NHS City and Hackney Clinical Commissioning Group (CCG) Board. Friday 31 May 2013,

Transcription

1 NHS City and Hackney Clinical Commissioning Group (CCG) Board Friday 31 May 2013, Bandura 2, Tomlinson Centre, Queensbridge Road, London, E8 3ND AGENDA Part Two Open session of the CCG Board Chair: Dr Clare Highton Agenda Items 3. Welcome, introductions and declarations of Interests Led by & Appendix number Clare Highton Verbal Timing (5 mins) 4. CCG Committee business: a. Minutes of the last meeting; b. Register of Interests; c. Summary of closed Board session; d. Matters arising. Clare Highton Papers 4a & 4b Pages (5 mins) 5. Questions from the public Clare Highton Verbal (15 mins) CLINICAL STRATEGY (FOR DECISION) 6. Intermediate Care: Receive and agree recommendation on reablement and intermediate care service lead provider. Clare Highton Paper 6 Page (10 mins) 7. Homerton A&E recovery plan Sue Edwards Papers 7a, 7b & 7c (10 mins) Pages PERFORMANCE 1 Chair: Dr Clare Highton Chief Officer: Paul Haigh

2 8. CCG Finance update: Mildmay Mission Hospital waiver; Richard House waiver. Philippa Lowe Papers 8a, 8b & 8c Pages (10 mins) 9. Harmoni Out of Hours contract Care Quality Commission Harmoni report; CSU assurance on contract monitoring; Update on Out of Hours Guardian allegations Primary Care Trust report. Will Huxter Papers 9a, 9b, 9c, 9d, 9e & 9f Pages (20 mins) FOR INFORMATION 10. Severance payment and whistleblowing CCG Constitution change Clare Highton Papers 10a & 10b Pages (10 mins) 11. Commissioning for Quality and Innovation measures update Sean Overett Paper 11 Pages (10 mins) 12. Reports from Subcommittees of the Board: a. Key issues from the Wednesday 8 May 2013 Clinical Executive Committee; b. Key issues from the Tuesday 21 May 2013 Remuneration Committee; c. Key issues from the Thursday 23 May 2013 Audit Committee. Clare Highton Papers 12a, 12b & 12c Pages (5 mins) 13. Friday 28 June 2013 CCG Board agenda Clare Highton Paper (5 mins) Pages Any Other Business Clare Highton (5 mins) 2 Chair: Dr Clare Highton Chief Officer: Paul Haigh

3 MINUTES OF THE NHS CITY AND HACKNEY COMMISSIONING GROUP BOARD HELD ON FRIDAY 26 APRIL 2013 AT EMILIA HALL, TOMLINSON CENTRE, QUEENSBRIDGE ROAD, LONDON, E8 3ND PRESENT: Dr Clare Highton (CCG Chair) Dr Haren Patel (CCG Clinical Vice Chair) Mariette Davis (CCG Governance Lay Member) Jaime Bishop (CCG Public and Patient Involvement Lay Member) Honor Rhodes (CCG Associate Lay Member) Siobhan Clarke (CCG Board Nurse) Christine Blanshard (CCG Board Consultant) Paul Haigh (CCG Chief Officer) Philippa Lowe (CCG Chief Financial Officer) IN ATTENDANCE: Dianne Barham (Hackney HealthWatch) Lynn Strothers (City of London HealthWatch) Sean Overett (CSU Director of Contracts) Jenny Singleton (CSU Quality Assurance Manager) Dr Rhiannon England (CCG Mental Health Clinical Lead) for agenda item 4 Robert Dolan (ELFT Chief Executive) for agenda item 4 Kevin Cleary (ELFT Medical Director) for agenda item 4 Jonathan Warren (ELFT Director of Nursing) for agenda item 4 Will Huxter (CSU Director of Contracting and Quality) for agenda item 5 Susan Tokley (CSU Head of Quality) for agenda items 4-5 Karl Thompson (CCG Head of Corporate Affairs and Urgent Care Programme Director) Matthew Knell (CCG Business Co-ordinator) The Chair, Dr Clare Highton (CH) welcomed members to the April 2013 first formal meeting of the NHS City and Hackney Clinical Commissioning Group (CCG) Board. Dr Gary Marlowe (CCG Board GP) and Emma Craig (Hackney HealthWatch) had sent apologies for the meeting, with Hackney HealthWatch represented by Dianne Barham at the meeting. Agenda Item 1 Declaration of Interests Haren Patel (HP) and CH declared an interest in agenda item 7 as GP partners in local practices. Paul Haigh (PH) noted that the CCG is currently refreshing or requesting declarations of interest for every individual working with the CCG. Agenda Item 2 CCG Committee business Minutes of the last meeting The minutes of the Friday 22 March 2013 CCG Board meeting were cleared with a change to agenda item 7 to indicate that the Audit Committee had not received assurance that the 3 Chair: Dr Clare Highton Chief Officer: Paul Haigh

4 NHS North East London and the City (NELC) transfer document was wholly correct and that the CCG would not have a role in confirming the list, which remained a Primary Care Trust responsability. Register of Interests The Board noted the Register of Interests. Matters arising The Board noted the circulated response to the urological cancer consultation and agreed that the Public and Patient Involvement (PPI) Committee would receive the summary of patient comments made. ACTION: PPI Committee to receive the urological cancer consultation summary of patient comments made. Agenda Item 3 Questions from the public Michael Vidal (MV) asked when the Primary Care Trust (PCT) report on the Guardian newspaper allegations regarding Harmoni was to be published. PH answered that it is currently being finalised by NHS England and should be released within two weeks and will be presented to the CCG Board meeting. Agenda Item 4 East London Foundation Trust Serious Incident assurance Robert Dolan (RD), Kevin Cleary (KC) and Jonathan Warren (JW) joined the Board to present the East London Foundation Trust (ELFT) response to the KU/PD serious incident discussed at the March 2013 CCG Board meeting. The Board thanked ELFT for the circulated response to the letter from the CCG and Rhiannon England (RE) noted the great work and positive response since the incident occurred in 2010 by the Trust. RD briefed the Board on the incident, that it prompted a wide and detailed response by the Trust, on which they secured external assurance and have now been visited twice by the Care Quality Commission (CQC), with the 2012 review certifying the service as fully compliant. The Board outlined their concerns regarding staffing levels, linkages with patient safety and the quality of services and the value of benchmarking against comparative Trusts. ELFT responded that benchmarking is particularly challenging for mental health Trusts due to the nature of the clinical wards and work and the requirement to set a consistent benchmark across a sufficient number of Trusts in order to provide accurate data. ACTION: CSU to develop proposals for a system of benchmarking ELFT performance against relevant comparators to indicate performance in the staffing level and ratio area for inclusion in the quarterly quality report. 4 Chair: Dr Clare Highton Chief Officer: Paul Haigh

5 ELFT have benchmarked their performance and other measures across the London region and recently presented the findings to their own Board, which resulted in an increase in minimum staffing levels across their services. Although the minimum staffing level is centrally set, every ward Matron has the power to increase staffing levels to meet clinical needs. ELFT employ 95% of their staff in substantive posts, seeking to minimise the use of interim or bank staff ELFT quoted that this rate is the highest in London and, in their experience, provides a higher quality service. ELFT is supporting the continuing development of its nursing staff through education, performance and human resources and has a joint recruitment system in place with local Universities. Honor Rhodes (HR) asked ELFT how wide their language coverage extends and ELFT responded that East London is a challenging area in this regard, and that while they have most common languages available within their staff, they also have access to a translation service that they can call on when needed and have a commonly used phrases crib sheet available to all staff. They monitor the use of translation services to identify and recruit in demand languages, recognising that best practice is a native language speaker, familiar with individual cultures. Lynn Strother (LS) asked how ELFT involve the variety of local communities in their work and in particular, how did they work with the appropriate communities post the KU/PD serious incident. ELFT responded that met with community representatives several times post incident, attended the local Bangladeshi Mental Health Forum and have started working with a local Imam to help support residents. ELFT recognise that work is never done in this area and always seek to do better. RE returned to the subject of benchmarking performance, reiterating that a comprehensive benchmarking system would need national support and that other new initiatives taken by ELFT had provided clinical and patient benefits, including the recent carers strategy, supported by a Commissioning for Quality and Innovation (CQUIN) measure to improve the carer-elft relationship. The Trust was also making good use of the floating nurse staff member on night shifts, providing a reliable boost to staffing levels where it was needed. ELFT added that further staff were available on call up beyond the floating nurse, but that there was always that spare resource available when needed. The Board noted that ELFT had reached level three of the NHS Litigation Authority Risk Management Standards, noting that it was one of the few Trusts to do so. The Board asked how ELFT share the principles and lessons from incidents within and across the organisation. ELFT responded that their management team rotates working within the wards every week to speak directly to staff and cascade information through the clinical staff bands (ie from band 8 clinical managers to band 7s to band 6 nurses etc). Reflection workshops are also run regularly to provide a space for feedback and discussion of practice. ELFT have an occupational health team to provide support for any stressed or distressed staff members. ELFT closed the discussion by inviting member of the CCG Board and CCG to visit their premises for further discussion. 5 Chair: Dr Clare Highton Chief Officer: Paul Haigh

6 Agenda Item 5 Out of Hours service Will Huxter (WH) joined the Board for this agenda item. Karl Thompson (KT) presented the distributed papers outlining the proposed contract management arrangements for the Harmoni Out of Hours (OOH) service and the process for the new procurement of an OOH provider. KT updated that the CCG has met with NHS England (NHSE) to discuss the contract handover and the draft Guardian report and with Harmoni to discuss the monitoring arrangements and incoming CQC report. Contract monitoring KT outlined the approach to monitoring the current OOH contract inherited from the PCT, prompting a Board discussion on how to monitor and measure the rota fill. Harmoni had committed to providing two methods of monitoring, firstly a weekly copy of the predicted rota fill and secondly the actual rota fill for the previous week to indicate the true position and allowing comparison across the predicted and actual. The Board requested that the reports detail who is rota d a doctor or nurse. Harmoni have invited random CCG visits to inspect the service and the Board discussed if and how HealthWatch could be involved in those visits. ACTION: OOH monitoring reports to indicate if the rota is filled with a doctor or nurse. The Board emphasised that the monitoring process needed to move from retrospective review and audit to active management and that any new regime needs to apply to the new providers post procurement as well. The proposed monitoring regime will be built by analysis of best practice, experience of current systems and the principles of the CCG with a much stronger clinical emphasis. The Board moved on to discuss clinical audit, noting that the Royal College of General Practitioners (RCGP) provided widely recognised tools for audit of out of hours care and noted that the Harmoni Medical Director currently audits the service using these tools. The Board expressed concern that this didn t constitute an independent approach, even with CCG spot checks on the data. The Board asked if the CCG could arrange a swap with another London CCG to ensure a true independent audit process could be arranged. ACTION: CCG to investigate swapping out of hours audits with another London CCG to ensure an independent approach to clinical audit and to build this into future contract monitoring. It was noted that contract monitoring would be available to the Finance and Performance Committee and be included in the quarterly quality reports produced by the CSU and available publically. Contract procurement KT moved on to present the proposal for a procurement process for the new OOH provider. The process has been discussed by the Audit Committee and their changes have been 6 Chair: Dr Clare Highton Chief Officer: Paul Haigh

7 incorporated into the paper presented to the Board. Legal advice has been sought at each stage of the process so far and changes made to comply with the advice received. WH informed the Board that the document outlines the process towards procurement and who is involved. The process is a robust, efficient procurement process detailing an open tender which is split into a Part A and Part B application. Part A is a selection of yes/no questions resulting in a pass/fail if a question is answered no. If Part A is passed, Part B requests detailed information on the providers proposal. WH emphasised that the CCG needs to recognise that the process and mobilisation of a new provider will take time. Two subcommittees of the CCG Board are proposed to oversee the process, a Steering Group to manage the Commissioning Support Unit (CSU) and the procurement process and an Evaluation Panel, chaired by an independent clinician to score the applications and to make a recommendation to the CCG Board on awarding a contract. The Market Event that had been proposed has been recommended to be removed from the process due to concerns that it may provide an unfair advantage to providers who can field representatives at what would probably be short notice due to the procurement timetable. Legal advice received on the process to date has not indicated any problems with the proposal, although has recommended several changes to the Evaluation Panel to provide a true independent and informed membership. These recommendations have been incorporated. Undertaking this exercise is providing valuable lessons for both the CSU and CCG which can be applied to any and all future procurements. Mariette Davis (MD) confirmed that the Audit Committee will continue to follow the procurement process and provide advice and assurance to the CCG Board that it is satisfied with the procurement process. MD confirmed that the Audit Committee had reviewed the process recommended by CSU in some detail, noting the legal advice to the CCG from DAC Beachcroft and that changes had been incorporated into the document. MD was comfortable to assure the CCG Board on behalf of the Audit Committee. The Board discussed how the 111 system will impact on and work with the OOH service, noting that it appeared that locally the 111 system had been helped by the use of THDOC and the OOH provider to help screen callers, resulting in the area not seeing the problems witnessed in other areas across the country. The Board noted that the status of the request for a judicial review of the Primary Care Trust s (PCT s) decision on the OOH service undertaken earlier this year was unknown and the CCG wasn t able to confirm details with the legacy team. The Board asked that this line of enquiry be pursued and escalated if needed. ACTION: CCG to confirm status of the judicial review of OOH procurement with the legacy team. The Board agreed the procurement process as detailed, with a single change to ensure that at least two patient engagement events are programmed into the timetable to ensure residents can communicate their views. 7 Chair: Dr Clare Highton Chief Officer: Paul Haigh

8 ACTION: CCG to ensure at least two patient engagement events are scheduled in the OOH procurement process. DECISION: The Board agreed the proposed contract monitoring arrangements and the establishment and membership of the Out of Hours Quality and Service Performance Group. DECISION: The Board agreed the process and timescale for the procurement of a new Out of Hours provider. DECISION: The Board agreed to the establishment of the Out of Hours Steering Group and the Out of Hours Evaluation Panel to manage this process. Agenda Item 6 Safeguarding Assurance CH presented a summary paper to the Board detailing the CCGs arrangements for Safeguarding and several papers providing further detailed information. The CCG has produced an interim Safeguarding policy for authorisation but further revision of the policy into a final document has proved challenging due to little guidance or confirmation of arrangements from NHSE and the CSU. The papers outline what is in place and what is proposed for further development, recognising that more robust arrangements are required for the CSU to assure the CCG of the quality of all commissioned services and how safeguarding is addressed. The CCG is also proposing to setup a Safeguarding Assurance Group (SAG) to obtain this assurance and to review all aspects of safeguarding. The CCG will also be recruiting an Adult Safeguarding Clinical Lead to work with the CCG and Local Authorities (LAs) to raise awareness. Honor Rhodes has agreed to chair the SAG. DECISION: The CCG Board noted the Terms of Reference and members and agreed to the establishment of the CCG Safeguarding Assurance Group (SAG) which will report to the CCG Clinical Executive Committee and oversee safeguarding arrangements in contracted services. DECISION: The CCG Board agreed that Honor Rhodes will chair the SAG. DECISION: The CCG Board supported the establishment and recruitment to a Clinical Lead role for adults safeguarding. The Board noted that further assurance on care homes will be provided by the CSU to address the issues where lead responsibility sits when the provider is located in another Borough but houses a CCG patient. ACTION: CSU to provide the CCG with further developed assurance on safeguarding arrangements for external care homes. 8 Chair: Dr Clare Highton Chief Officer: Paul Haigh

9 The Board discussed how important communications are in this area, how the CCGs policies and the organisation itself must be open to the public and able to listen to any instances of whistleblowing. Jenny Singleton (JS) noted that the recent CQC pilot inspection of the local areas safeguarding arrangements had been awarded outstanding and the Board congratulated everyone involved in the area and inspection. Agenda Item 7 Prescribing Budgets HP presented the proposed 2013/14 prescribing budgets, advising the Board that they have been discussed and cleared previously by the Prescribing Programme Board (PPB), Clinical Executive Committee (CEC) and the Audit Committee (given these are payments to GP practices as providers). The 2012/13 budget was now closed and had ended up 2.9m underspent with only three of the forty four practices overspending last year, this position bought us into the top 20% performance in London. The Board offered their thanks to everyone involved in the area for their hard work, including the joint committee with the Homerton University Hospital Foundation Trust (HUHFT). The 2013/14 budget is based on a fair shares formula, and the PPB and Medicines Management Team (MMT) will be working with any practice with concerns regarding allocations to provide advice and support on how they can meet the challenge. No sanctions would be applied for overspends, just further offers of support and advice from the CCG and CSU. The uplift applied to the 2013/14 proposal covers inflation and an allowance for new drugs high cost drugs have largely moved to be controlled by NHSE and are not in the CCGs budget this year. Philippa Lowe (PL) advised the Board that the methodology for allocating funding to prescribing within the CCG was consistent with other areas of CCG budget setting. The Audit Committee had reviewed this, given the potential GP conflicts of interest and supported the proposal. DECISION: The CCG Board agreed the methodology underpinning budget setting and the budget distribution across practices. The overall budget sum would remain provisional until such time as the overall CCG 2013/14 financial plan was agreed. Agenda Item 8 St Joseph's Hospice /14 Contract PL presented the proposed 2013/14 contract for services from St Josephs Hospice (SJH) for the Boards approval. The Board asked for confirmation of an equality assessment of the services and staffing ratios provided at SJH and agreed the proposal, noting that NHS funding was matched by charities. 9 Chair: Dr Clare Highton Chief Officer: Paul Haigh

10 ACTION: CCG to investigate an equality assessment and staffing ratios of services at St Josephs Hospice. DECISION: CCG Board agreed the 2013/14 St Josephs Hospice contract proposal. Agenda Item 9 Commissioning Support Unit (CSU) City and Hackney Quarterly Quality report JS presented the latest quarterly quality report covering quarter four of 2012/13, noting that this would be the last report produced under the historic PCT process and that the next report is under development with the CCG to ensure it reflects all commissioned services. Highlights of the report included CQC reports of inspections of the Mary Seacole Nursing Home and the HUHFT elderly care and maternity wards. The Mary Seacole report in particular resulted in an outstanding report and there were no causes for concern across any of the inspections. The Royal London Hospital (RLH) site at Barts Health (BH) was experiencing problems with mixed sex accommodation breaches, the Board expressed surprise and concern regarding this development, considering the expansion of the site into new premises which should have been able to prevent these issues. JS advised the Board that a single placement into a mixed sex environment could results in multiple breaches for example, a female patient onto a ward with five male patients would equal six breaches. The Board noted a deterioration in the quality of services at BH and the RLH site since the merger, particularly in cancer care and Accident and Emergency (A&E). Safeguarding arrangements at BH were another concern, although the latest quality report did not indicate levels of staff training, the most recent data indicated that the Trust was far behind where it needed to be. The Board also expressed concerns with the timeliness and quality of discharge and outpatient department (OPD) communications from BH, noting that practices across the area had raised issues. ACTION: CSU to investigate and provide data to the CCG on the levels of staff safeguarding training at Barts Health and across its sites. ACTION: CSU/CCG to monitor Barts Health discharge and outpatient communications for timeliness and quality. PH stated that the CCG is now an associate commissioner of Barts Health, with Tower Hamlets (TH) CCG taking the lead for the contract and quality monitoring. The Board can feed in comments via TH, with the City of London Corporation also in contact with TH to express concerns with the level of services the Trust was providing to its residents. The Board moved on to discuss the development of the next quality report, requesting that comprehensive, relevant benchmarked data is included to allow the CCG to identify areas of good practice and concern. A future Board will also receive a report from the PPI Committee which will be considering soft quality, such as provider complaints, patient satisfaction etc. CSU will provide the information to the PPI Committee and they will 10 Chair: Dr Clare Highton Chief Officer: Paul Haigh

11 identify any commissioning issues as well as seeking assurance on how providers have changed in light of concerns raised. ACTION: CCG Board requested that future quality reports include comprehensive, relevant benchmarked data. ACTION: Future CCG Board to receive a report from the PPI Committee which will be considering soft quality, such as provider complaints, patient satisfaction etc. ACTION: CSU to provide information to the PPI Committee and identify any commissioning issues and provide assurance on how providers have changed in light of concerns raised. Agenda Item 10 CCG Finance update PL briefed the Board that there is not a final 2013/14 financial plan yet due to delays and issues resolving a number of allocation issues, including with the national specialised commissioning budget splits. The CCGs 2013/13 non-recurrent budget is seeing pressure as allocations are transferred from CCG budgets to specialised commissioning in NHSE. The latest movement was 9.7m from the CCG and PL expressed concern that this process posed a risk to the CCGs financial position. A reconciliation process is proposed between NHSE and CCGs, with further details expected soon but it left significant uncertainty of the financial impact that would only be resolved in year. PL moved on to update the Board on the progress of the 2013/14 contract negotiations, noting that Heads of Terms are almost agreed with East London Foundation Trust (ELFT), however there are still several issues to deal with HUHFT and that the CCG is now in stage one of the escalation process. The gap between the CCG and HUHFT position is sizable, and complicated by the changes in commissioners of services to CCGs, LAs and NHSE. Most of this gap is in productivity and the Community Health Services (CHS) transfer agreement, where all CCGs are looking to see savings from improved productivity and for the Trust to ensure its CHS support a reduction in emergency activity. The CCG is currently awaiting a response from HUHFT to its latest proposal and given the allocation issues, contract settlement on the current offer was important for the recurrent financial position. The Board confirmed the critical importance of productivity and the role of the CHS. TH CCG is starting to address the BH contract and the Board should note that there is a risk that the CCGs may need to revert to a Payment by Results (PbR) basis and a withdrawal of provided transition support. As part of the ELFT agreement, the Trust is considering the closure of some elderly care wards. Clinical Leads across three CCGs will need to review the data and business case for this and the Board noted that formal proposals would require public consultation. 11 Chair: Dr Clare Highton Chief Officer: Paul Haigh

12 Agenda Item 11 Reports from Subcommittees of the Board The Board accepted the reports from its subcommittees and noted the contents. Agenda Item 12 Friday 31 May 2013 CCG Board agenda The Board noted the agenda of the following months meeting and requested that the Board Assurance Framework is discussed at the Board after the Audit Committee has discussed and cleared the document. ACTION: Board Assurance Framework to be discussed and cleared by the Audit Committee and the CCG Board. Agenda Item 13 Any Other Business PL raised that the CCG needed to give twelve months notice under the terms of its service level agreement with the CSU in order to negotiate any change to the individual services it receives from the CSU. The CCG had suggested to CSU a revision of the notice terms to allow variations to be dealt with without notice on the whole contract; however pending agreement to this, the CCG was recommended to serve notice now to allow flexibility for service changes or alternatives to be negotiated or sought. DECISION: CCG Board served the required twelve months notice to CSU under the terms of the service level agreement. AGREED BY: AGREED ON: 12 Chair: Dr Clare Highton Chief Officer: Paul Haigh

13 Name Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Dr Clare Highton 18/04/2013 CCG Chair and Long Term Conditions Clinical Lead Lower Clapton Group Practice Principal Partner at Lower Clapton Group GP Practice, our practice now provides a CCG Commissioned community ENT clinic run by my GP partner Dominic Roberts with our local ENT consultant. The practice also employs 3 Heart Failure nurses and their HCA. Lower Clapton is a research associate practice, so does not hold grants but does participate in research that is funded. Dr Clare Highton 18/04/2013 CCG Chair and Long Term Conditions Clinical Lead Tavistock and Portman NHS Trust Rob Senior, the Medical Director at the Tavistock GP and Portman NHS Trust is my husband. Dr Haren Patel 16/04/2013 CCG Clinical Vice Chair, Clinical Executive Committee Chair and Prescribing Clinical Lead GP Latimer PMS Plus Practice Senior Clinician and Management Lead for Project and Intermediate/Secondary Mental Health Service Provision. Interest in mental health Dr Haren Patel 16/04/2013 CCG Clinical Vice Chair, Clinical Executive Committee Chair and Prescribing Clinical Lead GP Latimer PMS Plus Practice Partner, Dr Geeta Patel clinician with special interest. Dr Haren Patel 16/04/2013 CCG Clinical Vice Chair, Clinical Executive Committee Chair and Prescribing Clinical Lead GP North East London Medicine Management Committee Co-Chair of North East London Medicine Management Committee Dr Haren Patel 16/04/2013 CCG Clinical Vice Chair, Clinical Executive Committee Chair and Prescribing Clinical Lead GP City and Hackney Local Medical Committee Member of the City and Hackney Local Medical Committee (the representative body for GPs) Dr Haren Patel 16/04/2013 CCG Clinical Vice Chair, Clinical Executive Committee Chair and Prescribing Clinical Lead GP Acorn Lodge Nursing Home Lead Clinician providing NHS GMS and Enhanced Services under Nursing Home LES to the Acorn Lodge Nursing Home. Interest in intermediate Dr Gary Marlowe 16/04/2013 CCG Board GP and Planned Care Clinical Lead GP De Beauvoir Surgery Partner at De Beauvoir Surgery of GMS services and a provider of Locally Enhanced Services. Dr Gary Marlowe 16/04/2013 CCG Board GP and Planned Care Clinical Lead GP London-wide Medical Committee City and Hackney Representative at the Londonwide Medical Committee, the representative body for London s GPs. Dr Gary Marlowe 16/04/2013 CCG Board GP and Planned Care Clinical Lead GP British Medical Association London Regional Council Representative for the British Medical Association (the major trades union for medical practitioners) - regional Christine Blanshard N/A CCG Board Consultant Salisbury Hospital NHS Foundation Trust Medical Director at Salisbury Hospital NHS Foundation Trust that does not hold any Siobhan Clarke N/A CCG Board Registered Nurse YOUR HEALTHCARE CIC MANAGING DIRECTOR OF YOUR HEALTHCARE CIC WHICH HOLDS CONTRACTS FOR HEALTH AND Mariette Davis 16/04/2013 Governance Lay Member, Audit Committee Chair and Remuneration Committee Chair Acanthus Advisers Private Equity Limited Acanthus Advisers Private Equity Limited, a placement agency not operating in or with the 13

14 Name Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Mariette Davis 16/04/2013 Governance Lay Member, Audit Committee Chair Aletheia Partners LLP Aletheia Partners LLP, a Private Equity advisory and Remuneration Committee Chair firm not operating in or with the NHS. Mariette Davis 16/04/2013 Governance Lay Member, Audit Committee Chair Tower Hamlets CCG Lay Member for Governance for Tower Hamlets and Remuneration Committee Chair CCG Jaime Bishop 16/04/2013 Public and Patient Involvement Lay Member and Public and Patient Involvement Committee Chair Fleet Architects LTD Director of Fleet Architects LTD, a company working on socially valuable buildings. We do not currently have any involvement in the City and Jaime Bishop 16/04/2013 Public and Patient Involvement Lay Member and Public and Patient Involvement Committee Chair Jaime Bishop 16/04/2013 Public and Patient Involvement Lay Member and Public and Patient Involvement Committee Chair Jaime Bishop 16/04/2013 Public and Patient Involvement Lay Member and Public and Patient Involvement Committee Chair HealthPorts LTD Architects for Health Barretts Grove Practice Fleet Architects own 33% of HealthPorts LTD, a (as yet not trading at all) company established to design accessible sustainable modern health centres. Fleet provide design services. There are currently no projects although in the course of Executive Committee Member and Head of Education at Architects for Health, I run annual Student Design Competitions in conjunction with other healthcare stakeholders including NHS Patient as a Hackney General Practice, Barretts Grove. Jaime Bishop 16/04/2013 Public and Patient Involvement Lay Member and Public and Patient Involvement Committee Chair ELIC (East London Integrated Care) LTD Member of the ELIC (East London Integrated Care) LTD (a Practice Based Commissioning body) Audit Committee that is overseeing the wind up of the dormant social enterprise. ELIC is now defunct save some final legal winding up proceedings underway. Honor Rhodes 16/04/2013 CCG Associate Lay Member Barton House Practice Patient at Barton House, Albion Rd Practice Honor Rhodes 16/04/2013 CCG Associate Lay Member Tavistock Centre for Couple Relationships Director of Strategy at the Tavistock Centre for Couple Relationships. Honor Rhodes 16/04/2013 CCG Associate Lay Member Children and Family Courts Advisory and Support Service (CAFCASS) Non Executive Director at Children and Family Courts Advisory and Support Service (CAFCASS). Honor Rhodes 16/04/2013 CCG Associate Lay Member Early Intervention Foundation Trustee at the Early Intervention Foundation. Honor Rhodes 16/04/2013 CCG Associate Lay Member The Institute of Wellbeing Mentor to CEO of The Institute of Wellbeing, a voluntary agency who may seek to contract with the NHS in future in South London. 14

15 Name Date of Declaration CCG Position / Role Nature of Business / Organisation Nature of Interest / Comments Honor Rhodes 16/04/2013 CCG Associate Lay Member Oxleas CAMHS Partner is a Consultant Family Therapist with Oxleas CAMHS Paul Haigh 16/04/2013 CCG Chief Officer ELIC (East London Integrated Care) Chief Executive of ELIC (East London Integrated Care) (a Practice Based Commissioning body registered as a social enterprise). The social enterprise has now ceased trading and is being wound up Also member of ELIC s Audit Committee that is overseeing the wind up of the dormant social enterprise. Paul Haigh 16/04/2013 CCG Chief Officer NHS England Partner - Helen Bullers is Regional Director of HR and Organisational Development (London), NHS England. Philippa Lowe 16/04/2013 CCG Chief Financial Officer GreenSquare Group Group Audit Committee Chair and Group Development Committee member for GreenSquare Group, a Group of Housing Associations. KPMG are internal audit provider to the HA and external auditors to the CCG. GSG hold many contracts with public and private sector bodies. Philippa Lowe 16/04/2013 CCG Chief Financial Officer PIQAS Ltd Director of PIQAS Ltd, a Consultancy firm. Dormant company from 1/4/13. Emma Craig N/A London Borough of Hackney Healthwatch No return No return Representative Dianne Barham 16/04/2013 London Borough of Hackney Healthwatch Urban Inclusion Community Director of Urban Inclusion Community Representative Dianne Barham 16/04/2013 London Borough of Hackney Healthwatch Representative Healthwatch Tower Hamlets Chief Operating Officer of Healthwatch Tower Hamlets Dianne Barham 16/04/2013 London Borough of Hackney Healthwatch Representative ELFT Tower Hamlets CCG Hackney and the City PCT Lynn Strother 18/04/2013 City of London Healthwatch Age UK London The Greater London Forum for Older People Sean Overett N/A Commissioning Support Unit representative No return No return Undertaken research for ELFT, Tower Hamlets CCG, Hackney and the City PCT. The charities I am employed by Age UK London and The Greater London Forum for Older People are funded by grants and donations. 15

16 BOARD DECISION RECOMMENDATON: To receive and agree the recommendation that HUH is the reablement and integrated care service lead provider: Development of intermediate care services presented to Mar 2013 CCG Board where it was agreed that oversight of the selection of a lead provider should be delegated to Reablement and Intermediate Care Board (RIC Board) Of the two current providers of intermediate care only the Homerton expressed an interest in becoming a lead provider (the other provider being LBH Social Services) The Homerton was formally interviewed 21st May 2013 by the RIC Board with additional user representation from Health Watch and OPRG re their outline plans for the service (presentation from Dylan Jones, Natasha Arnold and Rob Blackstone) The Homerton was appointed as lead provider in principal, subject to approval of the CCG Board, and was asked to work up a full service model Next steps: The Homerton to submit a fully worked up service proposal to the RIC Board The RIC Board to create a new performance framework for the new service with oversight of the pooled budget between LBH and the CCG To enter in a contractual agreement for the service 16

17 Delivery of the A&E 4 hour operational standard UPDATE TO CCG BOARD For information and for decision 31 May

18 CONTEXT We have received letters highlighting long waiting times in A&E from NHS England regarding the current pressure the urgent and emergency care system is experiencing and the impact on the 4 hour operational standard. The following essential activities are underway: The CCG will work in partnership with local providers supported by NHS England to develop a local recovery and improvement plan to ensure performance against the 95% of patients admitted, transferred or discharged within 4 hours, is sustained. Our existing Urgent Care Board will have oversight of these plans and will review and monitor performance recognising that this is not just a performance metric but a key quality indicator. We will also be reviewing the 70% A&E threshold monies and their future utilisation. Given the current green performance (above target for month, quarter and year to date) of the Homerton University Hospital, we are initially focussing on the standard requirements for a recovery and improvement plan, attached, although are undertaking to complete the more detailed good practice checklist which gives more detailed areas of focus to ensure robust plans are in place. 18

19 DECISIONS The Board is asked to; Agree the proposed local recovery and improvement plan, to be sent to NHS England Note that the more detailed completion of the good practice checklist is being undertaken in collaboration with the Homerton University Hospital which will be reviewed and monitored by the Urgent Care Board in conjunction with our CSU colleagues. 19

20 NHS England: Improving A&E Performance Gateway ref: A. The Issue 1. Long waiting times in A&E departments (often experienced by those awaiting admission and hence ill patients) not only deliver poor quality in terms of patient experience, they also compromise patient safety and reduce clinical effectiveness. 2. We have an operational standard of 95% for patients being seen and discharged within 4 hours and we use this to be sure patients are being treated quickly. This operational standard is designed to deliver patients rights under the NHS Constitution. A&E performance has deteriorated significantly over the last six months. In the last quarter of 2011/12, 47 out of 152 providers failed to meet the 95% standard for patients being seen and discharged within 4 hours. For the last quarter of 2012/13 this figure had increased to 94 out of 148 providers, double the previous number. 3. Despite much analysis there is no single trend or factor to explain the deterioration and there remains a wide variation in performance both across the country and within the same areas where similar factors apply. This has also been borne out in the perceptions from Clinical Commissioning Group (CCG) commissioners, gathered through the NHS Commissioning Assembly Rapid Reference Group. 4. A number of factors are assumed to have played a part in this deterioration, and not all of them pertain to every situation: Increased numbers of patients arriving at A&E. There is a general rising tide with 5.9% more attendances in 2012/13, than in 2009/10. However, the total numbers attending in Q4 of (which is when the significant deterioration began) was 1.7% lower than the previous Q4. Increased number of acute admissions putting pressure on beds. There were 10.6% more emergency admissions in 2012/13 than in 2009/10. There is general consensus (though it is hard to identify the evidence) that patients presenting are more ill and hence more likely to need admission and have longer stays. Hospitals being less proactive in process management which plays a very significant part in their ability to admit patients. Patients who require admission are the ones who are most likely to wait over 4 hours. 1 20

21 A lower threshold in hospitals for admitting or discharging patients to ensure safety standards. In some cases, this is perceived to be linked to the seniority of the workforce in A&E. A lack of specific services available to acute trusts in a timely fashion for certain specific patient groups, such as those with mental health, alcohol or drug abuse problems. More delayed discharges because primary, community or social care services are not place. 5. There are also many assumptions as to why these factors have played a greater part than in previous years: Perceived lack of availability of primary care and community services, especially out of hours. Reduction in bed numbers and staff as hospitals try to deliver cost improvement plans. The Francis report and its impact on clinical decision making thresholds. Lack of focus during transition for commissioners and uncertainty about changing roles in the new system. Pressure on social care budgets. Introduction of NHS 111. B. Response 6. NHS England s role is to oversee the whole commissioning system and to ensure that, working in partnership with CCGs, patients receive the right standards and quality of care. Resolving the current situation will require the commissioning system to work with all key partners in hospitals, primary care, and local authorities to create a single national framework to ensure that we see rapid and sustainable improvement. The work needs to be considered in 3 phases: i. An urgent recovery programme with significant attention given by local and national commissioners and providers to all factors which can help recover the standards, (including clear performance management). ii. A medium term approach to ensure delivery over the next winter period. This will include care system planning as well as a review of the levers and incentives in the system. iii. In the longer term, the implementation of the urgent care strategy in order to deliver safe and sustainable services. 7. Although all the above elements are inter-related and aspects of the work can be undertaken in parallel, this paper focuses specifically on the 2 21

22 immediate plan to improve A&E performance thus ensuring patients are seen swiftly and treated safely. 8. The plan builds on existing planning and contracting arrangements and discussions taking place to deliver Everyone Counts: Planning for Patients This includes the triangulation of plans and assessment of confidence in delivery, particularly where a reduced number of A&E attendances and emergency admissions is planned. We will need to be very clear about the level of tolerances in these assumptions, the potential impact on providers and the mitigating actions if assumptions prove to be incorrect. 9. In its planning guidance to CCGs published in December 2012, NHS England highlighted the importance it puts on commissioners and providers ensuring that waiting times for patients in A&E departments are kept to a minimum. It has set out that the NHS Constitution minimum of 95% of patients to be admitted, transferred or discharged within 4 hours of their arrival must be met. To follow through on this requirement, it was made part of the standard contract between commissioners and providers and will be part of CCG Assurance i.e. CCGs will be subject to intervention if their providers are not maintaining a sufficient level of performance. 10. In addition, Everyone Counts has set out that no patients should wait more than 12 hours on a trolley in an A&E department a requirement that did not exist under the previous system and CCGs are empowered to take action (i.e. fines) against providers that breach this condition. 11. This document has been prepared in conjunction with NHS Trust Development Authority (TDA) and Monitor, as they themselves work closely with providers to support the changes they need to make internally. However, NHS TDA, Monitor and NHS England all recognise the need for there to be a joint approach and one which is also agreed, at both national and local level, with our partners in local authorities, particularly social services. 12. A range of national actions have been agreed between us, including a joint oversight function which is detailed here. 13. Much of the document focuses on the actions expected of NHS England s Area Teams. However, local commissioners have the key role in supporting and ensuring the delivery of high quality emergency services, including that they are delivered in line with the NHS Constitution rights and that the 95% operational target is met. 3 22

23 14. This document focusses specifically on that commissioning role and the need for commissioners to ensure that: They bring the system together and ensure good relationships and prevent fragmentation. They provide strategic oversight for the system. They have a clear focus on outcomes. They tackle the obstacles. They ensure that all the appropriate services are in place and they hold each provider to account for playing their part. They promote integration and close working between all partners but especially health and social care. 15. They should ensure that providers, including primary care providers, are given a strong leadership role in determining the best way to deliver high standards. 16. We are asking all Area Directors to facilitate a local partnership approach. This will include providing assurance that an Urgent Care Board is set up for each local health community, ensuring coverage for every A&E department. In some parts of the country, Urgent Care Boards (or a similar arrangement) are already in place and these should be utilised as appropriate. 17. In addition, we will undertake a review of the financial levers and incentives that will contribute to improved performance. 18. NHS England would like to acknowledge the excellent work undertaken by the King s Fund in a review of urgent care in the South of England. This describes a range of actions which are needed to improve urgent care, and particularly A&E services. We have drawn on this work significantly in the production of our plan. The work also includes a comprehensive checklist of actions which is appended to our plan. We commend this to local health economies as an excellent source of good practice. C. National Oversight and Actions 19. Implementation of local and national actions will be overseen by a tripartite group from NHS England, NHS TDA and Monitor. This group will also work closely with Local Government Association and Association of Directors of Social Services and with CCGs through the NHS Commissioning Assembly. The group will include: Chief of Staff and a regional director, Monitor; 4 23

24 Director of NHS Operations and Delivery (Corporate), NHS England; and, Director of Delivery and Development, NHS TDA. 20. This group will: a. Set the timescales for the delivery of recovery and improvement plans which set out when performance will be achieved and maintained; b. Have oversight of the delivery of recovery and improvement plans, with each organisation operating in line with its regulatory framework to hold individual commissioners and providers to account for delivery where required. c. Sponsor the requirement for regular information which gives insight into the system; d. Working with the NHS Commissioning Assembly, and the full range of provider representatives, to determine the specifications for any national support programme. 21. The detailed Terms of Reference for the group and the partnership agreement which underpins these are currently being developed and will be shared during May. 22. The group will commission research in a number of A&E systems to understand why there has been this change in performance. In essence, we need to understand what has happened between October 2012 and April 2013 that was different to previous years and have the evidence base to underpin this. 23. The group would be given delegated authority to act on behalf of the three organisations with access to organisational plans, to monitor and manage the reversal of the current situation in line with the regulatory framework for each sector. In response to current performance we will implement the winter management model which includes regular system wide conversations, deep-dives into organisations with difficult problems, trajectories for improvement and monitoring of progress and in parallel we will ask all communities to undertake an urgent review of winter and bring forward arrangements for next winter (we note that many commissioners are doing this). 24. We have already agreed that NHS IMAS will run a series of workshops across the country to support local health systems identifying best practice and the methods to implement this. 5 24

25 25. This tripartite arrangement will be mirrored at regional level. The regional arms of the NHS TDA, Monitor and NHS England, in line with the regulatory framework for each sector, will set up tripartite panels which will review and monitor the delivery of the plans. This will include intervention where plans are not delivered as agreed. 26. NHS England, Monitor and NHS TDA will be part of a programme oversight group which will include CCGs and will ensure the work is coproduced and learns from best practice. D. Local Actions 27. NHS England Area Teams should facilitate the production of a recovery and improvement plan for each health community by working in partnership with CCGs, providers and local authorities. Recovery and improvement plans will need to look at each step of the patient s journey through the emergency system in three phases: firstly, prior to arrival at A&E; secondly, the patients journey through the hospital system; and thirdly, the discharge and out of hospital care. 28. Area Teams will ensure that Urgent Care Boards have been convened for all communities, which will feed into individual A&E departments. The Urgent Care Board will need to include all key stakeholders from health and social care as well as patient representatives and the appropriate clinical expertise. 29. We expect those Urgent Care Boards to ensure that: They review the full range of appropriate data. Best practice is adopted by all concerned. The effectiveness of primary care services is reviewed, including out of hours and admission avoidance schemes. The effectiveness of community services is reviewed, including any walk in centres, minor injury units and how they integrate with secondary care. The effectiveness of ambulance services is reviewed. The effectiveness of NHS 111 is reviewed. There are local plans in place to support the care of the key categories of patient who attend or are admitted frequently: Patients with multiple comorbidities especially those with poorly controlled chronic disease: o Frail elderly, especially those with mental health problems; o Sick children; and, 6 25

26 o High dependency individuals, especially vulnerable adults (homeless, drug and alcohol related problems, mental health problems). A full range of services is available to acute trusts for those patients in A&E who need services not provided by acute hospitals are in place. Working with local authorities, a review to ensure early discharge is feasible is undertaken. 30. Where areas have not already agreed plans and committed funds, we expect the Urgent Care Board to oversee the use of the 70% funding retained from excess care urgent tariff. In particular, the use of this money must be clearly identified to support any aspect which will support the urgent care system and acute providers ability to deliver the operational standard. 31. We would expect the use of this money to be signed-off jointly by CCG leaders, NHS England Area Directors, provider Chief Executives, and local authority Chief Executives by the end of June, so that schemes can be implemented ready for next winter. The use of the money must be clearly linked to specific delivery of outcomes and improvements in standards. 32. Urgent Care Boards will be expected to sign-off all aspects of the local recovery and improvement plan. 33. Recovery and improvement plans will need to include: An agreed local plan to bring the performance back on track by the end of Q1, including a sustainability plan, produced by the Area Team, including sign-off from Health and Social Care Partners. Preparation for working on a winter plan 2013/14 to sign-off by Area Team by November Evidence the best practice from Emergency Care Intensive Support Team (ECIST). 34. Recovery and improvement plans should consider the following aspects of care although this list of actions is not exhaustive and we must acknowledge there may be different issues at a local level: A. Prior to A&E: Strengthening primary and community care for frail and elderly patients. Use of community diversion schemes. 7 26

27 Strengthening GP out-of-hours services. Use of virtual wards in the community. Support to care homes to avoid emergency referrals. Peer review of GP emergency referrals. Reducing ambulance conveyance rates. Patient education on appropriate use of emergency services. Roll-out arrangements for NHS 111. B. Flow within the hospital: Prompt booking of patients to reduce ambulance turnaround delays. Full see-and-treat in place for minors. Prompt initial senior clinical assessment within A&E and rapid referral if admission is needed Prompt initiation of blood and radiological tests with rapid delivery of test result. Prompt access to specialist medical opinion. Full use of computer-aided patient tracking and system for progress-chasing. Regular seven-day analysis should be in place for rapid identification and release of bottlenecks. Bed base management Daily consultant ward rounds. Provision of specific services for patients groups such as those with mental health problems. C. Discharge and out of hospital care: Designation of expected date of discharge (EDD) on admission. Maximisation of morning and weekend discharges. Full use of discharge lounges. Minimisation of outliers. Delayed transfers of care reduced. Flexing of community service capacity to accept discharges. Review of continuing care processes. Assessment of use of reablement funding by local authorities. 35. In developing recovery and improvement plans, communities are encouraged to think about innovation and not simply commission traditional approaches. To facilitate this we would advocate the use of the NHS IQ improvement function, in particular ECIST, to ensure that best and good practice is adopted. 8 27

28 36. The recovery and improvement plans should draw on existing ECIST reports on local services and ensure these reports recommendations are implemented. 37. The recovery and improvement plans should also describe how the 70% funding retained from excess care urgent tariff will be used in the health community to reduce pressure on A&E (either within the hospital setting or in the community) or make improvements within A&E itself. It should demonstrate how all parties have been involved in the use of this funding and the responsibilities associated with the receipt of any of this funding, particularly in describing the expected outcomes and improvements in standards. 38. NHS England will ask its Area Teams to collate recovery and improvement plans and carry out initial quality assurance. These plans need to be completed and submitted to Regional Directors by 31 May 2013 to enable tripartite discussions with the NHS TDA and Monitor to commence. E. Conclusion 39. Working closely with other key stakeholders, and building on the views already shared from CCGs and providers, NHS England will put in place an approach that will support the emergency and urgent care system, reduce pressure and ensure that patients do not have to wait longer than the agreed standards as identified in the NHS constitution and thus meet the national operating target of 95%. 40. This document outlines the overall approach and identifies the actions which Area Directors should now put in place to ensure that the commissioning system responds appropriately to support providers of A&E and urgent care services. 9 May

29 Appendix: Emergency Care Checklist Urgent and Emergency Care: A review for NHS South of England (The King s Fund, March 2013) It is vital that health communities intelligently adapt what is known to work effectively and then ensure that this is actively managed and kept under review. The following approaches are based on current guidance from the Emergency Care Intensive Support Team and findings from our research. Note that the evidence to support the ideas that follow is variable and many depend on the local context. Urgent Care Boards Establish a local Urgent Care Network (UCN) which incorporates strategic and operational leads across the emergency care system including consultants, GPs and ideally patient representatives. Develop robust terms of reference for the local UCN using the good practice set out in the DoH Emergency Care Network guidance. 1 Map out the range of existing groups/boards to ensure there is clarity with regard to both process and communications between the UCN and the local Trust Boards. Align commissioner and provider priorities and incorporate within a local strategy. Ensure all urgent care work streams report back to the UCN to support improved communication. Ensure all work streams are supported by programme management and leadership to enable whole system implementation. Develop a dashboard to monitor the overall impact of the programme and manage system resilience. The following example of a suite of whole system metrics may be helpful: o A primary care access metric at general practice level. o Ambulance turnaround times (30 minute arrival to clear) and category A and B response time delivery. o The four hour standard (underpinned by disposal profiles, showing the % of patients leaving the department after three hours forty five minutes has elapsed (for admitted patients, and two hours for non admits) o Adult non elective bed occupancy rate using an agreed non expanded bed number consistently as the denominator. o Percentage of discharges from hospital before and after midday. 1 Emergency care networks checklist (2004) Department of Health (accessed 6th Jan 2012) This checklist shows how networks can improve patients' care by connecting all the members of a health community. It offers suggestions for membership and an example terms of reference, as well as early steps and specific actions for building effective local networks. It also contains links to support and resources

30 o Community service based performance metrics (e.g. rate of delivery of a 4 hour standard for admission avoidance and a 12 hour standard for early supported discharge). o Average time from referral to assessment for mental health patients with no physical illness. o Social care response and performance metrics. o Outcome and patient experience metrics (mortality, effectiveness of pain control, patient reported outcome measures etc). Communication and information There should be a clear vision aligned to an emergency care system strategy aimed at improving capacity, demand, patient experience and quality across system. There should be a narrative that focuses on the safety and quality benefits for patients, and the development of a culture that views the system flow as everyone s responsibility across the health and social care community. A broad campaign to implement and embed practices known to work (particularly in the hospital) should be considered, this should engage all members of staff in understanding their roles and actions required to improve emergency care performance, and patient flow. There are mobilising and organising techniques which are useful to win hearts and minds and gain commitment further information on large scale sustainable change is available from the NHS Institute. 2 Identify champions to optimise delivery of the emergency care strategy and engage other staff in making a high performing emergency care system everyone s business. Clinical Directors should view good patient flow and capacity and demand management as part of their responsibility for quality and safety. A real time directory of services with capacity information seems to be an important aspect of management. The idea of notification systems, GP dashboards and other methods to inform GPs and case managers that their patients are in hospital should be explored. Root cause analysis of emergency care system failures Root cause analysis of system failures (such as ambulance handover delays, closure of multiple wards from Norovirus etc.) should be owned and undertaken by individual organisations, but findings shared across the system. There should be a robust assessment of the root causes, with a genuine effort made to get to the real root causes, rather than trying to demonstrate system failure was unavoidable. The system must ensure findings result in action and improvement a process of senior review would demonstrate the importance that organisations place on root cause analysis and learning from it. 2 NHS Institute information on large scale change: (accessed June 2012) 11 30

31 Commissioning Unscheduled care commissioning intentions need to be clear, shared and communicated. The strategy and commissioning intentions need to be owned by local stakeholders and therefor developed with meaningful input from providers. Commissioning decisions should be made around the approaches that are known to be effective in managing emergency care, these are outlined below. Commissioners should also ensure that the financial flows and contracts for services support patients moving through the system, and do not create dis incentives and gaming. Encouraging CCGs to federate and have a single dialogue with providers would go some way to enabling positive relationships to be established. Commissioning around outcomes and allowing the provider to determine the detail of how services should be provided seems to be a key factor in successful approaches. The model of commissioning emergency care needs to be rethought, with providers given a stronger leadership and responsibility role in determining delivery. Commissioning emergency care needs to shift from a sometimes adversarial approach of micromanaging to one where CCGs take an oversight and scrutiny role, supported by a system dashboard that highlights the system capacity and demand. Internal professional standards Response standards should be agreed for the whole system, including community, ambulance and hospital services, and cover time to: o Assessment (including diagnostics, investigations and therapy services). Within this implement single assessment processes to reduce duplication. o Treatment. o Review. o Referral. Within this simplify referral processes, rather than using them as mechanisms to hold back work. o Discharge (refer to the section below on discharges). Use metrics to measure performance and consistency of delivering IPS. Staff training Ensure relevant staff are trained in practices known to be effective (RAT, See and Treat etc.) Primarily focus effort on training key staff and consider using a train the trainer approach to roll out new practices quickly. GP practices 12 31

32 Ensure there are appointments available for urgent cases and follow published guidance. 3,4 Consider the use of GP telephone triage and GP call back to manage demand, although studies around this approach are small scale the evidence is encouraging. Note that it also requires significant redesign of workflows it is not a simple intervention Stagger home visits to reduce batching. Using the ambulance service, nurses or a physician of the day may be one solution. Raise patient awareness of alternative services available (other than the emergency department, note that there is limited evidence of the effectiveness of patient education around emergency department avoidance. Undertake training and education around end of life. Ensure advanced planning is implemented consistently. Ensure all patients who need advanced care plans and end of life plans have them in place and that all health professionals they are in contact with are aware of these plans. Extending primary care hours is an approach that has yet to be proven and should be monitored. Implement productive general practice and other approaches to increase the availability of same day appointments. Consider methods for improving continuity of care for complex patients. Ensure high quality input into nursing and residential homes, this may require some reallocation of responsibilities. GP out of hours Out of hours service contracts should be outcome based to promote joint working and integration with other services. Ensure GP out of hour services have access to patient records and care plans. Promote a greater emphasis on using alternative systems and patients being able to access the appropriate service based on their need. Look to co locate GP out of hours within the hospital. Walk in centres and minor injury centres There are growing concerns around the effectiveness of walk in centres and these centres should be evaluated rigorously. Ensure opening times are aligned to other parts of the emergency care system to reduce duplication. 3 Urgent care: a practical guide to transforming same day care in general practice. Primary Care Foundation (2009) (accessed 26th November 2012) 4 Introduction and User Guide Urgent Care in General Practice Toolkit A practical Toolkit to help GP Practices and GP Consortia improve patient experience and surgery workload. ECIST 13 32

33 Where possible co located and integrate with emergency departments. 5 Consistently use the See and Treat model. 6 Ensure clinical governance and management is integrated with the emergency care system. Ensure access to diagnostics. Ensure consultant advice is accessible. Work with the ambulance service to promote the centre as an alternative when appropriate. Community services As noted above the number of evidence based models and actions for community services are less well understood but appear to include the following: Critically examine pilots, projects and approaches. Ensure that initiatives are thoroughly evaluated and only roll out the most cost effective and promising. Remove some of the complexity, overlaps and individual schemes to create services on a large enough scale to be able to make significant differences in terms of supporting patients with long term conditions Ensure community services and can anticipate demand and are able to flex capacity to meet needs. Ensure there are simple referral criteria and streamlined assessments and documentation that enable patients to be transferred quickly. Consider basing community services around key hospital providers to enable strong relationships and integrated teams to be established. Use case management and risk stratification when appropriate. 7 Provide integrated health and social care crisis support teams. 8 Provide IV support to patients in the community. Nursing and care homes There is evidence that nursing and care home residents receive low levels of clinical care and that making good these shortfalls significantly reduces the number of emergency 5 Chalder. M., et al (8 March 2003) Impact of NHS walk in centres on the workload of other local healthcare providers: time series analysis. BMJ: Primary Care. Vol &fulltext=%22walk%20in%20centres%22&searchid=1&firstindex=10&sortspec=date&resourcetype=hw CIT (accessed 26 th November 2012) 6 Keep things moving see and treat patients in order (2008) Quality Service and Improvement Tools. NHS Institute _tools/keep_things_moving_ _see_and_treat_patients_in_order.html (accessed 1st Nov 2012) 7 Purdy, S. et al. (2012) Interventions to reduce unplanned hospital admission: A series of systematic reviews. Final Report June University of Bristol, University of Cardiff, National Institute for Health Research 8 Thistlethwaite. P. (2011) Integrating health and social care in Torbay: improving care for Mrs Smith. London: King s Fund 14 33

34 attendances and admissions. 9 It is estimated that between 8% and 40% of patients seen in the emergency department that come from care homes could have been cared for outside of the department. 10 This patients are also at risk of rapidly decompensating once in the hospital, and where possible should be treated within nursing and care homes. Provide and end of life education, training and support to nursing and care homes. Implement advanced care plans. 11 Ensure regular case review and medicines management reviews. Increase the level of medical care and access to specialist advice (geriatricians and GPs) in nursing and care homes. 12,13,14 Provide IV support. Frail elderly Although these represent a relatively small number of overall admissions this patient group has a very high propensity to be admitted and once in hospital often decompensate, have a long length of stay and are problematical to discharge, therefore generating a large number of bed days. The successful discharge of frail older people following an emergency admission to hospital relies on effective joint working between NHS, social care partners and the independent sector. In organising discharge systems, a whole systems approach is important. This should aim to anticipate and promptly respond to potential bottlenecks or obstacles, smooth patient flow, and recognise the interdependency between partners. It is important to commission and embed practice and processes with a proven record of enhancing patient flow within acute hospitals a summary of these effective 9 Steves. C.J., Schiff. R., Martin. F.C. (2009) Geriatricians and care homes: Perspectives from geriatric medicine departments and primary care trusts, Clinical Medicine 9: Carter., Skinner., Robinson. (1998) Patients from care homes who attend the emergency department: could they be managed differently Emerg Med J doi: /emermed ) 11 Caplan. G.A., et al (2006) Advance care planning and hospital in the nursing home. Age and Ageing 2006; 35: (accessed 26 November 2012) 12 Steves. C.J., Schiff. R., Martin. F.C. (2009) Geriatricians and care homes: Perspectives from geriatric medicine departments and primary care trusts, Clinical Medicine 9: Crilly. J., Chaboyer. W., Wallis. M. (2011) A structure and process evaluation of an Australian hospital admission avoidance programme for aged care facility residents, Journal of Advanced Nursing 68:2, Evans. G. (2011) Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice based audit. Journal of Evaluation in Clinical Practice. 17:

35 approaches is available from the Intensive Support Team. 15 These approaches should also ensure there is an active pull from the community to ensure frail elderly patients who are medically fit to be discharged can return to the community. Addictions and mental health There is evidence from local studies that a small number of users of emergency services are frequent attenders that often result in admission. Many of these frequent attenders suffer from drug and alcohol addictions or mental illness, or have social problems such as homelessness or unemployment. Develop and implement an alcohol strategy. Alcohol abuse has been found to account for 12% of emergency department attendances and 6.2% of hospital admissions. 16 Establish rapid response services for people with mental illness. 17 This should include approached for both known and unknown users. Implement psychiatrist input out of hours; case management; assertive outreach services; and within hospital liaison services especially for mental illness and alcohol abuse to reduce attendances, admissions and costs. 18,19 Paediatrics Evaluate GP access, particularly between 3pm 8pm. Look at the GP skill mix and ensure paediatric primary care is available at a high standard. Review the appropriateness and availability f of paediatric cover in hospital. Ambulatory emergency care directory The Ambulatory Emergency Care Directory was published in 2007 by the NHS Institute, identifying 49 emergency conditions and clinical scenarios that have the potential to be managed on an ambulatory basis. 20 Actively managing patients with ambulatory care sensitive conditions (through vaccination; better self management; disease 15 Effective Approaches in Urgent and Emergency Care. Paper 3. Whole system priorities for the discharge of frail older people from hospital care. (2012) ECIST 16 Pirmohamed. M., et al (2000) The burden of alcohol misuse on an inner city general hospital. QJM (2000) 93 (5): doi: /qjmed/ (accessed 2 Nov 2012) 17 Glover. G., Arts. G., Babu. K.S. (2005) Crisis Resolution teams and inpatient mental health. Centre for Public Mental Health, University of Durham. 18 Althaus. F., Parox. S., Hugli. O., Ghali. W.A., Daeppen. J B. et al (2011) Effectiveness of interventions targeting frequent users of emergency departments: a systematic review, Annals of Emergency Medicine, 58:1, Tadros. G., Salama. R., Mustafa. N., Pannell. R., Balloo. S. (2011) The Rapid Assessment Interface and Discharge Liaison Team, City Hospital Birmingham: Evaluation Report December 2009 September Ambulatory Emergency Care Directory (2007) (accessed 5 th December 2012) 16 35

36 management or case management; or lifestyle interventions) prevents acute exacerbations and reduces the need for emergency hospital admission. Ambulatory care services should be provided as an unscheduled service with closer working between the emergency department consultants and acute physicians. Have a clear plan to roll out at least two emergency conditions to the service each year and mainstream them. Ensure senior clinical decision makers are available to decide on the need for admission. Ensure ambulatory emergency care is available for all patients who meet the criteria. Ensure access to timely investigations to support clinical decision making. Community clinics for diabetes, heart failure and respiratory patients can be very expensive and the approaches to these inconsistent. Linking these outreach clinics to ambulatory care models may be a good use of scarce resources. Ambulance services Analysis of ambulance demand is key to understanding where to focus attention in the emergency care system. Although there are some known approaches to improving performance (outlined below), the ambulance services still remains a largely untapped resource of skills and experience, both clinical and managerial, that should be explored further. Access to care plans and advanced care plans was flagged as an important area. Establish emergency care practitioners. 21,22,23 Ambulance handover should follow guidance available. 24 Review contracts to ensure that transport is available in a timely manner for patients who are medically fit and require ambulance transport back into the community. Analyse ambulance call outs to identify causes and areas of increase. Target frequent callers including GPs The emergency department Mason. S., O Keeffe. C., Coleman. P., Edlin. E., Nicholl. J.(2007) Effectiveness of emergency care practitioners working within existing emergency service models of care, EMJ. 24: O Hara. R., O Keeffe. C., Mason. S.. Coster. J.E., Hutchinson. A. (2012) Quality and Safety of care provided by emergency care practitioners, EMJ. 29: Ibid O Hara et al (2012) 24 NHS South West Ensuring timely handover of patient care ambulance to hospital (2008) (accessed 30th Nov 2012) 17 36

37 Implement Rapid Assessment and Treatment (RAT) for majors patients. 26 Early senior review is likely to increase the number of people able to be managed at home and to prevent adverse outcomes. 27 Implement See and Treat for patients with minor injuries and illnesses. 28 Reduce or eliminate triage. Emergency department crowding Adopt the College of Emergency Medicine guidance around full capacity protocols. 29 Use appropriately trained nurses to admit patients in liaison with specialities. Review layout and physical capacity of the emergency department. Review services provided in the emergency department to ensure that inappropriate services (such as review services and follow up services) are removed to free up clinical time. Trusts need have a clinical staffing strategy to ensure the provision of the required competencies on an hour by hour basis. An appropriate mix of consultants, middle grades, advanced nurse practitioners, majors nurse practitioners, physician assistants and extended role HCAs need to be developed. This needs to be underpinned by robust job planning. Patient streaming Create separate streams for minors and majors, with dedicated staff, processes and coordination. Create processes to ensure that the major s stream is not halted by a full resuscitation room. The ED should avoid acting as the default arrival point for referrals that do not require resuscitation or stabilisation (e.g. most GP or clinic referred patients) these patients should by pass the emergency department and go directly to acute medical units or specialist beds. 25 Effective Approaches in Urgent and Emergency Care. Paper One. Priorities within Acute Hospitals (2011) ECIST ( T_Paper_1_ _Priorities_within_Acute_Hospitals.pdf (accessed 5th December 2012) 26 Effective Approaches in Urgent and Emergency Care. Paper Two Rapid Assessment and Treatment Models in Emergency Departments. (June 2012) ECIST T_Paper_2_ _Rapid_Assessment_and_Treatment_in_EDs_June_2012.pdf (accessed 30th Nov 2012) 27 Caring to the End? A review of the care of patients who died in hospital within four days of admission A report of the National Confidential Enquiry into Patient Outcome and Death (2009) (accessed 7th Jan 2013) Emergency Admissions: A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007) (accessed 7th Jan 2013) 28 Keep things moving see and treat patients in order. Quality Service and Improvement Tools. (2008) NHS Institute _tools/keep_things_moving_ _see_and_treat_patients_in_order.html (accessed 1st Nov 2012) 29 The College of Emergency Medicine Crowding in Emergency Departments (August 2012) secure.collemergencymed.ac.uk/code/document.asp?id=6296 (accessed 1 st Nov 2012) 18 37

38 Ensure senior decision makers in high volume specialties are available to attend the emergency department within thirty minutes of referral. Ensure the emergency department has direct admission rights using agreed protocols. Provide short stay capacity for patients with an anticipated length of stay of up to two midnights (assessment and short stay capacity is usually co located in acute medical units). A review of what is achievable through short stays in unscheduled care has been published by the NHS institute. 30 Further streams should be to specialist beds (for complex speciality patients requiring greater than seventy two hour stays), beds for patients with complex discharge needs (e.g. the frail elderly) and catastrophic illness (e.g. critical care and stroke patients). Ambulatory emergency care should be provided where appropriate. Acute Assessment Unit (AMU) There is an issue with a lack of standard terminology across the country (they can also be known as Clinical Decision Units / Observation Units /Acute Medical Units / or Surgical Assessment Unit), which can lead to confusion as to what is being described and what the core function of these units is. The ownership, role and responsibility of all such units should be clearly defined and agreed by the clinical leadership of the trust. The Royal College of Physicians has set out a clear set of standards for medical assessment units; these have been supplemented recently with guidance on workforce and job planning. 31 When undertaking clinical duties on the AMU, the consultant should be free from any other specialty, ward or management commitments. Individual consultants duties on the AMU should be for two or more consecutive days; any variation must be specifically designed to optimise continuity of care on the AMU. Appropriate diagnostic and support services should be provided seven days per week, to ensure that the full benefits of consultant delivered care to patients are realised. During the period of consultant presence on AMU, all newly admitted patients should be seen within six to eight hours, with the provision for immediate review as required according to illness severity. A newly admitted patient must be seen by a consultant within 14 hours after arrival on AMU. 30 Focus on Short Stay: NHS Institute (2007) cts_id,192.html (accessed Jan 7 th 2013) 31 care toolkit 4.pdf (accessed 7th Jan 2013) 19 38

39 All patients in the AMU should be reviewed twice each day by the AMU consultant or appropriate specialty team. Consultant presence on the AMU should start no later than 8am. Duration of an individual consultant s presence on the AMU should usually be between eight and 12 hours. Extended evening working until 10pm should be considered, depending on local patterns of patient referral and arrival. The units should also ensure: It stays below 85 90% utilisation at all times so that it has capacity to care for the anticipated number of arrivals hour by hour. 32 Consultant led rolling ward rounds to avoid batching patients to be seen on set piece ward rounds. Clear systems for patients requiring specialist care, so they can be cared for in the most appropriate setting as quickly as possible. A targeted discharge standard of all patients to be discharged by 1pm, to be reviewed at an 8am board round (anything beyond that would be regarded as a breach and attract the same root cause analysis as an emergency department breach). Standardised clerking documentation. Home for Lunch schemes, whereby the hospital gives patients written commitment to get them home for lunch on their day of discharge, and therefore to plan to move the patient from their bed to the discharge lounge early in the day; family members and carers are also alerted. Regular patient experience monitoring supported by performance information as the patient experience of these busy, noisy units is often very poor and patients often stay there for inappropriately long periods. The Surgical Assessment Unit at one trust had a clear patient cohort and it takes referrals from the emergency department and direct from GPs. The Unit is well supported, with a co ordinator undertaking a nursing assessment and a junior doctor reviewing within 30 minutes. More senior support at middle grade or consultant level is easily accessible, with an operating list close by providing ready access if required. Access to diagnostics was good, with ring fenced ultrasounds and reserved CT slots, duplex scanning and a set weekend consultant radiologist schedule. There are twice daily board and safety rounds of each patient with a multi disciplinary team present around the white board (scripted morning meeting at 9am focussing on actions required to discharge home, then a briefer handover meeting at 12pm). The estimated discharge dates are consultant led and a discharge lounge available for fit for discharge patients. 32 Planning for predictable flows of patients into unscheduled care systems beyond the Emergency Department: Meeting Demand and Delivering Quality. (February 2010) ECIST 20 39

40 Escalation beds Adding the capability to flex capacity has the risk of changing admission thresholds and the story of winter wards that prove impossible to close is well known. Solutions that allow capacity flex, without creating supplier induced demand are required. The effective use of AMUs (that maintain approximately 15% free capacity) can mean specialities wards can operate at close to 100%. Specialty Wards Ensure that a consultant sees all patients, and their care plans are confirmed, within two to three hours of admission to the ward (or a maximum of twelve hours if admitted out of hours), and sooner if the patient s clinical need requires it. Twice daily one stop board ward rounds should be the standard. Develop one stop ward rounds, where tasks such as completing a To Take Out form and filling request forms are completed before the round moves onto the next patient (avoid batching work to the end of the round). Ward managers need to be supernumerary to coordinate and drive care. Schedule main ward rounds for the mornings, and see potential discharges first, so that beds are freed as early as possible. Step down facilities Look into establishing step down beds for patients awaiting complex care packages, and private funded nursing home patients deciding on placements. This would improve the flow of the hospital. Using community services or contract home care nursing providers for rapidly creating home care support also seems to be effective Readmissions Discharge planning, risk stratification of patients being discharged, support with medications and community and social care support are all well understood interventions in this area. There have been some successful approaches to hospital led discharge teams, who provide continuity of care to patients in the first few weeks after discharge and have prevent readmissions. Another approach is to have a dedicated number for possible readmissions and access to a clinic for patients to come to and be reviewed by a consultant. Discharge planning Every patient having a consultant led expected date of discharge (EDD) completed within 12 hours of admission (a number of trusts have found specifying a morning discharge helps improve bed availability earlier)

41 Care plans must include an EDD and criteria for discharge. Empower the multidisciplinary team to discharge when criteria are met (particularly at weekends), rather than waiting for senior medical confirmation. There should be daily, early morning board rounds by a senior clinical decision maker (normally a consultant) to ensure that the care plan is on track. Schedule short board rounds for the mornings, and see potential discharges first, so that beds are freed as early as possible and those patients who are deteriorating are picked up early by a senior doctor. Clinical criteria for discharge recorded in each patient s notes. Any non clinical change to the EDD should be captured separately and reviewed. Identify patients at risk of prolonged stay at an early stage using simple tools like the Blaylock assessment. 33 Manage planning for frail elderly people assertively to avoid in hospital decompensation with associated prolonged stays. 34 Ensure services required for discharge are accessible at weekends. Co locate social services staff with the discharge planning team in the hospital. Another option which has been effective is twice weekly conference calls with a strong chair and with decision makers present. Simplify the documentation and forms surrounding patient transfers. System capacity and demand management Develop system wide predictive modelling based on demand and capacity utilising the national bed management tools. 35,36,37 Often the bed bureau / bed management office within trusts is operated by staff retaining knowledge in their heads and being reactive, rather than operating easy to understand systems that are aimed at increasing capacity up stream. 33 Mistiaen. P., Duijnhouwer. E., Prins Hoekstra. A., Ros. W., Blaylock. A. (1999) Predictive validity of the BRASS index in screening patients with post discharge problems. Blaylock Risk Assessment Screening Score. J Adv Nurs 1999, 30(5): Effective Approaches in Urgent and Emergency Care. Paper 3. Whole system priorities for the discharge of frail older people from hospital care. (2012) ECIST 35 Faster access: Bed management demand and discharge predictors (2004) Department of Health (accessed 26 November 2012) 36 Planning for predictable flows of patients into unscheduled care systems beyond the Emergency Department: Meeting Demand and Delivering Quality. (February 2010) ECIST 37 Demand and Capacity Basic Concepts (2008) Institute for Innovation and Improvement _tools/demand_and_capacity_ _basic_concepts.html (accessed 5th December 2012) 22 41

42 Develop an agreed system wide escalation protocol that has input from all relevant stakeholders. Use a tool to predict the expected number of admissions if anticipated admissions exceed expected bed availability, escalate early. Where there has been a spike in admissions systems to anticipate the following spike in demand for community and social care is requried Undertake demand and capacity management within primary care. Within the acute trust each specialty and supporting department should plan to match capacity to demand. Staffing rotas should be designed to match demand profiles. In general, focus on early assessment by senior and experienced staff to plan care is likely to be the most important step to reduce the unnecessarily long acute hospital stays which some patients endure. Experience of hospitals which have worked hard to follow the principles of best practice is that length of stay does fall substantially. More importantly perhaps, patient satisfaction increases and complaints fall. Critical incidents become less frequent and the safety of the patients in hospital is improved Planning for predictable flows of patients into unscheduled care pathways beyond the Emergency Department: Meeting Demand and Delivering Quality. (February 2010) ECIST 23 42

43 Appendix 1 - Recovery and Improvement Plan (R&IPs) Requirements: Plans must be informed by an objective diagnostic of the bottlenecks and pressures within the urgent and emergency care pathway the local health economy identified during winter 12/13. The following is a collaborative update that has been produced between the CCG, Homerton University Hospital and the North East London Commissioning Support Unit. A. Each step of the patient s journey through the emergency system in three phases; (i) Prior to arrival at A&E, Access Initiatives City and Hackney CCG, through its Urgent Care and associated Programme Boards, has taken a whole systems approach to monitoring and redesigning the urgent and emergency healthcare offer to City and Hackney residents, This starts with access in primary care, and the CCG has sought clarity from NHS England with regard to the scope, remit and resource of new commissioning organisations to implement access improvement initiatives in primary care. Social Marketing Programme The CCG is exploring the possibility of a social marketing programme in 13/14 that mirrors the whole system approach of analysing residents motivation for accessing the healthcare they do at relevant times. Consultant Advice Services The CCG has a number of Consultant advice lines in operation with Homerton University Hospital (HUHT) Consultants that provide advice to GPs to try and enable patients to be managed in the community when possible. This includes an Emergency Department GP advice line manned by the consultant in charge of the department that day. The Line is used regularly by GPs to seek advice, gain access to a second opinion, access emergency diagnostics and avoid emergency admissions where possible. It will be audited in Q2 13/14 in parallel with a survey of GPs to inform further development. Non-Clinical Navigators Non-clinical navigators are in place at the front door of A&E to signpost people to their GPs / support with new GP registration, pharmacies, Out of Hours etc if other health provision is more appropriate than emergency / urgent care. Patients may also be diverted to the Primary Urgent Care Centre (PUCC) for which there are agreed pathways and threshold criteria. PUCC pathways will also be reviewed by the Urgent Care Board in July HUHT members of the Urgent Care Board have noted the positive impact of the nonclinical navigators on patient flow throughout the department and will be contributing to a structured evaluation in 2013/14. Out of Hours The CCG also commission an Out of Hours (OOH) service which is currently provided by Harmoni as well as an overnight GP service in A&E which is provided by the Homerton. The CCG are in the process of tendering for a new OOH service. The aim is to procure a high quality and 43

44 efficient OOH service, which has local clinical knowledge and works with other parts of the urgent care system to ensure patients receive the most appropriate and safest care. The OOH service aims to reduce the number of patients attending A&E through telephone consultation, home visits and face-to-face consultations where clinically required. The overnight GP is also helping to manage primary care demand within the A&E department. London Ambulance Service City & Hackney CCG are part of the pan-london, London Ambulance Service (LAS) contract. The ethos of the commissioning arrangements with LAS is the reduction in conveyances to A&E. This is managed in particular through the following KPI in the contract: Ambulance calls closed with telephone advice or managed without transport to A&E (where clinically appropriate) a) Calls closed with telephone advice b) Incidents managed without the need for transport to A&E The CCG s Urgent Care Programme Board intends to work with LAS to help implement pathways to deliver these KPIs. Intermediate Care and integrated Care The CCG, in partnership with the Homerton Hospital, is currently undertaking a large scale review of intermediate care services and integrated care in City and Hackney. The aim is to improve current services and commission new services to allow patients to be managed closer to home. Audit of Emergency Admissions The CCG also is planning to under take an audit of emergency admissions in City and Hackney to help inform the best use of resources to reduce the current trend of rising emergency admissions. (ii) The patient s journey through the hospital system Observational Medical Unit The Homerton (in partnership with the CCG) developed an Observational Medical Unit (OMU) that formally commenced on January 1 st This development signified a move to a more evidence based model of care which should mean a reduction in inappropriate observation admissions, a reduction in referrals to inpatient specialty teams for admissions and an increase in the number of patients discharged directly from ED. To underpin this there will be a structured twice daily Consultant ward round. The key posts in the department include: Band 7 Nurse Band 5 Nurses Locum Consultant Junior Doctors 44

45 This will provide sufficient clinical leadership to maximize the impact of the new service and sufficient practical cover to manage a greater volume of patients. The staffing allows full provision on a 24/7 basis. Building work has taken place within the Department to expand the physical capacity of the OMU. The formal pathways which have been now developed and signed are: Low risk chest pain High risk NSTE - Suspected ACS pathway Pyelonephritis Diagnostic and Treatment Suspected Ureteric Colic FRDT Assessment Nausea and Vomiting in pregnancy Malaria rule out DVT The formal pathways completed but awaiting sign off are: ACERS COPD Asthma Nursing care awaiting discharge (patient not suitable for d/c lounge) Cellulitis Toxicological Ingestion (including intoxication/overdose) Allergy- Anaphylaxis Head injury Post sedation The formal pathways which are planned or in development include: Subarachnoid haemorrhage Tonsillitis Epistaxis Direct Admissions from Emergency Department Direct admission from ED to wards are possible if patients condition warrants admission and is appropriate through use of spidering (system where ED consultant identifies patients who can be admitted without being assessed in ED by speciality). A sticker system is in place to ensure these patients are highlighted and moved through the system. There is also access to fracture clinic for those patients who have simple fracture and are treated by ED and then given follow up by orthopaedics. (iii) Discharge and out of hospital care using the framework set out in Delivery of the A&E 4 hour operational standard (gateway 00062) Patients waiting to go home from ED, if waiting for transport, are moved to the discharge lounge. As highlighted above there are ambulatory care models in place via OMU. 45

46 The CCG has embarked on a significant programme of integration of reablement services in 2013/14 via its Long Term Conditions Programme Board, working in partnership with HUHT and the London Borough of Hackney, with the dual goals of preventing and reducing hospital admissions; and preventing the need for long term care. Discussions with the LAS via the Urgent Care Programme Board have already identified opportunities for communication / assessment / direct referral pathways to be redesigned to avoid conveyance / referral to A&E through closer working with alternative services and professionals. B. Indicate how the A&E 4hr operational standard will be met by the end of quarter 1 and sustained for each of the following quarters, articulating how previously identified bottlenecks and pressures are being addressed. The May meeting of the Urgent Care Programme Board identified that in comparison to the (same period) in 12/13, not only had attendances increased by 10%, but that the acuity of patients had increased (anecdotally attributed to impact of recession causing people to continue working and seeking medical help at a later stage), and the peak time for attendance had changed from 6 to 11pm. HUHT have in light of this reviewed their rotas and will do so again for the August medic changeover to ensure staffing shift patterns meet demand. ACU review within hospital to ensure admission pathway meets patients and hospital needs. The Homerton have been asked to undertaken work on this shift in activity patterns to inform demand and capacity planning to support work on sustaining delivery of the A&E standard. The CSU works closely with the Homerton to monitor performance and support delivery of the A&E standard; with plans for the bank holiday periods discussed with the trust. Performance against the 4 hour turnaround standard is monitored daily; with detailed weekly exception reports requested and discussed with the Trust via monthly performance and contract meetings where there is underperformance against the A&E standard. The exception reports and shared with City and Hackney CCG, and NHS England. The Homerton is currently on track to meet the A&E standard for quarter /14, although will remain on escalation level 1 (second lowest level) until there evidence of sustained delivery of this standard. The CSU undertakes surge management and winter planning service on behalf of City and Hackney CCG (and the other 11 CCGs). Trust performance is monitored daily and system wide actions, where requested, undertaken to support clinical safety of patients. Clinical discussions between the CCG, Emergency Department Staff, PUCC staff and LAS, take place at the Urgent Care Programme Board which meets bi-monthly. This includes discussions about breaches of the 4hr operational standard, emergency admissions, high quality patient care and patient flow through the urgent care system. The CSU has recently undertaken a review of winter 2012/13 with the 8 local acute providers across north central and north east London. This information has been shared with the local CCG leads and NHS England; and is commencing work on behalf of City and Hackney CCG and in collaboration with local acute and community providers over the next couple of months to help prepare for winter 2014/15. 46

47 C. Indicate, if health economy QIPP plans anticipate reductions in non-elective admissions and A&E attendances, progress on these reductions. Similarly if CIP plans anticipate reductions in bed capacity the RIP must explain how demand and activity flows through these with reduced length of stay. QIPP plans in 13/14 focus on the evaluation of the redesigned emergency and urgent care offer in City and Hackney, to inform targets for 14/15. Non clinical navigators working closely with ED, PUCC and primary care to ensure patients are aware of the range of health care within Hackney which is most appropriate their health needs. OMU model and pathways in place ensures patients do not have an increased length of stay. D. Articulate how demand and capacity planning for winter 13/14 is being addressed in order to meet the A&E 4 hour target in quarter 4 and ensure prompt recovery post- Christmas 2013 E. Standardised procedures to manage risk and issues, surges in demand, winter and mutual support between health economies; 1. Standard operating procedures for the OMU and the department are in place to ensure consistent care via evidence based pathways. 2. Work force planning 3. CSU performance management F. How ECIST recommendations have informed the plan and where the ECIST have worked with the local health economy in the last 2 years, what progress has been made in implementing their recommendations. The CSU is working in partnership with the Homerton on behalf of City and Hackney CCG to support delivery of the A&E standard. This work has included sharing emergency care best practice with the Trust. The CSU will be working closely with the Homerton and partner organisations to ensure that the A&E recovery and improvement plan, as well as the winter planning demand and capacity plans reflect latest best practice. G. R&IPs should show leadership of the urgent care system at CCG, Trust Board, Chief Executive and Medical Director level, as well as throughout each organisation and how leadership capacity in urgent and emergency care is being grown throughout organisations, including improvement teams and analytical capability. Urgent Care Programme Board The CCG has an Urgent Care Clinical Lead and Urgent Care Programme Board director. An Urgent Care Programme Board has been operational since July The Urgent Care Board by ED consultants, senior nurse and PUCC lead. Frequent Attenders Group Frequent Attenders group looks at the care for patients who attend more than 10 times in a year. If there are particular social or psychological factors a psychotherapist contacts the patient and primary care to address any social, psychological or family concerns. Some patients have been able to reduce their attendances dramatically. The CCG Children s Board will be establishing a parallel review process for paediatrics frequent attenders. 47

48 Breech Meetings Breach meetings (happen daily) indicate the reason for any breaches of the ED target. This enables analysis of the reasons for the breaches and to put processes in place to manage them in the future. Reasons for the breaches are circulated Trust wide. Need to make clear the links between the Trust processes and communication / reporting with the CSU and CCG. CSU provide daily briefings for the CCG. H. The terms of reference and the role played by the Urgent Care Board or equivalent to monitor delivery of this plan and the process at Board level to monitor attainment of the 4 hour target. The Urgent Care Programme Board has been established since July 2012 with regular and consistent attendance from clinical commissioners (with a Clinical Lead Chair), clinical and managerial provider representative, LAS colleagues, GP provider and 111 staff. There are clear governance arrangements between the Board, the HUHT, the CCG Board and the two local Health and Well Being Boards (Hackney, and the City of London Corporation). I. A dashboard with metrics aligned across the health system to monitor improvement impact. A&E performance has been central to the remit of the Urgent Care Programme Board and is integrated in the standard monthly reporting completed on behalf of the CCG by NELCSU. The Urgent Care Programme Board is reviewing the requirement for an aligned urgent care dashboard and will develop this further following the collation of the recovery plan. The Urgent Care Board meets every two months; interim commissioner meetings have been agreed to ensure resilience, and the Terms of Reference will be reviewed as part of the recovery plan process. J. Indicate how best practice guidelines are being incorporated into plans through prioritised evidence based projects based upon root cause analysis. OMU pathways in place within the department are evidence based. Primary Care urgent care pathways have been developed which are aligned with pathways within the ED and OMU. The Urgent Care Board is planning to work with LAS to develop pathways which can be used by both paramedics and community staff. K. Plans must be signed off by Health and Social Care Partners, Trust CEOs, CCGs and the Urgent Care Board. 48

49 Financial Plan/Financial Risk Update 2013/14 NHS CITY & HACKNEY CCG BOARD MEETING 31 May NHS City & Hackney CCG

50 Overview A final version of the CCG s Financial Plan for 2013/14 was submitted to NHS England (NHSE) on 20 th May in accordance with the national deadline. This paper highlights the key changes from April There remain a number of risks to the Plan, in particular, there is additional risk and uncertainty with the Specialist Services deductions and the impact on the CCG s allocation and contracts. The CCG has refreshed the financial risk model NHS City & Hackney CCG

51 Summary * The table shows the CCG allocation with growth at 2.3% and an assumed return of a proportion of the PCT s 2012/13 surplus. The Plan meets the mandatory requirement of 1% surplus. Since the April draft plan, the Specialist Commissioning adjustment is reflected as an allocation reduction, the anticipated GPIT allocation has been added and the 70% marginal rate tariff has been presented as required by NHSE. There has been a minor reduction to the Expenditure Plan to reflect actual contracts agreements rather than estimates. The CCG receives a separate allocation for running costs calculated at 25 per head of constrained population. Funding can be moved to Programme activities (the table above), but not vice versa. The Plan is unchanged from April. Running Costs 2013/ /14 Running Cost Allocation 6, , /14 Running Cost Expenditure 6, ,543 Under / (Overspend) Constrained Population size 261,712 spend/head( ) NHS City & Hackney CCG

52 Allocations and allocation risks Recurrent Non - recurrent Anticipated allocations Community Pharmacy* 1,447 * 1,447 Mental Health in Primary Care WIC closure transfer from NHSE NHS Direct funding transfer 1,500 1,500 LSCG adjustment to actual** Carry forward of PCT Surplus 1,000 1,000 GP IT shortfall m Specialist Care Adj 9,742 9,742 Total Anticipated allocations 14,032 1,000 15,032 *Responsibility for this is now likely to sit with NHSE which will remove the issue ** Likely to be +/- 1.2m Total Allocation Issues The CCG was only permitted to reflect in its Plan allocations notified or anticipated allocations agreed by NHSE. As reported at the April Board, the CCG continues to chase funding for a number of issues where funding should have transferred to the CCG. An initial response from NHSE was unsatisfactory in resolving the issues and the CCG will continue to press for a funding transfer where funding has incorrectly ended up in NHSE or a different interpretation of guidance has been applied. The CCG is also working with all other London CCGs to ensure the late notification of the allocation deduction of 9.7m is adjusted for the true cost of specialist services that will no longer be part of CCG contracts with providers. The CCG estimates that the 9.7m should be returned and the true adjustment is in the range of +/- 1.2m. Specialist Commissioning do not appear to have the resources to resolve this issue to a satisfactory timescale NHS City & Hackney CCG

53 CCG Risks & Mitigation Assessed Risk Description Risk 000s Risk of Acute Over Performance 3% overperformance on emergency activity 2,634 Acute NCAs 3% overperformance on emergency activity 42 Continuing Care 3% increase in cost 150 Prescribing 3% increase in cost 834 Other Commissioning 3% increase in cost on 50% of activity 189 Allocation Risk Risk includes 9.7m Specialist and non-neutral adjs 12,000 NHS Direct & 111 Non-return of NHS direct costs and Commuter 2,000 QIPP slippage Assume 50% delivered and 50% slippage on balance 1,400 Contract Planning Risk Contract risks including misattribution 3,800 Procurement slippages Additional cost of delays in procurement exercises 300 TOTAL POTENTIAL RISK 23,348 Readmissions Not Committed - 2,269 Emergency Tariff Not Committed - 1,115 2% Non Recurrent Reserve Uncommitted Mandatory - 2,811 1% Contingency 0.5% Mandatory - 3,476 Other miscellaneous reserves Reserves for specific issues eg IFRs, 111 etc - 1,832 PCT Carry Forward less commitments - 6,145 Investment delay/deferral - 2,210 1% Surplus / 2% from 2014/15 Mandatory - 3,556 Total Risk Mitigation - 23,414 GAP/(Surplus) - 65 Notes If mandatory reserves are utilised to cover recurrent risk in 2013/14, these will need to be restored in 2014/15 and will add to the QIPP requirement in 2014/15. The CCG anticipates readmissions and emergency tariff funds will be invested to address some of the causal acute performance issues. The table shows the potential financial risks and potential mitigation. Modelling of financial risk was undertaken using the methodology shared previously with the Board. The major risk remains the allocations issues covered on the previous page. Whereas the CCG previously had the capacity to withheld significant in year risk, the removal of 9.7m for Specialist Commissioning has significantly diminished the CCG s ability to cover risk and fund potential investments in local services in 2013/14. Given the uncertainty of funding transfers, establishing sustainable provider contracts and the risk of misattribution of activity in new contracts, this will be a key area to remain under review throughout 2013/ NHS City & Hackney CCG

54 Conclusions The Board is asked to note the detail of the final submission of the 2013/14 financial plan to NHSE, note the changes, note that there remain outstanding issues in finalising allocations and contracts and note the key financial risks and mitigation. This Plan will be the basis for commissioning budgets and running costs NHS City & Hackney CCG

55 CS010 Request for Waiver of Standing Orders CCG: City & Hackney SECTION 1: NOTES 1.1 This form is to be completed in all circumstances where the competitive quotation/tendering procedures required under the Trust s Standing Orders are to be waived. 1.2 All sections of the form must be completed in full by the Consortium Procurement Manager and/or requisitioning officer before submitting for approval to an authorising officer. 1.3 The authorised waiver form should be forwarded to the Consortium Procurement Department to enable the order to be raised. SECTION 2: DETAILS OF REQUEST Department NEL Commissioning Support Service, Newham Contracting Requisition Number Requisition Date 03/05/2013 Requisitioning Officer Anetta Toudji Supplier Mildmay Mission Hospital Description of goods Or services requested Purchase Value Mildmay Mission Hospital provides integrated specialist inpatient and day care services for people with HIV who have cognitive impairment, HIV related brain injuries or complex physical rehabilitation needs. Net Value VAT Total Value 111, SECTION 3: INFORMATION TO SUPPORT WAIVER REQUEST It is recommended that Mildmay Mission Hospital is awarded a single tender for 1 year until March Principally, this is requested based on the following reasons: Mildmay is the only specialist provider in London to people with HIV. The Mildmay contract ended on 31 st March 2013 and requires contract stabilisation in order to meet the commissioners expectations. The City & Hackney patients who have HIV need continuation of care. SECTION 4: SUBMISSION OF WAIVER REQUEST Request submitted by: Anetta Toudji Signature: Date: 03/05/2013 SECTION 5: APPROVAL OF WAIVER REQUEST Request approved by: Designation: Director of Finance 55 Signature: Date:

56 CS010 Request for Waiver of Standing Orders PCT: City & Hackney SECTION 1: NOTES 1.1 This form is to be completed in all circumstances where the competitive quotation/tendering procedures required under the Trust s Standing Orders are to be waived. 1.2 All sections of the form must be completed in full by the Consortium Procurement Manager and/or requisitioning officer before submitting for approval to an authorising officer. 1.3 The authorised waiver form should be forwarded to the Consortium Procurement Department to enable the order to be raised. SECTION 2: DETAILS OF REQUEST Department NELC Commissioning Support Service, Newham Contracting Requisition Number Requisition Date 15/02/2013 Requisitioning Officer Anetta Toudji Supplier Richard House Description of goods Or services requested Community specialist children s palliative care provision (short breaks and End of Life Care) Purchase Value Net Value VAT Total Value 285,000 SECTION 3: INFORMATION TO SUPPORT WAIVER REQUEST It is recommended that Richard House is awarded a single tender for up to 3 years until March Principally, this is requested for the following reasons: Richard House is the only specialist provider of community palliative care to complex needs children and young people in East London & City. This presents a limited choice of community specialist providers to patients in the local area. The Richard House contract ends on 31 st March 2013 and requires contract stabilisation in order to meet the commissioners expectations. SECTION 4: SUBMISSION OF WAIVER REQUEST Request submitted by: Anetta Toudji Signature: Date: 15/02/2013 SECTION 5: APPROVAL OF WAIVER REQUEST Request approved by: Designation: Director of Finance 56 Signature: Date:

57 Out of Hours - Harmoni UPDATE TO CCG BOARD For information and for decision 31 May

58 CONTEXT Attached is a suite of papers for Board decision; CQC Report Contract management arrangements for the OOH contract inherited by the CCG Clinical Audit Calendar The National Quality Requirements in the Delivery of Out-of-Hours Services is available at Quality%20Requirements% pdf. 58

59 DECISIONS The Board is asked to; Agree the proposed contract monitoring arrangements and the establishment and membership of the Out of Hours Quality and Service Performance Group Note that contract monitoring info will be available for the Board as part of the suite of reports produced by CSU Agree the process and timescale for the procurement of a new Out of Hours provider Agree to the establishment of the Out of Hours Steering Group and the Out of Hours Evaluation Panel to manage this process Note that the Audit Committee will be asked to provide the Board with assurance on the evaluation process and that the CCG will obtain legal advice on this as well 59

60 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Harmoni - North Central London Bloomsbury Building, St Pancras Hospital, 4 St Pancras Way, London, NW1 0PE Date of Inspections: 12 March March 2013 Tel: Date of Publication: May 2013 We inspected the following standards as part of a routine inspection. This is what we found: Respecting and involving people who use services Care and welfare of people who use services Safeguarding people who use services from abuse Management of medicines Requirements relating to workers Staffing Supporting workers Assessing and monitoring the quality of service provision Complaints Met this standard Met this standard Met this standard Met this standard Met this standard Action needed Met this standard Met this standard Met this standard Inspection Report Harmoni - North Central London May

61 Details about this location Registered Provider Overview of the service Type of services Regulated activities Harmoni HS Ltd Harmoni North Central London is the provider of out of hours GP services for Camden, Islington, Haringey, City and Hackney. The services include the provision of telephone medical advice to callers, face to face consultations with a doctor at four bases, one in each borough, and in some cases callers are visited by a doctor at home. The service covers approximately 250 GP practices and provides advice and treatment to a population of over 1.2 million people. Doctors consultation service Doctors treatment service Mobile doctors service Remote clinical advice service Transport services, triage and medical advice provided remotely Treatment of disease, disorder or injury Inspection Report Harmoni - North Central London May

62 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 What we have told the provider to do 4 More information about the provider 5 Our judgements for each standard inspected: Respecting and involving people who use services 6 Care and welfare of people who use services 8 Safeguarding people who use services from abuse 10 Management of medicines 11 Requirements relating to workers 12 Staffing 13 Supporting workers 15 Assessing and monitoring the quality of service provision 17 Complaints 18 Information primarily for the provider: Action we have told the provider to take 19 About CQC Inspections 20 How we define our judgements 21 Glossary of terms we use in this report 23 Contact us 25 Inspection Report Harmoni - North Central London May

63 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an announced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 11 March 2013 and 12 March 2013, talked with people who use the service and talked with staff. We reviewed information we asked the provider to send to us, talked with local groups of people in the community or voluntary sector and were accompanied by a specialist advisor. What people told us and what we found We inspected the services at the provider's office base on the 11th and 12th March We visited the provider's clinics where patients can see a GP at St Pancras and Whittington Hospitals and spoke with the manager, doctors and other staff working in the service. We spoke with people using the service and looked at various records, including employment and training records, quality monitoring documentation and complaints records. Overall, the provider had systems in place to enable patients to be assessed and where needed to see a doctor either at a clinic or at home. The feedback from people who used the service was very positive about the support they received when speaking to staff or having a consultation with a doctor. The doctors and other staff working in the service had completed the appropriate recruitment processes and received training to enable them to perform their roles. The provider has not managed to recruit and retain enough doctors to work in the service. This is a particular problem when doctors are unable to work at short notice or during peak periods such as bank holidays. This has resulted in patients taking longer to have their calls clinically assessed and longer to see a doctor when necessary. On occasions, staff have not been available at clinics to see patients. This has resulted in falls in patient satisfaction and potentially places patients at risk of not having the care and treatment they need. You can see our judgements on the front page of this report. What we have told the provider to do We have asked the provider to send us a report by 18 May 2013, setting out the action they will take to meet the standards. We will check to make sure that this action is taken. Inspection Report Harmoni - North Central London May

64 Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take. More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Harmoni - North Central London May

65 Our judgements for each standard inspected Respecting and involving people who use services Met this standard People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run Our judgement The provider was meeting this standard. People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Reasons for our judgement Harmoni North Central London is managed from its administrative base at St Pancras Hospital. This is also where calls are clinically assessed and where the doctors doing home visits come to start their shifts. People using the service may attend face-to-face consultations with doctors at St Pancras, covering Camden, or three other clinics which are the Whittington Hospital for people in Islington, The Laurels Medical Practice, covering Haringey; and the Homerton Hospital in Hackney. The out-of-hours service operates during weekday evenings and at weekends, when GP practices have closed. The inspection of Harmoni North Central London took place at a time of change for the handling of patient calls to the service. For patients living in Camden, Islington and Haringey the initial calls were from February 2013 being handled by the 111 Call Service. For patients living in City and Hackney, their calls were still coming directly to a call centre operated by Harmoni. This was proving complex for the provider as they had to adjust to the new systems and also have a manual back up system for occasions when the connection between the 111 Service and Harmoni did not operate smoothly. For patients accessing the Harmoni service a call handler logs their details and health conditions and, using a patient management computer programme called Adastra, assesses their needs and case priority. In cases where immediate life threatening conditions are identified the calls are put through to the emergency ambulance service. For patients who can still directly phone Harmoni, we were shown how calls were taken, logged and prioritised using the Adastra computer system. They were conducted in a concerned and respectful manner. The provider had access to interpreters whose service could be used for calls with people for whom English was an additional language. The interpreter service was available within 15 minutes. Patients are called back where needed by one of the provider's clinical staff to carry out a clinical assessment of their case. We were able to observe calls being taken at the St Pancras site and could see that these calls were being handled by qualified clinicians. We could hear people being advised by the staff and being given information and support Inspection Report Harmoni - North Central London May

66 regarding their care and treatment. Where people were advised to attend a clinic, the clinic location and appointment time was arranged and agreed with them dependent on where they lived and the priority of the call. We spoke with people attending two of the clinics for consultations and we contacted by telephone a number of other people who had used the service over the preceding few days. They said that the provider's call handling staff were polite, respectful and clear about how the service worked and what people should expect. A person told us, "Yes, they explained everything." People were told when they would be called back by a doctor. One person said, "The call staff were very helpful. They called back in just over an hour, even though we were told it would take longer." Another person told us, "When I initially called, the staff were very polite and helpful." In some cases, if callers had mobility problems or travelling was likely to worsen their condition, a home visit by a doctor was arranged. Home visits were conducted by doctors who were driven to appointments by drivers employed by the provider. The provider's cars were used and we were able to see that they were suitably equipped for the purpose. We were also able to observe the doctors arriving at St Pancras to meet the drivers and start their night shift of home visits. We could see that the doctors arriving for work were well presented, had good communication skills and were clear about how to undertake their work and the systems in place from Harmoni. We visited two of the clinics to see patients arriving for appointments. We could see the reception staff were polite and helpful. Where patients were late for their appointment they would phone them to ensure they were all right and still able to attend. Appointments were booked at 12 minute intervals and patients did not need to wait to see the doctor. The doctor would discreetly call patients when they were ready to see them. Consultations took place in individual rooms which maintained people's privacy and dignity. Patients told us the Harmoni service was a "good" and "convenient" service. Inspection Report Harmoni - North Central London May

67 Care and welfare of people who use services Met this standard People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. People experienced care that met their needs and protected their rights. On the occasions where the care provided by individual clinicians could have been improved this had been addressed appropriately. Reasons for our judgement People we spoke with were generally very happy with the service. At one of the clinics a person said, "This is not the first time I have used the service. It's good to get access to an out-of-hours doctor service without using the A & E." Another said, "The GP I saw was very good and nice, and I didn't have to wait." We asked doctors if the initial triaging by call handlers worked well. They said generally it did, although there were occasions when cases they considered to be routine had been prioritised as urgent. But they said this was preferable to urgent cases being downgraded to routine. We observed a doctor carrying out initial clinical assessments with people by telephone and monitoring ongoing cases. We saw that the system monitored calls coming into the service and alerted call handlers and clinical staff doing the assessments about timings to ensure that people were contacted within the appropriate timescale. A person using the service and attending one of the clinics told us, "I was running late for my appointment and they called to check that I was all right." We saw that call handlers and doctors had in some cases access to "special patient notes." These are records provided by GPs or specialist health care professionals which provide information about people's medical history. The notes ensure that information is shared with other health professionals and can be used to process people's calls more effectively. We were shown information packs used by call handlers with a list of lateopening pharmacies and information could be passed on to people with identified needs, illness or injury who called the service. This ensured people could be assisted to receive faster treatment, without the need to wait for a call back or attend one of the bases. People we spoke with confirmed that they were advised by the call handlers to call the emergency 999 number, or contact the provider again, if their condition worsened before a doctor had called back to carry out the clinical assessment. We saw a doctor carrying out clinical assessments by phone. Advice was given clearly to ensure the patient was able to understand the information they were given. Detailed notes of the calls were recorded on the computer system and were available both to doctors at the bases and those carrying out home visits through laptop computers which were placed Inspection Report Harmoni - North Central London May

68 in the Doctors' cars. This served to ensure that all clinicians involved in the people's treatment had accurate knowledge of the clinical assessments. A person using the service told us, "I have always found the doctor has been very thorough." We looked at the record of complaints for the five months from September 2012 to the end of January During this time Harmoni North Central London received over 42,000 calls. During that period there were 13 complaints received. Of these, eleven highlighted the need for individual staff members to reflect on and improve an aspect of their performance. Two of the staff members were call handlers, one was a receptionist, two were nurses undertaking triaging work and six were doctors caring for patients. In all the cases there was a record of a thorough investigation and the findings being fed back to the complainant and members of staff. Some of the complaints had resulted in specific areas for learning being identified that were shared with staff through a news letter or seminars. The complaints were all different and did not reflect any areas of systemic failings. Last November 2012, a baby sadly died whilst attending the clinic at the Whittington Hospital. We have read the inquest narrative from the coroner who said that, "clearly concerns have been raised regarding the systems Harmoni have in place and these systems have been examined and in my view they are robust." In this case an individual doctor working for Harmoni did not ask sufficient questions as part of a telephone clinical assessment meaning the baby was not seen urgently. Our inspection also found that the systems used by Harmoni to assess and see patients were effective. Inspection Report Harmoni - North Central London May

69 Safeguarding people who use services from abuse Met this standard People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement We saw the providers safeguarding policy that reflected local safeguarding procedures. The manager explained that all staff working for Harmoni are expected to be familiar with this procedure. We looked at the paper records relating to five doctors working for the provider and were shown evidence on the provider's human resources computer database that mandatory training in safeguarding had been provided. The doctors and other staff members we spoke with confirmed they had been trained in safeguarding and had read the provider's policy. The provider takes practical steps, where possible, to safeguard patients. For example, if a patient was seen at a base and wished to have a chaperone with them during face-to-face consultations then the reception staff would make themselves available. There had been no safeguarding alerts raised relating to the provider's service. Inspection Report Harmoni - North Central London May

70 Management of medicines Met this standard People should be given the medicines they need when they need them, and in a safe way Our judgement The provider was meeting this standard. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. Reasons for our judgement We saw the provider's Medicines Management Policy, which doctors were required to read during their induction and follow in their duties. Doctors we spoke with described the medication management process, which reflected the policy. All prescriptions were printed and recorded using the Adastra patient management computer system. Doctors carrying out home visits were instructed to record their hand written prescriptions on the Adastra system. In most cases the patients were able to collect the medication from a local pharmacy rather than the doctor needing to dispense the medication. The doctors did however have access to a small supply of medication which was available in a locked medication cupboard at the clinic or in a locked case in the vehicle. These did not include controlled drugs, for which there were arrangements in place with local pharmacies for these to be accessed as needed. Where the doctor dispensed medication this would be the full course of treatment. The medication at the clinics was monitored daily, as was the medication and equipment boxes carried in the cars for home visits. The boxes in the cars were also checked at the beginning of each shift by the driver and doctor. We saw that frequent medication and prescribing audits were carried out by the provider. Inspection Report Harmoni - North Central London May

71 Requirements relating to workers Met this standard People should be cared for by staff who are properly qualified and able to do their job Our judgement The provider was meeting this standard. People were cared for, or supported by suitably qualified, skilled and experienced staff. Reasons for our judgement During our inspection we checked if Harmoni was operating an effective recruitment procedure in order to ensure that the people they employed were of good character, suitably qualified, skilled and experienced. Harmoni had taken over responsibility for the out-of-hours service from another provider in A number of doctors and other staff who had worked for the previous provider were taken on under contract by Harmoni and following interviews they continued to work in the service. We looked at the paper records relating to five doctors working for the provider. All contained evidence of appropriate identification and Criminal Records Bureau (CRB) checks being carried out. We saw evidence of the doctors' professional registration being confirmed and a record of them being included on the relevant Primary Care Trust's NHS Performers Lists. This information assures that all the GPs are registered and affiliated with the correct medical bodies. We were shown a number of records on the provider's human resources database, which informed the manager and administrators when a doctor's professional indemnity insurance was due for renewal and when CRB checks needed to be updated. The service delivery manager told us that although the provider's head office had overall responsibility for CRB checks, an additional local process had been set up to monitor and ensure that the necessary checks were carried out in respect of all workers. We spoke about the recruitment procedures for new doctors. We were told that this always included a structured interview covering essential competencies needed for the role and this was confirmed by the doctors we spoke with. The provider explained that this process ensures the doctors employed have the appropriate verbal and written communication skills. Inspection Report Harmoni - North Central London May

72 Staffing Action needed There should be enough members of staff to keep people safe and meet their health and welfare needs Our judgement The provider was not meeting this standard. Overall, there were not enough qualified, skilled and experienced staff to meet people's needs. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement Doctors working for the provider were self-employed general practitioners, who had entered into contracts with the provider to work in the out-of-hours service. There were 110 doctors working for the provider under these arrangements. The service delivery manager told us that in addition three identified agencies were able to provide doctors to cover short-notice absences. The provider is required to comply with the National Quality Requirements (NQR's) in the Delivery of Out-of-Hours Services, published by the Department of Health. Providers must monitor their performance in accordance with the NQRs and report regularly to the commissioning Primary Care Trusts. We saw the breakdown of its NQR performance for the year From this we could see that from the start of November 2012 to the end of January 2013 (which were the most current figures available) that Harmoni North Central London had breached these targets in four areas. The percentage of urgent calls that were triaged within 20 minutes ranged from 84 to 86 per cent. The percentage of nonurgent calls that were triaged within 60 minutes ranged from 62 to 83 per cent. The percentage of urgent home visits that took place within 2 hours ranged from 83 to 88 per cent. The percentage of routine home visits that took place within 6 hours ranged from 82 to 86 per cent. For each of these standards the provider is required to achieve 95% to be considered fully compliant. The provider, when asked, explained that the main reason for not meeting these targets is the difficulty in recruiting GPs and covering shifts, especially when doctors are unable to work at short notice. We looked at the numbers of staff who had cancelled their shifts at short notice between October and the end of December 2012 (which were the most current figures available) and saw that this had happened on 52 occasions. We saw that one doctor had cancelled their shift on six occasions for different reasons and on one occasion had provided no reason. Another doctor had cancelled on seven occasions again for a variety of reasons. When we asked the manager why the provider continued to offer work to these staff they explained that they still needed them to work while they recruited more staff. Inspection Report Harmoni - North Central London May

73 The provider also explained that another factor which had led to non achievement of performance standards was high call volume and doctors themselves being unwell associated with the Norovirus outbreak over the winter period. We were also told that previous call volume and trend data had been used to decide staffing numbers of the Christmas period. We were told that the service underestimated the call volume over this bank holiday period resulting in people receiving a slower service. In order to understand the impact of these staff shortages we looked at the results of the patient survey. These showed that in December 2012, 22 per cent of patients who responded said they found the service poor or unsatisfactory. In January 2013, 17 per cent of patients who responded said they found the service poor or unsatisfactory. The provider showed us information which confirmed how many shifts it had been unable to cover. In December 2012 there were a total of 33 unfilled shifts (7 at the Tottenham base, 3 at the Homerton base, 2 at the Whittington base, 6 at St Pancras and the rest for home visits) and the provider used 115 hours of agency staff. In January 2013 there were a total of 295 unfilled hours resulting in unfilled shifts (a breakdown of where these took place was not available) and the provider used 240 hours of agency staff. We were shown the provider's risks register and saw that the provider had identified staffing as a cause for concern since it took over responsibility for the out-of-hours service. The risks register recorded steps being taken to investigate and address issues relating to recruitment and retention of staff. We saw that on various occasions attempts had been made to engage and build relationships with local GP practices, with a view to doctors from the practices agreeing to work in the out-of-hours service. There was reference to mail shots to local practices advertising vacancies, fast-track recruitment exercises and registrars being targeted and interviewed with a view to them joining the service immediately upon qualification. An exercise was ongoing at the time of the inspection to contact doctors who had left the service in the preceding three months to ascertain the reasons for them leaving. The manager told us this could lead to a more attractive employment package being introduced to retain staff in the future. Whilst it is positive that the provider has identified this issue and is exploring new measures to attract staff, until the issue is resolved it is impacting on patients and there is a risk that delays could affect the care and treatment received by patients using the service. Inspection Report Harmoni - North Central London May

74 Supporting workers Met this standard Staff should be properly trained and supervised, and have the chance to develop and improve their skills Our judgement The provider was meeting this standard. People were cared for by staff who were supported to deliver care safely and to an appropriate standard. Reasons for our judgement We looked at the training records of five doctors working for the provider. We also saw the provider's human resources database which listed all the mandatory and refresher training that doctors and staff had completed. The database highlighted when refresher training was due. We saw that induction training was provided to all staff. The induction included corporate and local aspects in order to enable new staff to understand how the company worked nationally and in the specific out-of-hours service locally. It included mandatory subject areas which were health and safety, fire awareness and manual handling. Doctors and clinicians received further mandatory training including basic life support, meningitis awareness, palliative care and full course prescribing. Much of this training was provided on-line to enable staff to complete this training at flexible times. They were also required to complete training on the provider's policies and procedures, information governance, infection control, mental health awareness, safeguarding children, safeguarding vulnerable groups / learning difficulties and dealing with challenging behaviour. Additional training was provided relating to child protection and paediatrics. The provider maintained a Clinician's Performance Database which was a record of each doctors' performance, covering time keeping, complaints and compliments, any breaches relating to the National Quality Requirements, incidents, concerns relating to clinical audits and appraisals. One doctor we spoke with said how helpful they found receiving feedback on their individual performance. Appraisals were conducted annually with all employed staff, all self-employed clinicians working more than 20 hours a week and any other clinicians who requested this. In addition to training needs, the appraisals covered such matters as service improvement, the staff member's personal and health issues. The provider's appraisals were in addition to those carried out by the Primary Care Trust. We spoke with the manager, the clinical lead, doctors and other members of staff at the St Pancras and Whittington Hospital bases. We contacted a number of other doctors and staff working for the provider by telephone. The clinical lead showed us quarterly corporate and local newsletters sent to doctors working for the provider, sharing information of interest. There was also a newsletter focusing on learning from complaints which included case studies that enabled the sharing of information based on real examples. We saw that Inspection Report Harmoni - North Central London May

75 there were quarterly group meetings with doctors to share knowledge and learn from cases and complaints. An example of this is that following the case of the baby who passed away a seminar has taken place including local paediatric consultants and Harmoni GPs to improve their knowledge. There was also an annual rolling education programme available to staff working for the provider. Other non-medical staff we spoke with said they received monthly supervision and annual appraisals. They said they were happy with their work. Two said they felt well-supported by management, but one told us that more was needed and that communication could be improved. They said they saw their managers every day and were able to raise any concerns. One said that they had recently been asked to take on extra duties. They had not received additional training, but were told to read an instruction manual and ask questions of a colleague who had received training. They said that staff meetings were held regularly. The manager told us that these take place during out of hours times and staff are encouraged to attend with other staff covering them where needed. Inspection Report Harmoni - North Central London May

76 Assessing and monitoring the quality of service provision Met this standard The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of the service people receive. Reasons for our judgement All providers of out-of-hours services must comply with the National Quality Requirements (NQRs) in the Delivery of Out-of-Hours Services, published by the Department of Health. They allow local NHS commissioners to monitor the performance of providers. The NQRs cover issues such as the number of calls not picked up and the time for calls to be answered. In addition, there are set times for the carrying out of the clinical assessment following the initial contact and for the face-to-face consultation with a doctor either at the provider's clinics (bases) or at a person's home. We saw that the provider produced regular reports to monitor its compliance with the NQRs. We were shown the provider's corporate audit handbook setting out numerous audits conducted to monitor the service. These included audits of medical record keeping (1 per cent or around 80 records each month), telephone consultation audit (listening to 20 to 30 recordings of calls each month), medication prescribing audit, compliance with guidance issued by the National Institute for Health and Clinical Excellence, policy audits and audits relating to the work of call handlers, base receptionists and drivers. We were able to see a checklist to show the manager had received training on how to conduct these audits. We saw that the provider regularly sought the views of people using the service by sending a patient feedback survey to 10% of people who used the service each month, who were randomly selected by the Adastra system. We saw the results of the surveys that were available for the year Inspection Report Harmoni - North Central London May

77 Complaints Met this standard People should have their complaints listened to and acted on properly Our judgement The provider was meeting this standard. There was an effective complaints system available. Comments and complaints people made were responded to appropriately. Reasons for our judgement People we spoke with were generally very happy with the service and said they had no cause to make a complaint. We saw that complaint forms were available at the bases. A member of staff we spoke with said, "If someone makes a complaint, I try and resolve it immediately. If I cannot then I would give them a complaint form." For the year , the provider had recorded almost 111,000 contacts with people using the service, which included telephone calls, face-to-face consultations at bases and home visits. We were shown figures relating to formal complaints made during the year and there 37 in total. The complaints related to a range of topics although most were concerns about communication in relation to individual clinical advice received. Six were regarding delays and 2 related to medication. Roughly half of the complaints had been upheld. We could see that all the complaints had been addressed in line with the timescales set by the company. We could also see that each complaint had been thoroughly investigated and lessons learnt were shared with the people concerned. Inspection Report Harmoni - North Central London May

78 This section is primarily information for the provider Action we have told the provider to take Compliance actions The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards. Regulated activities Transport services, triage and medical advice provided remotely Treatment of disease, disorder or injury Regulation Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 Staffing How the regulation was not being met: The health, safety and welfare of people using the service had not been safeguarded because the provider had not taken appropriate steps to ensure that at all times there were sufficient numbers of suitably qualified, skilled and experienced staff employed for the purposes of providing the service, in accordance with Regulation 22 of the HSCA 2008 (Regulated Acitivities) Regulations This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider's report should be sent to us by 18 May CQC should be informed when compliance actions are complete. We will check to make sure that action has been taken to meet the standards and will report on our judgements. Inspection Report Harmoni - North Central London May

79 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of dentists and other services at least once every two years. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times but we always inspect at least one standard from each of the five key areas every year. We may check fewer key areas in the case of dentists and some other services. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Harmoni - North Central London May

80 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Harmoni - North Central London May

81 How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. We make a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation) from the breach. This could be a minor, moderate or major impact. Minor impact people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Harmoni - North Central London May

82 Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Harmoni - North Central London May

83 Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Harmoni - North Central London May

84 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: Copyright Copyright (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Inspection Report Harmoni - North Central London May

85 Action plan to meet CQC essential standard. Staffing - INS No Problem Area Identified Action to be Taken Date to be Completed Whom Date Completed Action Taken Evidence of Completion 1 Clinical recruitment challenges in North Central London. 1.1 Clinical Lead is making a proactive effort in building connections with new and existing Out Of Ongoing monthly Dr Bobby Nicholas on going 1. Regular working Doctors meetings. 2. Hours GP workforce. This is important in retaining the local workforce Regional Medical Director to draw up action plan with local Clinical Leads at the next regional clinical leads meeting Encouragement to all working Doctors to assist with recruitment strategy and ensure Harmoni is an employer of choice. GP recruitment issue in London. Lots of competition. 1.2 Collaborative approach with local surgeries in the recruitment of full time GPs. Looking at hybrid jobs whereby practices looking for part time GP s can work collaboratively with Harmoni to offer full time work albeit some hours to be worked in the out of hours period 1.3. Business relationship manager currently carrying out a survey of GPs that have left the service within the last 3 months. The aim is to find out reasons why Gps have stopped working. The findings will be presented at the regional London quality assurance meeting 01 September 2013 Paul Bond, Dr Bobby Nicholas, Laura O'Riordan 01 June 2013 Paul Bond In Progress 1. Letter sent to all local GP practices inviting GP s to work for Harmoni - April A series of practice visits have been set up. The aim is to visit each willing practice in North Central London. Letter to practices. 1.4 GP Advert in BMJ 01 March 2013 Dr Angelique Edwards, Dr Bobby Nicholas 1. Advert placed in BMJ and on Website /viewjob.html?id= &search Type=jobsearch Surgeries extending opening hours in evenings and Saturdays to improve health care access mean that local GPs working days are too long and stressful to be able to take on additional work. 1.5 Communication sent out to surgeries regarding the opportunity for Job Sharing roles for Doctors. 01 May 2013 Laura O'Riordan, Dr Bobby Nicholas Discussion with the Clinical CCG leads and will utilise the Business relation manager to visit surgeries There are also challenges around getting to shift on time as the surgery day is longer. Where possible, London Clinician s OOH rota offers varying shifts starting at 1830, 1900 and 2000hrs on weekdays 1.6 Varied shift start times during the week continue to be available to clinicians, which enable them to be on time after day time surgery. Ongoing. Rotas are circulated 3 months in advance London Rota Team Rotas are circulated 3 months in advance There is a cultural shift in that GPs no longer feel responsible for OOH. 1.7 Agency Partners for temporary direct hire (TDH) GPs was implemented 01/2011 with 4 Agency Partners. 3 Agencies can regularly supply GPs in London. Contracts to TDH GPs is part of the resourcing strategy during periods with high demands such as Winter pressure. Current contribution of the 4 partners requires review and there may be a need to increase the number of TDH agencies 2 Sustainable GP work force working collaboratively with CCG groups to explore we could tackle the issue of GP recruitment on-going Eileen Lock RD 2.1 Explore opportunities with CCG s 01 June 2013 Paul Bond, Laura O'Riordan First performance meetings with CCG's were held in April CCG s are still in a state of flux due to April changeover from PCT s. 3 Continue effort in Recruitment and engagement 3.1 Close working with GPVTS trainees to encourage them to work within the Harmoni ooh service. 3 annual GPVTS Programmes annually GPVTS lead Dr Mir writes to all trainees as they approach end of training to encourage them to join Harmoni's clinical workforce Dr.Bobby Nicholas CL, Dr Mir GPVTS lead for London Working with GPVTS Doctors 3.2 Continuous engagement with current GP workforce. Safeguarding children Level 2 and Level 3 training TBC engaging with local paed team 3 and Working Doctors Meetings scheduled for Wednesday 29th May London Denary Registrar Supervision Course offered to Harmoni GPs to encourage GPs to apply for more shifts and train registrar. Course is paid for by Harmoni local incentives in place for local GPs to become a supervisor. 3.4 supporting GPs in preparing for revalidation- currently being reviewed by the Urgent Care Medical Director ways in which we can support doctors for appraisal and revalidation e.g. through MSFs, pt feedback, educational events etc to make the role more attractive and supportive to clinicians 3.5 NCL that you are encouraging more triaging drs to work from NCL base thus encouraging more local drs to work as is less travel time to our London region call centre 01 July 2013 Dr Bobby Nicholas Dr Awais Mir Level 2 and Level 3 Safeguarding Training organised TBC Working Doctors Meeting organised for Wednesday 29th May Clinicians productivity performance & support 4.1 Weekly Productivity report provides an indication to our Clinical Leads and SDM, potential clinicians who are performing below expectation. A review to be conducted on how this together with audit results are going to be used by Clinical Leads in managing performance, with action plan. 2. GP Clinical Navigator post is currently being piloted at St Pancras. The role of the Clinical Navigator has been implemented to mitigate risk and support clinicians whilst on shift. Ongoing Dr Bobby Nicholas, Laura O'Riordan Monitoring to continue the role of GP Clinical Navigator to be reviewed to identify positive impact. Results have already shown improvements with visiting NQRs. Engaging with gps to take on this role, e mail sent by Dr Nicholas and positive feed back 5 85

86 Contract management up-date of Harmoni Following the previously agreed approach to contract management of Harmoni and given the ongoing media scrutiny the following is a summary of existing activity to provide the Board with additional assurance that the existing Out of Hours service within City and hackney remains a key focus for the CCG and CSU Progress made since the update at the 26 April Board includes; Monthly meetings have commenced with open dialogue and Harmoni responding positively to our requests for additional information as we better understand our requirements Commencement of an agreed process for GPs to be able to feedback comments on the OOH service o GPs have started to feedback o Harmoni is going through a change of its internal complaints recording software but has agreed to retain and share high level trend analysis of feedback in addition to the current complaints detail The CQC report has been discussed with Harmoni and they have shared their response/action plan detailing the steps they are taking to improve GP staffing o Of the 9 criteria assessed, 8 met the standard with staffing requiring action o It is also useful to note that in relation to comments made in the press regarding the reliance on Advanced Nurse Practitioners, for City and Hackney, in April there were only 3 shifts for ANPs representing 0.5%. Harmoni also confirmed that they do not do home visits or cover the Homerton base. o They also advised that they are not aware of any GPs travelling significant distances across the country or from abroad to undertake shifts in City and Hackney o Rota fill continue to be an area of challenge however we continue to refine and agree the information Harmoni are sending the CSU with the latest agreement to send a forecast schedule on a Friday afternoon and an actual position on Monday so we can continue to see the variance. The Guardian report is yet to be made public however as previously advised elements highlighted within the report have been built into our monitoring processes Performance across the Quality standards has improved from March into April across areas previously highlighted as red or amber. We have also asked for some helpful additions to the monthly report in order to reflect a trend of performance rather than just the previous month. Of particular interest is the significant reduction evidenced across the total number of dispositions falling from 2151 in March to 1318 in April, a 39% reduction. This coincides with the roll out of NHS111 and so we are separately looking at where these patients may have presented. Whilst this is only one month in isolation, clearly there has been an impact with patients being triaged, referred and assessed via 111. Clinical audit continues to be discussed with Harmoni auditing all GPs focussing on specific areas each month and other audits agreed depending upon trends or concerns identified. Currently they have just completed a significant review of 86

87 Feverish children taking into account NICE guidance, in light of the tragic death of a child and will be sharing this with Dr Patel for review. o Dr Patel is in discussion with Dr Bobby Nicholas at Harmoni in order to agree the process of sharing their audit findings with us as well as supporting our local requirement to undertake our own sampling. Escalation of issues impacting the service has improved with Harmoni operations management providing ongoing dialogue with the CSU team. o It has been agreed that provisionally any concerns outside of normal working hours, where it is believed the commissioner would want to know, will be directly notified to Karl Thompson, CCG lead for OOH. o Whilst a more detailed agreement will be reached regarding escalation it was agreed that a pragmatic approach should be adopted initially. 87

88 Harmoni North Central London Monthly Monitoring Report Harmoni Performance Report City and Hackney April Page 1 29/05/2013 1

89 Harmoni North Central London Monthly Monitoring Report Contents 1. Rota Summary 2. Analysis of Breaches 3. National Quality Requirements a) City and Hackney performance b) Volumes predicted v Actual 3. Complaints, Compliments, Concerns & Comments a) Statistics b) Trends c) Overview d) Details 4. Incidents/Serious Incidents a) Statistics b) Trends c) Overview d) Details 5. Patient Audits a) Ratings summary b) Results summary 89 Page 2 29/05/2013 2

90 Harmoni North Central London Monthly Monitoring Report Rota Summary April 2013 Face to Face Number of Shifts Number of Hours Percentage Volume of Shifts hrs Unfilled hrs 3.35% Filled hrs 96.65% Filled by ANP hrs 0.50% Filled by GPs hrs 85.85% Filled by Agency Hours hrs 10.30% 90 Page 3 29/05/2013 3

91 Analysis for Breaches Harmoni North Central London Monthly Monitoring Report 1. Absence and Lateness, both Operational and clinical staff reporting short notice absence and late for start of shift. Action Taken 1. Lateness log is recorded daily to ensure we are aware of staff that are regularly late or cancel s a shift short notice. 2. Harmoni HR process of lateness and sickness is recorded and documented by management. Next Steps Actively monitoring and actions in process to performance manage both operational and clinical staff. 2. Workload of Clinicians 1. Monitoring number of cases completed whilst on shift. Any low activity without exception identified will be followed up by the Clinical Lead 2. GP Clinical Navigator post is currently being piloted at St Pancras. The role of the Clinical Navigator has been implemented to mitigate risk and support clinicians whilst on shift. 3. Unfilled Shifts 1. We are actively recruiting new local GPs. An advert was placed in the BMJ at the end of April. 2. Registrars that are due to qualify July/August 2013 are being targeted and invited for interview. 3. London Denary Registrar Supervision Course offered to Harmoni GPs to encourage GPs to apply for more shifts and train registrar. Course is paid for by Harmoni local incentives in place for local GPs to become a trainer. 4. Offering hybrid working with local GP practices Monitoring to continue and role of GP Clinical Navigator to be reviewed to identify positive impact. Results have already shown improvements with visiting NQRs. Dr Awais Mir is the clinical lead responsible for all registrars, he works closely with local site to ensure registrars are passed for interview when due to qualify. 91 Page 4 29/05/2013 4

92 NQR performance results for City and Hackney Harmoni North Central London Monthly Monitoring Report North Central London - City & Hackney Target Mar-13 Apr-13 Call Volumes N/A N/A Quality Standards 1 Reporting on NQRs for PCT 100% % % 2 % call information to practices by 8AM 100% % 99.82% 3 Special patient notes available 100% % % 4 Clinical Audit of patient contacts 100% % % 5 Patient experience audited 100% % % 6 Complaints handling 100% % % 7 Matching capacity to demand & contingency 100% % % 8a % calls rang not engaged 100% N/A N/A 8b % calls abandoned >5% N/A N/A 8c % answered in 60 seconds 100% N/A N/A 9a % calls passed to 999 within 3 minutes 100% % % 9b % calls triaged within 20 mins (urgent) 100% 92.41% 93.14% 9c % calls triaged within 60 mins (routine) 100% 90.93% 92.74% 10a % walk-ins passed to 999 in 3 minutes 100% % % 10b % walk-ins triage complete within 20 mins 100% % % 10c % walk-ins triage complete within 60 mins 100% % % 11 GP cons available at all times & places 100% % % 12a % emergencies consulted within 1 hour 100% % % 12b % urgents consulted within 2 hours 100% % % 12c % routines consulted within 6 hours 100% % % 12d % emergencies visited within 1 hour 100% % % 12e % urgents visited within 2 hours 100% 90.79% 96.08% 12f % routines visited within 6 hours 100% 93.80% % 13 Patient communication - special needs met 100% % % Breaches for triage: NQR9b 17 NQR9c 43 Colour Codes QR 8, 9, 10 & 12 95% - 100% 90% - 95% < 90% 92 Page 5 29/05/2013 5

93 Harmoni North Central London Monthly Monitoring Report Summary Data City and Hackney Monthly Service Report Calls Handled - Telephone Apr-13 Volume Patient Line - North Central London - City & Hackney 0 Percentage of total Total Telephone Calls Handled % Priority on Receipt of Call Emergency % (Includes NHSD Calls) Urgent % Routine % Calls of Other Priority % Total % Final Dispositions/Outcomes GP visit % (Adastra) PCC % GP/nurse advice % A&E / Admitted to Hospital % % Community Nursing % Call Handler only (Message only) % Other referral % Total % Walk In Pts % Quality Standards Faxing Target Local report QR 2 % call information to practices by 8AM 100% 99.82% Quality Standards Telephony Target Performance QR 8a % calls rang engaged 0.10% QR 8b % calls abandoned <5% QR 8c % answered in 60 seconds 100% QR 9a % calls passed to 999 within 3 minutes 100% % QR 9b % calls triaged within 20 mins (urgent) 100% 93.14% QR 9c % calls triaged within 60 mins (routine) 100% 92.74% No of Pts Quality Standards Walk In Patients Total Number of Walk In Pts NA 5 No Of Walk In Pts as % of PCC attendees NA 0.77% QR 10a % walk-ins passed to 999 in 3 minutes 100% % QR 10b % walk-ins triage complete within 20 mins 100% % QR 10c % walk-ins triaged complete within 60 mins 100% % No of Pts Quality Standards PCC Consultations QR 12a % emergencies consulted within 1 hour 100% % QR 12b % urgents consulted within 2 hours 100% % QR 12c % routines consulted within 6 hours 100% % No of Pts Quality Standards Visiting QR 12d % emergencies visited within 1 hour 100% % QR 12e % urgents visited within 2 hours 100% 96.08% QR 12f % routines visited within 6 hour 100% % 93 Page 6 29/05/2013 6

94 Harmoni North Central London Monthly Monitoring Report Summary Data City and Hackney Adastra Dispositions Mar-13 Apr-13 GP visit PCC GP/nurse advice A&E / Admitted to Hospital Community Nursing 15 7 Call Handler only (Iain Rennie, Message only) Other referral (Linkline) 8 12 Walk In Pts 6 5 Totals Adastra Dispositions Mar-13 Apr-13 GP visit 10.37% 10.47% PCC 44.26% 49.39% GP/nurse advice 40.45% 33.08% A&E / Admitted to Hospital 0.98% 1.75% % 0.83% Community Nursing 0.70% 0.53% Call Handler only (Iain Rennie, Message only) 1.81% 2.66% Other referral (Linkline) 0.37% 0.91% Walk In Pts 0.00% 0.00% Totals Adastra Priority Mar-13 Apr-13 Emergency 11 5 Urgent Routine Calls of Other Priority 1 2 Totals Adastra Dispositions: Advice v PCC v Visits City and Hackney Adastra Dispositions Mar-13 Apr-13 Visit PCC Advice Total Adastra Dispositions Mar-13 Apr-13 GP visit 10.90% 11.27% PCC 46.55% 53.14% GP/nurse advice 42.54% 35.59% 94 Page 7 29/05/2013 7

95 No official Complaints received in April 2013 Harmoni North Central London Monthly Monitoring Report Compliments Summary April 2013 Contact date Date received Description of Compliment Location Type Action taken I was very impressed with the knowledge and efficiency of the person who called in answer to my Phone call Consulting/Treatment Room Passed to Clinician I was very pleased with the way this home visit was handled and with the helpful and efficient clinician. : I want to thank you for visiting me late on Sat 23rd march to deal with my blockage. In the end a very efficient but kind locum consultant at UCLH digitally broke up the stubborn turd and washed it all out with an enema. What a relief! Your visit reminded me of my days in practice when we covered for our own out of hours care. Those were the days! Actually your kindness and professionalism helped restain my faith in Harmoni of what I have heard some unfortunate stories. Thanks again Patient's Home Patient's Home Passed to Clinician Passed to Clinician I found Harmoni extremely helpful and helped me considerably by giving a prescription for just a few tablets until I visited my surgery. Thanks for all your help Consulting/Treatment Room Passed to Clinician The Doctor I saw was polite, very caring and very thorough. In these days when grumbling seems to be the done thing, I would like to say a big thank you. Consulting/Treatment Room Passed to Clinician 95 Page 8 29/05/2013 8

96 Incident/Concern Summary April 2013 Harmoni North Central London Monthly Monitoring Report Incident Date 07/04/ /04/2013 Date Received 08/05/2013 City and Hackney PCT Type Category of Incident Patient Safety Clinical Assessment Description of Incident Incident Highlighted by patient s surgery. Patient was seen by out of hour s service on 7th and 9th April On 7th April patient was seen by a Harmoni base Doctor where it was noted patient has a lot of pain passing urine with bleeding. Patient was noted to have a pulse of 109 with blood protein, leucocytes, glucose but no ketones in urine. The Doctor recorded an examination of patients chest and heart but not her abdomen despite recording she had abdominal pain and did not record her blood pressure. The patient was advised to start antibiotics which implies a failure of communication as patient was already on antibiotics. The patient was seen again by the same doctor on 9th April, patient was noted to have worsening abdominal pain with fever, nausea and vomiting. Patient was noted to have a temperature of 37.5, pulse of 111 with blood leucocyles, nitrates and protein but no ketones in patients urine. Noted to be unable to drink much and on examination was mildly dry. Patients abdomen was felt but again blood pressure was not checked nor was blood sugar. Patient was prescribed Cyclizine. Description of Issues/Findings Incident is currently under investigation. Acknowledgement sent to surgery and statement from Harmoni Doctor requested. Spoke to doctor on and Dr advised response has been written and currently with MDU for advice before submitting. Contact date/ Date received PCT Description of Concern Location Type Action taken City and Hackney Patient s mother complained as she rang the C&H ooh's number and when waiting for someone to take the call it seemed the call had been answered but no one was there to take the call. Complainant advised she had to go through 111 for call to be answered. Call Centre Patient agreed to close as concern. LO advised that she had investigated and identified a technical issue with our phone lines which has been resolved by Harmoni IT support. 96 Page 9 29/05/2013 9

97 Harmoni North Central London Monthly Monitoring Report No Serious Incidents April Page 10 29/05/

98 Patient Survey Questionnaire City and Hackney Harmoni North Central London Monthly Monitoring Report 98 Page 11 29/05/

99 Harmoni North Central London Monthly Monitoring Report 99 Page 12 29/05/

100 Audits Please see below our Audit Calendar, additional to this we carry out 2 local led audits per year. We are currently in the process of completing the following audits: - NICE Guidance Feverish Child Audit - Use of call recording by clinicians at remote bases and when visiting April May June July 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit Reception Audit Driver Audit Co-ordinator Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit August September October November 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit Reception Audit Driver Audit Co-ordinator Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit December January February March 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit 1% Audit all Clinical Areas Call Handler Audits Call Listening Audit Prescribing (via pharmacy) Policy Audit 100

101 Constitution amendment UPDATE TO CCG BOARD For information and for decision 31 May

102 CONTEXT Attached is a letter from NHS England providing guidance and recommendations relating to a number of key governance areas; The CCG previously developed its constitution in line with legal advice utilising the NHS England s Model Constitution Framework for CCGs where we adopted the following standard format for whistleblowing guidance under section 9 The CCG as an employer ; The CCG will adopt a code of conduct for staff and will maintain and promote effective 'whistleblowing' procedures to ensure that concerned staff have means through which their concerns can be voiced. 102

103 CONTEXT NHS England recommend we make the following change to our constitution to ensure individuals employed by the CCG feel that they are protected and can raise concerns in an environment that is safe and which values openness and transparency, making it clear that nothing in the constitution alters the right to make a protected disclosure. The group recognises and confirms that nothing in or referred to in this constitution (including in relation to the issue of any press release or other public statement or disclosure) will prevent or inhibit the making of any protected disclosure (as defined in the Employment Rights Act 1996, as amended by the Public Interest Disclosure Act 1998) by any member of the group, any member of its governing body, any member of any of its committees or sub-committees or the committees or sub-committees of its governing body, or any employee of the group or of any of its members, nor will it affect the rights of any worker (as defined in that Act) under that Act. 103

104 DECISIONS The Board is asked to; Agree the proposed change to the constitution Note that the change will need to be ratified by the Members forum Note that the change will need to be ratified by NHS England, whilst recognising they have not currently confirmed the formal process and timings to complete this but that in the interim we adopt the spirit of the change. 104

105 Publications Gateway ref: W12 Quarry House Quarry Hill Leeds LS2 7UE To: cc: CCG Clinical Leaders CCG Accountable Officers NHS England Regional Directors NHS England Regional Directors of HR & OD NHS England Regional Directors of Operations and Delivery NHS England Area Directors 2 May 2013 Dear colleagues Update and advice for CCGs on the process for approval of severance payments and wording in constitutions on whistleblowing You will be aware of the sensitive and complex issues relating to whistleblowing in the NHS and severance payments and, in particular, perceptions around the use of gagging clauses. More recently, this has included stories to the effect that some CCG constitutions may have gagging clauses that prevent members from speaking out about the work of the CCG without the written approval of its governing body. In my capacity as Chief Executive of the NHS in England, I wrote to Chief Executives and HR Directors of NHS Trusts, SHAs and PCTs on a number of occasions including 11 January 2012, emphasising the importance I place on every NHS organisation supporting NHS staff seeking to raise concerns in the public interest, and informing about the arrangements for approval of severance payments. This remains an important issue for all NHS bodies. Whistleblowing is an important part of our clinical governance and patient safety systems, with direct implications for patient safety outcomes. Since the introduction of the Public Interest Disclosure Act 1998 (PIDA), whistleblowers have been legally protected when making public interest disclosures. I am writing now to reaffirm the importance that NHS England places on protecting and supporting those working in the NHS when making public interest disclosures, and to provide further advice on these issues. 105 High quality care for all, now and for future generations

106 Severance payments It is essential that all NHS organisations are clear about their responsibilities and the governance arrangements required for handling the use of payments to staff in severance type situations. As NHS bodies we have a duty, not only to ensure that the use of all public money is both transparent and appropriate, but to ensure that we fully support staff to raise genuine concerns and to speak out where it is in the public interest. In doing so we will ensure that the culture we create fosters openness and has clear lines of accountability. Existing guidance set out in Managing Public Money makes clear the need for due process and careful consideration of the use of public money in situations where such payments may be novel or contentious. For the avoidance of doubt, HM Treasury approval is required for any non-contractual payments made by an NHS body, including those arising as part of a settlement of employment issues. This includes any payments which are proposed under Judicial Mediation in the settlement of an Employment Tribunal. All NHS bodies are required to obtain agreement from a relevant national body prior to any business case being submitted to HM Treasury for consideration. For CCGs, the Department of Health has confirmed that from 1 April 2013 approval is required from NHS England on the basis of the accounting relationship between our organisations. These arrangements relate only to special severance payments and do not otherwise affect the employment flexibilities afforded to CCGs as individual employers. NHS Employers has recently issued guidance to assist NHS bodies in their handling of compromise agreements 1 and special severance payments 2. The guidance highlights the need to ensure that proper legal and audit advice is received prior to any cases being considered, and contains a business case template which should be used in all submissions to NHS England. I would encourage you to consider this guidance at your local Remuneration Committee as part of your own internal governance arrangements. In line with recent statements by the Secretary of State, NHS England will not support special severance business cases for consideration by HM Treasury unless confirmation is given that an explicit clause has been included within the compromise agreement associated with the severance transaction. That clause must be to the effect that no provision in the compromise agreement seeks to prevent the individual from making a protected disclosure under the Public Interest Disclosure Act This position was reiterated in a recent letter from Gavin Larner, Director of Professional Standards at the Department of Health, to professional regulators and trades unions. The letter also asks for each national body to use its communication channels to reinforce the messages to staff around their rights to speak up about matters of public concern. It is attached as Annex 1 to this letter Link to NHS Employers Compromise Agreements and Confidentiality Guidance 2 Link to NHS Employers Severance Payments Guidance

107 In the event that you need to seek NHS England s approval prior to submission of a case to HM Treasury you should liaise in the first instance with the NHS England Regional Director of HR & OD in your area. Their contact details are attached as Annex 2 to this letter. Please note that submission of a business case or approval from NHS England does not mean that approval from HM Treasury is guaranteed. If you need any further advice or guidance on these arrangements please contact the Regional Director of HR & OD for your area. CCG Constitutions The second issue I am writing about is the perception of gagging clauses in constitutions that prevent members or employees from speaking out about the work of the CCG without the written approval of its governing body. Having reviewed some of these clauses, we believe that the intention behind them is to ensure the consistency of media messaging among CCG members and staff, rather than to prevent disclosures that are in the public interest. However, it is important that any such clauses, whether in an employment contract or a CCG constitution, are not perceived as an attempt to cut across the right of any individual, under the Public Interest Disclosure Act, to raise concerns in the public interest. NHS England s Model Constitution Framework for CCGs (under Section 9 the Group As Employer) states at paragraph 9.9: The group will adopt a code of conduct for staff and will maintain and promote effective whistleblowing procedures to ensure that concerned staff have means through which their concerns can be voiced. It is vital that all members of the governing body and its committees, and individuals employed by the CCG, feel that they are protected and can raise concerns in an environment that is safe and which values openness and transparency. For the avoidance of doubt, we have drafted the following statement that could be adopted by CCGs: The group recognises and confirms that nothing in or referred to in this constitution (including in relation to the issue of any press release or other public statement or disclosure) will prevent or inhibit the making of any protected disclosure (as defined in the Employment Rights Act 1996, as amended by the Public Interest Disclosure Act 1998) by any member of the group, any member of its governing body, any member of any of its committees or sub-committees or the committees or sub-committees of its governing body, or any employee of the group or of any of its members, nor will it affect the rights of any worker (as defined in that Act) under that Act. 107

108 CCGs are therefore encouraged to: formally present an explicit minute at a public governing body meeting clarifying expectations and seeking formal adoption of the statement above; and include the statement in their constitutions making it clear that nothing in the constitution alters the right to make a protected disclosure. NHS England will shortly be issuing guidance on the procedures to be followed by CCGs and NHS England when requesting a change to a constitution. This will set out that requests to amend constitutions should be sent to the relevant Regional Director of Operations and Delivery, who will be responsible for approving the changes. Their contact details are included at Annex 3. Working with Providers It is for each NHS body, and each provider of NHS services to assure itself that it has appropriate arrangements in place to support staff to raise concerns and arrangements covering severance payments and compromise agreements. However, CCGs will also need to work closely with providers to satisfy themselves that these arrangements are robust and in line with the requirements of the NHS contract. I would like to thank you for your support in creating a culture in which all NHS staff feel protected and confident to raise concerns in an environment that is safe and which values openness and transparency. This is one of our greatest collective leadership challenges. Yours faithfully Sir David Nicholson Chief Executive 108

109 To: Chief Executives of Professional Regulators, Room 514 Members of Social Partnership Forum Richmond House 79 Whitehall London CC: Chief Executive NHS England, SWIA 2NL Chief Executive,NHS Employers, WB Helpline, Monitor, Care Quality Commission, NHS TDA th April 2013 Dear Colleague Compromise Agreements, Gagging Clauses and the Public Interest Disclosure Act 1998 Following the clear commitments on whistleblowing and confidentiality made by Sir David Nicholson in his role as NHS Chief Executive, I am writing on behalf of the Secretary of State for Health to seek your assistance in ensuring that all NHS staff are aware of their rights to speak up about matters of public concern. Both the Secretary of State and Sir David have written to the service on this issue in the last 18 months, but I should be most grateful if you would seek to ensure that your members and registrants are fully aware of their freedom to speak up where that is in the public interest. You will all be aware of the ongoing debate in the media and in Parliament about whether whistleblowers in the NHS are given adequate support to raise concerns, and in particular, about the allegations of NHS organisations gagging staff from speaking out on legitimate matters of public interest. It is crucial that each national organisation with an interest tackles this issue together as one system and I am therefore writing to ask you to use your links with NHS staff to communicate and reinforce an important message with any members or registrants, who may have signed, or may in the future sign, compromise agreements. Contracts of employment and compromise agreements are a matter between the employing organisation and its employee, and the use of confidentiality clauses is common across the public and private sectors to support both parties to move on after a dispute; or where sensitive and personal information is involved. 109 However, it is particularly important that the existence of a confidentiality clause does not in any way gag either intentionally or unintentionally - any individual who may wish to raise concerns in the public interest. It is vital all staff feel that they can raise concerns in an environment that is safe and one that values openness and transparency. 1