and once reviewed QIPP numbers will be available. The Chair referred to continuing healthcare (CHC) and questioned if there was any assurance on this area. TT responded that there is currently 100k net cost pressure on running costs with the main pressure on placements due to volume increase due to the shift from local authority into health. He reported that the finance and delivery committee are undertaking a deep dive into CHC which will

24 also review if this needs to be included on the risk register. The governing body agreed the financial position and the actions taken to achieve it. 6.3 Contracting report TT presented a report which provided an update on the contract performance for 2015/16 at Month 7 for acute, community and mental health services. BHRUT are failing to meet several of the national standards required in the Operating Framework. Commissioners continue to actively manage performance through a number of forums held on a weekly basis and as a consequence Contract Performance Notices have been served. There are action plans in place to recover the standards for A&E, Referral to Treatment (RTT), Cancer and Diagnostics. The Trust is held to account on actions required with associated penalties enforced in accordance within the contract. Barts operational and performance issues are being managed by the Lead Commissioner (Newham CCG) in line with the contractual governance framework. Barts are failing to meet several of the national standards required in the Operating Framework. There are a number of action plans currently in place for 18 weeks, Cancer, serious incident (SI) management and data quality that are being actively managed by the Lead Commissioner. The Trust is held to account on actions required with associated penalties enforced in accordance within the contract. A Care Quality Commission (CQC) report on Whipps Cross hospital was published on 17 March 2015 with a subsequent CQC report on Barts, Royal London and Newham, published on 22 May Poor performance at both acute has led to them being placed in special measures. National reporting of 18 weeks has been suspended for both BHRUT and Barts Health. NELFT are performing to contracted standards in their Community and Mental Health Service contracts with the significant exception of Increasing Access to Psychological Therapies(IAPT) services. PELC are currently the second best performing Out of Hours (OOH) and 111 Provider in London. They are also supporting ambulance re-triage for lower acuity calls. The London Ambulance Service (LAS) continue to be very challenged in their delivery of the 8 minute response standard, with the year to date for the Barking and Dagenham CCG at 64.5% against a standard of 75%.

25 KP welcomed the detail on diagnostics at BHRUT and the mitigating actions in place including recruitment and questioned when recovery is expected. TT responded that additional capacity is now in place and expects progress to continue, with non capacity related issues being picked up through CQRM. The governing body agreed the reported M7 position for the two main acute and two main non-acute contracts and; reviewed the performance against standards and requirements and agreed remedial actions being taken. 6.4 Quality in commissioning report JH presented a report which provided assurance that the CCG continues to implement the recommendations and requirements from the Transforming Care Programme (previously referred to as Winterbourne View) recommendations, quality and safeguarding improvement plans, actions to reduce health inequalities along with new initiatives around compliance with Francis. The following specific areas were covered: Transforming Care Programme Safeguarding Special Educational Needs and Disability (SEND) Looked after children Maternity commissioning Quality of care in Care Homes (with Nursing) Reducing health inequalities Frances Report Duty of Candour The Chair questioned how the CCG benchmarks its quality requirements across London. JH responded that NHSE were assured by the processes in place and have asked to review the quality tracker and formal feedback will be given. MP reported that the CCG had been rated good by NHSE for patient experience. JJ questioned if the 16/17 maternity commissioning framework will impact BHRUT. JH responded that having reviewed the specification she was assured that BHRUT will not be affected. She added that there could be a potential impact at Whipps Cross and Homerton Hospitals. RH questioned if there is a patient alert system for nursing homes. JH responded that there are a variety of processes including health

26 watch, local authority and quality surveillance group. She added that there has been a reactive approach to nursing home concerns but the CCG were starting to work more proactively with partners. KP welcomed the report and referred to the Francis/Winterbourne section, he questioned what the CCGs plans are to review recommendations from the recent Southern Healthcare report. JH responded that reports of this nature are always reviewed and will be reviewing how we disseminate the recommendations. She added that the CCG also work closely with providers to review unexpected deaths or suicides JH AG questioned how the CCG engages with hard to reach groups with learning disabilities. JH acknowledged that this an area which needs to be improved on and was proactively engaging with carers, schools and faith groups. CB reported on a recent media report on NELFT high death numbers. It was noted that this is currently being investigated. The governing body noted the report. 7.0 Development/governance 7.1 Remuneration & workforce report KP presented a report which provided key highlights of the remuneration & workforce committee held on 1 December The governing body noted the report. 7.2 Finance & delivery committee report The chair presented a report which provided key highlights of the finance and delivery committee held on 8 December The governing body noted the report. 7.3 Audit & governance committee report KP presented a report which provided key highlights of the audit and governance committee held on 8 December The governing body noted the report. 7.4 Minutes of sub committees: The governing body noted the minutes of: Patient engagement forum held on 19 November Joint executive team committee held on 12 November & 10 December Primary care commissioning committee held on 7 October & 13 November Investment committee held on 17 November 2015.

27 8.0 AOB There was no other business. 9.0 Questions from the public Miriam Greenwood noted there is large discrepancy between improving health and public health and the importance played by health diet and reducing emissions. The Chair welcomed the comments raised and CB agreed to feed these comments into the Healthy London Partnership which the CCG were part of and also suggested that it could be raised at the Health and Wellbeing Board. Miriam Greenwood commented that members of Healthwatch are members of other CCG governing bodies and questioned if Barking & Dagenham would consider this. CB responded that this would be considered if a formal request was made Date of the next meeting 22 March 2016.

28 Actions arising from the Barking and Dagenham Clinical Commissioning Group Governing Body 26 January 2016, Part 1 Action reference Action required Lead Progress 3.3 Delivery of IAPT operating plan standards It was suggested the use of practice based referral data could be used to target improvement in specific practices. RK Detailed within report on agenda. 5.2 Enhanced mental health liaison business case The chair requested that performance measures are included in future reports and highlighted the importance of strengthen community services. RK/SM Added to governing body forward plan for July. AG questioned if it would be possible to look at outcomes and diagnosis as part of a future performance audit. RK agreed to request this information from NELFT. 1

29 RK/SM agreed to discuss a further assurance report for the governing body in six months. 6.4 Quality in commissioning report KP welcomed the report and referred to the Francis/Winterbourne section, he questioned what the CCGs plans are to review recommendations from the recent Southern Healthcare report. JH responded that reports of this nature are always reviewed and will be reviewing how we disseminate the recommendations. She added that the CCG also work closely with providers to review unexpected deaths or suicides JH Update within quality report. 2

30 To: From: Meeting of the NHS Barking and Dagenham CCG Governing Body Dr Waseem Mohi, Chair Date: 22 March 2016 Subject: Chair s report Executive summary The report provides an overview of key activities undertaken by myself and the CCG since the last governing body meeting. As identified on the agenda there are a number of significant risks that we continue to manage, specifically with our acute providers. The reports in the assurance section outline the actions underway to mitigate these risks. I, along with our chief officer and chief operating officer are focussing our own and our teams efforts in addressing these. Recommendations The governing body is asked to note the progress report. 1.0 Purpose of the report 1.1 To provide an update on my activities since the last meeting and on key CCG news. 2.0 Clinical director elections and changes 2.1 Electoral Reform Services and the CCG have completed the process for the recent clinical director (CD) interviews. Following endorsement from members at the March meeting, I am pleased to announce that Doctors Hara and Kalkat will continue as clinical directors from April onwards. 2.2 I also want to report that our colleague Dr T C Mohan has decided to retire from general practice and as a CD. I want to express my sincere thanks for all of his hard work with the CCG, both as a pathfinder and established organisation. He has brought a wealth of experience to bear which has been invaluable. I could list many examples of his achievements, but his work in leading maternity commissioning from a clinical perspective in north east London has been a particular highlight given the improvements that we have seen in BHR over recent years. I am sure that fellow governing body members will want to thank him and wish him well as he retires from this role survey 3.1 Our 360 survey process for 2015/16 has begun and I have encouraged all members to share their views with us. The results from last year were helpful in determining how we

31 need to engage with members, partners and stakeholders. I hope that we have a high participation rate and look forward to reviewing the results later this spring. 4.0 King s Fund clinical leadership programme and membership of FMLM 4.1 I attended a helpful session last month with the King s Fund OD lead clarifying the arrangements for the CD leadership programme. There was a wider discussion at the February Joint Executive Team (JET) meeting, with the proposal being well received. The CDs present agreed to the proposal of a series of two consecutive days a month over 3-4 months. The sessions will include all CDs across BHR, but there will be the opportunity to break into smaller groups based on borough/area of interest or specialty as appropriate. 4.2 The governance team has identified possible dates and our director of corporate services is following up on the outline programme with the King s Fund OD lead. The sessions will begin in April or May 2016 and will take place at the King s Fund offices in central London. 4.3 In addition, the CCG has secured membership of the Faculty of Medical and Leadership Management (FMLM) for all CDs. The FMLM runs a number of useful events and has a wealth of resources on the website for leaders. I encourage all CDs to make the most of the opportunity. 5.0 Meetings 5.1 In addition to the many committee meetings that I attend, below is a summary of other meetings I ve been to since the last governing body. 5.2 Members meeting: We had a members meeting on 1 March where we updated colleagues and heard feedback from them about local and BHR developments. We also discussed our plans for improving the GP website/intranet. It will help improve communication and members will be able to draw down information on protocols and pathways from the site. It will also help us to collate issues of concern regarding current commissioned services through links with the GP alert system. At the meeting we also sought and received endorsement for the newly appointed clinical directors from members. 5.3 Informal CDs meetings: I have had a number of meetings with my CDs since the last governing body meeting. We ve focussed on the QIPP challenges that we have and how we plan to address them in the remainder of this financial year and next. 5.4 Joint Executive Team meeting (JET): I chaired the February meeting where our own Dr Gupta led an interesting discussion on diabetes. She produced a helpful paper that outlined the issues with some thoughts about what we need to do collectively to tackle the growing problem and prevalence of this disease in BHR. I understand that the diabetes leads across the three CCGs will be taking this work forward. There was a helpful discussion on the next steps with our broader vision for developing localities and shared transformation programmes and the benefits that the accountable care organisation (ACO) may offer with this. It was agreed that a longer session using the March JET time would be helpful to explore this further with clinical leads and some of their team members from BHRUT and NELFT. Mike Roberts of UCL partners facilitated the session. The clinical leaders from BHR have agreed to make some quick changes to improve patient care. We see this as

32 a starter to test the system, to see if it's ready to work in a collaborative way with the potential to truly integrate, leading to possible development as an ACO 5.5 Democratic and clinical oversight group: We now have fortnightly meetings with my equivalents in the local authorities and providers across BHR. I attended my first last month. These are helpful meetings for us as leaders to consider what we want to do as a system together and to consider the benefits an ACO may bring. 5.6 Health and wellbeing board: The 26 January meeting focussed on a number of areas including: delivering world class cancer outcomes for local people, our stroke consultation, the borough homelessness strategy and ACO developments. At the March meeting we discussed the Transforming Care Plan, London Ambulance Service quality improvement plans and the latest with the ACO business case. 6.0 Resources/investment 6.1 There are no additional resource implications/revenue or capital costs arising from this report. 7.0 Equalities 7.1 There are no direct equality implications from this report. 8.0 Risk 8.1 The CCG is managing a number of serious risks which are outlined in further detail in the assurance section of this agenda. 9.0 Managing conflicts of interest 9.1 There are no conflicts of interest arising from this report. 1 March 2016

33 To: From: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group Governing Body Conor Burke, Chief Officer Date: 22 March 2016 Subject: Chief Officer s Report Executive summary This report provides an overview of key activities undertaken by the Chief Officer and the CCG since the last meeting. Recommendations The governing body is asked to: Note the progress report 1.0 Devolution/Accountable Care Organisation (ACO) 1.1 Clinical leadership arrangements have been established and discussions are ongoing to help design the model, with considerable engagement with members and stakeholders planned. An update on progress will be provided later on the agenda. 2.0 Urgent and Emergency Care Vanguard 2.1 Extensive work has been undertaken by all partners to develop Value Proposition 2, detailing activity and financial modelling, and this was submitted to the national team on 8 February. The outcome of this bidding process is expected mid-march. Urgent and emergency care vanguards are expected to accelerate implementation and BHR has been awarded 1.3m of national funding for 15/16 to support this. Engagement and co-design events will be run throughout March. We are on track to deliver the key initial milestones of - 24/7 urgent care centre by the end of March and the co-design of the overall care model. 3.0 Primary Care Transformation 3.1 Work has progressed on the CCG s refreshed Primary Care Transformation Strategy. An update is provided later on the agenda. 4.0 Health and Wellbeing Board update 4.1 I attended Health and Wellbeing Board meetings on 26 January and 8 March. Discussions focused on delivering the 2020 ambition for world class cancer outcomes, stroke rehabilitation consultation, prevention schemes and Transforming Care for People with Learning Disabilities. 5.0 Sustainable Development update 5.1 The CCG continues to progress actions from its two year sustainable development plan. We have implemented a staff awareness campaign around energy and waste usage and have promoted national campaigns such as NHS Sustainability Day, which will be held on 24 March. For this we have asked each team in the CCG to make a pledge to change something in the way they work that will contribute to environmental sustainability and encourage Governing Body members to do the same. We have also encouraged staff to join HealthWorks a new online community to share ideas about staff health and wellbeing in the NHS which is designed to help us learn from each

34 other about health and wellbeing and to share ideas on how to improve our workplace. A full report on the progress of the current plan will come to the Governing Body later in the year. 6.0 Meeting attendance 6.1 I was invited to attend Healthcare People Management Associate event as a guest speaker on 2 February. I gave a presentation on our local joint plans for the development of an ACO, what that might mean for our workforce and what HR/OD capabilities we will need to make it happen. 6.2 On 17 February I attended the London Chief Officers meeting where discussions focused on business planning for 16/17, updates on ACO and Vanguard and the Healthy London Partnership programme. 6.3 I attended the Members Committee on 1 March and was pleased to see such high attendance from our GP membership. 7.0 Equalities 7.1 There are no equalities implications arising from this report. 8.0 Risk 8.1 There are no risks arising from this report. 9.0 Managing of conflicts of interest 9.1 There have been no conflicts of interest to manage.

35 To: From: Meeting of NHS Barking and Dagenham Clinical Commissioning Group Governing Body Sharon Morrow, chief operating officer Date: 22 March 2016 Subject: Governing body risk assurance framework report Executive summary The governing body assurance framework (GBAF) details the six significant risks to the organisation. These are: 1. Barking Havering and Redbridge University Hospitals Trust (BHRUT) emergency care performance 2. BHRUT referral to treatment times (RTT) performance 3. BHRUT cancer performance for the 62 days target 4. Improved access to psychological therapies (IAPT) 5. Quality, innovation, productivity and prevention (QIPP) delivery 6. Barts Heath contract financial risks Risks are reviewed on a monthly basis at various meetings and committees at the CCG and across BHR CCGs. This includes continued discussion as part of our assurance processes at our audit and governance committee in common. Recommendations The governing body is asked to: Note and comment on the current risks escalated to the GBAF and levels of assurance in the controls and mitigating actions being taken Raise and discuss other potential risks that may require escalation to the next GBAF 1.0 Purpose of the Report 1.1 The purpose of the GBAF is to outline the key strategic risks to the Clinical Commissioning Group (CCG) in achieving its corporate objectives and the controls in place to provide assurance that the risks are being affectively managed. 2.0 Background/Introduction 2.1 The CCG s governing body has a responsibility to maintain sound risk management and ensure that internal control systems are appropriate and effective, and where necessary to take appropriate remedial action. The CCG s risk register consists of risks that are local to the borough and risks that the CCG has in common with its collaborative partners, Havering and Redbridge CCGs.

36 3.0 Risks escalated to the GBAF 3.1 There are six on the GBAF. Please refer to appendix 1 for full details. These fall under four of the CCG s six corporate objectives and are as follows: Collaborative objective 3: Developing a system wide urgent care strategy and redesigning the urgent care pathway Risk 3.1: Continued concerns with urgent and emergency care at BHRUT - risks to patient care and viability of the trust. Frailty: Operational resilience plans - non delivery of additional initiatives and support to maintain performance over the winter period Mitigation: BHRUT being held to account via weekly operational performance monitoring meetings, escalated to monthly strategic review, reporting to the CCG governing body, quality and safety committee and CCG executive committee Improvement plan agreed (with Trust Development Agency (TDA)/ Care Quality Commission (CQC) / NHS England (NHSE) and CCGs) with monthly whole system Oversight and Escalation Group (OEG) to review progress against the plan. System Resilience Group (SRG) is leading the work to support improvement Friends and family scores recovery plan and performance monitored through Clinical Quality Review Group (CQRM) Trust performance improved significantly over the past year and is most nearer to the national standard On-going performance monitoring to ensure delivery and SRG planning 'winter' resilience for 15/16. Collaborative objective 4: Improved mental health services so that they deliver proactive and responsive care. Risk 4.1: Improved access to psychological therapies operating plan targets may not be met due to insufficient referrals into the service and insufficient capacity to meet recovery and waiting time targets. Mitigation: Joint recovery action plan being implemented with focus on increasing referrals into the services from practices. Referrals are being reported weekly to target interventions Havering is slightly below plan and has identified eight practices for additional support based on weekly referrals. An interim project manager has been recruited (three days/week) to strengthen PMO approach Communications plan finalised and with being implemented to raise awareness Plans are monitored monthly through joint meetings with provider with performance oversight at the weekly JMT meetings (identified as one of the CCG s top five risks) and bimonthly governing body meetings Twice weekly teleconferences with NHSE to report on progress. Corporate objective 5: Ensuring that planned care is appropriate, timely and of high quality. Risk 5.2: BHRUT 18 weeks referral to treatment times (RTT) failure to meet the national standards for RTT and data reporting. Page 2 of 4

37 Mitigation: Monthly joint OEG with the TDA to hold Trust to account for implementation and recovery reporting to the CCG governing body, quality and safety and executive committees. The agreed RTT admitted recovery plan being implemented with a significantly reduced backlog The full non-admitted plan reviewed with full RTT plan signed off by OEG in October 2015 Trust update weekly at Performance Assurance Group (PAG) on progress The clinical harm process and outcomes reviewed through the external harm panel chaired by Angela Lennox, associate medical director NHS England with BHR CCGs nurse director on the panel. Risk 5.3: BHRUT has failed to deliver the national 62 days cancer performance standard with potential impact on cancer diagnoses, treatment and clinical harm. Mitigation: Implementation of the full revised RTT recovery plan and trajectory (admitted and nonadmitted) agreed in October 2015 at the Joint Oversight and Escalation Group. Recovery monitored through PAG Detailed forward booking reviewed at weekly meeting to assess risk. Full contract levers applied. Risk managed through Performance Management Framework. Collaborative objective 6: Continued focus on our development as an organisation that delivers Risk 6.1: Failure to deliver identified QIPP schemes presents a risk to the achievement of planned surpluses 15/16-16/17 Mitigation: Review and escalation to the finance and delivery committees based on four specific trigger criteria: finance, activity, milestones and risk Confirm and challenge sessions implemented London and national horizon scanning to supplement locally developed schemes Linking to transformational activities and ensuring QIPP benefits trackers are applied through transformational projects governance BHR CCGs QIPP summit held in October 2015, with subsequent plan developed. Risk 6.2: Barts Health contract financial risks acute contracts, particularly Barts 15/16 contract has been signed by the lead commissioner and the CCGs are working with the collaborative to jointly manage the contract. The issues include; specialist commissioning movements, over performance risks and data quality risks. Mitigation: BHR CCGs engaged proactively in the commissioning collaborative and London wide arrangements to map specialist commissioning movements. BHR reserves the right of sign off to commitments of associates and continued strong application of contract management processes. Support and advise the lead commissioners and CSU in their engagement with Barts Health (BH) Page 3 of 4

38 Through lead commissioner arrangements enforce the accountability of Waltham Forest CCG and East London (WEL) under the lead commissioner contract BHR involvement and agreement in all finance decisions relating to the BH Contract 4.0 Resources/investment 4.1 There are no additional resource implications/revenue or capital costs arising from this report. The cost of operating effective risk management arrangements is met from within existing resources. 5.0 Equalities 5.1 There are no equalities considerations arising from this report. 6.0 Risk 6.1 This paper relates directly to risk. This report also links to the following GB papers being presented at this meeting which provide greater detail on key risks mentioned above and how they are being mitigated by the organisation GBAF ref. 3.1, 5.2 and 5.3 relates to item BHRUT performance risks GBAF ref. 4.1 relates to item 3.3 IAPT recovery 7.0 Managing conflicts of interest 7.1 There are no conflicts of interest considerations arising from this report. Attachments: Appendix 1 - Governing body assurance framework and summary Author: Pam Dobson, deputy director, corporate services, BHR CCGs Date: 19 February 2016 Page 4 of 4

39 Appendix 1 NHS Barking and Dagenham CCG Governing Body Assurance Framework (GBAF) Collaborative objective 3: Developing a system wide urgent care strategy and redesigning the urgent care pathway Risk Description: Failure to deliver quality improvement in urgent and emergency care at BHRUT could: a) threaten the long-term viability of the Trust and b) put patients at risk, cause reputational damage and delay the implementation of acute reconfiguration programmes. Initial Risk Rating 6/2013 Controls Assurances I = internal E = external Current risk rating Evidence for assurance Control Gaps Assurance Lead director: Alan Steward Risk ref: 3.1 Proposed actions Target Risk 31/03/16 Likelihood (4) x Impact (4) = Severe Agreed BHRUT original improvement plan with TDA/ NHSE monitored at monthly Oversight and Escalation meeting. Now replaced with phase two plan 2. Weekly Performance Assurance Group (PAG) and Operational Resilience Board 3. Contractual meetings SPR / CQRM and levers used fully 4. Monthly strategic review (MSR) meetings with senior leadership for overarching assurance and escalation of risk 5. System Resilience Group (Urgent Care Board) focused on system resilience with priorities focused on front door integration. 1. Minutes of the monthly oversight and escalation meeting (I) 2. Minutes of PAG and Operational Resilience Board (I) 3. Minutes of contractual meetings SPR / CQRM (I) 4. Minutes of strategic review meeting (I) 5. Minutes of the monthly System Resilience Group (urgent care board) (I) Likelihood (4) x Impact (4) = Severe 16 Item 3.2 on the agenda BHRUT exception report provides greater detail regarding how the CCG is managing this risk Continued monitoring and management through local performance management framework arrangements including weekly Operational Resilience Board, Performance Assurance Group, SPR and System Resilience Group. Continued liaison with NHS England and TDA to monitor arrangements and impact and ensure leading role for CCG SRG leading transformation programme (Vanguard) over next 2 years to transform urgent care. This will further assist the hospital to deliver the 4 hour target and improve quality. Likelihood (4) x Impact (3) = High Appendix 1_B&D GBAF and summary Mar 2016_Final Page 1 of 10

40 Collaborative objective 4: Improved mental health services so that they deliver proactive and responsive care. Risk Description: Improving access to psychological therapies (IAPT): Failure to deliver improved access to IAPT services could: 1) restrict people who would benefit from a service in accessing it and 2) threaten delivery of an operating plan commitment for a national mental health standard which will impact on CCG assurance ratings. Lead director: Sharon Morrow Risk ref: 4.1 Initial Risk Rating 9/2014 Controls Assurances I = internal E = external Current risk rating Evidence for assurance Control Gaps Assurance Proposed actions Target Risk 31/06/16 Likelihood (1) x Impact (3) = Low 3 1. Monthly review of activity plan and improvement actions by CCG 2. Teleconference with NHSE Assurance Team every two weeks to monitor progress and review of progress each month via activity return and assurance process. 3. Contractual meetings SPR / CQRM and levers fully utilised. 4. Delivery of improvement plan actions as discussed at the September 2015 GB meeting monitored through the governing body and relevant committees. 1. Monthly performance report minutes (I) 2. Minutes of NHSE assurance meetings (E) 3. Minutes of contractual meetings SPR / CQRM (I) 4. Minutes of the Executive and Finance and delivery Committee and the GB meeting.(i) Likelihood (4) x Impact (5) = Severe 20 Item 3.3 on the agenda IAPT recovery plan and report provides greater detail regarding how the CCG is managing this risk. 1. Action plan to be strengthened with additional interventions around marketing and communications 2. Weekly tracking of referrals going into the service 1. External assurance of plans and IAPT model 2. Weekly tracker introduced in December NHS England Intensive Support Team reviewed the CCG plan and report in September Comments incorporated into the CCG plan. Continued liaison with NHS England to monitor arrangements and impact. Likelihood (2) x Impact (4) = High Appendix 1_B&D GBAF and summary Mar 2016_Final Page 2 of 10

41 Corporate objective 5: Ensuring that planned care is appropriate, timely and of high quality. Risk Description: BHRUT 18 Week RTT a system upgrade exposed significant issues around RTT PTL management and reporting and therefore failure to meet the national standards for RTT and reporting for months. Lead director: Alan Steward Risk ref: 5.2 Initial Risk Rating 5/2014 Controls Assurances I = internal E = external Current risk rating Evidence for assurance Control Gaps Assurance Proposed actions Target Risk 31/03/16 Likelihood (5) x Impact (5) = Severe Monthly joint assurance meetings with TDA. 2. Weekly operational performance meeting with the Trust 3. Contractual meetings SPR / CQRM and levers used fully 4. Monthly Strategic review (MSR) meetings with senior leadership for overarching assurance and escalation of risk 5. Detailed clinical harm review framework and process including external panel 6. Implementation of the full RTT recovery plan and trajectory (admitted and nonadmitted) agreed in October 2015 at the Joint Oversight and Escalation Group. 1. Minutes of the TDA meetings (E) 2. Minutes of the operational performance meetings (I) 3. Minutes of contractual meetings SPR / CQRM contract notice issued (I) 4. Minutes of strategic review meeting (I) 5. Detailed clinical harm review framework and process progress monitored through PAG with outcomes monitored at CQRM (I). 6. Minutes of the joint oversight and escalation group for reporting process against plan (I) 7. Intensive Support Team (IST) providing support to Trust (E) Likelihood (4) x Impact (4) = Severe 16 Item 3.2 on the agenda - BHRUT exception report provides greater detail regarding the management of this risk 1. Return to national RTT reporting expected in February Demand management plan to address significant mismatch of demand over capacity 1. Independent report on PTL and pathway management 2. Demand management plan agreed by CCG The BHRUT exception report contains details of the issues, risks and mitigating actions. The CCG will review the independent assurance report on the systems, process and data quality necessary to return to reporting. Delivery programme board established with system director appointed reporting to Trust and CCGs. Clinical Reference Group developing demand management plan by February Likelihood (4) x Impact (3) = High Appendix 1_B&D GBAF and summary Mar 2016_Final Page 3 of 10

42 Risk Description: BHRUT cancer standards: failure to deliver national performance standards on cancer pathways for 62 day waits (now delivering on the 2 week standard) with potential impact on cancer diagnoses and treatment and clinical harm. Lead director: Alan Steward Risk ref: 5.3 Initial Risk Rating 5/2015 Controls Assurances I = internal E = external Current risk rating Evidence for assurance Control Gaps Assurance Proposed actions Target Risk 31/03/16 Likelihood (4) x Impact (4) = Severe Weekly Performance Assurance Group (PAG) meeting with the Trust. 2. Contractual meetings SPR / CQRM and Cancer CQN meeting with levers used fully 3. Monthly Strategic review (MSR) meetings with senior leadership for overarching assurance and escalation of risk 4. System wide assurance to NHS England 5. BHRUT 62 day cancer improvement plan and trajectory. 6. Implementation of the eight cancer high impact initiatives. 1. Minutes of the PAG (I) 2. Minutes of contractual meetings SPR / CQRM / cancer CQN meeting and associated remedial action plans. (I) 3. Minutes of strategic review meeting (I) 4. Minutes of NHS England assurance calls (E) 5. Minutes of the systemwide (NHSE / TDA / CCG) bi-weekly scrutiny (at PAG) (E) 6. Minutes of the PAG and SPR meetings for reporting progress against plan (I) Likelihood (4) x Impact (4) = Severe 16 Item 3.2 on the agenda BHRUT exception report provides greater detail regarding the management of this risk Likelihood (2) x Impact (2) = Medium Appendix 1_B&D GBAF and summary Mar 2016_Final Page 4 of 10

43 Collaborative objective 6: Continued focus on our development as an organisation that delivers Risk Description: Failure to deliver the CCG QIPP could: 1) adversely impact on the contractual activity agreements with relevant providers, 2) threaten delivery of an operating plan commitment which will impact on CCG assurance and 3) threaten the overarching year end budget delivery required for 15/16 Initial Risk Rating 8/2015 Controls Assurances I = internal E = external Current risk rating Evidence for assurance Control Gaps Assurance Lead director: Tom Travers Risk ref: 6.1 Proposed actions Target Risk 31/3/16 Likelihood (4) x Impact (5) = Severe 20 1 Monthly review of QIPP delivery ( finance and activity) 2 Monthly review of mitigating actions and risks per scheme where off plan 3 Formal escalation route to Finance and Delivery committee in place as due governance for all schemes that are off plan 4 Confirm and Challenge model in place for all new innovation / QIPP pipelines to ensure continual identification of schemes 1 Minutes of Monthly QIPP review meetings (I) 2 Risk log and mitigations for all schemes (I) 3 Minutes of Confirm and Challenge Sessions (I) 4 Minutes of Executive Committee and Governing Body (I) 5 Minutes of finance and Delivery Committee (I) 6 Monthly QIPP delivery summary reports against year trajectory. (I) Likelihood (3) x Impact (5) = Severe 15 Continued liaison Instigate JMT level monthly deep dive on QIPP as part of overarching finance and activity review. Dedicated QIPP dashboard instigated to inform review. Likelihood (3) x Impact (4) = High 12 5 Dedicated PMO in place as part of QIPP delivery infrastructure 6 Clinical Director QIPP and innovation meetings held monthly to embed clinical leadership and accountability and identification of required rectification plans Appendix 1_B&D GBAF and summary Mar 2016_Final Page 5 of 10

44 Risk Description: Barts Heath contract financial risks - Acute contracts, particularly Barts 15/16 contract has been signed by the lead commissioner and the CCGs are working with the collaborative to jointly manage the contract. Lead director: Tom Travers Risk ref: 6.2 Initial Risk Rating 5/2015 Controls Assurances I = internal E = external Current risk rating Evidence for assurance Control Gaps Assurance Proposed actions Target Risk 31/3/16 Likelihood (3) x Impact (3) = High 9 1 Lead Commissioner contract governance arrangements in place to manage contractual performance 2 Detailed contract variance drivers analysed and provided to Commissioners 3 Commissioning Support Unit (CSU) claims & challenges process in place and monthly engagement with Barts Health (BH) with status progress reports provided to Commissioners. 4 Waltham Forest and East London (WEL) and BHR finance leads engaged in joint management of risk. 1 Minutes of Clinical Commissioning Committee and Contract Review Group monthly meetings (E) 2 Minutes of NHS England assurance meetings and stocktakes (E) 3 Minutes of Executive Committee and Governing Body (I) 4 Minutes of Finance and Delivery Committee (I) 5 Monthly QIPP delivery summary reports against year trajectory (I) Likelihood (5) x Impact (4) = Severe 20 Support and advise the Lead commissioners and CSU in their engagement with BH Through lead commissioner arrangements enforce the accountability of WEL under the Lead Commissioner Contract BHR involvement and agreement in all finance decisions relating to the BH Contract Likelihood (3) x Impact (3) = High Appendix 1_B&D GBAF and summary Mar 2016_Final Page 6 of 10

45 Appendix 1 NHS Barking and Dagenham CCG GBAF - overall summary Lead / GBAF ref. Risk Description June 2013 Sept 2013 Jan 2014 March 2014 June 2014 Previous risk rating Sept 2014 Nov 2014 Dec 2014 Feb 2015 May 2015 Aug 2015 Oct 2015 Dec 2015 Current rating Feb 2016 End of year forecast This time Last time Target risk level A Steward 3.1 Failure to deliver quality improvement in urgent and emergency care at BHRUT 4 x 4 = 16 4 x 4 = 16 4 x 5 = 20 4 x 5 = 20 4 x 5 = 20 4 x 5 = 20 5 x 5 = 25 5 x 5 = 25 5 x 5 = 25 4 x 4 = 16 4 x 4 = 16 4 x 4 = 16 4 x 4 = 16 4 x 4 = 16 4 x 3 = 12 4 x 3 = 12 4 x 3 = 12 S. Morrow 4.1 Failure to deliver improved access to IAPT services 4 x 5 = 20 4 x 5 = 20 4 x 5 = 20 4 x 5 = 20 2 x 4 = 8 2 x 4 = 8 2 x 4 = 8 A Steward 5.2 Failure to meet the 18 weeks referral to treatment times targets at BHRUT 5 x 5 = 25 5 x 5 = 25 5 x 5 = 20 4 x 4 = 16 4 x 4 = 16 4 x 5 = 20 4 x 5 = 20 4 x 4 = 20 4 x 4 = 16 4 x 4 = 16 4 x 3 = 12 4 x 3 = 12 4 x 3 = 12 A Steward 5.3 Failure to deliver national performance standards on cancer at BHRUT 3 x 4 = 12 3 x 3 = 9 3 x 3 = 9 3 x 3 = 9 4 x 4 = 16 4 x 5 = 20 4 x 4 = 16 4 x 4 = 16 4 x 4 = 16 2 x 2 = 4 2 x 2 = 4 2 x 2 = 4 T Travers 6.1 Risk of failure to deliver the CCG QIPP plans 4 x 5 = 20 4 x 5 = 20 3 x 5 = 15 3 x 5 = 15 4 x 3 = 12 4 x 3 = 12 4 x 3 = 12 T Travers 6.2 New: Barts Health contract and financial risk 3 x 3 = 9 4 x 5 = 20 4 x 5 = 20 4 x 5 = 20 4 x 5 = 20 4 x 5 = 20 N/A 3 x 3 = 9 Risk Summary Number Total risks last report 5 New risk(s)escalated 1 Risks de-escalated this report 0 Total GBAF risk this report Appendix 1_B&D GBAF and summary Mar 2016_Final Page 7 of 10

46 NHS Barking and Dagenham de-escalated risks from the GBAF Lead / GBAF Ref. Risk description Initial risk rating Target risk level and date Risk rating when de-escalated J Himbury 4.1a & b (2 & 45) De-escalated in January 2015: a) A backlog of continuing health care reviews and outstanding initial assessments, inherited from the PCT, does present a clinical and financial risk to the CCG. b) Outstanding appeals and claims predating April x 5 = 25 June x 3 = 3 31 Dec x 4 = 12 Dec 2014 J Himbury 4.2 (10) De-escalated in June 2014: Assurance process of care homes. The CCG has not inherited a robust system for assuring quality of all providers the risk is that there is not a culture of sound monitoring. 3 x 5 = 15 June x 3 = 3 1 April x 3 = 3 June 2014 M Sheldon 3.3 (22) De-escalated in June 2014: Commissioning organisations are not able to run patient level validations for the first quarter to validate non contract activity which will present a financial risk 3 x 5 = 15 June x 3 = 3 1 April x 3 = 3 June 2014 S Morrow 3.2 (21) De-escalated in June 2014: Financial and operational pressures on practices associated with the transition of GP contracts to NHSE will impact adversely on practice engagement in QIPP delivery. The key risk is that we will fail to deliver our QIPP plan as a result of the issues. 3 x 5 = 15 June x 3 = 3 1 April x 3 = 3 June 2014 M Sheldon 3.1 (4) De-escalated in January 2014: Central allocation funding issue / specialised commissioning unexplained changes to the LSG calculations resulting in potential additional financial pressure to CCG 3 x 5 = 15 June x 3 = 3 1 April x 3 = 3 Sept Appendix 1_B&D GBAF and summary Mar 2016_Final Page 8 of 10

47 3.1.1 Appendix 1_B&D GBAF and summary Mar 2016_Final Page 9 of 10

48 How to interpret the CCG governing body assurance framework (GBAF): Lead director This is the executive lead with responsibility for: - managing the risks to the corporate objectives and - liaising with the risk lead to ensure the GBAF is up to date Reporting to the CCG governing body or other committee on progress Risk ratings: The risk rating is derived from conversation between the lead director (or nominated deputy) and the risk lead. The risk score is calculated using the risk grading matrix. There are three types of risk rating used in the CCG GBAF. - initial risk rating: this grades the risk as if there were no remedial measures in place. This is called the inherent risk. - current risk rating: this grades the risk taking into account the remedial measures. The remedial measures should aim to 1, reduce the likelihood of the risk materialising, 2, reduce the impact of the risk if it does happen and 3, reduce both. - target risk rating: this is the level of risk that the CCG is prepared to accept and the level of risk that must be aimed for. Risk ref This is a risk identifier attributed to the risk by the CCG risk lead wisk wef Lead Director 3.3 as wisk Description /ommissioning organisations are not able to run patient level validations for the first quarter to validate non contract activity which will present a financial risk Lnitial wisk wating (Wune 13) /ontrols 15 hur current control is we have issued instructions to the /SU not to pay un-validated invoices. Where we have a contract we will pay in line with the contract and monitor activity. Where there is no contract we will develop an alternative validation process. Until the process is developed we will not pay the invoices. Assurances A regular weekly report is being developed with the /SU to report on the progress. The audit committee will be updated on performance to only pay validated invoices. /urrent risk rating /ontrol Gaps 15 A detailed process for non contract invoicing requires urgent development. Assurance A regular report will be produced for the audit and governance committee troposed actions Develop new validati on process Target wisk 1/4/1 4 3 Proposed actions Where gaps have been identified, list the actions required to put them into place. Ensure they have a named lead and target date Risk description For each risk note down: Who can be harmed and how can they be harmed if the risk materialises. Areas to consider are: harm/ injury, objectives, claims or litigation, service disruption, staffing and competence, morale, financial, external assessment and adverse media interest Controls What is being done to reduce the likelihood and severity of the risk. One specific risk may be mitigated by a number of controls Assurance Assurances are inevitably bits of paper that act as evidence the controls are in place. Examples include: Job descriptions /organisation charts Regular reports Contracts / service level agreements Policies and procedures Minutes / agendas / terms of reference Gaps in controls What more can be done to control the risk and what controls could be improved Gaps in assurance What associated documentation will demonstrate that the controls are in place? Appendix 1_B&D GBAF and summary Mar 2016_Final Page 10 of 10

49 To: From: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group (CCG) Governing Body Conor Burke, Chief Officer Date: 22 March 2016 Subject: BHRUT Performance Risks Executive summary The CCGs are continuing to manage a number of performance issues at Barking, Havering and Redbridge University Trust (BHRUT) around A&E, Referral to Treatment (RTT) and Cancer access standards. These issues are all included in the CCG s Risk Register and Governing Body Framework. This report provides a further update on the key actions that the CCG is taking to seek performance improvements at the Trust. It is doing this by both holding the Trust to account through its contract and other mechanisms, as well as providing support through wider system initiatives overseen by the System Resilience Group. The CCGs are working closely with the Trust Development Agency (TDA) and NHS England (NHSE), as well as local partners as the system leader to ensure that performance is recovered and then sustained. Recommendations The Governing Body is asked to: Note the action being taken to date to mitigate the performance risks at BHRUT Suggest any further actions that the CCG should consider to address the performance and quality risks for local people. 1.0 Purpose of the Report 1.1 The CCG s Governing Body Assurance Framework and the risk register identify a number of areas where the CCG is concerned about performance issues at BHRUT. This report provides an update on the actions that the CCG is taking to seek performance improvements at the Trust on A&E, RTT and Cancer. 2.0 A&E 2.1 A&E performance at BHRUT has not achieved the national standard (95%) from August 2015 to date. Provisional performance in January was 83.3% compared to 83.0% in 2015 continuing a trend of year on year improvement. However February performance has dropped to 80.4% (provisional) and is significantly below 2015 (92.57%). 2.2 Comparative data for the year to date (April February) demonstrates a 5.6% (13,102) growth in attendances compared to the same period in 2015/16. However significant growth has been experienced of over 18% for the consecutive months January and February compared to the same period in This has continued a significant growth trend in attendances since Quarter Three. Ambulance conveyances have increased significantly during the winter period; while as a proportion of total attendances they remain consistent with prior year trends, the actual numbers each week have increased with an average of 1020 per week to Queens Hospital in January compared to 880 in January 2015 and significantly 367 to King George Hospital (KGH) compared to 307. This growth is consistent with wider London trends.

50 2.3 The Trust has reported that the high attendance rates coupled with clustering of attendances especially during out of hours periods coupled with challenged staffing levels have resulted in increased numbers of breaches. Commissioners continue to assess the A&E performance on a daily and weekly basis to hold the Trust to its contractual obligations. There have been daily calls across the sector to review issues affecting performance and flow and agree any further actions that are required. 2.4 The CCGs issued a Contractual Performance Notice (CPN) in July due to the failure of the Trust to consistently deliver the 95% standard. Through the Systems Resilience Group, it was agreed to develop a joint action plan focusing on how A&E performance can be assured and delivered through the winter, with a focus on the front door of A&E. This has improved performance compared to last year as highlighted above. Performance remains very fragile however driven by the following key issues: Significant surge in A&E attendances compared to prior year both walk-in and ambulance conveyance ED staffing shortages, in particular low proportion of medical rotas that are filled Poor performance during night shifts, related to access to access to senior decision making and surges of patients during the evening and night Reduced throughput in the Queen s UCC Multiple services at the front door of A&E that can be confusing to patients 2.5 The following actions are being taken to address these issues: Medical rotas are reviewed to ensure all mitigating actions are taken to prevent staffing issues. The Trust has appointed three emergency department (ED) consultants to commence in Quarter Four. The Trust is negotiating with the GP Federation to improve UCC utilisation at Queen s and to increase operational hours. The CCGs continue to challenge the increased A&E activity until this issue has been resolved. Review of Intelligent Conveyancing (IC) with London Ambulance Service (LAS) Commissioners are monitoring and seeking assurance through the CCGs weekly Performance Assurance Group (PAG) that all actions are being taken and escalation processes are in place. The ED improvement plan is the basis for monitoring progress through PAG. 2.6 Through the System Resilience Group (SRG) there is continued support to Emergency and Urgent Care through schemes implemented in 2014/15 and funded by 15/16 Winter resilience monies; these include GP Federation primary care hubs, care home schemes, rapid access to mental health service (RAID) and Frail Older Peoples Liaison Service (FOPAL), Community Treatment Teams (CTT) and Intensive Rehabilitation Service (IRS) and the Joint Assessment and Discharge team (JAD). In addition, the Trust continues to implement Majors-Light, A&E Urgent Care Triage, improving the Medical Receiving Unit and Elderly Assessment Units and improving earlier discharge. 2.7 The SRG Winter Resilience Plan 2015/16 builds on the measures introduced last year with an additional focus on mental health liaison, support around care packages and discharge to assess. There are separate reports on the agenda looking to extend funding for a number of these initiatives. 2.8 The CCGs will continue to hold the Trust to account through its existing arrangements including the weekly PAG and the monthly contractual Service and Performance Review (SPR) meeting. 3.0 Referral to Treatment Targets (RTT) 3.1 In December 2013, the Trust identified significant RTT issues following the implementation of its upgrade to a new Patient Administration System (PAS) including internal system and capacity

51 issues that have affected RTT performance. As a consequence of this, the Trust has suspended national reporting on RTT performance. 3.2 Due to the failure to report on these standards, commissioners issued a Contractual Performance Notice (CPN) that required a detailed recovery plan to be developed. 3.3 The resolution of the RTT data quality issues and the need to reduce the admitted and nonadmitted backlogs has been given high priority by the CCG. The CCG has met with the Trust weekly through its formal Performance and Assurance Group (PAG) to review progress to recover RTT standards (as well as A&E and Cancer). A monthly Oversight and Escalation Group with membership from the Trust, CCGs, NHS England and Trust Development Agency (TDA) to oversee and provide assurance on the recovery of the national standard. 3.4 In November 2015 with the detailed recovery and implementation plan nearing completion the CCGs established a joint Programme Board with the Trust to implement the recovery plan and ensure issues and risks are mitigated. A system director for RTT was appointed in January 2016 reporting directly to the Trust Chief Executive and CCG Accountable Officer. The recovery plan will be submitted to the Trust Board and CCG Governing Bodies for approval. The System Director and Programme Board will report formally through the CCG s governance to the Governing Bodies. 3.5 The core elements of the recovery plan are: improving internal trust productivity, outsourcing to secure additional capacity and demand management. To improve internal productivity the Trust has implemented additional weekend and evening theatre lists and clinics, commenced recruitment processes for consultants across a range of specialties who will be in post from April To support the ongoing validation of the waiting list, all patients who have waited greater than 52 weeks have been contacted by the Trust by phone to confirm their current waiting list status (circa 1,000 patients). 230 patients of those contacted have confirmed that they no longer require the appointment. The Trust will continue to call long wait patients with a further cohort of >45 week waiters to be called. The Trust will also be writing to patients who have waited >18weeks but <45 weeks to request confirmation of their waiting list status. An initial sample of 300 patients has been written to gauge the response rate and assure that potential risks are being managed. 3.7 An external analysis of theatre utilisation and productivity has been undertaken to identify process and practice developments that could improve theatre productivity. The Trust has appointed a project manager to lead development of the productivity plan to commence in February. 3.8 The Trust commenced outsourcing of patients requiring admitted treatment in July 2015; the conversion rate from offer of alternative provider to actual treatment is 31%. Factors affecting increased activity are patient choice and clinical exclusion preventing transfer. 3.9 A Clinical Reference Group (CRG) has been established to develop the demand management plan and is meeting fortnightly. The group has prioritised specialties where it is felt a greater impact can be made on wait times through referral management, clinical protocols or establishment of alternative pathways and new technologies; these include dermatology, ENT, Orthopaedics and Gastroenterology. The CCG has engaged with the national Behavioural Insights Team to support development of demand management plans to understand how to influence the behaviour of patients It is anticipated that the earliest recovery of the standard will be March 2017; however there remains substantial risk to achieving this due to the volume of patients who have already breached their 18 week wait. Priority is given to any patient that has waited over 52 weeks to make sure that they are treated as soon as possible.

52 3.11 The Commissioners and the Trust have agreed additional resources for increased activity in Quarter Four to bring forward outpatient attendances and treatment for patients with >52 week waits. An additional 757 outpatient attendances will be booked in February/March with an additional 114 surgeries to be undertaken The IST reviewed the Trust s RTT data quality, systems and processes in October The report from this review on the data quality is awaited and is a key requirement for the Trust to return to reporting. Despite escalation through NHSE to the IST, this report has yet to be received. Given the delay in receiving this report, the CCGs are commissioning an independent review of the Trust s system and processes The Trust has agreed a clinical harm process drawing on good practice developed elsewhere. This is being implemented with both an internal and external harm review panel meeting to review progress and outcomes. No significant or moderate harm has been identified from the cases reviewed for the admitted pathway. Locally the progress of clinical harm reviews is reported to the weekly PAG with the outcomes reviewed at the Clinical Quality Review Meeting (CQRM). 4.0 Cancer 4.1 Cancer performance is one of the eight national priorities for delivery. While performance overall on cancer pathways has improved at the Trust over the last six months with seven of the national standards being met until December, the 62 day standard has consistently been failed. 4.2 In December the Trust reported that the 2week wait, 2week wait breast and 31 Day First Definitive Treatment and 31 Day Subsequent Surgery standards. Provisional data for January shows the Trust has not recovered the standards. The Trust has indicated that patient choice over the holiday period, theatre and capacity issues in December and January have resulted in the breaches. The Trust is working to recover the 2week and 31 day standards by February reporting and have implemented additional activity to address capacity and backlog. 4.3 A CPN was issued against the 62 Day Cancer standard in 2014/15, which remains open due to the lack of improvement in performance. 4.4 The Trust has failed the 62 day standard (85% target) since June The Trust developed a Cancer Action plan which has been signed off by the CCGs, TDA and NHSE with a planned recovery of the standard by January 2016, with a trajectory provided showing how performance would improve month on month. The Trust did not achieve this trajectory and have presented a revised trajectory with recovery of the standard now expected in May A significant increase in the number of patients waiting with or without a decision to treat (DTT) was reported in February. These patients were known and were being tracked but were not being correctly reported through weekly submissions to the TDA. The Trust has - as required - reported this as an SI. The continued failure of the 62 Day Standard has resulted in escalation to weekly monitoring of planned and actual activity and the booking of patients who have waited greater than 62 days for treatment from referral against a weekly trajectory. 4.6 Recent deliverables that the Trust and Commissioners have implemented and continue to develop include: Increased activity in February May above run-rate to reduce the number of patients waiting, Tumour site specific plans with the implementation of straight to test pathways for some specialties and a focused change programme for urology with the continued implementation of the London prostate cancer pathway, Improving the tracking of patients on the suspected cancer waiting list and the analysis and reporting of the trends,

53 Completing pathway mapping with the support of NHS Elect a national NHS improvement agency. Five pathways out of the nine have been completed, and Improving compliance on transferring tertiary cases by day Due to the issues reported in February with regard to data and the failure to recover the trajectory in January, the CCG is looking to commission an independent review of the cancer pathway and process management. 4.8 Commissioners continue to monitor the number of over 100 days treatment breaches and have agreed with the Trust that from February patients who have waited >62 days are to be reviewed by Divisional Directors and reported to the External Harm Review Board. The Trust has issued guidance and timelines on the completion of these ham reviews. Harm reviews are expected to be complete and recorded within the second month after treatment. 5.0 Resources/investment 5.1 The CCG Chief Financial Officer and other senior leaders are working with NHSE, TDA and other partners to secure the required resources to deliver the changes. 6.0 Equalities 6.1 The implementation of the Trust improvement plan and the associated remedial action plans identified above will improve quality and reduce health inequalities. 7.0 Risk 7.1 This report highlights the key risks around each of these issues. These risks are included in the Governing Body s Assurance Framework and this report provides further detail to the Governing Body on the issues and action being taken to mitigate them. Author: Date: 2 March Conor Burke, Accountable Officer

54 To: From: Meeting of the NHS Barking and Dagenham CCG Governing Body meeting Dr R Kumar Date: 22 March 2016 Subject: Delivery of IAPT operating plan standards Executive summary CCGs are required to deliver two mental health standards related to Improving Access to Psychological Services (IAPT) in the 2015/16 operating plan - 15% of adults with relevant disorders will have timely access to IAPT services with a recovery rate of 50%. From 1 April 2016 CCGs are required to meet a waiting time access standard so that 75% of people referred to IAPT are treated within six weeks of referral and 95% will be treated within 18 weeks of referral. The BHR CCGs have all committed to meeting these targets for 2016/17 in their Operating Plan submissions of February Although B&D CCG did not deliver the access standard in 2014/15 or in Quarters 1 and 2 of 2015/16, it did meet the standard in Q3 following the implementation of a recovery action plan to increase activity into the service. B&D CCG is predicted to achieve the access standard again in Q4, with January s performance being very close to the target (1.24% against target of 1.25%) and the expectation that this slight underperformance in January will be recovered in February and March. B&D CCG has seen under-performance against the recovery standard of 50% in 15/16. Current waiting times for B&D are less than 5 weeks. Recommendations The Governing Body is asked to: Note the recent performance against the IAPT standards Comment on actions being taken to recover performance in quarter Purpose of the Report 1.1 This report provides an update to the Governing Body on actions that are being taken to improve performance against the Improving Access to Psychological Therapies (IAPT) standards.

55 2.0 Background/Introduction 2.1 The Governing Body has received reports in November 2015 and January 2016 notifying of the performance against the IAPT access target and actions in place to recover this performance where necessary. 2.2 CCGs are required to deliver the access standard for IAPT which is that 15% of adults with relevant disorders will have timely access to IAPT services and the recovery standard of a 50% recovery rate. 2.3 By 1 April 2016 CCGs are expected to deliver a waiting time standard for IAPT so that 75% of people referred to IAPT are treated within six weeks of referral and 95% will be treated within 18 weeks of referral. 2.4 Barking and Dagenham, Havering and Redbridge CCGs have contracted with NELFT to provide the IAPT service and have agreed additional investment to ensure that the capacity is in place to deliver these targets. 2.5 Delivery of the IAPT access and recovery standards was a component of the CCG operating plan in 2014/15 and continues to be so in 2015/16. BHR CCGs are some of the few in London not attaining the required access targets. 3.0 IAPT performance - access 3.1 Barking and Dagenham CCG exceeded the monthly target for October, November and December 2015 and were just under target in January Data for the neighbouring BHR CCGs is included in the table and figure below for comparative purposes. Please see table 1 and fig 1 below. Table 1: Access performance report Target B&D Actual Havering Actual Redbridge Actual (Provider monthly (HSCIC Monthly figures Apr - Oct 15) figures) April May June July Aug Sept Oct Nov Dec Jan 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 1.25% 0.39% 1.37% 1.32% 1.08% 1.08% 1.20% 1.37% 1.38% 1.28% 1.24% 0.22% 1.14% 1.32% 0.97% 0.99% 1.12% 1.24% 1.05% 0.73% 1.06% 0.21% 1.15% 1.25% 1.17% 0.70% 0.86% 1.01% 0.81% 0.57% 0.88% Page 2 of 5

56 Fig 1: Graph showing CCG performance against target (Provider data) Target B&D Actual Havering Actual Redbridge Actual Year-end projected access rates (see table 2 below) B&D CCG Current forecast rate of 14.22% access rate for full year 2015/16, and consistent achievement of 3.75% access rate from Q3. This is an improved position from the previous Governing Body report. Table 2: Expected performance 2015/16 15/16 forecast access rate (full year) Barking and Dagenham CCG 14.22% Havering 12.53% Redbridge 11.49% 3.4 The CCG is implementing a Recovery Action Plan to improve performance. CCG actions since January have focused on: Delivering a programme of practice visits to increase GP referrals to IAPT. 37 practice visits have been completed in B&D this year by the Clinical Lead for mental health and NELFT service lead, supplemented by locality meetings in October, November and February. Positive feedback has been received from practices on the educational support that has been provided which has improved their understanding of the service and addressed queries on the referral process Introducing a new/simplified GP referral form to support direct referrals Finalising and implementing a BHR marketing strategy and campaign, based on evidence and research gathered over the past few months, which has resulted in rebranding of the service (currently underway). Close monitoring of activity, including requesting GPs to consistently code referrals with the same input code, and develop weekly reports of activity to drive recovery actions. Page 3 of 5

57 Monitoring telephone response to callers to IAPT service (including mystery shopper exercise). 3.5 The Recovery Action Plan includes the following actions that will take place during March and April: Using weekly referral data to target practice visits and support; a practice based approach has been shown to be effective in improving referral rates Improvements to the telephone response to callers to the service to ensure that all people contacting the service are able to speak to someone promptly and are proactively managed Launch of marketing campaign to increase awareness of the service to those who would benefit from it 4.0 IAPT performance recovery 4.1 The recovery standard is that 50% of people who complete treatment are moving to recovery. NELFT is currently reporting an average recovery rate of 48.29% for Q3 which is marginally below target and is being monitored through the contract meetings to deliver a 50% recovery rate in Q IAPT Performance waiting times 5.1 Achievement of the waiting time standard is required from 1 April The standard is (i) the proportion of patients that wait six weeks or less for referral to entering a course of IAPT treatment against the number of people who finish a course of treatment in the reporting period (ii) the proportion of patients that wait 18 weeks or less for referral to entering a course of IAPT treatment against the number of people who finish a course of treatment in the reporting period. 5.2 Preparation for the delivery of the waiting time standard has been included in the Service Development and Improvement Plan as part of the NELFT contract. Delivery of this plan is on target. 6.0 Resources/investment 6.0 CCGs have identified additional dedicated project management support from within existing resources. 7.0 Equalities 7.1 Disparity in the quality and availability of mental health services is a long standing issue. The introduction of access standards for mental health is one step to ensuring that mental health is treated on a par with physical health. 8.0 Risks 8.1 The key risk is that patients are not receiving access to the care and support that they need. Non-delivery of the IAPT action plans will lead to failure to deliver the IAPT targets Page 4 of 5

58 by CCGs. This will impact on the annual CCG assurance rating from NHSE which determines whether the CCG can be considered to be a competent commissioner. 9.0 Managing conflicts of interest 9.1 There are no conflicts of interest considerations arising from this report Author: Gemma Hughes, Deputy Chief Operating Officer Barking and Dagenham CCG Date: 26 February 2016 Page 5 of 5

59 To: From: Meeting of the NHS Barking and Dagenham CCG Governing Body Sarah See, Director of Primary Care Transformation Date: 22 March 2016 Subject: Personal Medical Services (PMS) Review - update Executive summary The purpose of this paper is to brief the Governing Body on the latest position regarding the Personal Medical Services (PMS) Review, namely: the London offer agreed between NHS England (London) and London s Local Medical Committees and the draft commissioning intentions and the overall funding position for the CCG. Recommendations The Governing Body is asked to: Note the agreed London offer for PMS agreements; Comment on the draft commissioning intentions for the CCG, the overall funding; and Agree that review and discussion on these matters including the impact at individual practice level takes place at the Primary Care Commissioning Committee. 1.0 Purpose of the Report The purpose of this paper is to brief the Governing Body on the updated position regarding the Personal Medical Services (PMS) review, namely: the London offer agreed between NHS England (London) and London s Local Medical Committees and the draft commissioning intentions and the overall funding position for the CCG. advise that a Equality Impact Assessment (EIA) is being completed. 2.0 Introduction 2.1 In January 2015 the Governing Body received an update paper outlining progress on the nationally mandated review of PMS agreements. The paper reminded the governing body of the national and London principles underpinning the review and how the work was being taken forward across London and locally within the CCG. 2.2 Since then NHSE London have confirmed that the London offer has now been agreed with London s LMCs to ensure a consistent service offer for all Londoners.

60 3.0 The new PMS contract 3.1 It is confirmed that the main body PMS contract and Schedule 13 will form what will be referenced as the core PMS contract. The mandatory / non-mandatory key performance indicators (KPIs) and the premium service specification also form part of the London 0ffer and attracts funding above the core main body offer i.e. premium funding. 3.2 The funding associated with each of the above components is outlined below: Figure 1. New PMS contract components / funding PMS Contract Optional Premium Service Specification Mandatory KPIs Optional KPIs Schedule 13 Service Requirements Main body contract- Regulations prp 3.04 pwp 1.36 pwp pwp prp Premium funding Core funding (assumed GMS equivalent) 3.3 To remind governing body members, the main body of the contract largely comprises national PMS regulations and includes details such as contract holder, a definition of essential services, information on who can perform services, the management of patient records, termination clauses, etc. The contract can be viewed at Schedule 13 of the core contract sets out a list of services that patients can expect to be provided by a PMS contractor. Payment for this schedule is assumed as part of the main contract and therefore does not attract any additional payment above core funding. The requirements set out in this schedule are designed to be equivalent to the GMS contract but provide greater definition than corresponding elements in the GMS contract. 3.5 The proposed KPI schedule has been updated following discussions with all London LMCs; breast screening has now been removed from the mandatory KPI list. The following areas are now finalised as the mandatory KPI s: Cervical Screening; Vaccinations and Immunisations, i.e. childhood Immunisation, flu and Pneumococcal immunisations; and Patient Voice a selection of indicators that sourced from the national GP Patient Survey - CCGs need to select two from a number of suggested indicators. 1 This includes Saturday morning opening - cost 4 per raw registered patient based on an average practice of 6000 patients and improving access through the use of technology 1pwp for full achievement. Additional capacity has not been included as pricing for this is to be determined locally.

61 Optional KPIs - Breast Screening and Capacity & Access measures e.g. attendance at local Walk in Centres, Urgent Care Centres and A&E. The mandatory KPIs should be commissioned by all London CCGs/NHSE - although there is some local determination as to which patient voice indicators CCGs wish to commission. The capacity and access measures and breast screening are optional KPIs. 3.6 Performance and payment against the KPIs will be measured against 4 bands: Band A - Optimal Performance level Band B- Acceptable Performance Level Band C- Minimum Performance Level Band D- KPI Failure 3.7 The optional premium service specification describes services that will support implementation of the Strategic Commissioning Framework (SCF). NHSE have developed three areas which facilitate delivery on patient choice, contacting the practice, routine opening hours and same day access. 3.8 There are three premium provisions within this specification: Flexing Capacity sets out a requirement that practices extend core hours to include four hours on a Saturday morning (09:00 13:00); this attracts a payment of per registered patient (prp); Additional Capacity sets out a requirement for practices to offer additional appointments; cost to be determined locally; and Improving Access through Use of Technology incentivises practices to increase access to online services such as booking and cancelling appointments, access to patient records, ordering repeat prescriptions and electronic consultations. Maximum payment available is 1.00 pwp. 4.0 Financial implications 4.1 As outlined previously a number of key principles are in place that is: Any released PMS funding should be reinvested in general practice; CCGs with NHSE may choose to commission locally specific services with released PMS funding or use additional funding at CCG level; The review will establish as a minimum an agreed cost per weighted patient for the delivery of the agreed specification across all PMS providers at a CCG level; The review will ensure equality of opportunity across all GP practices - PMS, GMS and APMS - provided they are able to satisfy locally determined requirements; and Funding not invested in core PMS requirements should be reinvested in general practice for CCG or SPG specific services via PMS contracts or other commissioning mechanisms. 4.2 There are 11 PMS practices in Barking and Dagenham with a PMS premium of c 2.4m invested; there is a wide variation between individual practice premiums, the minimum being and the maximum per patient. 2 Based on a list size of 6000 registered patients.

62 The affordability of the London PMS contract has been modelled against the PMS premium available for each CCG. (see Table 1 below) Table 1 - London PMS offer Contract type Mandatory KPIs ( ) Optional KPIs ( ) Saturday opening ( ) Use of technology ( ) Additional capacity 3 ( ) Total London Offer Cost PMS 211,981 94, ,484 69, ,030 GMS 350, , , ,238 1,092,644 Overall 562, , , ,969 1,763,674 Commissioning the entire London offer in Barking and Dagenham, for both PMS and GMS practices will cost in excess of c 1.8m as the additional capacity element is to be costed locally. 5.0 Draft Commissioning Intentions 5.1 The CCG was required to submit draft commissioning Intentions to NHSE by 19 February These were submitted noting that they were draft intentions and further work would need to be completed once the CCGs financial baseline position was known and validated. These intentions will also need to be discussed with the LMC, agreed by NHS England and final approval sought from the Primary Care Commissioning Committee (PCCC). 5.2 From July 2016 the CCG proposes to commission 4 the following from all PMS practices: Mandatory KPI s Use of technology from April 2015 practices were contractually required to offer online services to patients and all practices are technically able to do this. However this provision and associated patient communication is variable. There is a national drive to improve the usage of on-line services and increase the number of appointments offered on-line to patients. This shift is expected to improve practice productivity. It is therefore proposed that this is commissioned to drive improvement further and encourage practices to actively offer these services to patients. It will also support implementation of the SCF. Additional Capacity this is an area which should be prioritised, subject to the outcome of negotiations and formal CCG approval. Patient survey (GPPS) results for B&D are below the London and national average. Currently in B&D a number of PMS contracts require practices to offer 100 appointments per 1000 patients per week, should this not be commissioned as part of the new offer this would have a detrimental impact on patient access in the borough. It is also felt that commissioning additional capacity in-hours from all practices would have a positive benefit on patients and would also support implementation of the SCF. 5.3 The CCG does not plan on commissioning the flexible capacity premium specification. This would not be cost effective, nor do all practices have the resources to offer Saturday opening. However Saturday opening is already commissioned for the whole population via GP Access Hubs (two currently operational in B&D albeit the second Hub currently only opens weekday evenings). Currently Hubs vary their opening hours and capacity to meet demand but from 1 April 2016, the CCG will need to, as a minimum, ensure 1 Hub is commissioned to open for four hours on Saturday mornings. ( ) 3 To be determined locally 4 Subject to approval from PCCC, agreement from NHSE and discussions with the LMC and local practices

63 5.4 The CCG also intends to commission the GMS equalisation on a staggered basis from 2016/17 as outlined below: 2016/2017 Improving access through use of technology 2017/2018 Mandatory KPIs 2019/2020 Additional capacity The table below sets out the cost of the local offer and the borough impact. The impact on individual practices will be reviewed at the PCCC. Contract type 2016/ / / / /21 PMS - Transition Cost 1,335,778 1,001, , ,944 0 PMS - Contract Premium Offer 780, , , , ,287 GMS 115, , ,561 1,289,512 1,289,512 Overall 2,231,302 2,247,681 1,913,736 2,403,743 2,069,798 Current B&D PMS Premium 2,450,009 2,450,009 2,450,009 2,450,009 2,450,009 Change in funding -218, , ,273-46, ,211 Note:- The figures shown above are based on 2015/16 list sizes are at 2016/17 prices. Future years will be subject to growth and inflationary increases. 5.5 Overall the new offer would mean that all practices would see a reduction in funding ranging from 10% to 30% of their current contract value. The intention would be that these reductions are staggered annually by equal amounts until 2020/21 by which time the final premium would be pwp. All GMS practices would financially gain over the four year period. As a result, by 2019/20 all patients would have the same level of services available to them at their GP practice, regardless of the type of contract in place. 5.6 It is envisaged that GMS equalisation will be funded incrementally - as PMS practices transition down annually money would be invested in GMS practices. Delegated responsibility from NHSE for Primary Care Co-Commissioning has identified a number of reporting and information risks leaving the CCGs with an underlying primary care funding gap. The PMS/GMS contacts form part of these budgets and therefore the on-going funding relating to changes in PMS/GMS contract values will be incorporated in the overall primary care co-commissioning position. In future years the local offer requires significant investment and will need to be reviewed in line with the transformation plans and the financial Plans. 6.0 Gap and Impact Analysis of decommissioning current services 6.1 Unfortunately despite the best efforts of NHSE and CCG staff the data and information available was limited due to some practices not completing a return. Currently a range of KPIs/ services are commissioned, but the CCG has been unable to ascertain activity levels. Based on discussions that have taken place it is felt that a majority of the services currently commissioned will be covered in new contractual arrangements. 7.0 Resources 7.1 The provisional resource implications of the PMS review are outlined in section 4 and 5 above. 8.0 Equalities A draft equality impact assessment has been undertaken as part of the review following engagement and communication with key stakeholders. This shows that there will be no negative or adverse impact for any of the equalities groups.

64 9.0 Risk 9.1 The CCG s Primary Care Commissioning Committee reviews the risk register relating to the delegated responsibilities (including the PMS review) on a monthly basis; high-level risks are escalated to the corporate risk register. Below are some of the key risks Risk and impact Prob Imp Severity Mitigating Action There is a risk that this may not be able to be delivered by the expected deadline in March Local working group meeting monthly. Project Plan and Communications Plan in place. Relationship between practices / members may be challenged if difficult decisions have to be made, leading to resistance and poor relationships with practices. All PMS practices give notice of terminating their contract / retire from contract Presentations and briefings currently underway at HOSC/HASS. Member drop in sessions held in January and communication to practices ongoing. Individual practice meetings planned between April-June Member drop in sessions held in January and communication to practices ongoing. The CCG is currently arranging to meet respective LMCs to discuss draft commissioning intentions. Individual practice meetings planned between April-June Managing conflicts of interest 10.1 This paper is for information only so that the Governing Body is kept updated on progress with and understands the construct of the proposed PMS contract and its implications for the CCG in terms of supporting the CCG s commissioning intentions and overall affordability. Author: Natalie Keefe, Head of Primary Care Transformation Date: 3 March 2016

65 To: From: Meeting of the NHS Barking and Dagenham CCG Governing Body Sharon Morrow, Chief Operating Officer, Barking and Dagenham CCG Date: 22 March 2016 Subject: Operational Planning 2016/17: update on submissions Executive summary This paper provides an update to the Planning Round briefing submitted to the January Governing Body and provides further detail regarding: Draft CCG Operating Plan submissions made in February and March Requirements for the final Operating Plan submission to be made on 11 April Requirement for the Better Care Fund (BCF) Plan Submissions in March and for the final BCF Plan submission to be made on 25 April The process required to sign off the final Operating Plan submission and BCF Plan submission. Recommendations To note the information given below regarding the draft Operating Plan submissions already made, and the final 11 April submission To note the information given below regarding the draft BCF Plan submission already made, and the second draft due on 21 March and the final 25 April submission To give delegated authority to the BHR CCGs Chief Finance Officer and Accountable Officer to sign off the final submissions ahead of the 11 April and 25 April submission dates. 1.0 Purpose of the Report This report provides a narrative summary of the draft Operating Plans submitted on the CCG s behalf on 8 February and 2 March 2016 and describes next steps required to develop plans for the full and final submission on 11 April. It also provides an update on the Better Care Fund Plan submissions in March and the next steps required to develop plans for the final submission on 25 April. 2.0 Summary of requirement for 2016/17 Operating Plans 2.1 The NHS England 2016/17 Planning Guidance confirms that for 2016/17, CCGs are required to compile and submit a single-year Operating Plan which covers finance, activity, capacity and key performance standards. The Operating Plan then represents year one of the five year Sustainability and Transformation Plan; a final version of which

66 is to be submitted in June. These plans must demonstrate how local health economies will accelerate their rate of transformation and deliver the vision of the Five Year Forward View by Draft Operating Plan submissions 8 February and 2 March The first draft Operating Plan was submitted on behalf of the CCG on 8 February. A second draft Operating Plan was then submitted on behalf of the CCG on 2 March. The second draft refined the activity and finance elements of the submission first made in February. No changes were made to the Constitutional Standards or mental health trajectories between the two submissions. 3.2 In activity terms the Operating Plan commits Barking and Dagenham CCG to reducing activity by 0.39% (1,275 units of activity across all acute activity types). This is the net effect of 2.3% growth for demographic and seasonality factors and a reduction of 2.69% for the anticipated effect of transformational/demand management schemes. 3.3 For the NHS Constitutional Standards and mental health standards, the draft plans commit the CCG to: Full achievement of RTT, diagnostics, dementia diagnosis and all IAPT standards Achievement of all cancer standards with the exception of 62 day, which will be achieved by July Achievement of the A&E standard by September 3.4 NHS England reviewed the CCG s Operating Plan to ensure the CCG is committing to act within its resources, to act in accordance with NHS Business rules, and has alignment with provider plans. A stocktake meeting was held between NHS England and the CCG on 22 February and the CCG is subsequently required to: Ensure subsequent submissions show alignment with provider (BHRUT) plans Ensure that two-thirds of QIPP schemes are developed in detail and are understood by relevant providers Identify the impact of Right Care wave one projects and work these through into savings which should feed into the CCG s financial plan Work with BHRUT to support delivery of the 95% waiting time standard by September 2016 (and mitigating actions if the assumptions do not support delivery by this date) Work with BHRUT to develop a jointly owned plan that reduces the RTT backlog and supports a run-rate to ensure sustained delivery of the standard Work with BHRUT to address the shortage of diagnostic capacity (particularly endoscopy) and understand how extra capacity will be sourced 3.5 The CCG s 7.6m high level QIPP target has been built into the plan. Detailed business cases are being ratified through the agreed confirm and challenge process. Current plans in development total 6.6m which is 86% of the target. 4.0 Next steps final Operating Plan submission 11 April 4.1 The next (and final) Operating Plan submission is on 11 April. 4.2 Work will continue to develop the plan (and supporting items) in respect of the NHS England feedback (above) and any feedback received relating to the second draft submitted on 2 March.

67 4.3 The final submission will also incorporate C.Difficile objectives for 2016/17, which NHS England are expected to publish imminently. 4.4 The 2016/17 Quality Premium measures are expected to be published in early March. In previous years CCGs have been required to submit Quality Premium trajectories/choices as part of Operating Plan submissions and this may recur for the 11 April submission. 4.5 The Governing Body is requested to give delegated authority to the BHR CCGs Chief Finance Officer and Accountable Officer to sign off the final submission ahead of the 11 April submission date. 5.0 Better Care Fund (BCF) Plan 5.1 The BCF Planning guidance was only published by NHSE in the last week of February, and the Local Authority and CCG were given a week to produce a draft finance & activity template which was submitted on 2 March. 5.2 The next step is to submit a second draft of the finance & activity template, with a Plan narrative, on 21 March. 5.3 The final plans have to be submitted on 25 April, having been formally signed off by the Health & Wellbeing Board. 5.4 The Governing Body is requested to give delegated authority to the BHR CCGs Chief Finance Officer and Accountable Officer to sign off the final submission ahead of the 25th April submission date. 5.5 It should be noted that CCG officers have worked in close partnership with Local Authority officers through the Joint Executive Management Committee to produce the first draft finance & activity template submission on 2 March, and will continue to work closely to produce the second draft submissions and the final submission. 5.6 The the guidance states that the BCF planning and assurance process will be integrated as fully as possible with the core NHS operational planning and assurance process 5.7 The Plan will go through an assurance process however, unlike for 2015/16 when there was a national assurance and resubmission process, for 2016/17 the assurance process will be owned by NHS England and local government regional teams. 5.8 There are a number of Plan requirements to be met before assurance will be given. These include a number of national conditions such as level of financial contributions for the CCG into the pooled fund; confirmation of agreement on how plans will support progress for seven-day services; better data sharing between health and social care based on the NHS number; a joint approach to assessments and care planning; agreement of a local action plan to reduce delayed transfers of care There is also a requirement to set national metric targets locally. 6.0 Resources/investment 6.1 A separate financial planning paper has been submitted to the March Governing Body, which details the financial allocations for the CCG.

68 7.0 Equalities 7.1 This paper does not identify any specific equalities issues. 8.0 Risk 8.1 There are currently no specific risks identified through this paper. 9.0 Managing conflicts of interest 9.1 There are no conflicts of interest considerations arising from this report Author: James Colley, Planning and Programme Manager, North East London Commissioning Support Unit Date: 7 March 2016

69 To: Meeting of the NHS Barking & Dagenham CCG Governing Body From: Tom Travers, Chief Finance Officer Date: 22 March 2016 Subject: 2016/17 Financial Planning Report Executive summary The purpose of this report is to present the draft 2016/17 Financial Plan to the CCG for approval. The draft plan sets out a planned 1% surplus of 2,703k, with the CCG planning to achieve the surplus in line with the required statutory duty. The paper identifies key assumptions and risks to achievement of the CCG s financial targets in 2016/17. The draft plan assumes achievement of business rules in relation to: - 1% Surplus - 0.5% Contingency. The plan currently includes a significant level of financial risk as highlighted in Section 5 of this report. The main risk factors include: Acute activity growth above the planned demographic levels. The current significant gap between CCG and provider positions in the 16/17 contract negotiations. Current business rules limit the scope to apply contract levers. The risk of QIPP schemes not delivering to the expected and planned levels. Additional costs associated with constitutional standards. Other risks include potential for Prescribing and Continuing Care costs to exceed planned levels. The only reserve mitigation to these risks is the 0.5% contingency within the plan. The QIPP requirement in the plan is 7.6m (3%). Recommendations The Governing Body is asked to note the high level of financial risk and approve the draft financial plan for 2016/17 which is consistent with the latest Operating Plan submission to NHS England (NHSE). A further Operating Plan submission will be sent to NHSE in early April. An updated set of financial plans/budgets will be presented to the next Governing Body meeting. These will be consistent with the updated Operating Plan.

70 1.0 Purpose of the Report 1.1 The purpose of this report is to update the CCG Governing Body on the 2016/17 Financial Plan. 2.0 Background/Introduction 2.1 The CCG is currently planning to deliver a 1.14% surplus in 2015/16. This was reduced in year from a 2% surplus. It faces ongoing financial challenges in order to maintain this level of surplus position in 2016/17. The Department of Health announced a 3.8bn real terms increase for the NHS in 2016/17 in the December Spending review which informed the allocations CCGs receive for 2016/17. Despite the increased allocations, however, the CCG continues to face significant pressures on its budgets due to: Growth in population. Increasing life expectancy and prevalence of long term conditions Growth in prescribing and continuing care costs Financial pressures at BHRUT and Barts Health Access standards for Mental Health Inflationary pressures The above factors mean that even with baseline funding growth, the CCG still needs to make significant Quality Innovation Productivity and Prevention (QIPP) savings to meet the financial targets outlined in this plan. 3.0 Report Content 3.1 The Planning Guidelines CCGs are required to submit plans reflecting Department of Health financial rules that assure the delivery of the CCG s commissioning objectives, including the key NHS constitution targets of: Maximum referral to treatment waiting times Access to cancer services Maximum wait times in A&E For 2016/17, NHSE guidance is that CCGs should set and deliver financial plans within NHS business rules. These results would equate to the following budget requirements. NHS Business Rules % m Surplus 1.0% 2.7 Contingency 0.5% 1.5 Uncomitted Non-recurrent Investment 1.0% 2.6 Currently the CCG s plan does not achieve the planned surplus nor the uncommitted nonrecurrent reserve requirements.

71 Plans have been produced to include the following key assumptions: Key Planning Assumptions Tariff Change - Acute 1.10% Tariff Change - Acute CNST 0.40% Tariff Change - Non Acute 1.10% Demographic Growth (Based on ONS data) 2.00% Non Demographic Growth - Acute 0.50% Non Demographic Growth - MH & Community 0.50% Prescribing 5.00% 3.2 Draft 2016/17 Budgets The CCG s draft 2016/17 budget is based on an allocation of 299m which includes: Barking and Dagenham 000 Baseline Allocation 254,571 Programme Growth 7,761 Primary Care Co-Commissioning 28,805 Return of 2015/16 Surplus 3,352 Running Cost Allocation 4,501 Total Resource 298, Growth The confirmed allocation includes a 3.06% recurrent uplift on 2015/16. This incorporates differential growth for elements of the budget; 1) A programme growth of 3.05%. 2) A Primary Care Co-Commissioning growth of 3.57%. Primary Care Co-Commissioning budgets for 2016/17 will be separately presented to the Primary Care Commissioning Committee for approval. It has been assumed that this budget will achieve a balanced position. 3) A running cost growth of 0.29%. The programme growth is constituted from the following factors: Programme Growth 000 Per capita growth 1,559 Population growth 5,132 GP IT & CAMHS 1,070 Total 7,761 The increased growth allocation is to achieve a greater equity of access through accelerating alignment of allocations so that in 2016/17 all CCG s are no more than 5% under target for CCG commissioned services and for the total commissioning streams for their population. The

72 increased funding to Barking and Dagenham make its distance from target above by 1.8% for programme allocations and under by -1.0% for Primary Care Co-Commissioning allocations. 3.4 The increased funding for the CCG has been more than offset by pressures on the CCG s underlying financial position, which include; Parity of esteem investment levels in mental health Funding GP IT and CAMHS recurrently Tariff uplift of 1.5% for acute and 1.1% for all other services. The remaining growth funding is required to fund demographic / non demographic growth, already agreed investments and cost pressures and for the CCGs to meet its business rules. The impact has been to reduce the CCG s position of a 2% surplus at the beginning of 2015/16 to a 1% surplus in 2016/17. The CCG running costs have been reviewed and will be contained within the allocation of 4.5m 3.5 Bridge Analysis A bridge from the 2015/16 plan (Programme spend only) to the 2016/17 Programme spend plan identifying key movements is summarised within the table below. This includes the change in baseline funding, business rules, and generic assumptions outlined in previous sections. Barking & Dagenham Programme Baseline 254, % Total Growth 7, % Underlying Position 2015/16 2, % Total Funds available 10, % Reinstate ETO funding % GPIT % CAMHS % Tariff Uplift 1.1% 2, % Prescribing 5% 1, % Demographic Growth (ONS) 2% 4, % Non-Demographic (0.5%) % 0.5% Contingency 1, % 1% Non Recurrent Risk Reserve 2, % CNST 0.4% % CQUIN Change % Investments & cost pressures 2, % Change year on year in surplus (650) (0.3%) QIPP (7,639) (3.0%) Total Increase in Expenditure 10, % 2016/17 Planned Surplus 2, %

73 The financial plan includes a number of cost pressures, some of which are the calls on growth monies described in section 3.3. The cost pressures include; Acute Over-Performance and RTT pressures Mental Health new targets investment Continuing Care Prescribing Tariff uplifts of 1.5% for acute and 1.1% for other services Demographic growth of 2% based on ONS population projections. Furthermore, the plan includes the financial impact of achieving business rules including 0.5% contingency and 1% non-recurrent funds, although the non-recurrent 1% has not been held uncommitted in planning. 3.6 Proposed Budgets The table below summarises the proposed budgets for the CCG in 2016/17. Barking and Dagenham CCG Base Budgets 2016/17 Annual Commissioner Function Allocation 000's Acute NHS SLA 130,991 Acute Other 11,339 Acute Sub-total 142,330 Mental Health and LD 30,439 Community Healthcare 33,106 Continuing Care 14,337 Programme Spend 12,191 Services Provided in a Primary Care Setting 30,579 Healthcare Provision Sub-total 120,652 CCG Running Costs 4,501 Running Costs 4,501 Primary Care Co-Commissioning 28,805 Primary Care Co-commissioning 28,805 Total Expenditure 296,287 Resource Limit 298,990 Surplus / (Deficit) 2,703

74 3.7 QIPP The CCGs 7.6m high level QIPP target has been built into the plan. Detailed business cases are being ratified through the agreed confirm and challenge process. Current plans in development total 6.6m which is 86% of the target. Further details are in Appendix A. 4.0 Equalities 4.1 N/A 5.0 Risk 5.1 A high level of financial risk has been identified within the operating plan. The currently identified risks are highlighted in the table below. Risks Full Risk Value '000 Probability of risk being realised % Potential Risk Value '000 Acute activity growth (2,869) 50.0% (1,435) Other contracting variances (3,500) 50.0% (1,750) Contract Levers (1,742) 50.0% (871) Continuing Care SLAs (520) 50.0% (260) QIPP Under-Delivery (3,888) 60.0% (2,333) CCG's use of 1% funds (2,623) 50.0% (1,312) Potential additional acute pressure (2,312) 50.0% (1,156) Other Risks (741) 54.0% (399) TOTAL RISKS (18,196) 52% (9,515) Contingency Held 1, % 1,639 NET RISK / HEADROOM (16,557) 47.6% (7,877) 5.2 The table shows the full risk identified and a potential risk assessed value. The risk assessed value after mitigating reserves totals 7.9m. 5.3 The main risk factors include: Acute activity growth above the planned demographic levels. The current significant gap between CCG and provider positions in the 16/17 contract negotiations (for example there is an NHS contract gap in excess of 40m across all BHR CCG s) Current business rules limit the scope to apply contract levers. The risk of QIPP schemes not delivering to the expected and planned levels. Additional costs associated with constitutional standards. Other risks include potential for Prescribing and Continuing Care costs exceeding planned levels. 5.4 The only reserve mitigation to these risks is the 0.5% contingency within the plan.

75 5.5 The CCG will take responsibility for commissioning Bariatric Surgery in 2016/17. This transfer will be reflected in future iterations of the plan. Currently it is assumed that sufficient resource will be transferred from NHSE to ensure that this does not create an additional risk. Assurance will be sought and required from NHSE on this issue. 5.6 Impact upon statutory duties The plan includes a high level of financial risk. The materialisation of any of these key risks could result in the CCG posting a deficit position in 2016/17. There is a similar risk profile across the BHR CCG s. Agreement would be required from NHSE to move one or more of the CCGs to a deficit plan. 6.0 Managing conflicts of interest 6.1 N/A 7.0 Recommendations 7.1 The Governing Body is asked to note the high level of financial risk and approve the draft financial plan for 2016/17 which is consistent with the latest Operating Plan submission to NHS England (NHSE). A further Operating Plan submission will be sent to NHSE in early April. A final set of financial plans/budgets will be presented to the next Governing Body meeting. These will be consistent with the updated Operating Plan. Attachments: 1. Appendix A QIPP Target

76 Appendix A Development of QIPP plans for 2016/17 Current plans in development total 6.6 which is 86% of the 7.6m target. Work is continuing on closing the gap and the process has resulted in the development of the following QIPP projects. QIPP Initiative PID Status Gross Saving Investment Total QIPP TARGET 7,639 Vanguard Draft Gastroenterology Draft CHC Draft Medicines Management Draft 429 (72) 357 Estates Draft Chronic Kidney Disease Draft BCF Draft RTT demand management Draft Right Care Draft 2,236 (33) 2,203 Current Total 6,690 (105) 6,585 % of target 86% QIPP Gap 1,054 Gap as % of target 14% The projects listed above are being progressed through the QIPP PMO review sessions. Additional QIPP projects will need to be developed in the first quarter of 2016/17. To close the QIPP gap, there is continued effort to identify and work up new opportunities. Failure to identify the 1.1m QIPP gap will present the CCG with a significant financial pressure in 2016/17. However steps are being taken to mitigate this risk through the additional opportunities identified, including: Review of current contracts and spend Scrutiny of other BHR CCG project implementation documents (PIDs) for implementation by Barking and Dagenham CCG Review of other CCG QIPP ideas, web based or through contact with other CCGs.

77 To: From: Meeting of the NHS Barking and Dagenham CCG Governing Body Sarah See, Director of Primary Care Transformation Date: 22 March 2016 Subject: Primary Care Strategy Update Executive summary The CCG is developing a strategy for the transformation of primary care over the next five years. The work is framed by national and London policy, the Barking & Dagenham, Havering and Redbridge (BHR) system commissioning challenges and takes account of substantial input gathered from local GPs and wider local stakeholders. The vision emerging is of primary care leading the provision of joined-up care in localities, with sustainable and productive practices at its foundation. This builds on the King s Funds concept of place-based care and wider evidence from places where this approach has been implemented. Extensive discussions with and between local clinical leaders are continuing about how this model will facilitate the development of local schemes which will deliver better care for local people and what the implications and opportunities will be for individual GP practices, their autonomy and sustainability. The transformation programme for 2016/7 will be primarily about provider development strengthening individual practices, progressing collaborative working amongst GP practices in localities and developing extended locality teams, bringing together GPs with all local health and social care professionals to provide the majority of care for patients. The plan is to draw on the CCG s strategies for planned, mental health and urgent and emergency care and identify specific local schemes, which can be used to inform development of collaborative governance and working arrangements in localities and as a proving ground in localities, ensuring they are wholly grounded in the business of local providers and the care needs of local people. An investment of additional time is needed in order to complete this dialogue properly, and we are now aiming to complete the strategy in time for formal review by the governing body in May At the same time, detailed plans and an investment strategy are being developed in order to secure the resource needed to assist primary care leaders with the transformation of primary care in their localities and underpin development of our local Sustainability and Transformation Plan. Recommendations The governing body is asked to: Note the contents of this progress report; Agree the programme of stakeholder engagement planned to review and refine the strategy proposals so that the strategy can be finalised; and Receive the final strategy at its meeting in May 2016.

78 1.0 Purpose of the Report 1.1 The purpose of this report is to advise the governing body of progress with the primary care transformation strategy and the timetable for its completion and enable it to assure itself that there is sufficient stakeholder engagement in the review and refinement of the strategy prior to formal governing body review in May Background/Introduction 2.1 The CCG is developing a strategy for the transformation of primary care in Barking and Dagenham over the next five years. The work is framed by national and London policy, the Barking & Dagenham, Havering and Redbridge (BHR) system commissioning challenges and takes account of substantial input gathered from local GPs and wider local stakeholders. 2.2 The governing body received a report on progress in January This paper provides a further report on progress ahead of a formal review of the completed strategy now scheduled for May It briefly describes the emerging vision, benefits and implications and proposed implementation approach and sets out the programme of stakeholder engagement to review and refine the proposals. 2.3 Further information on the proposals is provided in the attached primary care strategy communications slide pack, which is current as of 1 March Emerging Vision 3.1 The strategy proposes step-by-step migration to a place-based primary care-led delivery model for care out of hospital in each Barking and Dagenham locality. The model has at its foundation stronger GP practices and involves effective collaborative working across groups of practices and an extended team of community, social care, pharmacy, dental and ophthalmology professionals and the voluntary sector. 3.2 Primary care, strengthened and extended, will have the collective capacity and funding to take on the majority of patient care, as well as prevention services. 3.3 Evidence advanced by the King s Fund, drawing on examples from New Zealand, Chen Med and elsewhere, is that place-based care works best with a population of 50-70,000 people, and clinical leaders in the borough are assessing the suitability of existing commissioning clusters as the starting point for deciding on the geographic footprints for localities. 3.4 Practice productivity and collaborative provision and administration will be enhanced through better exploitation of available information, IT and digital solutions. 3.5 A BHR approach to the development of the primary care workforce will create the right staff mix for locality-based working, and localities will be empowered to co-design and deliver locally appropriate solutions for the recruitment and retention of staff. 4.0 Benefits for Patients and Implications for Practices 4.1 The benefits envisaged for patients from the primary care strategy are: Personalised, responsive, timely and accessible primary care, provided in a way that is both patient-centred and coordinated An integrated service that supports and improves their health and wellbeing, enhances their ability to self-care, increases health literacy, and keeps them healthy More treatment closer to home where previously provided in secondary care, and Involvement in the co-design of services with professionals in their locality.

79 4.2 The key implications for practices of the strategy are envisaged to be: Retention of practice autonomy, with GPs playing leading roles in locality-based care Improved financial sustainability through the pooling of resources to reduce costs and the creation of new opportunities to generate income Better practice productivity through improved team working and better use of IT, reducing administration and freeing up GP time for patient care, and The potential to develop more attractive career offers to recruit and retain primary care clinicians. 5.0 Implementation Approach 5.1 The King s Fund s framework for implementing place-based models of care will be used as the starting point from the implementation of primary care-led locality-based care in Barking and Dagenham. 5.2 It is proposed to work with a single locality within the borough as a pilot to design collaborative governance and working arrangements while working on selected prevention, planned care, mental health and/or urgent and emergency care schemes. This will enable initial lessons from localitybased working to be properly understood and the learning to be reflected in the designs and planning for the other localities. 5.3 A parallel programme of work will be put in place to help practices improve their productivity, make better use of information and IT systems and better understand their financial sustainability. 5.4 There is a month target timescale for all localities to be operational and effective. 6.0 Resources/investment 6.1 Resources will be needed to help primary care leaders in localities establish organisational and governance arrangements for collaborative working and operate these effectively and to assist with specific initiatives to strengthen practice productivity and enable wider use of information, IT and digital solutions. Resource will also be needed to run the transformation programme at the BHR level. A review of CCG organisational arrangements may identify some individuals with the right skills and experience from programme roles. 6.2 An investment strategy for primary care is currently under development. This will enumerate the funding required for the transformation programme. 7.0 Stakeholder Engagement 7.1 The following table shows the extensive programme of engagement planned for the socialisation of the primary care strategy proposals. Governing body members are asked to consider whether any changes or additions are necessary before the strategy is finalised. Level Meeting Date Barking & Dagenham PLE 1 March Barking & Dagenham Locality meetings 8 March Barking & Dagenham Health & Wellbeing Board 8 March BHR Primary Care Commissioning Committee 9 March BHR JET 10 March

80 Level Meeting Date Barking & Dagenham Health & Adult Social Care Committee 10 March BHR Primary Care Transformation Board 14 March Barking & Dagenham Primary Care Working Group 15 March Barking & Dagenham Patient Engagement Forum 17 March 8.0 Equalities 8.1 By delivering common standards of prevention, planned care, mental health and urgency and emergency care across the BHR system and organising delivery in localities, the CCG s overall approach aims to both reduce health inequalities and optimise services to meet the needs of local populations in Barking and Dagenham. 9.0 Risk 9.1 A detailed risk analysis is being undertaken, which will be included with the final version of the strategy document Managing conflicts of interest 10.1 This paper is for information only so that the governing body is kept updated on progress with the development of the Primary Care Transformation Strategy; the invest / resource required will be considered by the non-conflicted investment committee of the CCG. Attachments: 1. Primary Care Strategy Communications Slides current at 01/03/16 Author: Sarah See, Director of Primary Care Transformation Date: 1 March 2016

81 Primary Care Transformation March 2016

82 The emerging Primary Care Strategy for Barking and Dagenham The Primary Care Strategy sets out: The drivers of primary care transformation National policy London policy Feedback from GP s and other local stakeholders The system challenges The points we to address in our solution A vision of primary-care led locality-based care, founded on strong practices Localities make sense for place based care How locality-based care would work within the BHR system Delivery levels the BHR perspective The benefits for practices Implementation approach and timescales

83 What is the national and local policy context for Primary Care Transformation? Policy at a national and regional level is focusing on ensuring a sustainable high quality primary care landscape NHSE Five Year Forward View London Health Commission Strategic Framework for Primary Care in London Think tanks (Kings Fund, Nuffield Trust) Care Quality Commission Move funding from acute to primary care New incentives and models of care networks Expand primary care workforce Ambitious quality standards

84 Three areas of care form the basis of a vision for General Practice in London Patients and clinicians alike have told us about the importance of three areas of care; thhis forms the basis of the new patient offer (also called the specification) Accessible Care Better access primary care professionals, at a time and through a method that s convenient and with a professional of choice. Coordinated Care Greater continuity of care between NHS and other health services, named clinicians, and more time with patients who need it. Proactive Care More health prevention by working in partnerships to reduce morbidity, premature mortality, health inequalities, and the future burden of disease in the capital. Treating the causes, not just the symptoms.

85 Local GPs and their teams have identified issues with primary care as it is now..

86 Practices have provided their perspective on these challenges based on feedback from locality discussion We are facing a crisis in recruitment and retention of GPs and nurses, with many people about to retire too The current workload in general practice is unsustainable - GPs are seeing patients, coordinating care, chasing others for information and doing too much admin and not enough of the pro-active patient care that make being a GP rewarding My practice isn t financially sustainable I value my autonomy and the freedom to run my practice in a way that works for my patients and me.

87 HAV 65.8 years RED 63 years B&D 55.5 years 63.8 London average Healthy life expectancy; female HAV 63.4 years RED 62.7 years male What are the key challenges across BHR? B&D 61.1 years 63.4 London average Ranked in order of most deprived in England 119 th 166 th 3 rd Barking & Dagenham Child poverty 30.2% vs London 23.5% Havering Largest net inflow of Children in London Redbridge Highest rate of stillbirths in London % increase +110, population 750,000 Health and wellbeing challenges Care and quality challenges Funding and efficiency challenges 23% Barking & Dagenham vs 17% London BHR 24% Obese adults 23.1% Obese children vs London Alcohol abuse 7% harmful 17% high risk 14% binge drinkers Barking & Dagenham 19.6% Obese adults 22.4% Obese children LTC LTC 50% 1 in 4 People over 40 are living with at least 1 LTC 1 in 2 People over 75 are living with at least 1 LTC 60% of cases diagnosed BHRUT Local Authority funding reduction Public Health budget reduction Jobs section Out of work benefits BHR 12.2% (B&D 16.7%) vs London 11.6% Against national target of 67% Barking and Dagenham one-year survival rate: 64% vs 69% London BHR system wide budget gap of over 400m

88 In summary, we need to find a solution that addresses the following points The GP Good career offer and working environment for GPs - retain existing GPs and attract new recruits GP Practices Productive GP practices can retain their autonomy and have a financially sustainable future GPs have the time they need to provide quality patient care Minimise the time spent by GPs and practice colleagues on administration Respective roles and responsibilities of all local care providers in delivering care are clearly defined and consistently applied day-to-day by all parties Patient experience Our patients can continue to benefit from a relationship with their local GP Our patients receive a joined-up cost-effective care service with unnecessary duplication avoided Delivery We meet the health needs of our diverse local communities We contribute substantially to the improvement of health outcomes for our populations We meet, as a minimum, national and regional quality standards for primary care We work together with other locally-based providers to deliver the majority of patient care planned, mental health and urgent with a focus on prevention, reducing demand for acute care and enabling savings Infrastructure / enablers GPs and colleagues can rely on IT to present the information about their patients that they need to make the best decisions for patients at each point of care Care is delivered in premises that are fit for purpose in a way that makes the best use of existing assets

89 The emerging vision is primary care-led locality-based care, founded on strong practices Network arrangements Care provision Prevention Administration B&D Patients Baby Social Care Community Nursing Dental Co-producing their care Registered with a local practice, with treatment, referral and care oversight from their GP When needed, receiving personalised, joined-up care and support, mostly near home.... Outpatient services Optometry Pharmacy GP Practices High quality care Productive Financially sustainable GPs with time for patients Other services to be agreed Voluntary Sector Workforce development, recruitment and retention A team of around 100 professionals, with trusted relationships, working together to design and deliver a high quality locality care service that meets local needs cost-effectively Digitally-enabled scheduling and administration Patient-level information sharing at point of care Business intelligence: Ops management, Outcomes Smart use of available Locality estate

90 Locality-based care would be designed and delivered within a wider set of standards and priorities SPG / Borough Redbridge Barking and Dagenham Havering SPG / Borough level plan and priorities supporting implementation of BHR transitional programmes and CCG assurance measures GP Network and extended team: Outpatient services Social Care Community Nursing Dental OUTCOMES Delivery Improvement Primary care-led locality team forms and develops (framework in development) Locality developm ent Pharmacy Optometry Other services to be agreed Voluntary Sector Locality team sets outcomes and priorities to best meet local health needs Locality team defines local pathways and division of workload across practices, practice networks and extended locality team Delivery Individual GP practices

91 Localities make sense for Place Based Care Barking and Dagenham Picture does not represent actual B&D localities Locality level 50,000 70,000 per locality Provides integrated health and social care services through Local Accountable Care Organisations. Includes the right level of service consolidation that maximises value for money HWB strategy and challenges HWBB leadership Local consultation and engagement Borough level B&D: 200,000 Local plans to address local gaps and challenges Devolution test/aco development Delivery via contracts (lead commissioner) Local enabler plans Local out of hospital plans Redbridge Barking and Dagenham Havering BHR Level 750,0000 Overall Sustainability and Transformation plan strategy clinical and financial sustainability Issues needing a plan NEL approach: 1. Acute reconfiguration / pan NEL flows 2. Mental Health 3. Cancer 4. Urgent and Emergency Care (incl. LAS) 5. Maternity 6. Specialised 7. Estates and workforce coordination of enablers and interface with HEE/HLP etc. 8. Transformation funding The commissioning and provider landscape in BHR can be layered into locality level, borough level, BHR level, North East London level and London level, allowing services to be commissioned for specific groups, achieving a degree of local autonomy at the same time as achieving economies of scale where appropriate. Interface with HLP on agreed plan London initiatives Evidence advanced by the Kings Fund, drawing on examples from New Zealand, is that place-based care works best with a population of 50-70,000 people Barking & Dagenham has a history of working in localities which contain populations of this size, and it is proposed that place-based care be established within these boundaries NEL Level 1,800,000 London Level 8,500,000

92 The vision would have positive benefits for practices Retain autonomy - allow step-by-step change with GPs leading Working together help to ease financial pressures - pooling resources to reduce costs and creating new opportunities to generate income Partnership working - GPs have confidence to devolve routine work to other members of the primary care team (e.g. repeat prescriptions) i.e. reduce workload & free up GP time Integrated IT will help reduce duplication of work in the wider primary care team, including chasing information Integrated IT allows new ways of working that save time (e.g. e-consultations or multidisciplinary team meetings) Attractive career offer to retain and recruit staff:- Model will allow for more diverse job roles within the extended primary care team Enable new ways of working More rewarding work focusing on patients Create opportunities for career development for both clinical and non-clinical staff

93 Our Implementation Approach King s Fund framework to develop place-based care Define the population served and the system boundaries. Identify the partners and services that need to be included. Create a shared local vision and objectives, based on local need and the priorities and preferences of the population. Develop an appropriate governance structure which must include patients and the public in decision-making. Identify the right leaders to manage the system, and develop a new form of system leadership. Agree how conflicts will be managed and resolved. Develop a sustainable financial model for the system across three levels: the combined resources available to achieve the aims of the system the way that these resources will flow down to providers how these resources are allocated between providers and the way that costs, risks and rewards will be shared. Create a dedicated team to manage the work of the system. Develop ways to allow different members of the group to focus on different parts of the group s objectives. Develop a single set of measures to understand progress and use for improvement

94 Proposed Support for the set-up of Locality Teams Programme Manager Change Manager helping the locality team get up and running: - Governance set-up - Teambuilding - Practice productivity initiative - Exploitation of IT & digital - Specification and use of BI Operations Manager in place once the locality team is established (each covering 3 localities) Support required: Local manager Finance Business intelligence Administrator

95 The Programme builds locality-based working. Led by primary care, localities deliver outcomes Primary care transformation strategy Themes from emerging preventative, planned, mental health, urgent & emergency care strategies feeding into locality pathway development Productive practice development Collaborative working Core: forming OD Operational management Admin/back office Practice technology exploitation Able to deliver and cement working in: a) Individual practices b) Extended team c) Discharge First admin collaboration First locality strategy Move to joint delivery Further admin collaboration leading to reduced operating cost Implementation, training, new working arrangements, interoperability and user governance Info for operational management Digitally-enabled scheduling and administration Fully operational localities: Setting local outcomes Defining pathways Delivery as single team Productive practices Financially sustainable Registered with a local practice Treatment, referral and care oversight from their GP GP Practices - High quality care - Productive - Financially sustainable - GPs with time for patients Workforce Network arrangements - Care and prevention - Administration Patients Click, Call, Come In Urgent Care Receiving personalised, joined-up care and support for self-care, with the majority of care near home. Involved in the design of local pathways Pharmacy Dental Ophthalmology Community Nursing Social Care Voluntary Sector Interoperability: patient-identifiable information sharing at point of care Business intelligence: (1) Locality-level operational management (2) Monitoring outcomes, informing improvement The right mix of clinical and administrative roles in practices and across locality team planned, mental health, urgent & emergency care, designed locally to best meet Team of circa local population needs circa 100 professionals, with trusted working relationships, sharing workload and delivering continuity of care Compelling career and employment offer and a locality/system programme to recruit, develop and retain professionals Referral & discharge protocols Acute Care Related strategies Workforce future model Roles Offer ACO business case Recruitment, development and retention programme established Care City, CEPN Executing: Fewer leavers More recruits Right staff mix for PCL-PB model Prepare shadow Shadow Full, live

96 To: From: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group (CCG) Governing Body Conor Burke, Chief Officer Date: 22 March 2016 Subject: CCG strategic direction 2016/17 and onwards Executive summary While we have achieved much as a CCG over the past three years, we are entering a particularly challenging period from 2016/17. This means that we need to act radically to drive change resulting in better health outcomes for local people. We have a history of ambition and innovation, having bid and piloted a number of initiatives to deliver greater access to GPs, a complex care practice and urgent and emergency care improvements through the Vanguard to name just a few. Through our recent work on the primary care transformation strategy we are looking to develop primary care-led localities, providing integrated services for populations of 50-70k people. At the same time we are working within the Barking and Dagenham, Havering and Redbridge (BHR) CCG collaborative on system wide initiatives to transform mental, health, planned care and urgent/emergency care. We are exploring whether developing an accountable care organisation (ACO) across BHR would enable us to deliver better and faster results. The case, being developed by the CCGs with our local authority and provider colleagues will outline the resource opportunities and requests, proposed flexibilities and freedoms and identify the support that we may need to become a full pilot site for devolution. We will be considering the case as a governing body later this summer. Our proposals for the ACO will feed into the north east London (NEL) sustainability and transformation plan (STP) which we are required to produce across the wider geography. Recommendations The governing body is asked to: Note the strategic update 1.0 Purpose of the report 1.1 To provide the governing body with a brief overview of the overall strategic direction for the coming years, both for the CCG and the wider BHR health and social care economy.

97 2.0 Strategic direction 2.1 There has been considerable progress in developing and defining the CCG s plans for the next 1-5 years. Work is underway on the operating plan submission for each CCG, as referred to in paper 4.1 on this agenda. Given the challenges that we face as a system in terms of quality, finances and overall outcomes for patients, we have been working with colleagues within boroughs, across BHR and where appropriate across the NEL footprint. 2.2 It is a complex picture and we need to ensure that our leaders, staff, members and wider stakeholders understand and fully own the vision and plans for the years ahead. So we have been working to develop a simple narrative that explains clearly what our challenges are and how we plan to address them. The summary is attached as appendix 1.. We are also developing set of slides to support engagement. 2.3 We are also exploring the creation of a rich picture, which would be a graphic representation of our vision. Rich pictures are developed by engaging key leaders and stakeholders, and can be an effective tool for communication. It is a tool that has been used in BHR previously to positive effect. 2.4 The following section provides a summary of the key elements of our strategy from 2016/17 onwards. 3.0 Primary care and development of localities 3.1 The engagement and work to date on the primary care strategies in each of the BHR boroughs includes a proposal to develop primary care localities for populations of between 50-70,000 people. The localities in time, if the model is agreed, will provide fully integrated health and social care services to people, based on local need and priorities. There is an update paper on the agenda at 4.3 that provides further detail, outlining the emerging vision and wider proposals. 4.0 Transformation programmes 4.1 While developing localities within each borough will be key to improving quality and experience for communities in neighbourhoods, there are benefits to working with our partners at scale across the entire BHR health and social care economy. By negotiating arrangements with our fellow CCGs, local authorities and major providers we can manage contracts and risk across the wider patch. We can also develop consistent clinically led and agreed standards for pathways and the care that people receive. 4.2 Programmes for mental health and urgent care (including the Vanguard) have been running for several months now and work on developing a programme for planned care is underway. To support the running and resourcing of the programmes a portfolio management office (PMO) is being established. This will help to ensure that all the initiatives are fully joined up given the cross cutting nature of each programme. 5.0 Accountable care organisation 5.1 Work in progressing the business case is well underway. Our local plan, as an individual and collaborative of CCGs will be fed into the business case to ensure that the proposal is fully aligned to our strategic direction. The ACO is not about creating a new vision but is about exploring whether having full devolution could enable us to deliver better results and/or more quickly. We have a strong track record in working in partnership with local authorities and providers (through our Integrated Care Coalition), sharing an overall aim of commissioning/delivering better care for local people with a diminishing pot of resources and rising demand.

98 6.0 Sustainability and transformation plans 6.1 National NHS planning guidance issued in December 2015 outlined the requirement to develop sustainability and transformation plans (STP) by June These plans are to cover all health services, (and public health and social care services) over an agreed footprint. They are expected to set out an ambitious five year vision and programme to ensure that health and care services are sustainable into the future. 6.2 We are working in an STP footprint of north east London and work in developing the plan is underway. We have made it clear that our element of the plan will largely be derived from the ACO business case, but that we recognise the need for collaboration on key issues such as maternity services and acute reconfiguration because of the flows of patients between the BHR and WEL systems. Governance and planning arrangements are currently being finalised and the details will be shared as they emerge. 7.0 Resources/investment 7.1 As part of the business case process we will identifying the resources and support that we believe would enable us to develop as a devolution pilot area. We are also looking at how we make most effective use of our staff resources to ensure that we deliver our ambitious vision. 8.0 Equalities 8.1 Plans will be developed in line with equalities considerations with the aim of addressing health inequalities across our borough and BHR. 9.0 Risks 9.1 We cannot carry on without making radical changes to the way health and social care is delivered within our borough and across BHR. Our plans outline our ambition for trying something new to enable is to deliver the care that we think local people should receive Managing conflicts of interest 10.1 There are no conflict of interest issues in relation to this report. Author: Marie Price, director of corporate services Date: 2 March 2016 Appendix 1: Our vision draft narrative

99 Appendix 1 Our vision draft narrative Through our strong clinical leadership and partnership working over the past three years, we have begun to make significant improvements in the quality of care for local people. But we have more than our fair share of challenges too money, some very poor health outcomes, workforce challenges to name just a few. The current and inherited old ways of commissioning and the boundaries between organisations, people, commissioners/providers just won t enable us to deliver a sustainable system in the future, and it certainly won t enable us to deliver the care that we know local people need and have a right to expect. Primary care is the bedrock of any effective healthcare system. We are considering whether by developing primary care led localities or neighbourhoods; we could deliver the change we need. It is a model that has been emerging through the primary care transformation strategy engagement process. Each locality would self-organise and manage a significant chunk of the overall budget in line with their population - driving innovation and responsiveness to need at a local level, but could have a set of common characteristics. The initial focus would be on primary care, but the localities could develop to include wider health and social care input providing fully integrated and seamless services. To make it work though we would need to invest considerable set-up resources and look at running pilots perhaps as early as April 2016 if some patches feel ready. We would support each area to go at its own pace and ensure that the learning is shared across all. We have fantastic pockets of innovation within our three CCGs and across BHR. We have taken opportunities to gain national funding and opportunities to test and try new models of care. We have all heard about initiatives such as the Prime Minister s Challenge Fund, vanguard and accountable care organisation (ACO), but these are just ways of getting freedoms and flexibilities to deliver what we think is best for patients. As we develop our vision for improving services possibly through this locality model if GP colleagues agree we will at the same time be testing whether an ACO could help us to achieve better and or faster results. An ACO could enable us to have different payment mechanisms, greater collaborative working and where appropriate, shared leadership and governance arrangements. We think there is a chance that it could help, but if it becomes clear that it won t, then we won t be recommending the model. We also don t want to lose sight of the great work that clinicians have led together across our health economy big improvements in urgent and emergency care performance, intermediate care services that are keeping thousands more people well and through our current proposals for better stroke rehabilitation services. By working and investing together we have also begun to make real progress in helping people to access the mental health services that they need.

100 Through clinically led standardised pathways for key areas of care urgent/emergency, mental health and planned treatment as well as an agreed approach to managing risk with major contracts/providers across the BHR footprint, we can be effective by working together as three boroughs. The individual boroughs/ccgs will continue to be accountable. They will ensure that the democratic focus remains, and seek assurance that the required outcomes are being delivered at the locality and BHR levels, with appropriate governance designed for each. This is an approach that has emerged from some early discussions with clinical and political leaders and through the primary care transformation work. We want to test whether it is a model that GP leaders and practitioners believe could work and whether / how we should take it forward.

101 To: From: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group (CCG) Governing Body Dr Jagan John, Clinical Director Date: 22 March 2016 Subject: Improving patient flow front of A&E and supporting discharge Executive summary This paper puts forward the business case to recurrently fund additional nursing and occupational therapy support that has been funded to date through non-recurrent operational resilience (winter pressures) money, and which have demonstrated system benefits since they commenced in November The operational resilience money was used to fund additional nursing staff to work with Emergency Department in Queen s hospital to support achievement of the 4 hour wait target by identifying patients who are appropriate for community support and safely discharging them from A&E, and for additional nurses and occupational therapists to in-reach into wards to reduce length of stay. The business case indicates that the enhancement of support in the front of A&E has led to 402 avoided admissions (with an estimated saving of 366k). The in-reach service has achieved a reduction in the the total length of stay equivalent to a saving of 46 beds (compared to 2014). If funding was ceased for these services then length of stay may increase and directly impact on patient flow and A&E performance. The business case sets out a preferred option to maximise benefits and minimise cost. Recommendations: To continue to fund these services in 2016/ Purpose of the Report 1.1 The purpose of this report is to set out the rationale for continued funding for the front of A&E and discharge support services. 2.0 Background/Introduction 2.1 Operational resilience funding was received by the Barking, Havering & Redbridge system in the summer of 2014/15 and schemes for funding were prioritised, through the System Resilience Group, in line with the Barking Havering and Redbridge University

102 Hospitals Trust (BHRUT) Service Improvement Plan and identified gaps in existing provision k funding was agreed to extend support in A&E at Queens s hospital and pilot an inreach Intensive Rehabilitation Service to the orthopaedic and geriatric wards on both the Queens and King George hospital sites. 2.3 The service is provided by NELFT. The initial funding was agreed to cover the period from 1st November 2014 to 31st March 2015 and then in March 2015 the CCGs agreed to extend the pilot into Q1 of 2015/16 and in June 2015 it was extended again for 164k for Q2 and 409k for Q3/Q Service description 3.1 The following sets out how the operational resilience funding has been used to develop capacity in the services. Emergency Department based Treatment Team Identifies patients who are suitable for discharge (with support) directly from A&E to avoid the need for admission. Only based in Queen s ED not in community this is a separate team to the community based CTT. This was piloted in KGH but was not viable due to small numbers of suitable patients. Currently provided from 8am to 10pm for 365 days per year. Original service staffing includes 3 therapists and 1 social worker (funded by LB Havering) and the current team are also supported by 2 JAD social workers. Operational resilience funding has paid for 2 additional Band 6 nurses which has increased caseload capacity. Intensive Rehabilitation Service (IRS) in-reach Identifies patients from orthopaedic and geriatric wards, on both hospital sites, who are suitable for intensive support to reduce length of stay. This improves outcomes for patients and reduces bed usage Currently provided from 9am to 5pm 365 days per year. Operational resilience funding pays for three band 6 nurses and two band 6 occupational therapists, who make up the full in reach team Team supports the flow of patients from Queens and KGH and also supports Redbridge patients being discharged from Whipps Cross Hospital. 4.0 Recurrent funding proposal rationale The business case sets out the rationale for recurrently funding the additional service capacity based on avoiding admissions, reduced length of stay leading to bed savings and supporting the hospital to meet A&E 4 hour target as follows: Admissions Treatment Team The service effectively targets the most appropriate patients in A&E and has access to services in the community to safely discharge patients with the appropriate support. As a result no patient seen by the service has needed to be admitted to hospital. The case Page 2 of 4

103 assumes that all of the patients seen by the service might otherwise have been admitted to hospital and the intervention has saved approximately 402 short stay admissions with an estimated saving of 366k for the last 12 months. The Treatment Team service has contributed to delivery of the ED access targets, all patients are seen within an hour of referral. This is further supported by the views of ED clinicians. Bed savings - IRS The bed saving assumption in the pilot was that a patient seen by the A&E team would save 1 day and a patient seen by IRS would save 3 days this was on the assumption that admissions avoided by treatment team are likely to have short stays anyway and for IRS this would bring us to the benchmark linked to our Commissioning for Value comparator group. A caseload of 5-6 patients per day equates to a saving of 13 beds. The bed saving divided by the service cost would equate to 59k (compared to 60k average for a hospital bed). For IRS admissions the total length of stay (LOS) for patients admitted to the Geriatric Medicine, Orthopaedics and General Medical wards were compared for April October 2014 against April - October The total length of stay for patients admitted actually reduced by 9587 days in 2015 compared to 2014 and this equates to a saving of 46 hospital beds compared to the 12 bed target. While this does not have any direct cost savings for CCGs at this time this does support the system requirement to reduce acute bed usage and support the closure of hospital beds. A reduction in LoS expedites a patient s recovery as it minimises any loss of independence, risk of infection and longer term effects. Patients spending longer time in hospital could result in poor outcomes and excess bed days. The business case includes a case study that demonstrates the positive patient outcomes. 5.0 Resources/investment The total cost of the preferred option is 766,735 which is broken down by CCG: Treatment Team CCG Investment Estimated A&E saving Barking & Dagenham 82,622 84,180 Havering 247, ,540 Redbridge 28,738 29, , ,000 Page 3 of 4

104 Intensive Rehabilitation Service CCG Investment Bed saving Barking & Dagenham 93,727 Havering 207, beds Redbridge 105, , Recommendation The business case sets out a number of options for recurrently funding the elements of the Treatment Team and IRS service described above. The preferred option (Option 4) attempts to get best value by matching service delivery to seasonal need as follows: To continue to fund the Treatment Team in A&E from 8am-10pm 365 days per year, and IRS 9am-5pm for 7 days per week from November to March and 5 days per week from April to October. 7.0 Equalities 8.0 Risks There are no equalities issues raised by this paper. The risks associated with not implementing the proposed option are identified as: increased length of stay, increased admissions, poorer flow through ED and the hospital, increase in breaches of the four hour waiting time standard, delayed medical reviews risking clinical safety of patients in ED and wards The risks associated with implementation of the preferred option ; Failure to maintain current levels of performance Ability of provider to recruit permanently to posts increasing service cost 9.0 Managing conflicts of interest There are no conflicts of interest considerations arising from this report. Author: Sarah D Souza, Deputy Chief Operating Officer Barking and Dagenham CCG Date: 24 February 2016 Attachment 1: Business Case CTTIRS Page 4 of 4

105 BUSINESS CASE This template should be completed for business cases up to 2m. This document should be completed following approval of the Business Justification. Note 1 Guidance notes are incorporated into each section please delete them when no longer required. Note 2 Some sections may not be relevant to your business case. Please do not delete the section, but indicate accordingly. Note 3 Please remember to update the footer version number at the bottom of the page each time you update your case. Contents 1. Approval 2. Summary of project 3. Purpose 4. Current situation 5. Case for change a. Business needs b. Benefits c. Risks d. Interdependencies 6. Strategic context 7. Procurement 8. Activity implications 9. Workforce implications 10. Funding and affordability 11. Options considered & preferred option 12. Management arrangements 13. Governance arrangements 14. Consultation/communication 15. Timelines and deliverables 16. Other Organisational Involvement 17. Environmental considerations 18. Equality/ Diversity Business case TTIRS /11 Version 10

106 1. Approval This document must be approved by the following: Name Signature Title / Responsibility Date Version 2. Summary of project CCG CFO Quality Corporate CSU Commissioning Support Director Project Name Treatment Team (TT)/ Intensive Rehabilitation Service (IRS) Date 22/2/16 Executive Summary Cost of Business Case Confirm physical capacity already exists/included in costs Impact Treatment Team (TT) support in A&E at Queens hospital and an in-reach Intensive Rehabilitation Service (IRS) to the orthopaedic and geriatric wards on both the Queens and King George hospital sites. The cost of the preferred option is 766,735 for a full year if the service is recurrently funded. This is based on 2015/16 payscale rates. If the business case is agreed will be added to the NELFT contract baseline for 2016/17 and the appropriate business rules applied Yes physical capacity already in place Average of equivalent of 13 beds saved per month in the last quarter (October to December 2015). Cost per bed (based on cost savings) - 59k 3. Introduction Operational resilience funding was received by the Barking, Havering & Redbridge system in the summer of 2014/15 and schemes for funding were prioritised, through the System Resilience Group, both in line with the Barking Havering and Redbridge University Hospitals Trust (BHRUT) Service Improvement Plan and identified gaps in existing provision. 300k funding was agreed to extend Treatment Team (TT) support in A&E at Queens s hospital and pilot an in-reach Intensive Rehabilitation Service to the orthopaedic and geriatric wards on both the Queens and King George hospital sites. The service is provided by North East London Foundation Trust (NELFT). The initial funding was agreed to cover the period from 1st November 2014 to 31st March 2015 and then in March 2015 the CCGs agreed to extend the pilot in to Q1 of 2015/16 and in June 2015 it was extended again for 164k for Q2 and 409k for Q3/Q4. This paper summarises the development of the service and makes the case for continuation of funding. The cost for continuation of the service for 2016/17 is 766,735. Business case TTIRS /11 Version 10

107 4. Current situation Treatment Team (TT) The TT service is provided from 8am to 10pm for 365 days per year. This part of the TT service is based in ED and the focus is to identify patients who are suitable for discharge, with support, directly from A&E to avoid the need for admission. These staff only work in ED and do not cover the community community staff do also not in reach to ED. There was a TT service in ED at Queen s hospital prior to Operational Resilience funding. The service was staffed by 3 therapists and 1 social worker (the latter post is funded by London Borough of Havering) who supported setting up social care packages in the community and ED for patients of TT. The operational resilience funds were used to recruit two band 6 nurses to increase the caseload capacity of TT. In addition, the TT team have had support from two social workers from the JAD team. These staff are not included in the costs stated above and the arrangement for inclusion in the team will be picked up as part of JAD discussions at the System Resilience Group. Intensive Rehabilitation Service (IRS) The IRS service is currently provided from 9am to 5pm 365 days per year. The IRS team attend orthopaedics and geriatric wards on both of the BHRUT sites to identify patients suitable for intensive support with the objective of reducing length of stay and therefore improving outcomes for patients and reduce bed usage. There was no baseline funding for IRS although a pilot of therapy in reach at KGH had been undertaken. The Operational Resilience funding enabled recruitment of three band 6 nurses and two band 6 occupational therapists During times of peak pressure the IRS team support rapid assessment and discharge into the rehabilitation pathway from acute, and from community beds, to home in some cases. This level of intensive support managed, during peak time, to discharge from acute and admit into the whole bed base of intermediate care beds in a 10 day period - maximising support of flow in BHRUT. The team also virtually support the flow of Redbridge patients out of Whipps Cross Hospital. The extension of the services meant that a minimum of five new patients per day could be seen across the two teams. The table below shows the number of patients seen by month and the conversion to beds saved: CTT/IRS service - activity and bed savings by month Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Pts seen Bed target Proxy beds saved (average) Activity and resource allocation is split 25% CTT and 75% IRS Proxy measure is based on 1 day saved for CTT and 3 days saved for IRS The bed savings are based on a proxy measure agreed for operational resilience, but the quantified bed savings are shown under section 5b below. CCG split of activity The following table shows the split of the activity by CCG: CCG TT % of total IRS % of total Barking & Dagenham 23% 23% Havering 69% 51% Redbridge 8% 26% Business case TTIRS /11 Version 10

108 5. Case for change a) Business Needs When the Operational Resilience schemes were developed in 2014/15 they were all focused on reducing length of stay and admission avoidance to reduce the bed usage on the acute hospital sites. As part of their Service Improvement Plan, BHRUT identified a 72 bed gap between expected need and actual bed stock. This scheme aimed to release capacity equivalent to 12 beds. b) Benefits The combined TT/IRS services have focused on the release of inpatient bed days as the key measure of success and, in addition, the TT service has focused on admissions avoided in A&E. A case study as attached at appendix 4 which demonstrates the improved outcomes for patients of the IRS service. Admissions and total length of stay (LOS) for patients admitted to the Geriatric Medicine, Orthopaedics and General Medical wards were compared for April October 2014 against April to October The total length of stay for patients admitted reduced by 9587 days in 2015 compared to 2014 and this equates to a saving of 46 hospital beds. TT have avoided admissions for 100% of the patients that they see in A&E at Queens Hospital. It is important to reduce LoS as it limits the time that a patient is in hospital and expedites recovery to minimise loss of independence, longer term effects and risk of infection. Without LoS reduction, patients could end up with longer LoS resulting in poor outcomes and excess bed days. The average LoS for April to October 2015 has been compared to that for the same period in 2014, and for the same wards as stated above. The average LoS has reduced from 10.1 days to 8.5 days, a reduction of 1.6 days (16%). The majority of the bed savings are attributable to the IRS as they have been proactively identifying patients in orthopaedic and geriatric wards and reducing length of stay. The in-reach IRS has supported rapid access to the rehabilitation pathway for community IRS and beds. In addition to bed savings, the TT service has contributed to delivery of the ED access targets, all patients are seen within an hour of referral. They have managed to avoid 402 admissions in the last 12 months. This is because they target the most appropriate patients and have access to the services in the community in order to safely discharge patients with the appropriate support. The average price for a 0/1 day LoS is 910 and therefore the TT service alone has saved 366k. The in reach service provided by TT / IRS has supported BHR wide organisations to move to a discharge to assess pilot. This model of discharge has excellent benefits for the patients who are assessed for their needs in their home environment maximising recover, reducing bed occupancy and patient deconditioning which will lead to system benefits of reduced longer term health and social care need. In support of the case Dr Dan Harris, ED Consultant at BHRUT, stated that TT has been hugely helpful with facilitating discharge home directly from ED. They are now increasingly discharging patients from the Observation bay thereby preventing admissions into MRU and ERU beds. Their view is that the service has been critical to delivery of the 4 hour target. The TT team speed up assessment, work alongside medical teams to ensure timely and safe discharge home with required packages of care, where appropriate. They see/ treat and discharge from A&E before patients are admitted. They reduce admissions thereby freeing up on call teams to focus on people who need to be in hospital. Business case TTIRS /11 Version 10

109 c) Risks BHRUT have highlighted that if the services were not in place then the risks would be: increased length of stay, increased admissions, poorer flow through ED and the hospital, increase in breaches of the four hour waiting time standard, delayed medical reviews risking clinical safety of patients in ED and wards Admission avoidance is vital as there is strong evidence that once a patient is admitted they can deteriorate as a result of loss of independence and risk of infection and each admission can affect their recovery rate and future ability to self-care. Without IRS in-reach patients maybe in hospital longer than required and delays in rehabilitation could affect the speed of their recovery and their long term health and result in excess bed day costs as a result of longer lengths of stay. d) Interdependencies The TT is one of the services that would be part of a proposed Urgent and Emergency Care Vanguard programme to streamline provision at the front end of A&E. It is acknowledged that some of the services overlap, and the range of services can present a complex number of options for staff based in ED to navigate when trying to find the most appropriate pathway for patients but that there has been a positive impact on the system as a whole by having these services in place. It is not yet known what the impact of this would be and whether any savings would result from this work. For TT, it is essential to ensure good communication between the team and social services across all the local boroughs so that assessments don t have to be repeated and information can be passed on and acted upon with a single call. For IRS, relationships with the wards has been built which has supported greater awareness of discharge pathways. The links are essential with the community team and community beds. 6. Strategic context The TT and IRS service are just two of a number of initiatives that have been developed across BHR to bring care closer to home, reduce pressure on the acute trust, support to achieve ED waiting time targets and improve outcomes for patients. 7. Procurement Not applicable. 8. Activity Implications Activity will continue in line with the table in section 4 above. TT will see approximately 36 patients per month and IRS will see approximately 104 although there is some seasonal variation for the latter figures. 9. Workforce implications The posts are filled by agency staff currently so contracts would need to be extended or ideally recruitment to posts would be undertaken. There are two social workers who support the team, who are not part of the costs, who are seconded from JAD and would be essential to continuation of the service. As noted previously this will be picked up as part of the JAD discussion at the System Resilience Group. 10. Funding and affordability Option 1: Stop both services on 31/3/16 (No cost) Option 2: Fund TT 8am-10pm and IRS 9am-5pm for 365 days per year ( 847,195) appendix 1 Business case TTIRS /11 Version 10

110 Option 3: Fund TT 8am-10pm 365 days per year and IRS 9am-5pm for weekdays only ( 666,277) appendix 2 Option 4: Fund TT 8am-10pm 365 days per year and IRS 9am-5pm for 7 days per week from November to March and 5 days per week from April to October ( 766,735) appendix Options considered & preferred option The options are set out in section 10 above. The preferred option is option 4 as this reflects the additional demand over the winter months and will provide a responsive service to manage patients out of hospital as quickly as possible. The cost by CCG for option 4 is set out below: Barking & Dagenham 176,349 Havering 455,901 Redbridge 134, Management Arrangements The service is provided and managed by NELFT and the arrangement has been in place since November This would continue. 13. Governance arrangements Scheme performance is monitored through the System Resilience Group on a monthly basis and will also be reviewed through the monthly SpR that it is place with NELFT. 14. Consultation/communication No consultation or communication is required unless the service is ceased. If the decision was taken to not continue funding the service then A&E and the wards would need to be informed as this would mean a change to the pathways that have been in place since November The impact would also need to be feed through the capacity modelling that BHRUT will be required to undertake in preparation for resilience planning. 15. Expected timelines and deliverables Service is in place currently and the case is being made for continuation. 16. Other Organisational Involvement The services are provided in A&E at Queens and in-reach to both Queens and King George hospital sites and therefore there are significant links in place with BHRUT. The TT service is part of the proposal for streamlining A&E services (see 5d above) and links to the Urgent Care Vanguard development. The IRS service would need to be part of the discharge planning review. 17. Environmental considerations Not applicable 18. Equality/ Diversity Not applicable Notes on submission process: 1. The Head of Finance or Deputy Chief Finance Officer are available to assist and advise on the preparation of business cases. 2. Approval will be sought from JMT, CCG Executive, and/or CCG Board as determined by the business case approval process. Business case TTIRS /11 Version 10

111 Appendix 1 Option 2: Fund TT 8am-10pm and IRS 9am-5pm for 365 days per year ( 847,195) Option 2 - KGH & Queens A&E Liaison Service both CTT and IRS running 7 days per week for 365 days per year Band Rota Headcount Mon-Friday Saturday Sunday WTE needed Total (inc sickness and AL) CTT Pay -Rota 8am-10pm Nurse Band ,291 40,960 50, ,796 IRS Pay -Rota 9am -5pm Therapist.and ,056 58,515 72, ,706 Total Pay Costing ,503 Total 5% 36,675 Overheads 10% 77,018 Total Cost CTT/IRS 847,195 * Sickness/Annual leave at 20% Business case TTIRS /11 Version 10

112 Appendix 2 Option 3: Fund TT 8am-10pm 365 days per year and IRS 9am-5pm for weekdays only ( 666,277) Option 3 - KGH & Queens A&E Liaison Service 7 days per week for CTT and 5 days per week for IRS Band Rota Headcount Mon-Friday Saturday Sunday WTE needed Total (inc sickness and AL) CTT Pay -Rota 8am-10pm Nurse Band ,291 40,960 50, ,796 IRS Pay -Rota 9am -5pm Therapist.and , ,067 Total Pay Costing ,864 Total 5% 28,843 Overheads 10% 60,571 Total Cost CTT/IRS 666,277 * Sickness/Annual leave at 20% Business case TTIRS /11 Version 10

113 Appendix 3 Option 4: Fund TT 8am-10pm 365 days per year and IRS 9am-5pm for 7 days per week from November to March and 5 days per week from April to October ( 766,735) Option 4 - KGH & Queens A&E Liaison Service 7 days per week for CTT 5 days per week for IRS (April - October) and 7 days IRS (November - March) Band Rota Headcount Mon-Friday Saturday Sunday WTE needed Total (inc sickness and AL) CTT Pay -Rota 8am-10pm Nurse Band ,291 40,960 50, ,796 IRS Pay -Rota 9am -5pm Therapist.and ,056 29,257 36, ,387 Total Pay Costing ,183 Total 5% 32,759 Overheads 10% 68,794 Agency costs 10,000 Total Cost CTT/IRS 766,736 * Sickness/Annual leave at 20% Business case TTIRS /11 Version 10

114 Appendix 4 Case study Intensive Rehabilitation Service Patient Case Study Miss J.B (seen from 21/12/15-13/1/16) Patient Background: 92 year old female, admitted to acute on background of falls, increasing in numbers over a 2 week period. Diagnosed in acute with UTI, and treated with antibiotics. All falls occurred overnight, when patient was transferring to the toilet. The acute therapists felt that the falls were predominantly due to environmental hazards due to the location and nature. Patient was in acute environment for approx. 4 weeks prior to IRS intervention. Patients PMH: IRS In-Reach Experience: DAY ONE: IRS In reach therapist was asked to review patient as she was borderline for inpatient therapy vs IRS at home. Patient was transferring independently and mobilising independently with a rollator frame approx. 8m. On assessment IRS therapist concluded: - Current function level she appears at her baseline and is limited only by her anxiety around returning home. - Suggested that the ward complete a home visit with patient to try and reduce some anxiety around returning home - patient declined and reported she just wanted rehab. - Suggested a d/c home with full POC and IRS support - patient declined and reported she just wanted rehab // patient then became very tearful. -Reassured ++ and explained that no decision has been made currently but that feed back to ward staff would be expressed. Business case TTIRS /11 Version 10

115 - Explained the above to ward staff and reported that we cannot clinically reasoning with ease this lady being admitted to a rehab bed - suggested they investigate her anxiety around returning home further. DAY 2: Patient s daughter was then informed by the ward staff of the above conclusions made by the in-reaching therapist. Patient s daughter contacted the IRS team and spoke to the in reaching therapist to express her concerns regarding; what felt to her; the sudden change in plans around her mums discharge. IIRS in reaching therapist explained the findings of the assessment and reassured the patient s daughter. DAY 3: The ward staff, based on IRS recommendations completed a home visit with the patient and patient due for discharge the same day. DAY 4: IRS therapy started. IRS Intervention: This patient received 2-3 visits daily during her 21 day stay with the IRS teamfrom PT, OT and RA. On point of initial assessment patient was: - Mobilising with rollator frame independently but ++ anxious - Transferring independently - Requiring assistance one to complete washing and dressing in shower - Requiring assistance one to complete all kitchen tasks - She had an initial TUG of 44 secs On point of d/c patient was: - Completing all standing exercises independently and mobilising with rollator frame around her house independently. - Patient was independent with hot drink prep - Patient was able to independently wash in shower but continued to require assistance one to access secondary to steps. - She had a final TUG of 38.6 secs. Patient was also supported at home with a QDS POC and district nursing. Outcomes: Due to the input received from the IRS service the patient was able to be safely discharged from hospital, and regain her independence and confidence at home. The Acute hospital was able to receive advice and facilitation to an otherwise complex discharge, due to the IRS in reach service provided. This patient has had no further falls and no further admissions to acute services since her d/c home with IRS support. Business case TTIRS /11 Version 10

116 To: From: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group (CCG) Governing Body Dr Jagan John, Clinical Director Date: 22 March 2016 Subject: Response Car - London Ambulance Service and Community Treatment Team Executive summary The service was established in October 2014 and was funded from 2014/15 Operational Resilience Funding (the cost of the car was covered by the London Ambulance Service (LAS) from October to December 2014). It was set up by LAS and the Community Treatment Team (CTT) from NELFT to support the reduction in admissions/attendances and conveyances to an Emergency Department. Funding was agreed for 2015/16 through the System Resilience Group. The service consists of an ambulance car, staffed by a paramedic and a CTT nurse and responds to appropriate falls calls (criteria including the patient being over 65) identified by the LAS Control Centre. The team then do a full assessment of the patient in their own home and where possible keep the patient at home and avoid unnecessary conveyance. From April 2015 to January 2016 the team visited 1,150 patients and managed to keep 818 of these at home (71%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate) and it is estimated that there is a net saving of 390,827 as a result of the service being in place. Recommendations To continue funding for this service in 2016/ Purpose of the Report 1.1 The purpose of this report is to set out the rationale for the continuation of funding for the LAS/ CTT response car service. 2.0 Background/Introduction 2.1 Operational resilience funding was received by the Barking, Havering & Redbridge system in the summer of 2014/15 and schemes for funding were prioritised, through the System Resilience Group, in line with the Barking Havering and Redbridge University Hospitals Trust (BHRUT) Service Improvement Plan and identified gaps in existing provision.

117 2.2 The LAS/CTT service was established in October 2014 and was funded from 2014/15 Operational Resilience Funding (the cost of the car was covered by LAS from October to December 2014). It was set up to support the reduction in admissions/attendances and conveyances to an Emergency Department. 2.3 This paper summarises the development of the service and makes the case for continuation of funding. The cost for continuation of the service for 2016/17 is 473,377 and represents a 14% reduction ( 66,202) on the cost of the scheme in 2015/ Service description 3.1 An Ambulance car, staffed by a paramedic and a CTT nurse responds to appropriate falls calls (criteria including the patient being over 65) identified by the LAS Control Centre. The team then undertake a full assessment of the patient in their own home. If the patient requires support in order to stay at home then the team contact CTT in the community and hand the patients care over, ensuring continuity and reassurance for the patient. The team are able to provide and, where appropriate, fit some small items of equipment e.g. chair raisers, walking frames to address any immediate patient needs. 3.2 The service aims to enable the identified cohort of patients to be safely assessed, treated at home and discharged from care, without the need to convey to A&E. This supports reduction in attendances, admissions and ambulance conveyances to an ED. The service operates seven days a week, between the hours of 07:00 and 19: From April 2015 to January 2016 the team visited 1,150 patients and managed to keep 818 of these at home (71%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate). The forecast for a full year, on this basis is 1,380 patients visited and 982 kept at home. This forecast has been used for the estimated cost saving in appendix 1 of the business case. 4.0 Recurrent funding proposal rationale 4.1 The business case sets out the rationale for recurrently funding the service based on reducing admissions, attendances and ambulance conveyances to an ED and the fact that 71% of people are kept at home and the excellent patient experience and outcomes. Patient case studies and patient experience surveys are included in the business case. 98% of patients completing the survey were seen within 2 hours and would recommend the service. 4.2 The total cost of the service across BHR is 473k and it is estimated that the total annual savings, based on the current service performance, would be approximately 864k, if we assumed that 80% of patients would have been admitted, and therefore the net savings are 391k. Appendix 1 also shows the forecast savings, if either 100% or 60% of patients were admitted, and all forecasts show a net saving after fully funding the service. 5.0 Resources/investment 5.1 The service costs 473k per annum and this is split between 281k for LAS and 192k for CTT. Page 2 of 3

118 5.2 The cost and net savings by CCG are set out below: Service cost Total savings Net savings Barking & Dagenham 147, , ,168 Havering 245, , ,323 Redbridge 80, ,683 66,336 TOTAL 473, , , Recommendation 6.1 To fund the service for 2016/17 to ensure continuity of this service which has demonstrated the ability to manage patients in their own home and is forecast to save more than it costs. 7.0 Equalities 7.1 There are no equalities issues raised by this paper. 8.0 Risks 8.1 If the service was not in place then the risks would be: Increase in ED admissions and ambulance conveyances in an already significantly challenged system. Carers may end up in hospital which could have an impact on the person they are caring for. Once a patient is admitted they can deteriorate as a result of loss of independence and are at risk of infection which can affect their recovery rate and future ability to self-care. 9.0 Managing conflicts of interest 9.1 There are no conflicts of interest considerations arising from this report. Author: Sarah D Souza, Deputy Chief Operating Officer Barking and Dagenham CCG Date: 24 February 2016 Attachment: Business Case CTTLAS Page 3 of 3

119 BUSINESS CASE This template should be completed for business cases up to 2m. This document should be completed following approval of the Business Justification. Note 1 Guidance notes are incorporated into each section please delete them when no longer required. Note 2 Some sections may not be relevant to your business case. Please do not delete the section, but indicate accordingly. Note 3 Please remember to update the footer version number at the bottom of the page each time you update your case. Contents 1. Amendment History 2. Summary of project 3. Purpose 4. Current situation 5. Case for change a. Business needs b. Benefits c. Risks d. Interdependencies 6. Strategic context 7. Procurement 8. Activity implications 9. Workforce implications 10. Funding and affordability 11. Options considered & preferred option 12. Management arrangements 13. Governance arrangements 14. Consultation/communication 15. Timelines and deliverables 16. Other Organisational Involvement 17. Environmental considerations 18. Equality/ Diversity Business case CTTLAS /13 Version 1

120 1. Summary of project Reviewers This document must be reviewed by the following: Name Signature Title / Responsibility Date Version Project Manager (Owner) Executive Sponsor Project /Senior Management Accountant The Project Manager (Owner) is the person who will be responsible for delivering the benefits arising from this project. They would usually be a senior manager or clinician. The Executive Sponsor must be an Executive Director. They would usually be expected to present the case to the CCG Joint Management Team / CCG Executive Committee. Approval This document must be approved by the following: Name Signature Title / Responsibility Date Version CCG CFO Quality Corporate CSU Commissioning Support Director 2. Summary of project Project Name Community Treatment Team (CTT)/ London Ambulance Service falls car scheme Date 24/02/16 Executive Summary A response vehicle provided by the London Ambulance Service (LAS) crewed by a registered nurse and a registered LAS paramedic tasked to attend an identified group of patients within the geographical area of Barking & Dagenham, Havering and Redbridge Clinical Commissioning Groups (CCGs). This joint clinical response has the aim of enabling this cohort of patients to be safely assessed, treated at home and discharged from care, without the need to convey to A&E. Cost of Business Case 473,377 (LAS - 280,709, NELFT - 192,667) Confirm physical capacity already exists/included in costs Impact Yes physical capacity already in place Average of 82 patients kept at home per month from April 2015 to January From April 2015 to January 2016 the team visited 1,150 patients and managed to keep 818 at home (71%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate). The potential net savings for the scheme are 390,827 and this is set out in appendix 1. Business case CTTLAS /13 Version 1

121 3. Introduction Operational resilience funding was received by the Barking, Havering & Redbridge system in the summer of 2014/15 and schemes for funding were prioritised, through the System Resilience Group, both in line with the Barking Havering and Redbridge University Hospitals Trust (BHRUT) Service Improvement Plan and identified gaps in existing provision. The LAS/CTT service was established in October 2014 and was funded from 2014/15 Operational Resilience Funding (the cost of the car was covered by LAS from October to December 2014). It was set up to support the reduction in admissions/attendances and conveyances to an Emergency Department. An Ambulance car, staffed by a paramedic and a CTT nurse responds to appropriate falls calls (criteria including the patient being over 65) identified by the LAS Control Centre. The team then undertake a full assessment of the patient in their own home. The service operates seven days a week, between the hours of 07:00 and 19:00. This paper summarises the development of the service and makes the case for continuation of funding. The cost for continuation of the service for 2016/17 is 473,377 and represents a reduction of 66,202 on the cost of the scheme in 2015/ Current situation Table 1: From April 2015 to January 2016 the team visited 1,150 patients and managed to keep 818 at home (71%) avoiding the need for an emergency ambulance, A&E attendance and admission (where that would have been appropriate). The table below shows the number of calls attended each month from April 2015 and the number of patients kept at home: Month: Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sept 15 Oct 15 Nov 15 Dec 15 Jan 16 Total Calls attended ,150 Patients kept at home (Plan): Patients kept at home (actual): Variance: Case for change a) Business Needs When the Operational Resilience schemes were developed in 2014/15 they were focused on reducing length of stay and admission avoidance to reduce the bed usage on the acute hospital sites. As part of their Service Improvement Plan, BHRUT identified a 72 bed gap between expected need and actual bed stock. This scheme aimed to keep 20 patients at home, per week to reduce attendance / admissions / ambulance conveyances to an ED. b) Benefits The CTT/LAS team have patient experience at the forefront of the service and the focus continues to be keeping patients at home, wherever possible, to maintain independence and prevent further deterioration of ill health. Two patient case studies have been included at appendix 1, which demonstrate the benefit of the service to patients. Business case CTTLAS /13 Version 1

122 Achievements: c) Risks The Team won the international poster competition at the National Patient Safety Congress awards on 7 th July against over 200 other entries. The Team were shortlisted for an HSJ award The Team were asked to present their work to the executives and Trust board of LAS and to the commissioners in Essex with a view to replicate the model. If the service was not in place then the risks would be: Increase in ED admissions and ambulance conveyances in an already significantly challenged system Carers may end up in hospital which could have an impact on the person they are caring for (See case study, appendix 2) Once a patient is admitted they can deteriorate as a result of loss of independence and are at risk of infection which can affect their recovery rate and future ability to self-care. d) Interdependencies The service is closely linked with LAS and the community CTT team. Appropriate calls are sent to the car from the LAS control centre as well as the car having a Geotracker which enables them to identify suitable patients. Patients who can be kept at home with support are passed on to the local CTT team. 6. Strategic context The CTT and LAS service has been developed across BHR to reduce pressure on the acute trust and improve outcomes for patients by keeping them independent in their homes wherever possible 7. Procurement Not applicable. 8. Activity Implications The car will aim to keep at least 20 patients at home per week. 9. Workforce implications Paramedic and CTT nurse seconded into post on a rotation basis. 10. Funding and affordability The service costs 473k per annum and this is split between 281k for LAS and 192k for CTT. The breakdown of costs is attached at appendix 2. We have created a full year forecast based on the activity from April 2015 January This would give a forecast of 1380 calls attended and 982 patients kept at home. The service cost equates to a cost of 343 per call attended or 482 per patient kept at home. The cost of an ambulance conveyance is 236; the cost of an A&E attendance is 152 and the cost of a 0/1 day admission is approximately 910. Appendix 1 includes a comparison of service cost against savings and the net savings for the service are approximately 391k. Business case CTTLAS /13 Version 1

123 11. Options considered & preferred option The cost and net savings by CCG are set out below: Service cost Net savings Barking & Dagenham 147, ,168 Havering 245, ,323 Redbridge 80,347 66,336 TOTAL 473, , Management Arrangements The service is provided by NELFT and LAS and the arrangement has been in place since October This would continue. 13. Governance arrangements Scheme performance is monitored through the monthly SPR that is in place with NELFT and separate monitoring arrangements would be established with LAS. 14. Consultation/communication No consultation or communication is required unless the service is ceased. If the decision was taken to not continue funding the service then NELFT and LAS would need to be informed as this would mean a change to the pathways that have been in place since October The impact would also need to be fed through the capacity modelling that BHRUT will be required to undertake in preparation for resilience planning. 15. Expected timelines and deliverables Service is in place currently and the case is being made for continuation. 16. Other Organisational Involvement No other organisational involvement. 17. Environmental considerations Not applicable. 18. Equality/ Diversity Not applicable. Notes on submission process: 1. The Head of Finance or Deputy Chief Finance Officer are available to assist and advise on the preparation of business cases. 2. Approval will be sought from JMT, CCG Executive, and/or CCG Board as determined by the business case approval process. Business case CTTLAS /13 Version 1

124 Appendix 1 Service cost breakdown CTT Cost Summary Pay costs 162,064 Non pay costs 30,603 Total Cost 192,667 LAS Cost Summary Pay Costs 189,867 Vehicle Costs 29,826 Other Non-Pay Costs 61,016 Total Cost 280, /17 - LAS/CTT COSTS AND SAVINGS Service costs CTT 192,667 LAS 280, ,376 Service activity Annual Forecast (based on April Jan 2016 actual Calls attended 1380 Admissions avoided 982 A B C Savings Unit price 100% 80% 60% Ambulance conveyance A&E attendance , , ,480 Admission (0/1 day) , , ,042 Total 1,042, , ,522 Net savings 569, , ,146 The following have been developed as it may be incorrect to assume that everyone conveyed to hospital would be admitted A - assumes an admission saving for 100% of people kept at home B - assumes an admission saving for 80% of people kept at home C - assumes an admission saving for 60% of people kept at home Business case CTTLAS /13 Version 1

125 Appendix 2 - Patient Case Studies / Patient Survey Results Patient 1 84 year old female lives with her husband in warden controlled accommodation. Visited & assessed by CTT/LAS car K466 following a fall. Access to property gained as warden on site. On arrival of K466 patient found to be laying on the floor in the living room. PC fall, rib pain. HPC patient had a fall at home this morning, states she caught her foot on the edge of a rug which caused her to fall. Unable to get herself up off the floor. Husband was present but suffers with dementia & was unable to help her up. O/E Patient alert & orientated. Complaining of right sided rib pain & skin tear laceration noted to right forearm. Denies any other pain. Assisted up into armchair. Some distress due to rib pain. Pain worse on deep inspiration & movement. No chest pain. No radiation of pain. No obvious shortness of breath although states she is having slight DIB. No obvious swelling / bruising to rib area. Tender on palpation but no obvious bony crepitus felt. Chest auscultation chest clear & good air entry heard in all lung fields. Good colour. Not sweaty. No nausea or vomiting. PEARL. Denies hitting head. No LOC. Denies dizziness. No palps. Patient very anxious & upset at the thought of having to go to hospital & leaving her husband. Co-codamol 8/500mg x 2 given to the patient. SH lives with her husband in warden controlled accommodation. Carers BD for her husband as he suffers with dementia. Patient independent with ADL s. Mobilises using a walking stick. Able to cook etc. Has a wet room / walk in shower. Has a perching stool in kitchen. Feels that they usually manage when she is well. PMH hypertension, high cholesterol, under active thyroid, OA. Observations BP 148/78, P 82 reg, RR 20, O2 sats 97% on air, T 36.8, BM 5.6mmols, GCS 15/15. Imp fall secondary to tripping up rug. Rib pain.??# rib. Skin tear laceration. Plan advised the patient to take regular analgesia. Spoke to patient s GP who will carry out a home visit tomorrow to review the patient & prescribe more analgesia if required. Husband s care package increased to QDS as the patient may require more support in the short term to care for her husband. Skin tear laceration cleaned & dressed using mepitel one & mepilex border CTT to refer to DN for ongoing wound care. Rug removed with the patient s permission. Patient happy with the plan. The patient s husband suffered with dementia & becomes increasingly agitated & anxious if his wife is not about to help him. The patient was very reluctant to go to hospital as she was so worried about leaving her husband & stated he would never cope going into respite care if she were to go to hospital. By enabling the patient to be kept at home she was able to remain with her husband which made them both very happy & not only saved money from her not attending the ED & potentially being admitted but it also stopped her husband having to go into short term respite care which also would have been very costly. Business case CTTLAS /13 Version 1

126 Patient 2 76 year old female Lives with her husband in a house, privately owned. Visited and assessed by CTT\LAS car K466 following a fall and head injury. On arrival met by husband, patient in the living room sitting up holding blood stained cloth to head. PC: Fall, Head injury. HPC: Patient had a fall approx 30 minutes ago in the garden. Patient was feeding the birds bent down and fell backwards, hit head on the fence and sustained 3cm full thickness laceration to back of head. Nil LOC, alert and orientated GCS 15/15. Patient got herself up from the floor and mobilised to the living area. Husband called 999. O/E: Observations recorded and stable (see chart), patient alert and orientated, denies LOC, GCS 15/15 PEARL size 3, patient able to recall events, c/o mild headache pain score 4/10. Denies any other pain, nil sob, nil chest pain, nil palpitations, nil dizziness, nil sweating, nil nausea or vomiting. Cap refill < 2 seconds, looks well, pink and perfused. Sustained 3 cm full thickness laceration to back of head, currently not taking any anti coagulants, nil other injuries. Chest Auscultation- chest clear & good air entry heard in all lung fields. 12 lead ECG recorded, normal sinus rhythm. Wound cleaned with normal saline, closed with tissue glue. 1 gram paracetamol given. Head injury advice given to patient, head injury leaflet given. Husband will be with patient for next 72 hours. CTT leaflet given to patient and explained. SH: Lives with her husband in a house independent of ADL s. Wife is main carer for husband following a CVA 1 year ago. Patient states she is coping well and declined any further support from social services. Telecare leaflet given for patient to consider pendant alarm for her and her husband. PMH: palpitations and anxiety Medication: Sotalol Hydrochloride IMP: Fall, head injury Plan: Advised the patient to take regular analgesia. Husband will be with patient over the next 72 hours to observe. Head injury leaflet given and explained to patient. Advised to contact CTT if concerned or 999 in the case of an emergency. CTT to follow up tomorrow for neuro observations. This patient would have been conveyed to the ED if k466 wasn t in operation as the paramedics are unable to use tissue glue, and would not have the expertise to safely leave a patient who has sustained a head injury at home. The CTT followed the patient up the next day with a visit from a nurse and the following day with a telephone call and she was subsequently discharged. Business case CTTLAS /13 Version 1

127 Appendix 3 - Patient Survey results This report was generated on 11/12/15, giving the results for 40 respondents. What year is this survey being undertaken? 2015 (40) 2016 (-) What month is this survey being undertaken? January (9) February (5) March (7) April (6) May (-) June (-) July (-) August (5) September (3) October (-) November (-) December (5) Borough patient resides in Barking & Dagenham (10) Redbridge (18) Havering (12) Are you happy for your comments to be used? Yes (40) No (-) How quick was the service in responding to you? Within 2 hours (39) Within 12 hours (1) Within 24 hours (-) Hours (-) Over 48 Hours (-) How likely are you to recommend this service to friends and family if they needed similar care or treatment? Extremely likely (39) Likely (-) Neither likely nor unlikely (-) Unlikely (-) Extremely unlikely (-) Don't know (-) What do you think is the best thing about this service? Can t fault he service it was quick and put my mind at rest Professional, quick response, excellent service Everything- Kind,Efficient I think it is absolutely terrific I think it is brilliant that Stan and I are both in our 80 s and you are there for us The service is essential for keeping the elderly in their own home It is brilliant That they come quick and look for everything Business case CTTLAS /13 Version 1

128 Could not wish for a better service, both the nurses and paramedics are excellent. Both extremely efficient and both had a bedside manor What do you think is the best thing about this service? Listen to the patient, concerned for the patient and made mum feel at ease That they look after people in their own home and it isn t easy. Excellent service The fact that my father was able to stay at home and be checked over instead of going into hospital, which he was desperate not to do Thoroughness Quick service and preventing her from going to hospital. Being assessed thoroughly It seems to be a good thing if it helps the patient to stay at home and to get care Support for older patients Saves the patient from going into hospital, if not need be. Very helpful in assessing the needs and treatment of the patient very thorough Doing everything at home rather than taking us to hospital The service could not have been better Being treated at home by such lovely girls I think this service is brill The amazing capability and patience of the paramedics The service provided by lea and Vikki was excellent. Keeping us informed as to the steps to be taken regarding my wife s problem. Very professional Quick professional care that can prevent hospital visit Quick, efficient, very friendly here within 10mins amazing As a busy professional it was nice for CTT/LAS to take over, saved time and helped individual that needed assistance. Spend a long time investigating and explained everything. Marvellous service Rapid response, friendly staff Able to speak with GP and leave me at home. Efficient, friendly, spoke to the resident It was absolutely brilliant; they work in a team and explain everything Speed of the service, friendliness, excellent team work The speed and efficiency Reassurance that patient care comes first treating the patient with respect Home attendance Came to visit me at home and looked after me rather than going to hospital Friendly, caring, understands needs The speed efficiency and pleasantness of the staff How do you think we can make it better? Don t think it could be any better Wish all services were as good as this service Business case CTTLAS /13 Version 1

129 I don t think you could make the service any better I do not think it can The service we have received has been fantastic and could not be any better from my point of view Couldn t wish for it to be better More protection from Could not be made better More cars, paramedics, nurses By making more people aware of the service How do you think we can make it better? Very satisfactory Not sure it could be better very caring people First time used, looks like a good service Nothing else Increase in this service It is the first time we have used this service. but I must say the two ladies that attended were lovely and done a brilliant job and I could not think of any improvement that would be needed Make people more aware of the service Marvellous service, couldn t be better It could not be better No need to make it better Not at all, it is very good It seem, from my point of view that no improvement is necessary I cannot think of any improvement to the team s service Nothing, they were brilliant From what I saw today, it was very quick and reliable Fantastic anyway No, the service received was marvellous They can t make it any better All nurses being nurse prescribers Our experience of the service has been very good Could not be better I can t think of anything that would better the service What do you think would happen if you did not get support from this service? Had another fall and kill myself Without the help of the service would not have been able to cope Paralysed in bed and ended up in A+E Business case CTTLAS /13 Version 1

130 I would still be sitting on the floor with a numb bum It would involve myself and my 88 year old father, who has very limited mobility, sitting in A&E for hours with him getting distressed. I would have had to go to hospital I would be ready to die I believe I would be in serious pain Patient would have been taken to hospital It would be awful My father would have spent hours in A+E Patient would have got worse and left on floor for longer Would have felt a lot worse Hospitalization, lack of support given when coming out What do you think would happen if you did not get support from this service? My father would have been sent to hospital, as he had had a fall Would have been sitting waiting for the ambulance service to attend Would have been taken to hospital The procedure would have taken much longer A long wait in A+E Would have been up the hospital for hours waiting The patient may well have deteriorated to a life threatening state My wife would still be in server pain and worry An all night visit to A+E for cases that do not require it but need early medical attention. My 89 year old client would have spent 5-6 hours in A+E waiting to be seen Would have needed to stay for long period with client on the floor, which can cause him/her more stress. dial 999 for hospital Would have gone to the doctor Probably taken to hospital by an ambulance Pressure on other services I would not survive Ambulance would have been called and would have been taken to A+E Would have been on the floor a lot longer than ended up in hospital I feel the patient would have a further fall and possibly develop an infection I would have had to wait until help arrived to lift me off the floor Leg would have got worse as she couldn t get to the hospital or doctors Back to hospital Suspect that I would have had to go to A+E Business case CTTLAS /13 Version 1

131 On a scale of 1-10, how satisfied were you with the service? With 1 being not satisfied and 10 being extremely satisfied. 1 (-) 2 (-) 3 (-) 4 (-) 5 (-) 6 (-) 7 (1) 8 (1) 9 (1) 10 (36) Do you have any other comments you would like to make? A big thank you I can t praise you enough Yes, Thank you girls for coming so quickly otherwise I would have been sat there for ages, I feel this service is essential to the elderly community, it retains their dignity and their sense of wellbeing is preserved This service was amazing We are impressed and feel there and feel there is somebody out there if needed Very good Thank you More money to support this service in the future and expand it More people should be made aware of this service, to take the pressure off the ambulance service These girls made my day, I was in such terrible pain, they helped me so much Just keep on going- you are doing wonderfully I cannot think of any better service we have received This service should be in place. Great idea, great service and would save lots of elderly patients from enduring A+E for hours Explained themselves to client, did appropriate checks very helpful and caring The service is excellent even 9am and patient states we have arranged everything Lovely, lovely people I am very pleased that I have found help No, good service Friendly and reassuring paramedics Wonderful service Feel comfortable and relaxed that I have been treated in my own home Business case CTTLAS /13 Version 1

132 To: From: Meeting of the NHS Barking and Dagenham CCG Governing Body Sahdia Warraich, Lay Member - Patient and Public Involvement (PPI) Date: 22 March 2016 Subject: Patient Experience Report Executive summary As part of the Clinical Commissioning Group s (CCG) commitment to improving patient experience and outcomes, this paper summarises our patient feedback and insight over the last two months and how it will be used. The report includes a summary of: The last patient engagement forum (PEF) meeting and activities of PEF members. International Day of Disabled People 2016 planning The stroke rehabilitation consultation Progress in developing our new engagement strategy Progress in our Equality and Diversity Standard 2 (EDS2) work Recommendations The governing body is asked to: Consider the feedback provided from the wide range of sources by local patients 1.0 Purpose of the report 1.1 To provide a summary of the range of feedback that has come through to the CCG from patients and stakeholders. 2.0 CCG Patient Engagement Forum (PEF) 2.1 The last Barking and Dagenham (B&D) PEF meeting was held on 21 January. At the meeting we covered two main topics: diabetes prevention, early diagnosis and management and nutritional supplements and respiratory work. 2.2 The first speaker was Dr Anju Gupta, one of the CCG s clinical directors and lead clinician for diabetes. Dr Gupta gave an engaging and interesting presentation about the subject which was very well received by PEF members. 2.3 The second presentation was given by Imran Khan, Pharmaceutical Advisor/Interim QIPP Pharmacist for the three Barking and Dagenham, Havering and Redbridge (BHR) CCGs. Mr Khan provided an excellent insight into the current guidance regarding nutritional supplements.

133 2.4 On 18 January PEF members participated in a session about the Improving Access to Psychological Therapies (IAPT) service. The session was led by Stasha Jan, Practice Improvement Lead and Integrated Care Project Manager. It was an excellent opportunity to discuss future plans regarding mental health services in B&D, particularly for those PEF members who have an interest in mental health. As a result of this session a series of recommendations were produced which will be used to inform future development of the service. 2.5 On 4 February all three CCG PEF/PERF s Chairs, Vice-Chairs and lay members had their biannual meeting - this time held in Barking Hospital. The main purpose of these meetings is to share information and to give each other updates about current PEFs/PERFs work. The meetings are a helpful learning opportunity and we each find out more about processes and good practice across BHR. I wasn t able to attend the meeting but our PEF Chair and Vice Chair were present. One of the meeting outputs a letter to inform the engagement strategy is mentioned further down in this report. 3.0 International day of disabled people 2016 planning 3.1 We will participate in and support the Council-led International Day of Disabled People (IDDP).event again. The first meeting of the steering group for this year s event was held on 9 February. The main theme for this year will focus on sports activities for disabled people. 3.2 The evaluation report on the latest event held on 3 December 2015 has shown that the event was even more successful than previous year (2014). There was far greater attendance and the layout and content was commended - with information stalls, attendees and presenters all located in one large space. 4.0 Stroke rehabilitation consultation 4.1 The consultation is going well, with over 200 responses across BHR so far and still a month to go. The feedback on our approach to developing and managing this consultation has been positive, which I welcome. 4.2 In Barking and Dagenham we ve engaged with a number of organisations and groups in addition to our PEF. We ve also discussed the proposals and sought the views of the Health and Adult Social Services Committee (scrutiny) and Health and Wellbeing Board. We have further outreach planned, including a session at a supermarket in Dagenham. A further reminder to stakeholders encouraging their participation and response will be issued in the next week or so. 5.0 Engagement strategy development 5.1 Patient and Public Involvement (PPI) Solutions, who are leading this work for the CCG have had several meetings with a range of stakeholders, both individuals and groups over the past month. 5.2 On 3 February the BHR CCGs held a well-attended engagement event with more than fifty attendees. All three PEFs/PERF sent members, a GP lead; CCG staff, Healthwatches, voluntary sector organisations and other stakeholders were in attendance. The workshop was an excellent opportunity to share experience of engagement with the three CCGs, hear a summary of what stakeholders have said to PPI solutions and look at how we develop our strategy and all work together more positively together in future. Over 80% of participants provided positive feedback about the event.

134 5.3 Even more positive were the numerous pledges from individuals and groups as to how they could help us to better engage from here-on. All of the information was captured in a report and a set of the slides circulated to all who attended. 5.4 Our PEF Chair and Vice Chair, along with their equivalents in our fellow BHR CCGs, sent a helpful letter to the Director of Corporate Services outlining their feedback and suggestions for the strategy document. The director thanked them for their input and responded to the suggestions, most of which are being picked up in the strategy drafting. 5.5 A first draft of the strategy will be available by the end of the month and shared with stakeholders for their views. The strategy, once refined, will come to the next governing body meeting for agreement. 6.0 Resources 6.1 There are no resource issues relevant to this report. 7.0 Equalities 7.1 The work on engagement in our borough, through the CCG s patient engagement forum structure, and through collaboration with patients; the voluntary sector and other key stakeholders, should contribute to reducing inequalities in access to healthcare and support the CCG in meeting its equality objectives. 7.2 We have recently attended two equalities workshops organised by the London Leadership Academy. On 26 January the Pan London Equality and Diversity meeting took place. Our work on developing a Workforce Racial Equality Standard (WRES) has begun, with an initial report on workforce race data and outcomes. This work will be reported through to the Remuneration and Workforce Committee. 7.3 The CCG is required to monitor and oversee the implementation of the EDS2 and WRES of our local health service providers. We are assured of progress through information provided through the NELFT organised EDS2 Working group. 8.0 Risks 8.1 There are no identified risks in relation to this report. 9.0 Managing conflicts of interest 9.1 There are no conflicts of interest relevant to this report. Author: Boba Rangelov, Patient and Public Engagement Advisor, BHR CCGs Date: February 2016

135 To: From: Meeting of the NHS Barking & Dagenham Clinical Commissioning Group Governing Body Tom Travers, Chief Finance Officer Date: 22 March 2016 Subject: Finance and Activity Report Month 10 Executive Summary As reported previously, the CCG has agreed a revised risk assessed forecast outturn of 3,352k with NHSE. This represents a 1.14% surplus rather than the original planned 2% surplus. The revision to the forecast was based on a risk assessed view of the underlying data driving the month 6 year to date and forecast positions. As at the end of January (Month 10) the position has remained stable and the CCG has maintained a 1.14% forecast surplus. At month 10 this represents year to date slippage of 1,623k against the original year to date planned surplus of 4,417k and 1,948k slippage against the original planned fully year 2% surplus. Further mitigating actions will be required and implemented over the rest of the financial year. Trends of activity are being closely monitored to inform the on-going management of this risk assessed position, and the recurrent impact upon the 2016/17 position. In previous months a risk range including a downside scenario has been presented to the Governing Body. Risks identified have spread across a number of areas including acute activity, prescribing and continuing care. The main driver behind the reported position is Barts Health, where a significant over performance is reported. The latest risk assessed forecast overspend is 2,470k or a 14% contract pressure. The resource limit for 2015/16 is now 295,522k. The Month 10 budgets have been increased to reflect five allocations this month totalling 1,696k. Reported figures are based on the Month 9 monitoring data from providers and adjusted for outstanding challenges, contract penalties and fixed price contract agreements. Barts Health - The Month 9 data before adjustments indicates a high level of year end over performance. The Barts Health contract continues to present the largest financial risk to the CCG. The latest data received from the Trust highlights over performance reported across a range of points of delivery, including non-elective, critical care, elective care, maternity pathway, outpatient procedures, high cost drugs and treatments and unidentified QIPP schemes. A number of challenges have been made and the reported position includes assumptions that a number of challenges are successful, and that the worsening activity trends are mitigated. The CSU have carried out further analysis of the Barts position and risk rated the issues identified, to further inform the reported outturn position. BHRUT A fixed price contract has been agreed with BHRUT for 2015/16, including non-recurrent funding to support the delivery of the QIPP schemes and the achievement of key performance indicators, ensuring system sustainability in the coming years. The fixed price also includes funding to ensure operational resilience during winter and meet the targets set to address the RTT backlog at the Trust. The 2015/16 contract is being managed under full PbR rules, as in previous months there were a number of issues with the Month 9 data and the finance and activity plans. These are being flagged for correction with the Trust through the TSG and SPR meetings. As highlighted in previous reports the CCG faces a number of risks that may further impact the financial position. These include: further acute activity growth above planned levels, continuing care growth and prescribing growth. A number of mitigations are in place attempting to off-set these risks and include robust contract management, PMO QIPP process and on-going review of investments.

136 Month ten QIPP delivery, based on Month nine SUS data, has delivered a total of 626K actual savings against a target of 684K. This represents a year to date saving of 5.70M against a plan of 5.65M. Recommendations The Governing Body is asked to: 1 Agree the financial position noting the action taken to achieve it. 1 Purpose of Report The purpose of this report is to brief the Governing Body on the overall financial position for the month of January 2016 (Month 10). 2 Background/Introduction As at the end of Month 10 the CCG achieved a surplus of 2,793k against a year to date planned surplus of 4,417k. It is forecast the CCG will deliver a revised year end surplus of 3,352k. 3 Report Content Resource limit The CCG has a resource limit of 295,522k. There have been five changes to the resource limit at Month 10 to reflect 2015/16 Charge Exempt Overseas Visitors (CEOV) and non-rechargeable services allocation adjustment, delegated CCGs benefit, Lawns- North St Prescribing, Lawns- North St Cocommissioning and Healthy London Partnership. Barking and Dagenham CCG Opening Resources '000 Recurrent Programme Baseline Allocation 242,625 Growth Uplift 7,621 BCF Allocation 4,185 ETO Additional Funding 692 Primary Care Co-Commissioning 27,538 GP IT 680 London Transformation Fund (375) Waiting list validation and improving operational processes 7 Eating Disorders & Planning Tier 3 Neurology Commissioning Responsibility Transfer - NHS England 71 Tier 3 Specialist Wheelchairs Commissioning Responsibility Transfer - NHS England 69 CCG cost of Pharmacy Hub (8) Liaison Psychiatry - Mental Health 50 UEC Vanguard sites - Liaison Psychiatry 47 Latent TB Funding 44 Liaison Psychiatry 50 UEC Vanguard sites 47 Mental Health CAMHs - Transformational Allocation Quality Premium award CEOV and non-rechargeable services allocation adjustment 1,800 Delegated CCGs benefit 195 Lawns - North St Prescribing (234) Lawns - North St Co-Commissioning (204) Healthy London Partnership 139 Return of 2014/15 Surplus 5,456 Programme Resources 291,034 Running Costs Allocation 4,488 Total Resources ,522

137 Cash Draw Down The CCG is required to draw down cash from the DOH on a monthly basis to pay invoices and staff salaries. To date 191,650k of a full year Predicted Year End Value of 240,552k has been drawn down. The CCG is predicting to utilise all cash made available by year end. The closing cash position as at 31st January 2016 was 2,273k. The large closing cash balance is due to forecasted payments to the local authority in respect of Better Care Fund which could not be made due to the late raising of invoices by the Local Authority. A summary of Predicted Year End Value receipts and payments for the year is provided for information at Appendix 5. The cash to income and expenditure reconciliation at Appendix 4 reconciles the actual cash received and paid out by the organisation to the total charge within the income and expenditure account. Throughout January the CCG continued to operate within its expected cash envelope and was not overdrawn on any of its bank accounts at any time. The CCG is working closely with the CSU to ensure accurate and robust cash predicted year end values are in place, and that there continues to be appropriate cash and treasury safeguards. Month 10 Reported Position The CCG revenue financial position is summarised in the table below. A more detailed summary can be viewed in Appendix 1. Month 10-31st Jan 2016 Commissioner Function Annual YTD YTD YTD Predicted Year PYEV Allocation Budget Actual Variance End Value (PYEV) Variance 000's 000's 000's 000's 000's 000's Acute Barking and Dagenham CCG Financial Position 2015/16 Acute Clinical SLA 121, , ,155 (2,657) 124,788 (2,990) Acute Other 18,563 15,159 15,497 (338) 18,789 (227) Acute sub-total 140, , ,652 (2,995) 143,577 (3,217) Services Provided in a Primary Care Setting 56,455 47,425 47,856 (431) 56,576 (121) Community Healthcare 32,112 26,493 26, , Mental Health & LD 29,037 24,197 24, , Continuing Care 13,814 11,332 12,357 (1,025) 14,880 (1,066) Programme Spend 13,955 7,485 5,044 2,441 11,960 1,995 Healthcare Provision sub-total 145, , ,561 1, ,104 1,269 CCG Running Costs 4,488 3,740 3, ,488 0 Running Costs & Non-Healthcare Provision subtotal 4,488 3,740 3, ,488 0 Total Expenditure 290, , ,952 (1,623) 292,169 (1,948) Resource Limit 295, , , ,522 0 Surplus/Deficit 5,300 4,417 2,793 (1,623) 3,352 (1,948)

138 As at the end of January (Month 10) the CCG achieved a surplus of 2,793k, against a year to date planned surplus of 4,417k. The year end forecast outturn is a surplus of 3,352k. Acute contracts Barts Healthcare The contract for 2015/16 with Barts Health has been agreed, including challenging targets for QIPP delivery and productivity. A full PbR contract has been agreed ensuring full adherence to the NHS Standard contract, the claims and challenges processes, assessment of the achievement of productivity targets and CQUIN standards, and the levying of performance penalties where the Trust fails to meet national KPIs. Month 9 data received from the Trust and lead commissioner, before adjustments indicates a high level of year end over performance for Barking & Dagenham CCG. In addition to the increase in non-elective activity, there are also adverse movements in electives, critical care, maternity pathway, outpatient procedures, high cost drugs and treatments and unidentified QIPP schemes. Further analysis of the Barts data has been carried out by the CSU. The CSU are continuing to risk rate the issues identified to further inform the reported outturn position. The lead commissioner made adjustments to the forecast position for the items listed below: - Updated calculations for readmissions, productivity metrics and non-elective threshold. - A prudent risk adjusted view of claims expected to year end based on the Trust s responses to date. - Penalties at Month 9 have been calculated. However, the lead commissioner has assumed that virtually all metrics will be reinvested with the Trust. - Misattributed patient transport and pathology costs were redistributed to CCGs on the basis of 14/15 outturn for these items. - Critical care costs that were automatically extrapolated in the forecast position have been adjusted to address the extrapolation for unusually high cost patients. A view of uncharged critical care work in progress has also been included in the forecast. - A view of CQUIN achievement at 80% based on Q2 information (95% in 14/15). The risk assessment has resulted in a predicted year end over performance at Barking & Dagenham of ( 2,470k) Discussions have been on-going between the lead commissioners in WEL and Barts Health in relation to a fixed year end deal. The reported figures are in line with the potential year end agreement. In informing Barking & Dagenham s position, BHR has instructed the lead commissioner that all contractual fines and penalties should be applied and a risk assessed view of CQUIN applied. Analysis of the numbers provided by Barts Health indicate that there are further potential downside risks in excess of the reported position, if the mitigating actions, data challenges and contract levers are not successfully applied. If a yearend position is agreed at the reported level then the downside risk is removed.

139 BHRUT A fixed price contract has been agreed with BHRUT for 2015/16, including non-recurrent funding to support the delivery of QIPP schemes and the achievement of key performance indicators, ensuring system sustainability in the coming years. The fixed price also includes funding to ensure operational resilience during winter and meet the targets set to address the RTT backlog at the Trust. The planned activity underpinning the 2015/16 fixed price has been rigorously tested and approved independently by NHS England. As in 2014/15, the 2015/16 contract is being managed under full PbR rules to enable a sustainable and robust activity and Finance baseline going forward. This includes full adherence to the NHS Standard Contract and the claims and challenges processes, assessment of the achievement of productivity targets and CQUIN standards, and the levying of performance penalties where the Trust fails to meet national KPIs. As in Month 8, data submitted by the Trust included a finance and activity plan that has not been agreed by the CCGs and does not reflect previous discussions with the Trust. Issues identified last month remain in the Month 9 data, including the treatment of non-recurrent RTT, operational resilience and quality premium funding, the majority of which has been assigned to Havering CCG. Issues around incorrect POD mapping, counting and coding changes (including maternity), misattributed specialist commissioning activity and the contract split by CCG, persists. These have all been flagged to the Trust through the TSG and SPR. To aid the monthly analysis, the CCGs view of the plan was overlaid against the Trust s submission. A number of adjustments have been made to the Trusts position to comply with PbR rules and to extrapolate the year to date position to year end. They include; - Forecasting CQUIN achievement based on 2014/15 performance - Calculating the impact of penalties based upon performance data provided by the trust. Penalties include A&E and cancer waits, ambulance handovers, 52 week waits, and 18 week RTT. Penalties are expected to exceed the 2.5% contractual threshold. - Claims and challenges raised by the CCG on the activity received from the trust. These include the on-going coding challenge of non-elective and A&E unit prices. The Trust has failed to adequately respond to outstanding claims to date resulting in a high level of open claims. The expectation is that this will be resolved through the quarterly reconciliation process. - PbR technical adjustments including non-elective threshold adjustments. Work is underway to jointly agree the 2015/16 non-elective threshold baseline with the Trust. The significant increase in ambulatory care activity has continued and there remains evidence that ambulatory care is being double counted as non-elective admissions. This is being challenged through the claims process. In year financial risk remains around additional funding requirements for RTT/Cancer targets. The significant level of underlying over performance is under further investigation by the Informatics and Contract teams. Non-elective and A&E activity remain key drivers of over performance with the trend of lower than expected UCC attendances continuing. The plan for day cases and elective activity was increased non-recurrently to allow for RTT backlog clearance. These points of delivery remain significantly under plan to date.

140 Associates and other acute providers The contract with Homerton continues to be an issue and the over spend is due to IVF Treatments, Maternity, T&O and Gynaecology. Princess Alexandra data still has issues and the contract has not been agreed to date. The contracts team have met the Trust to discuss the activity and the contract data. We are meeting again to resolve before next month. The Guys position still includes the Critical Care patient who is still in the Trust, the forecast has been adjusted accordingly. UCLH has increased due to Critical Care, Knee Replacement & Cancer treatments. Data and invoices received from Care UK, Spire and BMI highlight YTD over performance. At Month 10, spending continues to increase in the same specialties relating to T&O, Audiology, Ophthalmology, Endoscopy, MRI, Other Diagnostics and Gynaecology. There does not appear to be a corresponding reduction in the NHS Acute Trust s spending patterns. This has caused some adverse movements and a wider piece of work to understand activity trends affecting several providers in the health economy is ongoing. BARKING AND DAGENHAM CCG 2015/16 REPORTING - MONTH 10 - JANUARY 2016 Annual Budget Month 10 Budget Month 10 Position Month 10 Variance Forecast Outturn 15/16 Variance ACUTE TRUSTS BARKING, HAVERING AND REDBRIDGE UNIVERSITY HOSPITALS NHS TRUST 92,410 77,009 77, ,410 0 BARTS HEALTH NHS TRUST 17,815 14,846 17,175 (2,330) 20,285 (2,470) BASILDON AND THURROCK UNIVERSITY HOSPITALS NHS FOUNDATION TRUST (26) 554 (30) CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST (2) 193 (1) GREAT ORMOND STREET HOSPITAL FOR CHILDREN NHS TRUST GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 1,307 1,089 1,472 (383) 1,749 (442) HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 1,270 1,058 1,423 (365) 1,679 (410) IMPERIAL (56) 398 (47) KING'S COLLEGE HOSPITAL NHS FOUNDATION TRUST (24) 410 (29) MID ESSEX HOSPITAL SERVICES NHS TRUST 1, , MOORFIELDS EYE HOSPITAL NHS FOUNDATION TRUST 2,350 1,959 1, , NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST (52) 240 (51) NORTH WEST LONDON HOSPITALS NHS TRUST ROYAL BROMPTON AND HAREFIELD NHS FOUNDATION TRUST (35) 104 (42) ROYAL FREE HAMPSTEAD NHS TRUST ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST (78) 638 (68) ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST (0) THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST (43) 96 (32) THE ROYAL MARSDEN NHS FOUNDATION TRUST THE WHITTINGTON HOSPITAL NHS TRUST (38) 104 (46) UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST 1,726 1,438 1, , TOTAL ACUTE TRUSTS 121, , ,376 (2,878) 124,788 (2,990) TOTAL OTHER ACUTE 17,000 14,167 15,106 (939) 18,163 (1,163) Winter Resilience Acute Reserves (256) 823 (256) 936 TOTAL ACUTE 140, , ,652 (2,995) 143,577 (3,217)

141 Healthcare Provision A summary analysis of the Month 10 position is provided as detailed in the table below: Healthcare Provision Annual Budget 000s Barking and Dagenham CCG Financial Position 2015/16 YTD Budget 000s Month 10-31st Jan 2016 YTD Actual 000s YTD Variance 000s Predicted Year End Value 000s Predicted Year End Value Variance 000s Services delivered in a Primary Care Setting 56,455 47,425 47,856 (431) 56,576 (121) Community Healthcare 32,112 26,493 26, , Mental Health & LD 29,037 24,197 24, , Programme Spend 13,955 7,485 5,044 2,441 11,960 1,995 Continuing Care 13,814 11,332 12,357 (1,025) 14,880 (1,066) Healthcare Provision Total 145, , ,561 1, ,104 1,269 Services Delivered in a Primary Care Setting The total predicted year end value is an over spend of 121k. The main drivers behind this are: Prescribing The first eight months of 2015/16 prescribing data have been received. Forecasts have been issued and show a predicted year-end over-performance of 413k. The total overall unfavourable variance reported also includes the 2014/15 adverse cash charge received for the end of the financial year which totalled 124k and non-recurrent income receipts of 265k. Given the historic volatility of the prescribing budget close monitoring will continue during the last few months of this financial year. Primary Care Co-Commissioning Following full delegation, January is the tenth month of reporting co-commissioning expenditure. NHS England have posted actuals and advised accruals against this area for Month 10. Currently an in month cost pressure is being shown with breakeven at year-end. This is mainly due to NHSE QIPP savings taken during the budget setting not yet being fully met by CCG implemented QIPP plans. Continuing Health Care Continuing Care was an area of significant pressure in 2014/15 and information received to date suggests this trend has continued in 2015/16. This area shows a projected year-end overspend of 833k, which is based on 2014/15 outturn plus 5% growth. The forecast also includes additional costs for 1 to 1 Nursing Care of 65k previously shown against the Mental Health budget. Further analysis of the CAPS system and invoices received is ongoing to inform the financial position. The CHC Assessment and Support team is forecasting a year-end overspend of 233k. The total forecast outturn for CHC is overspending by 1,066k. Community Services This area has a year-end predicted underspend of 366k. This is mainly due to the release of the community services reserve of 331k into the position. Mental Health & Learning Disabilities This area shows a predicted year-end underspend of 95k. This is due to a large swing in the Non Contracted Activity year-end forecast as patients using Female PICU services have been discharged. The contingency reserve has now been used to fund schemes commissioned under the parity of esteem initiative. Better Care Fund

142 All of the Better Care Fund spends and budgets have been reconciled and coded within the accounts according to NHSE instruction. The budgets and spend still sit within the relevant categories (Community, Mental Health and Programme) for monthly reporting purposes. CCG Running Costs Barking & Dagenham CCG Running Costs & Corporate Costs as at 31st January 2016 Directorate 2015/16 Annual Budget 000's M10 YTD Budget 000's Pay 000's Non Pay 000's M10 Total Costs 000's M10 YTD Variance 000's M10 Annual Forecast 000's M10 Annual Variance 000's Running costs CSU SLA 2,151 1, ,902 1,902 (109) 2,204 (53) Operations Management Corporate Costs & Services CEO / Board Office Chair and Non Execs (41) 378 (56) Non pay Inc Audit Fees Finance (3) 114 (2) Innovation Fund Strategy & Development Clinical Support Nursing Directorate Total Running Costs 4,488 3,740 1,513 2,226 3, ,488 0 Corporate Costs 3,087 2, ,882 2,755 (97) 3,267 (180) Grand Total Running & Corporate Costs 7,575 6,398 2,386 4,108 6,495 (97) 7,755 (180) All running costs are showing a forecast overall breakeven positon at Month 10. Corporate costs are showing a forecast overspend of 180k. The main drivers behind this relates to a forecast over spend of 233k in CHC Assessment & Support, over spend of 136k relating to Recharges from NHS Property Services Ltd, which is partly offset by forecast underspends in Medicines Management 7k, Safeguarding 4k, Primary Care IT 75k and Non Recurrent Programme Projects 103k. Statement of financial position The statement of financial position (SoFP) summarises the CCG s assets, liabilities and tax payers equity at a specific point in time. The CCG s statement of financial position as at 31 st January 2016 can be seen at Appendix 2. The cash and cash equivalent balance within the statement of financial position as at 31 st January 2016 was 2,152k. This was 121k less than the cash position shown within the actual cash and Predicted Year End Value cash position (Appendix 5) due to un-cleared payables orders currently outstanding and the release of BACS run on 27 th January which cleared the bank account on 1 st February. The statement of financial position shows the general ledger balance based upon un-cleared cash items, whereas the actual cash and the predicted year end value cash position only shows cleared items. Trade and other payables totalling 27,164k include 19,676k worth of outstanding invoices to NHS and Non NHS Organisations, as well as 7,488k worth of net manual adjustments most noticeably 4,093k in terms of Prescribing which contribute to the estimated financial position as at 31 st January 2016.

143 Predicted Year End Value of closing balances are based upon full utilisation of the CCG s cash limit in the financial year. Invoice payment performance measure Better Payment Practice Code (BPPC) The BPPC requires the CCG to aim to pay all valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. A summary of the year to date results can be found at Appendix 3. BPPC figures for the CCG as at the end of January 2016 show that 87.0% was achieved on the number of invoices paid and 93.6% was achieved on the value of invoices against the target of 95% on both indicators. The CCG is working closely with the CSU to ensure all valid invoices are being cleared in line with this target. QIPP The CCG governing body has agreed a QIPP plan of 7.8M for 15/16. Month ten QIPP delivery, based on Month nine SUS data, has delivered 626K actual savings against a target of 684K, however this includes 321K of benefit from the BHRUT fixed value SLA, which is not attributed to any schemes. Overall, this represents a year to date saving of 5.70M against a plan of 5.65M (inclusive of the BHRUT fixed SLA). Two schemes have been escalated to the Finance and Delivery committee as a result of underperformance (Emergency admission avoidance and Calprotectin). An escalation report has been developed for both schemes, which includes a detailed recovery plan.

144 QIPP Scheme Name Project Leads Target saving/ Planned Activity 15/16 Actual Saving/Activity YTD Target Saving/Activity YTD Urgent Care A&E Attendance Reduction Emergency Admission Avoidance Project Lead: Stasha Jan CD Lead: Dr Jagan John Exec Lead: Sharon Morrow Project Lead: Stasha Jan CD Lead: Dr Jagan John Exec Lead: Sharon Morrow Activity 27, ,738 Finance ( 000) Activity 2, ,554 Finance ( 000) 1, Calprotectin Project Lead: Kam Sahota CD Lead: Dr Rami Hara Exec Lead: Sharon Morrow/Richard Clements Activity Finance ( 000) , Planned Care Cardiology Project Lead: Kam Sahota CD Lead: Dr Rami Hara Exec Lead: Sharon Morrow/Richard Clements Activity 3, Finance ( 000) Contract Efficiency/Budget Reduction: Cherry Orchard and Outlook Care Project Lead: TBC CD Lead: TBC Exec Lead: TBC Finance ( 000) Local Enhanced Services - Realignment of budget Project Lead: Jamil Ahmed CD Lead: Dr Gurkirit Kalkat Exec Lead: Sharon Morrow Finance ( 000) Primary Care Primary Care Surge Scheme Everyone Counts Project Lead: TBC CD Lead: Dr Gurkirit Kalkat Exec Lead: Sharon Morrow Richard Clements Project Lead: CD Lead: Exec Lead: Finance ( 000) Activity Finance ( 000) Medicines Management Project Lead: Sanjay Patel/Vicki Kong CD Lead: Dr Gurkirit Kalkat Exec Lead: Belinda Krishek Finance ( 000) TOTAL - ALL SCHEMES Finance ( 000) 3, , ,482.6 Other QIPP Identified QIPP Unidentified QIPP 0.0 Fixed BHRUT benefit Financial Summary As at the end of January (Month 10) the CCG achieved a surplus of 2,793k against the original plan of 4,417k and a breakeven position on the revised year to date plan. A number of risks have been identified within the reported position. These are being managed and it is expected that the mitigating actions identified will allow the CCG to deliver its 3,352k revised planned surplus. 4 Resources/Investments n/a 5 Equalities n/a 6 Risk As reported previously, the current forecast projects slippage against Barking and Dagenham CCGs planned surplus of 5,300k. A number of risks are factored into the financial position which means that the CCG planned surplus has been reduced to 3,352k, a 1.14% surplus. The main risks reported in the financial position relate to Barts Health and independent sector providers. There are however, additional risks and mitigations that could impact on the reported outturn.

145 The table below sets out the key financial risks associated with the current reported position and actions that can be taken to mitigate these. This table includes risks that are deemed to have a significant increase or decrease in planned expenditure. Barking and Dagenham CCG Key Risks Area Risk Assumption in Forecast Value Of Risk Downside Reported Up Side '000,s '000,s '000,s Action taken to mitigate risk Acute Contracts Barts and other costs over performance and QIPP delivery risk Contract values are delivered Finance and performance monitoring. Robust contract challenges process in place. Activity / cost will be identified at practice level where possible and a proposed clinician and officer working group established to identify options for activity flows which mitigate the financial pressures Primary Care Prescribing Delivery plans monitored through QIPP process faciliated by Medicine Management team. Downside is a risk assessed view of the data available. Co-Commissioning FOT co-commissioning reported as break even in the ledger. Downside assumes no QIPP. Upside mitigated by NHSE 1% funding Continuing Care Continuing care placements exceed growth in budget 14/15 spend plus 5% growth Review of packages and process by placement teams. Further analysis of CAPS system and invoices. Other Programme Projects, and unidentified QIPP Upside and downside of QIPP slippage and investments The table shows a range of risk that faces the CCG and without mitigating actions would further impact the CCG s ability to deliver its revised financial position. Although possible, it is not expected that all of the adverse or favourable risks will occur in full. Monitoring of these risks and actions will continue throughout the year, and where necessary further actions implemented. 7 Managing conflicts of interest n/a

146 Appendix 1 Barking and Dagenham CCG Financial Position 2015/16 Month 10-31st Jan 2016 Commissioner Function Annual YTD YTD YTD In month In month In month Predicted Year Predicted Year Allocation Budget Actual Variance Budget Actual Variance End Value End Value Variance 000's 000's 000's 000's 000's 000's 000's 000's 000's Acute Healthcare Acute Commissioning 121, , ,155 (2,657) 10,150 10,390 (240) 124,788 (2,990) Acute Commissioning Other 3,263 2,719 2, (118) 2, Winter Resilience High Cost Drugs (2) 1 1 (1) 13 (3) Ambulance Services 7,375 6,146 6, ,375 0 Clinical Assessment and Treatment Centres 4,029 3,358 3,779 (421) (1) 4,552 (523) NCA 3,003 2,502 2,692 (190) (18) 3,230 (228) Acute sub-tot Acute sub-total 140, , ,652 (2,995) 11,640 12,018 (379) 143,577 (3,217) Mental Health & LD Mental Health Contracts 24,815 20,679 20, ,068 2,071 (3) 24, Mental Health Services - Adult (1) Non Acute NCA Mental Health Services Other 2,893 2,411 2,438 (27) (20) 2,924 (31) Mental Health & LD sub-total 29,037 24,197 24, ,420 2,422 (2) 28, Community Healthcare Community Services 30,901 25,483 25, ,560 2, , Palliative Care Hospices Long Term Conditions (51) (66) Wheel chair service Community Sub-total 32,112 26,493 26, ,661 2, , Continuing Care CHC Adult 11,438 9,352 10,109 (757) 903 1,075 (172) 12,117 (680) CHC Adult Full Fund Pers Hlth Bud (13) 4 9 (5) 101 (55) CHC Assessment and Support (151) (11) 582 (233) CHC Children (43) (26) Funded Nursing Care 1, (62) (17) 1,107 (72) Continuing Care Sub-total 13,814 11,332 12,357 (1,025) 1,101 1,246 (145) 14,880 (1,066) Programme Spend Commissioning - Non Acute Better Care Fund 4,185 3,488 3, ,185 0 Health Analytics Counselling services (120) (120) 242 Safeguarding (4) Non Recurrent Programmes Programmes Projects 5, (1,490) 2,214 (693) (1,360) 667 4,201 1,744 Reablement NHS NHS Prop.Co (114) (114) 977 (136) Programme Spend Sub total 13,955 7,485 5,044 2, (570) ,960 1,995 Services Provided in a Primary Care Setting Out of Hours 1, ,059 0 Everybody Counts 1,042 1, , ,039 3 Commissioner Schemes ,175 (1,064) (123) 154 (21) Primary Care Co-Commissioning / LES 27,584 22,986 23,305 (319) 2,146 2,233 (87) 27, Medicines Management Primary Care IT (5) GP Prescribing 24,682 20,775 20,954 (180) 1,924 1,927 (3) 24,931 (249) Oxygen Central Drugs (32) (13) 723 (32) Services Provided in a Primary Care Setting Sub-total 56,455 47,425 47,856 (431) 4,455 4,473 (18) 56,576 (121) Sub-total Healthcare provision 285, , ,212 (1,623) 22,291 22, ,681 (1,948) Running Costs CCG Running Costs 4,488 3,740 3, ,488 0 Running Costs Sub-total 4,488 3,740 3, ,488 0 Gross Expenditure 290, , ,952 (1,623) 22,665 22, ,169 (1,948)

147 Appendix 2 Barking & Dagenham CCG Statement of Financial Position Position as at 31st January Mar Mar Annual January Change Non-current assets Property, plant and equipment Intangible Other financial assets Trade and other receivables Total Non Current Assets Current Assets Inventories Trade and other receivables 4,240 1,491 4,240 - Other financial assets Cash and cash equivalents 280 2, (230) Total Current Assets 4,520 3,643 4,290 (230) Total Assets 4,520 3,643 4,290 (230) Current Liabilties Trade and other payables (22,574) (27,164) (22,574) - Provisions (2,001) (974) (501) 1,500 Borrowings Total Current Liabilites (24,575) (28,138) (23,075) 1,500 Net Current Assets/(Liabilities) (20,055) (24,495) (18,785) 1,270 Trade and other payables Provisions Borrowings Total Non-Current Liabilites Total Assets Employed (20,055) (24,495) (18,785) 1,270 Financed by: Taxpayers Equity General Fund (20,055) (24,495) (18,785) 1,270 Revaluation reserves Total Taxpayers Equity (20,055) (24,495) (18,785) 1,270

148 Appendix 3 Barking and Dagenham CCG Invoice Payment Performance Measure Position as at 31st January 2016 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Cumulative Number Value Number Value Number Value Number Value Number Value Number Value Number Value Number Value Number Value Number Value Number Value '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Non-NHS Creditors Total Bills paid in the year 608 3, , , , , ,258 1,270 5, , , ,925 7,597 37,210 Total Bills paid within target 564 2, , , , , , , , , ,436 6,669 31,196 Percentage of Bills paid within target 92.8% 74.8% 92.2% 55.2% 96.6% 93.3% 96.8% 90.3% 91.5% 70.2% 84.3% 94.6% 77.6% 90.6% 77.2% 86.0% 90.7% 89.3% 91.3% 83.3% 87.8% 83.8% NHS Creditors Total Bills paid in the year 36 13, , , , , , , , , ,973 2, ,168 Total Bills paid within target 27 13, , , , , , , , , ,826 1, ,457 Percentage of Bills paid within target 75.0% 100.0% 62.5% 96.5% 72.2% 95.7% 83.8% 95.5% 87.9% 93.9% 88.7% 89.0% 92.8% 98.0% 86.3% 96.8% 89.5% 96.0% 93.3% 99.1% 84.4% 95.8% All Creditors Total Bills paid in the year , , , , , ,273 1,629 22,341 1,193 20,705 1,015 18, ,898 9, ,378 Total Bills paid within target , , , , , ,836 1,319 21, , , ,262 8, ,653 Percentage of Bills paid within target 91.8% 95.1% 82.6% 88.4% 93.8% 95.2% 93.2% 94.3% 90.1% 90.4% 84.9% 90.0% 81.0% 96.2% 79.3% 94.7% 90.4% 95.1% 91.8% 96.6% 87.0% 93.6%

149 Appendix 4 Barking and Dagenham CCG Cash to income and expenditure reconciliation Position as at 31st January January 2016 Cashflows from Operating Activites Net operating cost before interest operating surplus/deficit (238,952) Depreciation and amortisation Impairments and reversals Interest paid (Increase)/decrease in inventories (Increase)/decrease in trade and other receivables 2,751 Increase/(decrease) in trade and other payables 4,590 Provisions utilised (26) Increase/(decrease) in movement in non cash provisions (1,001) Net cash inflow/(outflow) from operating activities (232,638) Cash flow from investing activities Interest received (Payments) for property, plant and equipment (Payments) for intangible assets (Payments) for other financial assets Proceeds of disposal of assets held for sale (PPE) Proceeds of disposal of assets held for sale (Intangible) Proceeds from disposal of other financial assets Net cash inflow/(outflow) from investing activities - Net cash inflow/(outflow) before financing (232,638) Capital element of payments in respect of finance leases and On-SoFP PFI and LIFT Net parliamentary funding 234,510 Net cash inflow/(outflow) from financing activities 234,510 Net increase/(decrease) in cash and cash equivalents 1,872 Cash and cash equivalents (and bank overdraft) at beginning of the period 280 Cash and cash equivalents (and bank overdraft) at YTD 2,152 Reconciliation of Cash Drawings to Parliamentary Funding Total cash received from DH (Gross) 192,745 (Less)/plus: transfers (to)/from other resource account bodies Plus: cost of Co-Commissioning (central charge to cash limits) 20,360 Plus: drugs reimbursement (central charge to cash limits) 21,405 Parliamentary funding credited to General Fund 234,510

150 Appendix 5 Barking and Dagenham CCG Cash position and Predicted Year End Value Position as at 31st January April May June July August September October November December January February March Total Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Actual Receipts Balance bfwd 286, ,521 2,849,739 1,222, ,146 3,279, , ,980 2,471,463 2,054,022 2,272,969 1,961, ,413 NCB Drawdown 18,000,000 19,000,000 16,000,000 19,000,000 19,750,000 19,750,000 21,500,000 21,250,000 18,400,000 19,000,000 19,000,000 29,901, ,551,559 Other 3,123,136 4,442,555 4,429,799 6,154,125 3,237,743 6,112,688 3,829,949 5,428,357 2,539,444 3,915,172 1,928, ,250 45,783,352 PCS Payments Reimbursements 42,267-3,267 12,342 13,510 5, ,903 VAT 17,392 20,626 17,068 27,165 37,836 27,479 14,020-25,913-13, ,144 Total 21,469,208 24,364,702 23,299,873 26,416,126 23,314,235 29,174,797 26,244,991 27,317,337 23,436,820 24,969,194 23,214,748 32,505, ,899,371 Payments Creditors NHS 13,980,392 14,806,028 15,040,837 16,512,003 14,819,808 19,568,907 17,062,578 16,658,951 16,335,913 15,971,822 14,935,242 21,832, ,525,102 Creditors BACS 3,093,234 3,286,529 3,243,114 4,103,494 2,517,278 4,260,590 3,132,190 3,962,940 2,447,613 2,809,748 6,220,117 10,525,300 49,602,147 Creditors CHAPS 303,127-41,027 1,088,100 11,860 53,110 2,124,155 76,415 5,340 1, ,704,470 Salary CHAPS ,208-3, ,815 Cleared Payable Orders 5, , ,179 23,602 4,349-25, , ,852 Salaries & Wages 45,905 48,565 47,683 46,951 47,148 48,448 48,089 54,262 51,227 56,148 56,148 56, ,722 Pensions 11,700 12,345 12,534 12,543 11,845 12,217 11,756 11,688 12,504 12,490 12,490 12, ,602 Tax & NI 24,353 24,596 22,983 23,869 23,946 24,131 24,899 24,962 41,908 29,000 29,000 29, ,647 Standing Orders/Direct Debits Foreign Payments - 1, ,708 Other 3,103,564 3,335,192 3,463,817 4,246,841 2,579,390 4,302,268 3,180,136 4,030,849 2,483,940 3,698, ,424,305 Total 20,567,687 21,514,963 22,077,379 26,140,980 20,034,877 28,274,020 25,606,011 24,845,874 21,382,798 22,696,225 21,252,997 32,455, ,849,370 Balance cfwd 901,521 2,849,739 1,222, ,146 3,279, , ,980 2,471,463 2,054,022 2,272,969 1,961,751 50,000 50,000

151 To: From: Meeting of the NHS Barking and Dagenham Clinical Commissioning Group (CCG) Governing Body Jacqui Himbury, Nurse Director Date: 22 March 2016 Subject: Quality in Commissioning Executive summary The Clinical Commissioning Group (CCG) is committed to improving the quality of care for all services we commission and to driving improvements in the quality and outcomes of all our commissioned services. We do this in a number of ways and across all our activities, as quality underpins all that we do. Within our operating plan we have described our priorities for 2015/16 and confirmed our continued commitment to delivering the recommendations from the Francis, Berwick and Winterbourne View Reports. We have also confirmed that we will deliver the statutory functions that we are required to do as part of the CCG Assurance Framework along with responding to new national policies, for example, the Transforming Care Programme (2015). This paper provides assurance to the governing body on delivery of these functions. In addition this paper provides assurance that we implement recent legislative and policy developments with regard to quality and safety. This paper has been written to advise the governing body on the progress made since the last report. Recommendations The Governing Body is asked to: Review progress and improvement actions being taken to date Suggest any further actions required to provide further assurance. 1.0 Purpose of the Report 1.1 The purpose of the report is to provide assurance to the governing body that the CCG continues to implement the recommendations and requirements of the Transforming Care Programme (TCP), quality and safeguarding improvement plans, actions to reduce health inequalities, along with new initiatives around compliance with Francis. 2.0 Transforming Care Programme 2.1 In October 2015 a national three year plan called Building the Right Support, jointly developed by NHS England (NHSE), the Local Government Association (LGA) and Association of Directors of Adult Social Services (ADASS) was published. Its publication marked the next important milestone for cross-system service transformation and includes the requirement to establish a Transforming Care Partnership to re-shape local services to meet the needs of people with a learning disability and/or autism and behaviour that challenges, including people with mental

152 health needs. This is supported by a new service model for commissioners across health and care that defines what good services should look like. We have now established our Transforming Care Partnership (TCP) to lead the transformation. 2.2 The Barking and Dagenham, Havering and Redbridge (BHR) TCP is a partnership from the three Local Authorities (LAs), the three Clinical Commissioning Groups (CCGs), NELFT NHS Foundation Trust, NHS England (NHSE) Specialist Commissioning and people with a lived experience of using our services. 2.3 The national plan builds on other transforming care work to strengthen individuals rights; roll out care and treatment reviews to reduce unnecessary hospital admissions and lengthy hospital stays; and test a new competency framework for staff, to ensure the workforce have the right skills in the right place. There is a requirement for us to deliver this national plan locally and we are currently working with our partners to develop a local plan that sets out how we will achieve this and deliver: a reduction in inpatient bed usage over the next three years; improved quality of care; and improved quality of life. 2.4 In order to achieve these outcomes NHSE, LGA and ADASS have set out a number of actions for each TCP to deliver as part of the CCG operating plan, which is due for submission on 11 April These actions include: agreeing a shared vision: BHR TCP must develop a shared vision of how the services will change across the new TCP geographical area and what we will achieve; developing a detailed three year plan; BHR TCP must clearly set out how it will deliver the outcomes listed above and identify the resources required to ensure success; and mobilising the plan; BHR TCP must have a strong foundation to deliver this challenging transformation plan with strong leadership, clear governance and a programme of work with clear outcomes. 2.5 The plan must demonstrate that the views of people with a lived experience of using assessment and treatment inpatient services have been used to inform the design of the new service model. 2.6 Over the past two months representatives from the BHR health and care economy have been working together to produce an initial vision for the TCP. At this stage no resources have been committed by any of the member organisations, although partners are expected to align existing resources to achieve the vision for this group of people. 2.7 Locally across BHR our vision is consistent with the national service model and is currently People with a learning disability and/or autism, including people with complex and challenging behaviour, can lead fulfilling and rewarding lives while being part of a community that is able to support them with dignity and respect and ensure that people s individual wellbeing is at the heart of decisions. Please note that this is subject to further stakeholder engagement, after which we will confirm the exact wording, 2.8 The partnership has confirmed a commitment to achieving this vision by designing and implementing care and support services that; provide support and interventions in the least restrictive manner and for the shortest possible time; 2

153 provide respite for families and carers that enables people living at home to stay there with positive family relationships; ensure that people who need inpatient care do not have to travel long distances to access it; strengthen multi-disciplinary and multi-agency working to reduce health inequalities; make better use of community provision across the three boroughs; ensure people have choice and control over their own health and care services; ensure that early identification and early support is commissioned and provided; and enable people with learning disabilities and/or autism and their family and carers to have access to the right level of information, advice and advocacy. 2.9 Our draft plan was presented to a review panel led by NHSE on 25 February The review panel included representatives from ADASS, LGA, advocacy services and people with a lived experience of using assessment and treatment unit services. We received formal feedback that our plan was partially assured and since that feedback we have been working to improve the plan and define and co-produce our future service model for people with learning disabilities and/or autism A more detailed report describing the TCP aspirations, plans, risks and next steps will be presented to the next governing body meeting The next steps are: Continue to develop and strengthen the plan working as a partnership; Submit a detailed operating and financial plan to NHSE on 11 April 2016: and Work with NHSE to mobilise the plan from 1 April Safeguarding 3.1 At the last governing body meeting it was reported that In December NHSE undertook a deep dive assurance review of our adherence to the NHSE Safeguarding Assurance and Accountability Framework and compliance with statutory functions. This covered both adults and children s safeguarding across the three BHR CCGs. 3.2 We have now received formal notification of the review outcome and have received an overall judgement of good using a four point judgement scale of not assured, limited assurance, good and outstanding. 3.3 The deep dive assurance process covered 4 key domains: governance, systems and process workforce capacity levels in the CCG assurance systems 3.4 We received a good judgement for three of the four domains. For workforce we were given a judgement of limited assurance. This is predominantly because of safeguarding training, especially for the PREVENT agenda. PREVENT training is now a mandatory requirement for all CCG employed staff and is available as an online module. The national requirement is 85% of the workforce must be trained in PREVENT and as of 29 February 2016 the CCG performance was significantly below this requirement. To address this we have published the training requirement in the staff news, the designated nurses are speaking to individual staff members and we are monitoring performance weekly. 4.0 Special Educational Needs and Disability (SEND) 3

154 4.1 The strategic SEND group continues to meet and has developed a combined BHR CCGs response to the forthcoming inspections. From April, there will be an inspection of both the services that support this agenda and the ability of each partner organisation to respond to the needs of the overall system to improve the quality of the children and young people s lives. The inspection will also focus on the involvement of children, young people and their families and how their views have shaped services. 4.2 As reported previously there is a need to ensure each organisation informs the local community of the services and support they offer to improve quality. This is through the local offer website of each LA. The CCG is working closely with the LA to enhance and improve the current site to describe and detail all that we commission. This will be a useful reference site for general practitioners and universal community services once completed. 4.3 The number of children and young people with complex health, education and social care needs continues to increase, which is placing increased demand on all services, including community paediatric and therapy services. Therefore there is to be a service demand and capacity review during 2016/17 to ensure that the CCG has commissioned the right level of support to meet the identified need. 5.0 Maternity Commissioning 5.1 The national review of maternity services, led by Baroness Cumberledge has now been published and the CCG is currently completing a benchmarking process and gap analysis against the recommendations to inform our improvement plan. The outcome of this benchmark review and improvement actions will be presented to the next governing body meeting. 5.2 The North East London Maternity Clinical Network is now meeting as planned and is monitoring the maternity flow and delivery capacity across the system as there is an emerging risk that the agreed annual delivery capacity numbers for each maternity unit may be exceed, especially as the birth rate is rising. To mitigate this risk monthly delivery numbers are reviewed and monitored at the BHRUT maternity clinical quality review group. BHRUT are currently within their agreed annual cap of 8,000 births, although this is projected to increase to 8,500 during 2016/17. To mitigate this risk BHRUT have commenced a piece of work to increase the utilisation of their birthing centre, recognising that their maternity activity continues to increase in line with our other providers. 6.0 Quality of care in Care Homes (with Nursing) strategy 6.1 This is an update to advise the governing body of the progress with the strategy to improve the quality of care provided in care homes (with nursing). The purpose of the strategy is to develop a systematic and consistent approach and methodology to drive improvements in the quality of nursing care within our care homes with nursing, and to respond effectively and swiftly when poor care is identified. This work is one of the work streams we have that will implement the national nursing strategy, The 6 C s. 6.2 We recognise that currently we have examples of excellent and good practice across the BHR geography, although this is not consistent. Therefore the intention is to develop a strategy that outlines the process for garnering early warning signs from across the economy focused on the quality of care, to develop a range of responses when poor care is identified and to establish a central repository for all information so that all CCGs in BHR can have access to all the information related to our nursing home cohorts. The strategy is expected to be finalised in July 2016, and once approved by the Quality and Safety Committee it will be shared with the governing body. 4

155 7.0 Frances Report Duty of Candour 7.1 The CCG has designed and developed a Duty of Candour reporting template which has been implemented by our two main providers BHRUT and NELFT. This is populated directly from their incident reporting system data and enables the CCG to be assured on the provider s compliance with the Duty of Candour. 7.2 Both NELFT and BHRUT are now fully compliant with their Duty of Candour regulatory requirements. The CCG is in the process of confirming that Barts Health NHS Trust is compliant. We are working with the lead commissioners to request evidence of compliance. 8.0 Berwick/Winterbourne 8.1 We have robust quality assurance systems and processes in place across all of our providers, and this includes providers of services to patients with learning difficulties (LDs). We undertake continuous review of our systems and this happens on a quarterly basis through our Quality and Safety Committee. 8.2 Our quality strategy continues to be implemented as planned. Our early warning system using the Key Line of Enquiry (KLoE) tracker is now fully developed and operational. This is a sophisticated quality assessment, assurance and improvement model that enable the CCG to identify key risks, trends and issues as they emerge and to monitor the impact of any improvement actions. We are in the process of sharing this with NHSE London as an example of good practice. 8.4 However, it is recognised that this model can be improved upon and currently we are working to develop an automated system of reporting and increase the functionality of the KLoE tracker. 9.0 Resources/Investment 9.1 There are no resource investment implications arising from this report Equalities 10.1 There are no equalities implications arising from this report Risk 11.1 The risks arising from this report have been described in the relevant sections of the report along with the mitigating actions Managing conflicts of interest 12.1 There are not any conflict of interest implications for this report. Authors: Jacqui Himbury and the Quality and Safeguarding Team 29 February

156 To: NHS Barking and Dagenham Clinical Commissioning Group (CCG) Governing Body From: Marie Price, Director of Corporate Services Date: 22 March 2016 Subject: Revisions to committee terms of reference (TORs) and establishment of an auditor panel Executive summary: Following a review of the commitments of a number of governing body members and issues with the workings of some committees, a number of amendments are proposed to TORs. Audit and Governance Committee: The secondary care consultant was included as a member of the committee in 2013 initially because there was a concern that the committee may struggle for quoracy. It was acknowledged that this was not the best use of secondary care consultant expertise. The meeting has not been inquorate in the three years that it has been in operation. It is therefore recommended that secondary care consultant be removed as a member. Remuneration and Workforce Committee: See above for rationale. There is not an additional co-opted member on this committee, but again there have not been issues with quoracy. It is therefore recommended that secondary care consultant be removed as a member. Investment Committee: because the committee deals with matters where there are conflicts of interest there is a greater risk that this committee could be inquorate on occasion. It is therefore proposed that the quorum be amended to enable members of other CCGs e.g. lay member for PPI, chair or secondary care consultant from another CCG to be included as a substitute member should there be a quoracy issue for one or more of the CCG committees (recognising that this is three committees meeting as one). This is in line with how we have made decisions previously where one or members have not been able to take part in a discussion or decision due to a conflict of interest. Primary Care Committee: The terms of reference have been updated in line with the recommendations to this governing body on 26 January (see attached appendix A) Quality and Safety Committee: That the Redbridge secondary care consultant continues to act as chair of the committee for 2016/17. That the CCG chairs nominate attendees for 2016/17 who can commit to the schedule of meetings as outlined.

157 Establishing an auditor panel The Local Audit and Accountability Act 2014 requires CCGs to appoint an auditor panel, which will advise on the appointment of external auditors for 2017/18. The governing body must decide how it appoints the panel and it can be an existing committee. Nationally, draft TORs have been prepared that assume the audit committee will perform this function. It is therefore recommended that our existing Audit and Governance Committee act as the auditor panel. Recommendations The Governing Body is asked to: Endorse the proposed amendments to the committee TORs Agree that the Audit and Governance Committee act as the auditor panel. Author: Marie Price, Director of Corporate Services Date: 29 February 2016

158 Barking and Dagenham Clinical Commissioning Group Primary Care Commissioning Committee-in-Common Terms of Reference February 2016

159 Revision History Revision date Summary of Changes Writer / Reviewer Version Nov 2014 First draft as part of delegated commissioning application Sarah See 1.0 Jan 2015 Amendments made to reflect feedback from NHS England as part of the application process Sarah See / Rod McEwen May 2015 Amendments to reflect changes in Delegation Agreement Sarah See May 2015 Review and comments Rod McEwen June 2015 Amendments regarding urgent meetings Sarah See / Rod McEwen June 2015 Review and final comments by Primary Care Commissioning Committee members Committee members June 2015 Amendments around representatives of Local Medical Committees, HealthWatch and Health and Wellbeing Boards Rod McEwen / Sarah See Oct 2015 Amendments around proposed changes in GP representation 1 Feb 2016 Amendments as suggest by NHS England following changes to the membership of the Committee. Further review may be necessary upon publication of a national CoI review currently being undertaken (Project Starlight) Sarah Everiss/Sarah See/Rod McEwen Sarah See / Rod McEwen

160 Introduction 1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that NHS England was inviting CCGs to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG. 2. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended) ( NHS Act ), NHS England has delegated the exercise of the functions specified in Schedule 2 to these Terms of Reference ( ToR ) to NHS Barking and Dagenham CCG ( CCG ). The Delegation Agreement is set out in Schedule The CCG has established the NHS Barking and Dagenham Primary Care Commissioning Committee ( the Committee ). The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers. 4. NHS Havering CCG and NHS Redbridge CCG have agreed to establish a committee ( committee-in-common ) with the same membership and the same terms of reference as the committee established by the CCG (although depending on the identity of the committee such members would not necessarily have the right to vote on such committee (further particulars as are set at paragraph 18 in Terms of Reference for each such committee)). The three committees shall be known together as the BHR PCC Committee-in-Common. Notwithstanding that the Committee shall also operate as a committee incommon, where it does so, it shall always do so in recognition of and cognisant of the CCG s own duties to the patients and population of Barking and Dagenham. Statutory Framework 5. NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act. 6. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between NHS England and 3

161 the CCG. These arrangements are set out in the separate delegation agreements entered into by the CCG and NHS England dated 1 April Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including: a) Management of conflicts of interest (section 14O); b) Duty to promote the NHS Constitution (section 14P); c) Duty to exercise its functions effectively, efficiently and economically (section 14Q); d) Duty as to improvement in quality of services (section 14R); e) Duty in relation to quality of primary medical services (section 14S); f) Duties as to reducing inequalities (section 14T); g) Duty to promote the involvement of each patient (section 14U); h) Duty as to patient choice (section 14V); i) Duty as to promoting integration (section 14Z1); j) Public involvement and consultation (section 14Z2). 8. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those duties set out below: Duty to have regard to impact on services in certain areas (section 13O); Duty as respects variation in provision of health services (section 13P). 9. The Committee is established as a committee of the CCG in accordance with Schedule 1A of the NHS Act. 10. The CCG acknowledges that the Committee is subject to any directions made by NHS England or by the Secretary of State. Role of the Committee 11. The Committee has been established in accordance with the above statutory provisions to enable the CCG to make decisions in common with NHS Havering CCG and NHS Redbridge CCG on the review, planning and procurement of

162 primary care services within Barking and Dagenham, Havering and Redbridge, under delegated authority from NHS England. 12. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and the CCG, which will sit alongside the delegation and terms of reference. 13. The functions of the Committee are undertaken in the context of a desire to promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers. 14. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act delegated to the CCG under the terms of its delegation. 15. This includes the a number of functions that have been specified by the Delegation Agreement (full particulars of which are set out in Schedules 2, 3 and 4), including: Planning of the provider landscape in the area, including: decisions on establishing new GP practices in an area and procurement of associated Primary Medical Services contracts; decisions on practice mergers and closures, and on any associated list dispersals; agreement on GP practice boundary changes; and decisions on practice list cleansing. Design and commissioning of urgent care for out of area registered patients, including home visits as required. Premises Cost Directions Functions, including: making decisions in relation to applications for new payments or revisions to existing payments; and premises and strategic estates planning. Design and commissioning of Enhanced Services ( Local Enhanced Services and Directed Enhanced Services ). Design and offering of Local Incentive Schemes in addition or as an alternative to the national framework (including Quality Outcomes Framework or Directed Enhanced Services) provided they are voluntary and have undergone consultation with the Local Medical Committees; Primary Medical Services contract management including: the design of PMS and APMS contracts and periodic contract reviews to ensure value for money; monitoring of contracts with respect to observance of specifications

163 and quality standards; and performance management of poorly performing practices. Making decisions on discretionary payments (e.g., returner/retainer schemes) in accordance with the Statement of Financial Directions. 16. In order to successfully deliver its delegated primary care commissioning functions the Committee will need to carry out the following activities: Management of the delegated budget for commissioning of primary medical services in Barking and Dagenham. The Committee will ensure that the required financial processes are in place for planning, reporting, risk management, contingencies, probity and conflict of interest management. It will also agree any Quality, Innovation, Productivity and Prevention (QIPP) plans and manage their delivery. The Committee is accountable for the development of the Primary Care Strategy for Barking and Dagenham ("the Strategy"). The responsibility of Strategy development in BHR will rest with the Primary Care Transformation Programme Board (PCTPB), which will carry out key tasks such as supporting the Joint Strategic Needs Assessment, designing the models of care within the NHS England Strategic Commissioning Framework for Primary Care Transformation in London, and leading consultations and public and patient engagement. However, as the budget holder The Committee will sign off the Strategy and will liaise with the PCTPB to ensure that it is in line with the financial plan. The Committee will take all decisions on investment, procurement and contracting with regards to the strategy. The Committee will review, investigate and manage unacceptable variations in care by regularly reviewing information on outcomes, patient experience, complaints, incidents and CQC reports. The Committee will also authorise investigations into practices where there are concerns about quality of care, liaising with the CQC and putting in place performance management arrangements when necessary. The Committee will also work with NHS England Regional Team to monitor compliance of practices with key contracting processes (such as the completion of annual practice declarations).

164 Geographical Coverage 17. The Committee will take decisions in respect of the population of NHS Barking and Dagenham CCG. Membership 18. The Committee shall consist of the following voting members: Lay Member, Barking and Dagenham CCG Lay Member, Audit Chair, Barking and Dagenham CCG Accountable Officer, Barking and Dagenham CCG (Executive Member) Chief Finance Officer, Barking and Dagenham CCG (Executive Member) Nurse Director, Barking and Dagenham CCG (Executive member) Director of Primary Care Transformation, Barking and Dagenham CCG Secondary Care Consultant, Barking and Dagenham CCG GP partner and/or GP Clinical Director and /or a GP employee of a Member of Barking & Dagenham Clinical Commissioning Group (x 2) An Independent GP The following shall be in attendance as members of the Committee but shall be non-voting: Chair, Barking and Dagenham CCG NHS England (NHS England representative) Barking and Dagenham Health and Wellbeing Board (local authority representative) The Barking & Dagenham and Havering Local Medical Committee (BH LMC representative) Barking and Dagenham Healthwatch (HealthWatch representative) Lay Member, Havering CCG Lay Member, Redbridge CCG Secondary Care Consultant, Redbridge CCG Chair, Havering CCG and GP partner and/or a GP employee of a Member of Havering Clinical Commissioning Group (x 2)

165 Chair, Redbridge CCG and GP partner and/or a GP employee of a Member of Redbridge Clinical Commissioning Group (x 2) Havering Health and Wellbeing Board (local authority representative) Redbridge Health and Wellbeing Board (local authority representative) Redbridge Local Medical Committee (Redbridge LMC representative) Havering Healthwatch (HealthWatch representative) Redbridge Healthwatch (HealthWatch representative) A list of the individuals who hold these positions is set out in Schedule 3 to these terms of reference. 19. The Chair of the Committee shall be Lay Member of a BHR CCG. 20. The Vice Chair of the Committee shall be Lay Member of a BHR CCG. Meetings and Voting 21. The Committee will operate in accordance with the CCG s Standing Orders. The secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than 5 working days before the date of the meeting. Where the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify and the papers for the meeting shall be circulated in accordance with his/ her instructions. 22. Each voting member of the Committee shall have one vote. The chair of the Committee will work to establish unanimity as the basis for decisions of the Committee. If, exceptionally, the Committee cannot reach a unanimous decision, the chair will put the matter to a vote, with decisions confirmed by a simple majority of those voting members present, subject to the meeting being quorate. Quorum 23. The quorum shall be 5 voting members who shall include at least one lay member and one executive member (as defined at paragraph 18 above) and at least one GP partner or a GP employee of a Member of Barking & Dagenham Clinical Commissioning Group.

166 24. If the committee cannot be quorate for the purposes of any business because of the declarations of interest that have been made by its members, the committee shall have the power to co-opt one or more lay members from another CCG s Governing Body onto the committee. Frequency of meetings 25. The Committee will meet on a monthly basis on the 2 nd Wednesday of each month. After 12 months the frequency will be reviewed. 26. Meetings of the Committee: a) shall be held in public, subject to the application of paragraph 26(b) below; b) (the Committee) may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time. c) the closed confidential part of the meeting (as provided for at 26 (b) above) shall be referred to as Part 2 of the meeting and shall have a separate agenda and minutes. d) the Committee may resolve to exclude the representatives of the local authority, Local Medical Committees and Healthwatch from Part 2 of any meeting where it considers it is not appropriate for such representatives to attend all or part of Part 2 of the meeting. 27. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view. 28. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions. 29. Members of the Committee shall respect confidentiality requirements as set out in the CCG s Constitution.

167 30. The Committee will present its minutes to the governing body of NHS Barking and Dagenham CCG for information. 31. The CCG will also comply with any reporting requirements set out in its constitution. 32. Terms of Reference will be reviewed on an annual basis. Immediate and urgent decisions 33. There may be instances when the Committee is required to make a decision in advance the regular full committee meetings in light of unforeseen circumstances. Depending on the urgency of the matter such decisions may need to be immediate (i.e. to be made 24 hours) or urgent (i.e. to be made in timeframes longer than 24 hours but in advance of the next scheduled meeting). 34. The Director of Primary Care Transformation will decide when an immediate or urgent decision is required and will initiate the decision making process. 35. In the instances where an immediate decision is needed the Director of Primary Care Transformation will arrange a meeting with the Chair (or Vice Chair if the Chair is not available) and the CCG Accountable Officer to take the decision. Such decisions will only be taken in exceptional circumstances, such as the need to close a practice due to clinical reasons or contractor death. Any immediate decisions taken under this procedure will be presented at the next Committee meeting. 36. In the instances when the Director of Primary Care deems it necessary to request an urgent decision the Chair will be contacted. The Chair (or Vice Chair if the Chair is not available within the required timeframes) may deem it necessary to call a meeting at short notice outside the regular full committee meetings, as set out in paragraph 21 above. 37. In these instances the meeting may be held by virtual means such as telephone, or internet conferencing, with papers circulated by in advance to members. Accountability of the Committee 38. The CCG has Prime Financial Policies and Detailed Financial Policies and this Committee shall act in accordance with the same.

168 39. For the avoidance of doubt, in the event of any conflict between these Terms of Reference and the Prime Financial Policies and Detailed Financial Policies of the CCG, the latter will prevail. 40. The Committee will have regard to the CCG s duties to make arrangements to secure that individuals to whom the services are being or may be provided are involved in the planning of the commissioning arrangements by the group, and in the development and consideration of proposals by the CCG for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and in decisions of the CCG affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact. Procurement of Agreed Services 41. Detailed arrangements regarding procurement will be set out in the delegation agreement but for the avoidance of doubt, the Committee will consider the CCG s procurement law duties as set out inter alia in the following:- The Public Contracts Regulations 2006 (as amended from time to time); Overarching principles enshrined in the treat on the Functioning of the European Union; and The National Health Service (Procurement, patient Choice and Competition) No.2 Regulations 1023 ("the S75 Regulations" ) and Monitor s substantive and enforcement guidance on the S75 Regulations or any such additional / replacement guidance and/or regulations from time to time in force. Decisions 42. The Committee will make decisions within the bounds of its remit. 43. The Committee will ensure that conflicts of interest are dealt with in accordance with the CCG s Constitution and Standards of Business Conduct Policies which for the avoidance of doubt may include members (voting or otherwise) being excluded from a decision and/or the discussions leading thereto. 44. All decisions taken in good faith at a meeting of the Committee shall be valid even if there is any vacancy in its membership or it is discovered subsequently

169 that there was a defect in the calling of the meeting, or the appointment of a member attending the meeting. 45. The decisions of the Committee shall be binding on NHS England and NHS Barking and Dagenham CCG. [Signature provisions]

170 BarkingDagenham - PB signed.pdf Schedule 1 Delegation Agreement

171 Schedule 2 Delegated Functions Delegated Functions Planning and reviews Planning the provider landscape Urgent care services Enhanced services commissioning Design of Local Incentive Schemes Procurement and new Contracts Delegated CCG responsibilities Plan the commissioning of primary medical services, including: Carrying out regular primary medical health needs assessments (to be developed by the CCG) to help determine the needs of the local population in the Area; Recommending and implementing changes to meet any unmet primary medical services needs. Develop the Primary Medical Services commissioning strategy and take the key planning decisions, including for: Establishing new GP practices in the area; Procurement of new contracts; Closure of practices and branch surgeries; Approving practice mergers and closures; Dispersing the lists of GP practices; Agreeing variations to the boundaries of GP practices; Co-ordinating and carrying out the process of list cleansing Manage the design and commissioning of urgent care services (including home visits) for patients registered out of area The CCG will agree on, design and commission enhanced services for the area by: Assessing the needs of the local population; Developing the necessary specifications and templates for the Enhanced Services; Consulting with Local Medical Committees, Health and Wellbeing Boards and other stakeholders in accordance with the duty of public consultation; Liaising with system providers and representative bodies to ensure that the system in relation to the Enhanced Services will be functional and secure; and Supporting GPs to enter into data processing agreements and Data Controllers in to provide fair processing information. Design and offer Local Incentive Schemes for GP practices in addition to or as an alternative to the national framework (i.e. QOF or DES), provided that such schemes are voluntary and have undergone consultation with the Local Medical Committee; Make procurement decisions in accordance with the NHS England procurement protocol, ensuring that any locally designed contract has undergone LMC consultation and can demonstrate that the scheme will improve care in the area.

172 Delegated Functions Primary Medical Services Contract management Management of poorly performing practices Delegated CCG responsibilities Manage the Primary Medical Services Contracts and perform NHS England s obligations under the contracts, including: Actively managing the performance of the counter-party to secure the needs of the service users, improve service quality and improve efficiency of provision; Ensuring respect of quality standards, incentives and the QOF, observance of service specifications, and monitoring of activity and finance; Assessing quality and outcomes (including clinical effectiveness, patient experience and patient safety); Managing GP practices providing inadequate standards of patient care, conducting practice reviews, agreeing remedial action plans and issuing contract breach notices when necessary; Managing variations to the relevant Primary Medical Services Contract or services; Agreeing information and reporting with practices: Agreeing local prices and ensuring value for money. Keeping records of all contracts Make decisions in relation to the management of poorly performing GP practices, including in liaison with the CQC where there has been a reported non-compliance with standards (but excluding any decisions in relation to the performer s list). This includes: Ensuring regular and effective collaboration with the CQC and taking appropriate action to CQC findings; Ensuring that risks are appropriately identified, managed and escalated; Responding to CQC assessments of practices where improvements is required; When a GP practice is placed into special measures lead a quality summit to develop an improvement plan and ensure the monitoring of the said plan; Discretionary payments Make decisions on discretionary payments, including in relation to QOF, Enhanced Services and Local Incentive Schemes Premises Cost Directions Make decisions in relation to the Premises Costs Directions Functions concerning: Applications for new payments and revisions to existing payments Working together with other CCGs to manage premises and to carry out strategic estates planning; Liaising with NHS Property Services Limited and Community Health Partnerships Limited.

173 Schedule 3 - List of Members Position Individual name Committee role Voting members GP partner and/or a GP employee of a Dr Gurkirit Kalkat Clinical Director Member of Barking & Dagenham Clinical Commissioning Group x2 Lay Member, Barking and Dagenham CCG Sahdia Warraich Lay Member, Audit Chair, Barking and Kash Pandya Vice Chair Dagenham CCG Accountable Officer, Barking and Conor Burke Executive member Dagenham CCG Chief Finance Officer, Barking and Tom Travers Executive member Dagenham CCG Nurse Director, Barking and Dagenham Jacqui Himbury Executive member CCG Director, Primary Care Transformation, Sarah See Barking and Dagenham CCG Secondary Care Consultant, Barking & Dr Steven Ryan Dagenham and Havering CCGs An Independent GP TBC Non-voting members Barking and Dagenham Healthwatch Frances Carroll Chair Barking and Dagenham Health and Wellbeing Board Matthew Cole Director, Public Health NHS England Alison Goodlad Head of Primary Care Commissioning B&D and Havering LMC representative Terilla Bernard Support Officer Barking and Dagenham CCG Dr Waseem Mohi Chair

174 To: From: Barking & Dagenham CCG Governing Body Kash Pandya, Vice Chair of the Finance & Delivery Committee and Lay Member, Governance Date: 22 March 2016 Subject: Feedback report from the February 2016 Finance & Delivery Committee meeting Summary The Barking & Dagenham CCG Finance & Delivery Committee provides the minutes of each meeting to the Governing Body. To provide additional assurance to the Governing Body, this brief feedback report provides key highlights from the last meeting. Key challenges discussed and risks addressed:- Finance report The month 9 report based on month 8 data was reviewed and discussed: Barts Health the biggest single risk to the CCG continues to be the level of financial over performance at the Trust. BHRUT - the first 8 months of data indicate over performance across a number of points of delivery. The Trust is also highlighting a significant RTT pressure which they have estimated to be in excess of 17m. Independent Sector - significant levels of activity are still being reported. The CSU presented an updated analysis report to the Committee on referrals to the Independent Sector. CHC a forecast overspend of 1,050k was reported. The Committee was concerned about the level of challenge still facing the CCG if it was to achieve the agreed financial targets for 2015/16 and those for 2016/17. The Committee identified number actions at the locality level to support the delivery of these financial objectives. Borough risk register: The risks were discussed and Committee members agreed to additional risks being added; issues with the Electronic Referral System (C&B), London Ambulance Service, PELC. QIPP Committee members were briefed on the month 8 QIPP position for 15/16. Exception reports on two QIPP schemes were presented to the Committee; Calprotectin and Emergency Admission Avoidance. A review of QIPP schemes for 15/16 took place in the form of a presentation followed by a discussion on QIPP plans for 16/17. Contracts/deep dives: The contracts report was discussed and the CSU also presented a deep dive report into Barts Health maternity. The CCG is currently forecast to overspend on maternity services by over 1m with Barts Health contributing to 726k.

175 Recommendation: The Governing Body is asked to note this feedback report and the February Committee minutes which provide more detail on all the matters considered. 3 March 2016

176 Draft Minutes of the Barking and Dagenham CCG Finance & Delivery Committee held on 16 February 2016 at Barking Hospital Members: Kash Pandya (KP) Dr Gurkirit Kalkat (GK) Sharon Morrow (SM) Attendees: Dr Jagan John (JJ) Rob Adcock (RA) Richard Clements (RC) Anna McDonald (AM) Gayathri Ananthkrishan (GA) Jeremy Cridland (JC) Mark Pearse (MP) Lay Member, Governance Deputy Chair Clinical Director Chief Operating Officer Clinical Director Deputy Chief Finance Officer Programme Lead, Service Transformation Business Manager Business Intelligence Specialist - CSU Associate Director, Business Intelligence CSU Deputy Director, Contracting CSU Apologies: Dr Waseem Mohi, Tom Travers 1.0 Welcome and apologies Action The Chair welcomed those present and apologies for absence were noted. 1.1 Declarations of interests There were no additional declarations of interest. 1.2 Minutes of the last meeting The minutes of the meeting held on 8 December 2015 were agreed as an accurate record. 1.3 Matters arising/actions log The actions log was reviewed and updated. Choose & Book System (C&B) MP advised that it had not been possible to produce a report for the meeting due to the changes to the electronic referral system. JJ stressed his concerns about the on-going problems with the system and said it is an un-acceptable situation that needs to be resolved. There are no appointments available on the system to be able to refer patients to services at BHRUT and the Trust will not accept paper referrals. The CDs expressed their frustration and said GPs feel they are doing a dis-service to their patients as they are being sent to and fro and primary care activity is being lost. SM addressed the CSU representatives and explained that the CDs were escalating the matter as a clinical risk and said it would be helpful to know how the situation is being managed and escalated back to the Trust. MP said he would raise the concerns with BHRUT and promised to feedback to the Committee outside of the meeting. Members said that an interim solution is needed as a matter of MP 1

177 urgency followed by a more permanent solution KP asked for C&B to be added to the risk register and said he would discuss it with Conor Burke when he next meets with him. SM KP Dr Kalkat joined the meeting 2.0 Finance reports / risks 2.1 Financial risks report month 9 The CCG has agreed a revised risk assessed forecast outturn of 3,352k with NHS England, which represents a 1.14% surplus rather than the original planned 2% surplus. The biggest single risk to the CCG continues to be the level of financial over performance at Barts Health. A number of challenges and claims have been issued, but the final quarter one position has not yet been agreed. Barts Health - The latest data received from the Trust highlights over performance across a range of Points of delivery, including Non elective, Critical Care, Elective care, maternity pathway, OP procedures, High cost drugs and treatments, and unidentified QIPP schemes. BHRUT - the first 8 months of data indicate over-performance within a number of points of delivery, particularly non elective, non-elective non-emergency, A&E, Outpatient first attendances and Critical Care. A number of challenges have been issued to the trust in relation to the data, they include, the relationship between ambulatory care and non-elective coding, and un-coded data. Associates the main two financial pressures are the Homerton contract which is reporting a forecast overspend of 420k and Guys and St Thomas s which is reporting a forecast overspend of 507k. The main drivers at the Homerton are IVF cycles and also coding on the maternity pathway. The position at Guys has worsened by 292k since month 7 as a result of a critical care patient being admitted. Independent Sector - significant levels of activity are being reported across the range of independent providers. This has led to a forecast overspend across the ISTC, Independent Diagnostics, Spire and BMI budgets of 1,164k. This position has worsened by 49k from month 8 as a result of small movements across a number of independent providers. Continuing Health Care a forecast overspend of 1,050k is being reported. The forecast outturn represents an increase in excess of 5% on 14/15 outturn levels. Work is on-going to finalise the operational reporting with the CAPS system. Prescribing - The latest PMD forecast provided by the NHSBSA highlights an outturn over spend of 282k. The final outturn position will be heavily impacted by QIPP delivery and Category M prices. The CCG prescribing team have identified a potential further risk of approximately 556k. In regard to Barts Health, JJ said one of his concerns is the year end effect on next year s surplus and asked if there is a possibility that the discussions will go to arbitration. RA responded saying the expectation is that an agreement will be reached without the need for that. GK said one of his concerns is about BHRUT s RTT and the fact that GPs have to refer to other providers outside of the area because of the problems with C&B. He gave an example of a patient who told him they had received a telephone call from the Trust telling them they needed to refer them elsewhere. RA added that RTT as a whole is a significant financial risk. 2

178 KP referred back to the critical care patient at Guy s & St Thomas s and questioned what had gone wrong with the process that meant the CCG wasn t aware of the patient. He asked what action was being taken to ensure the same situation doesn t happen again and asked how the CCG can be sure that there aren t more critical care patients in the sytem that the CCG isn t aware of. MP responded saying the Trust should be providing the host commissioner with a work in progress report for long stay critical care patients. The CSU team is trying to obtain the clinical notes to determine if the case relates to specialist commissioning. JJ said practices know their patients but the CSU may not be aware of all the critical care patients in the system. RA explained that the invoice is submitted upon discharge and there was an error between the flow of data for the patient in this case. GK and JJ referred to an exercise carried out previously in regard to high cost patients and it was agreed that practices would be asked at the Locality meetings to keep a record of those patients and provide the information to their Practice Improvement Leads (PILs). RA gave the committee an indication of the budget allocation for next year and a discussion regarding demographics and the population growth in the borough followed. JJ referred to the Riverside development and said NHSE should be taking things like that into account but added that there has been no change in the CCG s surplus requirement. RA explained that the demographic is based on current GP list sizes but JJ said he thought it was based on the 2014 list size. RA to look into it and confirm outside of the meeting. KP asked, when the funding catches up with the demographics. RA to ask NHSE at the next meeting with them. KP expressed his concern about the risks associated with the delivery of the proposed 2016/17 budget, in particular, if activity levels were not reduced and QIPP not delivered. He asked for a line by line review of the budget to identify opportunities for savings and a report back to the Committee. GK/JJ RA RA SM 2.2 Independent Sector Referral Analysis JC presented the analysis report which showed planned care activity trends in the independent sector and activity and referral information for the current year (Apr Dec) with the same period for last year. First outpatient activities there has been a 9% increase in first outpatient appointments (excluding Clinical Physiology specialty). 99.7% of the referrals to Independent Sector providers are from GPs and there has been a 21% increase in Trauma & Orthopaedic (T&O) referrals. Follow-up activities there has been a 12% increase in follow-up activities and a major increase in T&O, Physiotherapy and Ophthalmology. Planned procedures - there has been a 17% increase in planned procedure activities; T&O, Ophthalmology and general surgery. RA asked the CSU to carry out some mapping of outpatient procedures, T&O in particular. JJ said he would like to know what the Arthroscopy rate is compared the average hospital and GK asked for a comparison between the different providers to see what the conversion rates are. JC said they will concentrate on T&O for the next meeting as there has been a major increase in that particular area. JC JJ gave his view that the increase in activity for the Independent Sector is a result of the C&B issues. SM reminded the Committee that the CCG is required to refer patients to the Independent Sector as part of patient choice. RA confirmed that the Independents are on the same tariff as the local 3

179 hospitals. GK added that patients are waiting 6-8 weeks for physiotherapy/mcat appointments. JJ said patients comment that the appointments for the Independent Sector come through very quick and GK added they comment that the follow-up care is also very good. JJ said the CDs and Locality meetings need to look at critical care patients and T&O. 2.3 Borough risk register review SM updated the Committee on the main risks including BCF, IAPT and the ISTC. In regard to the PMS review, JJ commented that the funding change is quite significant for some practices and poses a risk for them. KP asked for the target risk rating column to indicate when the CCG expects it to be achieved. He also asked for C&B, PELC and LAS to be added and for Intermediate Care to be removed. AM to circulate the updated risk register to the Committee after the meeting. JJ asked if void space is a risk in B&D. RA said there are on-going discussions with NHS Property Services at the Finance & Estates group meeting. KP added that TT is producing an Estates Strategy. RA to check what the deadline for completion is. KP asked for Voids and spaces to be an agenda item for discussion at the next meeting. SM AM RA TT 2.4 QIPP Delivery 15/16 SM presented the month 8 report. Flex data is reporting achievement of 769k actual savings against a target of 673k which represents a year to date saving of 5.05m against a plan of 4.96m. Two QIPP schemes have reached escalation level and exception reports on each were submitted to the Committee Exception reports Calprotectin the recovery plan is to increase the uptake rate of Calprotectin testing within primary care. Specific practices where tests are not routinely generated will be targeted in addition to wider messaging to all practices. To date the CCG has held practice visits with outlier practices but uptake has remained static. Emergency Admission Avoidance the CCG has delivered the planned admission reduction at month 8 based on flex data. The ICM work stream is the biggest contributor towards the failure of the QIPP trajectory so the CCG s focus will be on reviewing and improving current ICM services as well as reviewing the implementation of the Everyone Counts and BCF schemes. JJ said these are the things that need to be discussed at locality meetings. SM said to bear in mind that it had been agreed with practices that agendas for Locality meetings would focus on primary care improvement. GK suggested a slot on Calprotectin could take place at a PTI event instead and the focus could be on the surgeries who are not using the test. JJ added that the Calprotectin pathway needs to be on the website. KP to raise it with Marie Price at their next meeting. KP queried the green rating for Calprotectin on the status report and RC explained the rating relates to the finance and not the activity. RC added that there are some issues with the PMO report that are being addressed. GK/JJ KP QIPP plans 2016/17 and review of QIPP 15/16 RC presented a report based on his thoughts as the programme lead for service transformation and said he was happy to answer any questions. GK 4

180 said it all makes sense but needs to be focussed around locality work and how the CCG moves services from secondary care into primary care. JJ said a lot of support is needed to develop the transformational aspect and concentrating on key areas will help to push transformation forward. GK said practices are quite willing to undertake some of the work. SM said we need to understand what the Urgent & Emergency Care Vanguard is going to deliver next year and suggested that the Right Care approach - Commissioning for value could be used as a starting point. JJ said it is important to have some synergy between the schemes. KP added that CD ownership is essential and asked GK to ask WM if the presentation could be an agenda item for the next Executive Committee meeting to share it with the other CDs. MP asked what joint working has been done with the Trusts and RA explained that is what the Accountable Care Organisation (ACO) approach will be about. JJ concluded the discussion by saying that safety is paramount in whatever schemes we do. GK 3.0 Contacts position and deep dive reports 3.1 Contracts Position The report was noted and it was agreed that everything that needed to be raised had been discussed earlier in the meeting. 3.2 Deep dive Barts Health maternity The CCG is currently forecast to overspend on Maternity Services by over 1m with Barts Health contributing to 726k of this. Barts Health has reported an underperformance against planned activity for deliveries at 14% but, with case mix, reports an over performance of 8%. This follows a movement in activity between normal and assisted deliveries/caesarean section. The data shows a growth in deliveries for the CCG of 11% between 2013/14 and 2015/15 which compares to 8% in Havering, 15% in Redbridge and 3% across the NEL/Essex patch. Barts Health accounts for the majority of this increase. MP explained that since the report was produced, a decrease in the number of bed days has been seen. It was noted that there has been an increase in problematical births which has led to an increase in outpatient procedures. KP asked if mothers are referring themselves to Barts and not BHRUT. GK explained that in some areas of the borough, GPs have to refer to Barts for maternity and JJ added that the borough has the highest term rates and highest young pregnancy rates. KP thanked the CSU for the helpful report and asked what the next steps are. GK said we have to accept that this will continue and SM added that we need to plan for more births. 3.3 Updated schedule of contracts Problems with the Concordia contract were discussed. GK and JJ reported that old results are being received, some as far back as 4-5 months. SM explained that a re-call exercise is being carried out. KP asked for the rating of the contract to be changed from amber to red and for any further issues to be fed back to SM. KP also asked for an explanation on what the care homes risk stratification that is in progress means to be provided for the next meeting; for the contracts coming up for renewal to be highlighted and for the schedule to include the reasons why a number of the contracts have not been signed off/issued. It was also suggested that the contract with the Federation should added and this was agreed. KP asked for the same for the other two CCGs. MP MP KP raised de-commissioning plans on behalf of Dr Mohi and it was agreed that they will form part of the QIPP discussions. 5

181 4.0 Any other business KP asked GK and JJ to feedback at the next meeting on the CDs and Locality meetings. GK/JJ 5.0 Date of the next meeting 26 April 1.30pm 3.30pm Venue TBC - either Barking Hospital or the CCG s new offices 6

182 To: From: Date: Subject: Barking & Dagenham, Havering and Redbridge CCGs Kash Pandya, Chair of Audit & Governance Committee November Governing Body meetings Feedback from the 19 January 2016 Audit & Governance Committee meeting Summary The BHR Audit & Governance Committee provides the minutes of each meeting to the three BHR Governing Bodies. To provide additional assurance, this Committee Chair s report provides the key matters arising from the last meeting on 19 January 2016 to be drawn to the attention of the Governing bodies. Progress in closing down and preparing the 2015/16 accounts and the annual report is on track The Committee remains very concerned about the risks still to be addressed to achieve the 2015/16 year-end financial targets and the outlook for meeting them in 2016/17. Areas of particular concern include continued over-activity at our acute providers, the unquantified Referral to Treatment (RTT) backlogs, the continuing health care (CHC) overspends and difficulties in delivery of QIPP targets. The Committee noted the mitigations in place or being developed by officers and requested a further report on progress made in achieving financial balance at the March Audit Committee meeting The Committee approved the external audit plan for 2015/16 and noted the progress on the delivery of the internal audit and local counter fraud plans for 2015/16. The Committee were assured that the arrangements for the payment of CHC invoices had been strengthened and that a review on sponsorship had not identified any matters of significant concern. However, the Committee decided that it wanted continued vigilance by auditors and officers over the arrangements for sponsorship and declarations of interests. A standing group of the Audit Committee is continuing to review the effectiveness of these arrangements. The Committee considered the arrangements for the delivery of QIPP. The Committee welcomed the deep dives being undertaken on QIPP schemes that were not delivering as expected but expressed concern about the limited progress in delivering QIPP targets that are currently protected by the BHRUT fixed price contract. A further report on QIPP delivery will be considered by the Audit Committee during The Committee approved several information governance policies and were assured that good progress was being made by the CCGs in completing mandatory information governance training by 31st March The Audit Committee minutes refer to a variety of other matters which are not recorded within these key messages. Kash Pandya, Audit Committee Chair 2 March 2016

183 Draft Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs Audit &Governance Committee held on 19 January 2016 at Becketts House pm. Present Members Kash Pandya (KP) Khalil Ali (KA) Charles Beaumont (CB) Richard Coleman (RC) Ah-Fee Chan (AFC) In attendance-officers Marie Price (MP) Tom Travers (TT) Paul Hunt (PH) Anne-Marie Keliris (AMK) Rob Meaker (RM) part Sarah See (SS) part Pam Dobson (PD) part In attendance-auditors Nick Atkinson (NA) John Elbake (JE) Gemma Higginson (GH) Charlie Nicholl (CN) Stephen Bladen (SB) Kevin Suter (KS) BHR Audit Chair, Lay Member for Audit & Governance Lay Member PPI Redbridge CCG BHR Co-opted Member for Audit & Governance Lay Member PPI Havering Secondary Care Consultant BHR Director of Corporate Services BHR Chief Financial Officer (CFO) NELCSU, Senior Financial Control Manager BHR Company Secretary Director of Innovation Director of Primary Care Transformation Asst. Director of Corporate Services Internal Auditor, RSM Internal Auditor, RSM LCFS RSM LCFS, RSM External Auditors Ernst & Young External Auditors Ernst & Young 9.00 Committee Members held a short private meeting and a further brief meeting with the Internal Auditor Action /16 Welcome and Apologies for absence Apologies were received from Sahdia Warraich. 02/16 Declaration of Interests (DOI) Members declared no further interests to that on the 3 CCG registers provided. 03/16 Minutes of meeting held on 8 December 2015 The minutes of the previous meeting were agreed subject to the change of locus to focus the minutes would be signed by the Chair as a correct record. AW Draft Minutes BHR Audit Committee 19 January 2016 v1 1

184 04/16 Matters Arising Further to minute 110/15 JE agreed to report an update to the next committee on primary care self-certification. Further to minute 112/15 The next LCFS benchmarking report will be shared with members. JE RSM 05/16 Primary Care A recently issued Internal Audit report, prepared by exception, that included findings on Co-commissioning and Contract Management was provided and discussed. The report highlighted the overspend position at M7 for all three CCGs but the forecast remained at break-even by year end. The report also provided good practice benchmarking for consideration. In response to the detailed findings an action plan had been agreed by management with low-medium priority actions. SS reported that the self-certification was not ready for review. She added that steps have been taken to address clinical engagement on the PCC and delivery of the QIPP. There had been suggestions around good practice including a clinical senate which needed to be explored further. RC questioned where the clinical senate would sit within the governance structure. SS responded that this still needs to be explored and would be discussed with WEL colleagues as we would be reluctant to add an unnecessary meeting to an already busy corporate calendar. KA questioned if the responsibilities of the clinical senate would be similar to that of the former professional executive committee adding that this would need to align to our strategies and a strong business case would be required for its creation. CN reported that only contracts over the value of 200k needed to include a fraud profile and would welcome a discussion on this outside of the meeting to clarify this. RC highlighted 2 errors for correction in section 3.5 and 3.8. SS reported that all actions are currently being picked up and she would update on progress at the next meeting. RSM SS The Chair questioned when the risk awareness training would be taking place for GB members. CN reported that this would take place at executive committees and the Chair confirmed he would also attend. The IA report was noted. 06/16 Internal Audit 06/1 Cover report on BHR and CSU progress- The report highlighted progress against IA plans and reports. Two final reports had been issued on Primary Care Commissioning (referenced above), Contract Management and an advisory report on Continuing Health Care payments. Work continued on the audits of QIPP, Procurement, IG and IT security. The GP Federation conflicts of interest review will start in February. It was noted that NHSE had requested early notification of any issues relating to the Internal Governance Statement 6/1 BHR Progress Two low priority IA recommendations had been followed up and were now implemented. Early notification of any known governance issues were required on Draft Minutes BHR Audit Committee 19 January 2016 v1 2

185 an exception basis as part of the M9 data collection and these were required to be signed off and submitted by 21 January. The draft HOIAOs were due by 22 Feb and it was confirmed these were on track. The report also highlighted a number of briefings issued since the last meeting Referring to the draft HOIAOs, the Chair questioned if there were any negative features in the report that the committee should be aware of. JE reported that the Barking & Dagenham CHC issue would be raised but it will still be a positive report. TT commented that he was not expecting this to be included or feature significantly as this was not on the original work plan. KP agreed that reference to this being an advisory piece of work needed to be clear. 6/2 CSU Progress Final reports had been issued on IT General Controls, Business Continuity/Disaster recovery and Continuing Health Care and these had been considered at the Quality Assurance Group. There were three reports out as drafts on Procurement, Co-Commissioning and Provider Quality Management. There had been a follow-up of 10 recommendations, 7 of which had been implemented and the remaining 3 were not yet due. The Internal Audit reports were noted. 07/16 LCFS 07/1 BHR progress The report referred to the completed local proactive exercise on Sponsorship discussed below. The report listed a number of activities for completion by the March audit meeting that included raising awareness by inform and involve and protect and deter exercises, completing review of non-creditor matches, early work on 2016/17 LCFS work-plan, and considering a local proactive exercise on Organised Crime Profiles (OCPs). Emerging fraud risks included a bogus invoice , elsewhere in London, and public wi-fi access for cyber fraud. For reactive work there had been 4 referrals for investigation, 2 since closed and 2 still under investigation. 07/2 Sponsorship review The exercise had identified areas of good practice and 5 medium level management actions suggesting best practice identified from national benchmarking. The recommendations would be monitored and a full and final report issued to a subsequent meeting. CN thanked the CCG for their assistance with the review and was pleased to report that overall good processes are in place at the CCG. He added it was good to see the frequency of submissions by the medicines management team. MP reported that she had discussed the outcome with Belinda Krishek and will be continuing the working group to review if sponsorship should continue. The Chair asked for an update on the previous minute TT reported that the staff member in question was no longer employed by the Provider. There had been a local exercise on impact and patient safety with a focus on small contracts to ensure lessons learnt. The Provider was working through the action plan which will need to be agreed by the CCG to give assurance on patient safety and processes. TT confirmed the matter was on the risk register. KA referred to the CCGs checking processes in procurement and questioned how deep can we go in terms of how good their processes are in checking fraud schemes were in place, suggesting that this should be part of the procurement process and PQQs. TT responded that the findings of the investigation would be reviewed to see if the Draft Minutes BHR Audit Committee 19 January 2016 v1 3

186 processes in place were risk satisfied. 08/16 External Audit The report that was provided outlined on-going progress of planning procedures as described in the External Audit Plan agreed in December. This included reviewing the operation of the Better Care Fund (BCF) where the CSU had provided a paper considering accounting implications for the CCG s financial statements. EA would review the paper and seek agreement with the CCGs on the accounting treatments proposed. Noting a risk assessment of the Value for Money (VFM) conclusion, KA expressed concern that this was based on a pure finance response. The Chair understood the concern raised but risk assessment was based on information available. KA questioned the robustness of the cover report and how this covers inequality and could be strengthened as this could help in preparation for the annual report. MP referred to a recent report around stroke consultation and engagement where significant thought was given to inequalities. She asked if KA could point out particular reports where more detail could be included and she would raise this with individual directors and would also explore other ways to improve this area. The update was noted. 09/16 Information Governance 09/01 Mandatory training update RM reported that 84% of staff had completed mandatory training and was confident that the target would be achieved. Outstanding members of staff will be spoken to individually and a formal update will be reported to the next meeting. RM 09/02 Update on IG breaches No formal breaches. 09/03 IG Policy-Data Protection v13 to approve The committee approved the policy. The Chair highlighted section 9 on the role of the audit committee and ensuring that the committee is adhering to the policy. 09/04 Process for managing IG security incidents v13 to approve The committee approved the policy. The Chair drew attention to section 4, the role of the audit committee/governing Body and ensuring that the committee/gb is adhering to the policy. Communication with staff was also highlighted. TT highlighted that it was a joint policy and needed to refer to the CCG. RM The updates were noted and the two policies approved subject to minor amendment. 10/16 Governance 10/1 Mapping of Assurances MP presented a first draft for comment of the mapping of where the CCG gains assurances. The Chair welcomed the useful starting point and this should be presented to the Governing Body in the future to see if all these meetings are required with the right people attending. KP questioned if there was similar mapping at other organisations and SB responded that there was and he would share similar information. SB KA welcomed the helpful first draft and would find it useful to include who owns Draft Minutes BHR Audit Committee 19 January 2016 v1 4

187 risks and see that each committee/group has a risk register to ensure that risks can t be missed. KS agreed adding that it is essential to be able to track a risk through the network of committees and the map is a good starting point. Members discussed how we could capture work such as the Healthwatch reports to ensure triangulation but without creating an industry. TT had some additional groups to add to the mapping and would discuss this with MP. The Chair added that there needed to be links to the GBAF and PD would be developing he map further. 10/2 Risk Appetite-next steps MP reported that monthly reviews take place with directors and risk appetite will be discussed at the next meeting. Consideration would be given to a GB session exploring risk appetite and an update would be provided. 10/3 Feedback from Working Group MP presented the minutes of the working group adding that the group are continuing to look at DOI in more detail including LMC membership. It was noted the group would continue to meet on a quarterly basis. KP welcomed this arrangement, adding it was important to ensure that reputational risk is mitigated. The governance reports were noted. 11/16 Finance updates 11/1 Financial Out-turn TT presented the report and highlighted the projected outturn with a revised position previously reported. Main risk continues to be exposure to acute overperformance at Barts Health and the private sector. For Barts Health there was on-going negotiation and discussion with WEL and there was confidence in reaching an agreed position shortly. The Chair referred to Barts Health as the most serious issue impacting on both Redbridge and Barking & Dagenham and questioned if there are any suggestions to do anything differently to what was being done already. External Audit responded that lines of communication need to be kept open to try to agree the best position for year end. AFC questioned if the Barts Health contract need to be reviewed. TT responded that not all was related to patient activity and this was a complex issue discussed at the Finance and Delivery committee. TT The Chair raised whether charging for over-performance was appropriate whilst primary care provision is available. He proposed that everything to support BHRUT recovery should be done to enable patients to choose them over Barts Health and the private sector. TT agreed adding the CCG were taking a more robust approach. AFC commented that RTT needs to be reviewed and TT agreed adding that a commissioning clinical reference group had been established to review referral quality and protocols to reduce pressure. The Chair added that Audit Chairs colleagues in Imperial College and Barts Health are similarly concerned and welcomed any good practice to share. 11/2 Update on outstanding debt 2014/15 TT reported that the vast majority relates to walk-in-centre debt, which is a London-wide issue that relates to patient identifiable data (PID) and a next steps meeting has been arranged. KA questioned if there was assurance on the PID issue and TT reported that this was part of work undertaken across a London Draft Minutes BHR Audit Committee 19 January 2016 v1 5

188 agreement. The Chair agreed to raise this with London audit chairs. CB would welcome a detailed breakdown of all outstanding debt last year for comparison with this year when available. TT agreed to present a process map for outstanding debt at the next meeting. TT 11/3 Debt Recovery Write off There were no write-offs required at present. 11/4 Annual Accounts/Annual Reports timetable and update on 9 month interim close-down TT reported that month 9 closedown had been completed within the NHS timetable and BCF was in line with the year- end timetable. The Chair asked the committee to note the proposed timetable for comments on draft accounts by 29 April 2016 and requested that members focus on their own individual CCGs. 11/5 IA final report on CHC payments at B& D and CHC financial position. TT presented an advisory report on CHC payments in Barking & Dagenham which highlighted 3 areas of significant exposure. RSM reported that the audit included a 3 month review of invoices. The same new process applied to all 3 boroughs where there were full records of patients and we were only paying for care we have commissioned. CB questioned how we recover the overpayments. RM responded that payments are recovered from the correct commissioners. The Chair referred to the Internal Audit during summer 2015 and the work undertaken to assure that patients under the care of our CCG are BHR patients and where legacy over-payments have to be recovered. RM referred to the Section 75agreement, with Redbridge having the biggest issue but not a large amount. The Chair asked for outstanding CHC debt to be included in lists of debtors. He was reassured by the report but requested a follow up with a broader CHC audit in due course. TT 11/7 Robustness of QIPP delivery The report provided outlined new measures this year to enhance the robustness of QIPP delivery. There had been a BHR wide QIPP summit in October, the QIPP programme had ben aligned to the One Team structure, there was greater emphasis on the QIPP plan at CCG level and the PMO were doing review of where QIPP delivered successfully across the country. A 16/17 QIPP pipeline and QIPP development timeline had also been agreed. TT reminded the committee that the three CCGs were separate statutory bodies. The Chair welcomed the work done and alignment to the Vanguard status. TT felt there was a stronger process this year and the QIPP was discussed at each individual finance and delivery committee and deep dives were undertaken. The Chair questioned how our local processes compare, noting the useful QIPP summit and positive working across the CCGs and by year end would we be delivering the QIPP that we wanted. CB questioned how it related to our forecast for next year. TT advised that the QIPP requirement was yet to be landed and whilst QIPP could deliver in financial terms at BHRUT, not so for activity. The primary care elements were raised and TT had to reach agreement with NHSE on the QIPP plan and there was tracking and monitoring at the PCC. The Chair added that the one team approach was vital to ensure CDs remain engaged together on particular QIPP areas. The Committee noted the contents of the progress report. Draft Minutes BHR Audit Committee 19 January 2016 v1 6

189 12/16 Messages for Governing Body The Chair would liaise with the secretary on the key messages for feedback to the next Governing Bodies. 13/16 Any Other Business It was noted that the NHSE had requested early notification of any issues relating to the internal governance statement which need to be agreed by KP and Conor Burke. It was suggested that discussion would be needed to decide if key risks with providers should be highlighted. KP/ MP/ RSM 14/16 Next Meeting The next meeting was confirmed as 8 March /16 Items for Noting 15/1 Assurance Committee Minutes-the minutes of the meeting held on 2 October were noted. 15/2 Information Governance Steering Group Minutes-the minutes of the meetings held on 25 August and 23 September were noted. 15/3 Draft Finance & Delivery Committee Minutes-the minutes of the meetings held on 3, 8, 9 December 2015 were noted. Signed..Date. Draft Minutes BHR Audit Committee 19 January 2016 v1 7

190 To: From: Date: Subject: Barking & Dagenham, Havering and Redbridge CCGs Kash Pandya, Chair of Audit & Governance Committee March Governing Body meetings Feedback from the 8 March 2016 Audit & Governance Committee meeting Summary The BHR Audit & Governance Committee provides the minutes of each meeting to the three BHR Governing Bodies. To provide additional assurance, this Committee Chair s report provides the key matters arising from the last meeting on 8 March to be drawn to the attention of the Governing bodies. The Committee remain concerned about the about the level of risk associated with the delivery of the financial objectives for 2015/16 and 2016/17. The Committee were assured by the Chief Financial Officer (CFO) that with the mitigations in place, the 2015/16 financial targets would be met. He said that the budget for 2016/17 was still being worked on and several risks remained that had still to be mitigated, including the outcome of contract negotiations with BHRUT, level of Referral to Treatments (RTT) backlogs that would require to be funded and delivery of QIPP plans. The Committee requested a further update on progress made with the 2016/17 budget at its next meeting and also requested that internal audit review the robustness of the 2016/17 budget and QIPP plans. The Committee were advised that the preparation of the annual accounts and the annual report for 2015/16 remain on track for delivery for audit by 19th April There are no issues of concern to report on the accounts at the present time. The Committee approved the delegated functions self-certificated return to the NHSE for Quarter 3 of 2015/16. The Committee noted the actions being taken to mitigate the risks associated with the outcome of the PMS funding reviews for GP practices (currently in progress) and the actions being taken to ensure that conflicts of interests were effectively managed at PCCC meetings. The Committee also urged that greater priority be given to workforce planning to address current and projected shortfalls in GPs and nurses in primary care within the CCG area. The Committee was advised by internal audit that on the basis of their work to date, the CCG would most likely receive an unqualified Head of Internal Audit Opinion for 2015/16 with no caveats. The Committee also approved the internal audit and the local counter fraud plans for 2016/17. The plans include reviews of the budget, QIPP, procurement arrangements, contract performance management, PMS, cybersecurity and collaborative working arrangements. The Committee approved the updated 2015/16 external audit plan, including their proposals for assessing value for money arrangements. The Committee is also making arrangements to reprocure external audit services for 2017/18 onwards. The Committee were advised by officers that, subject to an internal audit review, the CCG was expecting to achieve a Level 3 for information governance for 2015/16. The Committee welcomed the progress made and thanked officers for their efforts. The Audit Committee minutes refer to a variety of other matters which are not recorded within these key messages. Kash Pandya, Audit Chair 14 March 2016

191 Draft Minutes of the Joint Barking & Dagenham, Havering and Redbridge CCGs Audit &Governance Committee held on 8 th March 2016 at Becketts House pm. Present Members Kash Pandya (KP) Khalil Ali (KA) Charles Beaumont (CB) Richard Coleman (RC) Sahdia Warraich (SW) In attendance-officers Marie Price (MP) Tom Travers (TT) Paul Hunt (PH) Angela Ward (AW) Rob Meaker (RM) part Sarah See (SS) part BHR Audit Chair, Lay Member for Audit & Governance Lay Member PPI Redbridge CCG BHR Co-opted Member for Audit & Governance Lay Member PPI Havering Lay Member PPI Barking & Dagenham BHR Director of Corporate Services BHR Chief Financial Officer (CFO) NELCSU, Senior Financial Control Manager BHR Company Secretary Director of Innovation Director of Primary Care Transformation In attendance-auditors Nick Atkinson (NA) Gemma Higginson (GH) Stephen Bladen (SB) Kevin Suter (KS) Internal Auditor, RSM LCFS RSM External Auditors Ernst & Young External Auditors Ernst & Young Committee Members held a short private meeting and a further brief meeting with Internal Audit (IA) and Local Counter Fraud Service (LCFS) leads from RSM. Action 16/16 Welcome and Apologies for absence There were no apologies for absence. 17/16 Declaration of Interests (DOI) In addition to the declarations on the registers provided, SW advised that her earlier interest as a Healthwatch director had ceased on 7 December The register would be updated. AW 18/16 Minutes of meeting held on 19 January 2016 The minutes of the previous meeting were agreed and would be signed by the Chair as a correct record. Draft Minutes BHR Audit Committee 8 March 2016 v1 1