A G E N D A. Meeting Title Governing Body Meeting Date Wednesday 11 April Chair Dr Julian Povey Time 9.30am

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1 William Farr House Mytton Oak Road Shrewsbury Shropshire SY3 8XL Tel: A G E N D A The meeting is to be held in public to enable the public to observe the decision making process. Members of the public will be able to ask questions at the discretion of the Chair Meeting Title Governing Body Meeting Date Wednesday 11 April 2018 Chair Dr Julian Povey Time 9.30am Minute Taker Mrs Tracy Eggby-Jones Venue / Location Room SGH026, The University Centre, Guildhall, Frankwell, Shrewsbury, SY3 8HQ Reference Agenda Item Presenter Time Paper GB Apologies Shailendra Allen, Sarah Porter, Finola Lynch, Julie Davies Julian Povey 9.30 verbal GB Members Declaration of Interests Julian Povey 9.30 verbal GB Introductory Comments from the Chair Julian Povey 9.30 verbal Minutes of Previous Meetings GB Meeting held on 14 March 2018 Julian Povey 9.35 enclosure GB Matters Arising Julian Povey 9.40 verbal Patient Voice GB Patient Voice Meredith Vivian 9.50 enclosure Clinical and Financial Sustainability GB Progress Report on Quality, Innovation, Productivity & Prevention (QIPP) schemes Claire Skidmore enclosure GB MLU Pre Consultation Business Case Jessica Sokolov verbal GB Emotional Health & Wellbeing Service update Lisa Wicks enclosure GB Out of Hospital Transformation Programme Lisa Wicks enclosure Page 1 Shropshire CCG Governing Body meeting Agenda 11 April 2018

2 Corporate Performance Reports GB Financial Report Claire Skidmore enclosure GB /19 Finance Plan and Budget Claire Skidmore to follow GB Finance & Performance Committee 8 March, including revised Terms of Reference Keith Timmis enclosure BREAK Corporate Performance Reports GB Corporate Performance report Charles Millar enclosure GB Contract Performance report 2017/18 Gail Fortes-Mayer enclosure GB Quality Exception Report Dawn Clarke enclosure Strategic Planning Reports GB Sustainability & Transformation Plan (STP)/ Future Fit Governance Simon Freeman enclosure GB Executive Structure Simon Freeman enclosure GB Governing Body Assurance Framework (GBAF) Sam Tilley enclosure For Information Only/Exception Reporting GB Clinical Commissioning Committee 21 February Sarah Porter enclosure GB Quality Committee 28 February Meredith Vivian enclosure GB Primary Care Commissioning Committee 7 March Keith Timmis enclosure GB A&E Delivery Board 27 February Simon Freeman verbal GB Locality Boards North Locality Board 22 February South Locality Board 14 February Shrewsbury & Atcham Board 15 February Tim Lyttle Shailendra Allen Deborah Shepherd enclosure verbal enclosure GB Questions from Members of the Public At the discretion of the Chair questions from members of the public will be invited If you would prefer to put this in writing, by noon Tuesday 10 April to Dr Julian Povey, Clinical Chair, Shropshire CCG, Somerby Suite, William Farr House, Mytton Oak Road, Shrewsbury, SY3 8XL or via SHRCCG.CustomerCare@nhs.net Julian Povey verbal Page 2 Shropshire CCG Governing Body meeting Agenda 11 April 2018

3 GB Any Other Business Julian Povey verbal Date of Next Meeting Wednesday 9 May 2018, time and venue to be confirmed TO RESOLVE: That representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest. (Section 1 [2] Public Bodies [Admission to Meetings] Act 1960). Dr Julian Povey Clinical Chair Dr Simon Freeman Accountable Officer Page 3 Shropshire CCG Governing Body meeting Agenda 11 April 2018

4 Agenda Item GB CCG Governing Body Shropshire Clinical Commissioning Group MINUTES OF THE SHROPSHIRE CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY MEETING HELD IN ROOM SGH026, THE UNIVERSITY CENTRE, GUILDHALL, FRANKWELL QUAY, SHREWSBURY, SHROPSHIRE, SY3 8hq Present Dr Julian Povey Dr Jessica Sokolov Dr Simon Freeman Mrs Claire Skidmore Dr Finola Lynch Dr Steve James Dr Deborah Shepherd Dr Shailendra Allen Dr Tim Lyttle Mr Kevin Morris Dr Ed Rysdale Dr Julie Davies Ms Dawn Clarke Mrs Nicky Wilde Professor Rod Thomson Mr Keith Timmis Mr William Hutton Mrs Sarah Porter Mr Meredith Vivian Mrs Tracy Eggby-Jones AT 9.30 AM ON WEDNESDAY 14 MARCH 2018 (CCG Chair) (Deputy Clinical Chair & Clinical Director Women & Children s Services) (Accountable Officer) (Chief Finance Officer) (Clinical Director Communications & Engagement) (Clinical Director - Primary Care) (Chair Shrewsbury & Atcham Locality) (Chair South Locality) (Chair North Locality) (General Practice Representative) (Secondary Care Clinician) (Director of Performance & Delivery) (Director of Nursing, Quality and Patient Experience) (Director of Primary Care) (Director of Public Health) (Lay Member Performance) (Lay Member Governance & Audit) (Lay Member Transformation) (Lay Member Patient & Public Involvement) (Corporate Services Manager - Minute Taker) In Attendance Mr Graham Shepherd Mrs Jane Randall-Smith Mr Jonathan Bletcher Mrs Lisa Wicks Mr Charles Millar (Shropshire Patient Group Observer) (Healthwatch Shropshire Observer) (Head of Assurance & Delivery, NHS England) (Head of Out of Hospital Commissioning) Agenda item GB (Head of Planning Performance and Contracting) - Agenda item GB Dr Povey welcomed members, observers and the public to the Shropshire Clinical Commissioning Group (CCG) Governing Body meeting being held in public. Minute No. GB Apologies 2.1 Apologies were noted from: Mrs Sam Tilley (Director of Corporate Affairs) Mrs Gail Fortes-Mayer (Director of Contracting & Planning) Minute No. GB Declarations of Interest 3.1 Dr Povey reported that Members had previously declared their interest, which were listed on the Governing Body Register of Interest and available to view on the CCG s website ( However, Dr Povey asked Members to confirm any declarations of interest they had in relation to the agenda items. These were noted as follows: Professor Thomson declared that he was the Director of Public Health at Shropshire Council and Deputy President of the Royal College of Nursing. Page 1 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

5 Mr Vivian declared that his wife was an employee of Shrewsbury & Telford Hospital NHS Trust (SATH). Mr Morris declared that he was a managing partner at Cambrian Medical Practice and his wife was an Executive Director at Telford & Wrekin CCG. Dr Allen declared that he was a GP partner at Highley & Broseley Medical Practices. Dr Lyttle declared that he was a GP partner at Bridgewater Family Medical Practice and Claypit Street Medical Practice. Dr Lynch declared that she was a locum GP at Bishops Castle Medical Practice and her husband was an employee of Shropdoc. Dr Sokolov declared that she was a GP partner at Market Drayton Medical Practice, her father was a County Councillor and Governor on the Board at West Midlands Ambulance Service (WMAS) and her husband was an employee of Shropshire Community Health NHS Trust. Dr Povey declared that he was a GP partner at Pontesbury Medical Practice. Dr Rysdale declared that his wife was a GP at Beeches Medical Practice, Bayston Hill. 3.2 There were no other declarations of interest raised. Minute No. GB Introductory Comments from the Chair 4.1 Dr Povey advised that he had no introductory comments to make. Minute No. GB Minutes of the Previous Meeting 14 February The minutes of the Governing Body meeting held on 14 February 2018 were presented and approved as and true and accurate record. RESOLVE: MEMBERS FORMALLY RECEIVED AND APPROVED as an accurate record the minutes of the meeting of Shropshire Clinical Commissioning Group (CCG) held on 14 February Minute No. GB Matters Arising from the Minutes of the Previous Meeting 6.1 An update on the matters arising from the previous meeting was noted as follows: a) GB Corporate Performance Report Dr Povey reported that he had ed the Medical Director at Shrewsbury & Telford Hospital NHS Trust (SATH) in relation to A&E performance and business continuity action plan and that a meeting had been scheduled jointly with Telford & Wrekin CCG. b) GB Quality Strategy & Delivery Plan 2018/19 Ms Clarke to check that a copy of Appendix 2 of the Quality Strategy & Delivery Plan had been circulated to Governing Body Members. c) GB Questions from Members of the Public Dr Freeman reported that he would raise the issue of the Sustainability & Transformation Plan (STP) Programme Board meetings being held in public at the next meeting. 6.2 Mrs Randall-Smith referred to the matters arising from the 10 January 2018 meeting where it had been agreed that a meeting with Dr Freeman, Mr Sandbach, Mr Shepherd, Mrs Randall-Smith and Councillor Sheinton would be arranged in relation to the ongoing work on the Out of Hospital Programme. Dr Freeman confirmed that this was in the process of being arranged. 6.3 There were no other matters arising noted. Page 2 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

6 . ACTION Ms Clarke to check that a copy of Appendix 2 of the Quality Strategy & Delivery Plan had been circulated to Governing Body Members. Dr Freeman to raise the issue of the Sustainability & Transformation Plan (STP) Programme Board meetings being held in public at the next meeting. Dr Freeman to meet with Mr Sandbach, Mr Shepherd, Mrs Randall-Smith and Councillor Sheinton in relation to the ongoing work on the Out of Hospital Programme. CLINICAL AND FINANCIAL SUSTAINABILITY Minute No. GB Progress Report on Quality, Innovation, Productivity & Prevention (QIPP) schemes 7.1 Mrs Skidmore presented a progress report on the current position in relation to the CCG s Quality, Innovation, Productivity & Prevention (QIPP) programme for 2017/18, as at Month 10 (January 2018), and reported that the CCG had an outturn delivery of m against the target of 17.71m. Mrs Skidmore reported that and reported that there had not been a material change to the CCG s position from months 8 and Mrs Skidmore acknowledged the significant work undertaken by the Executive Directors and Project Managers in delivering the savings to date. 7.3 Mrs Skidmore noted that an update in relation to 2018/19 QIPP was included in the Budget report presented under agenda item GB Mr Timmis referred to paragraph 7 of the report, where it was noted that the Finance & Performance Committee had received a lessons learnt report which had reflected on the QIPP related activities over the past 12 months, including developing governance processes, and made recommendations for further improvement. 7.5 Mr Timmis noted that QIPP delivery had remained unchanged for the past 3 months and sought assurance that robust monitoring was in place and that there would not be any surprises at year end. Mrs Skidmore advised that there had not been any material changes in the CCG s QIPP position over the previous couple of month and reported that a deep dive was planned at Month 11 to ensure there was no change to the forecast position. 7.6 Mr Hutton also sought assurance that there were no potential additional risks to the QIPP year-end position. Mrs Skidmore advised that she had not been alerted to any additional risks by Project Leads and was assured that there would not be a material change to the year-end forecast position. 7.7 Dr Povey noted that the current QIPP outturn delivery ( m) equated to 3.5% of the CCG s total allocation and wished to record his thanks to Executive Directors and Project Leads in achieving this delivery. Dr Povey asked how Shropshire CCG compared with other CCGs regionally. Mr Bletcher advised that Shropshire CCG was comparable in its QIPP target, however, noted that some CCGs had differences in what they attributed to QIPP and, therefore, their delivery may differ. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the current position in relation to the QIPP schemes as at Month 10, with a predicted outturn delivery of m against the target of 17.71m. Minute No. GB Out of Hospital Transformation Programme 8.1 Mrs Lisa Wicks, Head of Out of Hospital Commissioning, was in attendance for this item. 8.2 Mrs Wicks presented a briefing paper which provided Members with an update on the Out of Hospital Transformation Programme. Page 3 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

7 8.3 Mrs Wicks reported that since the last Governing Body meeting the inaugural meeting of the programme working group had taken place on 15 February, with the next meeting planned for 22 March. The Locality Clinical Task & Finish Groups had also met on 7 March to commence the collaborative design across all providers of the programme. 8.3 Mrs Wicks reported that a stakeholder event was held on 28 February with approximately 40 delegates and noted discussion took place with regards to how and who to engage with in the programme in order to support the development of an Engagement Strategy. 8.4 It was noted that the key focus of the next workshop would be crisis beds and Diagnostics, Assessment and Access to Rehabilitation and Treatment (DAART). 8.5 Members who had attended the workshop and Task & Finish Group reported that feedback was positive and that there had been good representation from across key stakeholders. Mrs Wicks recognised the need to ensure all parties were involved in the programme and advised that she had contacted providers who were unable to attend the event to ensure they were kept up to date on developments and aware of future dates. 8.6 Dr Davies acknowledged that partner organisations had operational pressures which made it difficult for key individual staff to attend events and advised that this was being picked up with provider Executives. 8.7 Ms Clarke asked how sufficient engagement from hard to reach and minority groups would be obtained. Mrs Wicks advised that this had been raised at the workshop on 28 February and that some good ideas had been put forward, which were currently being explored. 8.8 Dr Povey noted that Shropshire Community Health NHS Trust (SCHT) was fundamental to the programme and, given that the future of the Trust was uncertain, he felt there could potentially be a negative impact on the programme and asked for an update from the work of the Sustainability Board. Dr Freeman advised that commissioners had not had any signification involvement in the proposed dissolution of the Trust, as this was being managed by NHS Improvement. However, Dr Freeman reported that he had attended the presentations by the two potential bidders, SATH and South Staffordshire & Shropshire Healthcare NHS Foundation Trust (SSSFT), who had set out their vision for the Trust, but noted that the decision on the future of SCHT had been delayed by a few weeks. 8.9 Dr Davies confirmed that both SATH and SSSFT were in attendance at the Task & Finish Group and emphasised that the Out of Hospital Programme would not be delayed until the ultimate destiny of SCHT was known. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the update on the Out of Hospital Transformation Programme. Minute No. GB Acute Ophthalmology Services 9.1 Dr Davies presented a briefing paper which provided an update to Members on the re-opening of acute ophthalmology services in Shropshire. 9.2 Dr Davies began by reminding Members that, due to the challenges in ophthalmology services at SATH, there had been a temporary suspension of new referrals in glaucoma, general and adult squint surgery at the Trust in order to address the backlog of patients and ensure that patients waiting for follow-up appointments were seen in a timely way. 9.3 It was noted that during the period of closure Shropshire CCG patients had been referred out of county for acute care or to the Community Ophthalmology Service (Community Health and Eye Care Ltd). 9.4 Dr Davies reported that SATH had now recruited to the vacant consultant posts and would be able to move to re-open to new glaucoma and general ophthalmology referrals from 1 April 2018, subject to a consultant completing some surgical training. 9.5 Dr Davies advised that adult squint surgery services would remain closed, as the new consultant required additional training, which may not be completed until towards the end of 2018, although it was hoped this would be completed sooner. Dr Davies reported that SATH had explored the possibility of having a sub contract arrangement in place in the interim which had been unsuccessful. Page 4 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

8 9.6 It was noted that SATH would remain open for orthoptic reviews for adult squint, as the majority of patients were treated with glasses and exercises. Historically, on average SATH delivered one operation per week for adult squint and patients requiring this service would continue to be referred to an out of area provider of their choice in the interim. 9.7 Dr Davies reported that a joint communication would be sent out informing patients of the re-opening of the two services as soon as possible. These communications would also be sent to CCG healthcare service providers and other stakeholders. 9.8 Dr Davies reported that it had been proposed that the Ophthalmology Task & Finish Group continued to meet to monitor demand and capacity at SATH following the re-opening of the service and the repatriation of patients who had received treatment out of county. In addition, an Ophthalmology Needs Assessment would be conducted, with the support of the CCG s Ophthalmology Adviser (Claire Roberts), to ensure the future sustainability of the service. 9.9 Mr Timmis referred to the one operation per week for adult squint and asked if this was sufficient to maintain the necessary skills of the consultant and sustain a local service. Dr Davies acknowledged the low number of patients requiring this service, but gave assurance that the consultant would receive clinical peer support from North Staffordshire in order to maintain their competencies Mr Vivian sought clarity as to what support was required from the CCG in relation to SATH s reopening of their ophthalmology service and if this included financial support. Dr Davies gave assurance there were no financial implications for the CCG, but that the CCG needed to be certain that the Trust was able to meet patient demand Dr Povey referred to paragraph 8 of the report, which stated that the Trust was closed to adult squint surgery but remained open for orthoptic reviews for adult squint. Dr Povey felt that it needed to be made clear to the Trust that if a GP referred a patient to the adult squint service, who was subsequently identified as requiring surgery, then it was the responsibility of the consultant to make the onward referral for out of county surgery not the GP. Dr Davies advised that she would pick this up at the next Task & Finish Group and ensure the referral pathway was made explicit. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the update on the re-opening of acute ophthalmology services in Shropshire. THE GOVERNING BODY SUPPORTED SATH s re-opening of their two ophthalmology services (general ophthalmology and glaucoma) on 1 April 2018 and AGREED that a joint communication document be issued to inform patients and stakeholders of the reopening. THE GOVERNING BODY NOTED SATH would remain open for referrals for orthoptic reviews for adult squint, but that the adult squint surgery service would not be reopened until later in the year, once appropriate training had been completed and AGREED that a further joint communication would be issued to this effect. THE GOVERNING BODY GAVE THEIR SUPPORT for commissioners to have a continued contribution to the Ophthalmology Task & Finish Group in the short term, in order to continue to apply scrutiny to ophthalmology services across Shropshire to ensure services were sustainable. ACTION Dr Davies to raise issue of referral pathway for adult squint services at the next Ophthalmology Task & Finish Group. Minute No. GB Shropshire, Telford & Wrekin Local Maternity System (LMS) Transformation Plan 10.1 Dr Sokolov presented the Shropshire, Telford & Wrekin Local Maternity System (LMS) Transformation Plan and sought support for its system wide implementation It was noted that in order to implement the recommendations within the Better Births, NHS England (NHSE) had instigated a National Maternity Transformation Programme and were monitoring delivery at Sustainability & Transformation Plan (STP) level through the Local Maternity Systems (LMS). As a result the LMS across Shropshire had worked collectively to develop a Transformation Plan for delivery over the next 3-5 years in accordance with NHSE timelines. Page 5 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

9 10.3 The plan s implementation would be an evolving process which had been co-produced with women and their families to ensure services commissioned and delivered were equitable, the safest they could be and delivered within the financial commissioning envelope Dr Sokolov reported that the plan was submitted to NHS England as a draft in October 2017 with positive feedback received and a second version, to respond to the key lines of enquiry, had been submitted on 12 February It was noted that this version was now available on the CCG s website along with links to LMS partner s websites and a copy attached as Appendix 1 to the report Oversight and monitoring of the plan would be undertaken via the NHS England Regional Maternity Board reporting into the National Maternity Transformation Board Mr Timmis, as Chair of the LMS Programme Board, reported that positive feedback had been received from NHSE in relation to the LMS Transformation Plan and that there was a system wide commitment to improve maternity services Dr Sokolov concurred with Mr Timmis s comments and noted that the Transformation Plan outlined the step change required to improve local maternity services, which was in line with the recommendations of Better Births Professor Thomson welcomed the plan, but sought assurance around its implementation given the workforce issues identified at SATH, which had resulted in the temporary intermittent closures of rural Midwife Led Units (MLUs). Dr Sokolov reported that the MLU review formed part of the LMS and that the review had given consideration to the staffing issues at the Trust and that a new proposed model of care had been developed to that would address these issues Mr Timmis advised that the plan have been co-produced with input from midwives, women and their families to ensure that services commissioned were equitable and the safest they could be and delivered within the financial envelope available. Mr Timmis reported that the LMS had submitted bids for additional resources, particularly in relation to perinatal mental health. Mr Timmis also noted that the recommendation of Better Births was to encourage more midwife led births rather than consultant led births and felt the plan delivered this Mrs Randall-Smith referred to the establishment of the Maternity Voices Partnership, which comprised women and their families, commissioners and providers (midwives and doctors) working together to review and contribute to the development of local maternity care. Mrs Randall-Smith reported that the MVP would be involved in the work locally through the LMS Dr Povey referred to page 30 of the plan, where it was reported that the current maternity service was running at a 7m loss and asked how this would be addressed given the work underway locally and through Future Fit. Dr Freeman reported that commissioners currently paid tariff for maternity services and that Shropshire did not meet the criteria for additional rural funding. Dr Freeman advised that the 7m mainly related to the need for the Trust to pay a clinical negligence premium for all its services, not just maternity services. Dr Freeman also explained that as part of the Future Fit Programme and the reconfiguration of acute services, the only element that could potentially affect maternity services was the proposed co-location of the women s and children s unit with the trauma unit Mr Timmis acknowledged that there was more work to be undertaken in relation to finance as part of the LMS and advised that a number of acute trusts had raised concerns with NHS England regarding the current tariff paid, which would have to be addressed nationally. RESOLVE: THE GOVERNING BODY RECEIVED Shropshire, Telford & Wrekin Local Maternity System (LMS) Transformation Plan AND SUPPORTED its implementation system wide. CORPORATE PERFORMANCE REPORTS Minute No. GB Finance and Contract Report to 31 January 2018 (Month 10) 11.1 Mrs Skidmore presented the Finance and Contract Report to the Governing Body. The report reflected the finance and contract position as at 31 January 2018, which was the Month 10 financial position for 2017/ The following key points noted were: a) Shropshire CCG continued to be in directions and in formal financial recovery. Page 6 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

10 b) The overall financial position to 31 January 2018 was forecasting an in year deficit of m. It was noted that, further to agreement with NHS England, the position had moved adversely by 4.650m from Month 9. The deficit reflected the gap between the CCG s current plan and the excess of expenditure over resource allocation ( m). c) CCG risks had been reflected in position for month 10, which included No cheaper stocks obtainable (NCSO) and equated to an additional expenditure of 2.1m. d) The cumulative financial position for 2017/18 showed a forecast deficit of 56.7m, which included brought forward 32.6m from previous years. e) The CCG had achieved the Better Payment Target (BCF) for the month, exceeding 95% of the volume of invoices paid within 30 days. f) The CCG was achieving the cash target to date 11.3 Mrs Skidmore reported that the deterioration in the financial position was due to the CCG s forecasting not meeting the actual expenditure, specifically in relation to acute and complex care. Mrs Skidmore gave assurance that this did not relate to contract over performance or over activity but was due to a shortfall in forecast modelling 11.4 Mrs Skidmore advised that the 4.650m adverse deterioration would be abated slightly as the CCG would be able to release 0.5% of its 1% contingency reserve in Month 12, which should reduce the deficit position by approximately 2m Mr Timmis highlighted that as a result of the further deterioration in the financial position, the CCG would have a cumulative deficit of 56.7m, which he acknowledged was a significant challenge. Mr Timmis was encouraged that emergency activity was broadly on plan, but was concerned by the pressures facing complex care and as a result reported that the Finance & Performance Committee would be undertaking a deep dive in to complex care expenditure, particularly in relation to the step change in the number of patients from Month 5 to Month Mrs Skidmore referred to the step change in complex care patients and reported that it related to an input of backlog of data onto the Broadcare system but recognised the need to ensure robust forecasting processes were in place and that was the rationale for undertaking the deep dive Dr Freeman reported that there was significant work being undertaken in complex care and that external support had been provided by NHS England to review the financial and operational processes and ensure robust forecasting protocols were in place Mr Hutton referred to the movement in the CCG s running costs, which was showing a year to date over-spend of 1.257m, with a forecast overspend of 1.414m. Mr Hutton sought clarity with regards to this. Mrs Skidmore began by explaining that the CCG had a level of unmitigated risks, which had previously been reported, and at Month 10 these risks had been released into the CCG s financial position, part of which related to the CCG s running costs Dr Povey was concerned that there appeared to be forecasting issues that had led to the deterioration in the CCG s position and sought assurance that the figure now reported was robust and that stringent processes were in place going forward. Mrs Skidmore gave assurance that where issues had been identified, systems and processes were reviewed in order to prevent the issues reoccurring. However, Mrs Skidmore was mindful that there may be other issues that had not yet come to light, but reported that she was doing everything in her power to minimise any risks to the CCG. Mrs Skidmore also reported that she had secured external support to undertake a financial due diligence review before year end Mr Timmis concurred with the comments made and emphasised the need to ensure robust controls and processes were in place and embedded within the organisation. RESOLVE: THE GOVERNING BODY RECEIVED the Finance and Contract Report to 31 January 2018 (Month 10) and NOTED the further deterioration in the CCG s financial position by 4.650m, resulting in a forecast in year deficit of m. Minute No. GB /19 Finance Plan and Budget 12.1 Mrs Skidmore presented the Finance Plan and Budget for 2018/19 for consideration by the Governing Body, which she noted had been developed in line with the 2018/19 planning rules Mrs Skidmore reported that the paper sets out how the 2018/19 finance plan had been constructed and drew attention to the risks inherent in the figures. Page 7 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

11 12.3 Mrs Skidmore advised that final sign off was not yet possible due to a number of outstanding issues that may materially impact on the CCG s ability to deliver its plan and proposed that a further report be brought to the April Governing Body meeting once the final position was clearer and in readiness for submission of the final plan to NHS England by 30 April Mrs Skidmore highlighted the following key points: a) Early modelling showed the CCG hitting its control total for 2018/19 ( 13.3m deficit) despite a significant deterioration in its underlying position during 2017/18. b) Planning guidance and national tariff headlines had been published and set out the key elements and requirements for CCG plans, which included: Tariff inflation 2.1%, efficiency 2% hence net 0.1% uplift HRG4+ now fully incorporated into tariff and recurrently in RRL IR (specialised services) allocation changes now recurrently in RRL National acute activity growth assumptions should be planned for c) In constructing its plans the CCG had applied inflation and growth assumptions as shown in point 25 of the report. d) A recent requirement to plan at national activity growth levels (which far exceed the CCG s modelled requirement) meant that there was not sufficient coverage in the CCG s QIPP programme to absorb the additional cost ( 5m). Hence the initial plan recently submitted to NHS England indicated that the CCG would achieve an 18.3m deficit in year rather than 13.3m. e) The impact of updating the CCG s Long Term Financial Model (LTFM) for the percentages would increase planned spend by 5m. The current finance model proposes a budget that misses the CCG s required control total ( 13.3m) by 5m, as the CCG was currently unable to confidently identify a further 5m QIPP that it could deliver in-year to accommodate a plan for spending this additional money. Also, it was noted that local modelling suggested that the national growth assumptions did not align with the CCG s view of the levels of activity that it needed to commission nor did it align with the current transformation work underway. f) Setting aside the 5m cost impact of national growth, the CCG s current QIPP programme of 19.4m (4.4% of the CCG s total allocation) was hugely challenging but should be deliverable. To date 18.7m QIPP schemes had been identified, but it was noted that it was getting increasingly difficult to find schemes which would exceed the QIPP target and that the Governing Body may need to consider other unpalliative options. g) The CCG had an accumulated deficit that would be carried forward each year, which was still required to be repaid in full. Therefore, the CCG s 2017/18 exit deficit of 24.1m would be added to the historic brought forward of 32.6m and which meant that the CCG would enter 2018/19 with a historic debt of 56.7m to repay. h) Risks totalling 12m had been identified, for which around 7m of mitigations had been found. This meant that the CCG plan opens the 2018/19 financial year with an unmitigated risk in the region of 5m. 7m of the 12m reported risk was attributable to QIPP risk which was a reflection of the fact that some contract negotiations were yet to be completed. i) Final Governing Body approved plans were not due to be returned until 30 April and, therefore, there was time for the CCG to finalise its contract negotiations and agree a position on planned growth with NHS England before the Governing Body needed to finally sign off 2018/19 budgets Mrs Skidmore advised that the draft plan had been submitted to NHS England last week showing that the CCG would miss its control total by 5m, ie the CCG would achieve an 18.3m deficit in year rather than 13.3m, which did not meet the planning requirements. In reporting a variance from control total at this stage Mrs Skidmore noted that this would mean that the CCG would not be able to access the Commissioner Support Fund. Page 8 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

12 12.6 Mrs Skidmore also reported that contract negotiations had not concluded with providers and she, therefore, proposed that the plan was accepted by the Governing Body at this stage as a working draft Once local contract negotiations and national discussions about planned growth were complete, the plan could then be refreshed with firmer figures and a final draft presented to the April Governing Body meeting for approval. By this time the CCG would have a greater sense of the true level of risk within its budgets and know more about the national growth requirement Dr Povey opened discussion to Governing Body Members, the following points were noted: a) Mrs Porter asked if there were any potential risks in relation to completing contract negotiations with providers. Mrs Skidmore advised that current negotiations were moving in the right direction, with SATH having the largest gap at present, but she was confident that an agreement would be reached shortly. b) Dr Sokolov expressed concern that having to meet the planning requirements, particularly in relation to the national acute activity growth assumptions, would create a cost pressure for the CCG and was at odds with the CCG s modelled requirements. Dr Freeman acknowledged Shropshire s position, but highlighted that there were a number of other CCGs that required the activity growth, therefore, the national planning guidance had been set to take this into account. Dr Freeman advised that it was for the CCG to have separate discussions with NHSE in relation to seeking a variation to the planning guidance. c) Mr Bletcher felt that the report provided Members with a good level of detail and advised that the issue around the national acute activity growth assumptions should be raised at the CCG s next regional escalation meeting to see if a variation to the planning guidance could be agreed. d) Mr Timmis welcomed the report and agreed that the Governing Body was not in a position to sign off the budget at present. He advised that the Finance & Performance Committee had had detailed discussions in relation to the budget setting and planning for 2018/19 and noted that there remained a level of risk, particularly in relation to QIPP, which was significantly challenging. Mr Timmis felt that transformational changes were required, which needed to be delivered through the STP. e) Dr Povey noted that currently the 2018/19 budget had approximately 5m of unmitigated risks, a gap of 655k in its QIPP programme and potentially 5m attributed to the national acute activity growth assumptions, totalling 11m, which would have a negative impact on the CCG s cumulative deficit. f) Professor Thomson agreed with Dr Sokolov s comments in relation to the planning guidance and highlighted that nationally Shropshire was not recognised as a rural county and, therefore, was not attracting appropriate national funding. Professor Thomson advised that Public Health England and the Local Government Association had raised the issue of rural health inequalities nationally and that it had been recognised that the rural planning guidance was incorrect. Professor Thomson acknowledged that the CCG needed to work within the guidance, but felt that these issues should be recognised by NHS England nationally. Dr Freeman emphasised that there were clear rules in relation to rurality and acknowledged that there were some areas of the county that met the criteria, but overall Shropshire did not. This was particularly the case for rural maternity tariff uplifts, whereby the CCG did not meet the national criteria. g) Mr Vivian welcomed the approach taken in the report, but noted that there would be an impact on other organisations within the local health economy as a result of the CCG having to deliver its QIPP target. Furthermore, Mr Vivian sought assurance that quality and innovation would not be overlooked when delivering the QIPP programme. Dr Povey emphasised the quality and safety was fundamental in the provision of healthcare and that QIPP ensured the best use of resources whilst providing high quality healthcare for patients. Dr Povey acknowledged that the STP needed to move towards a system wide budget in order to ensure partnership working. Mrs Skidmore also reported that all QIPP schemes were underpinned by Quality Impact Assessments (QIAs), Privacy Impact Assessments (PIAs) and equality assessments, in order to ensure robust evidence based decisions were made, which were not predominantly driven by finance. Mrs Skidmore advised that not all QIPP schemes were patient facing, some related to contractual issues. RESOLVE: THE GOVERNING BODY: RECEIVED the 2018/19 Finance Plan and Budget and NOTED the level of risk associated with it. Page 9 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

13 SUPPORTED the plan as a draft as it was subject to the conclusion of a number of outstanding issues which were noted in the report. AGREED to receive a further Budget paper at the April meeting in readiness for submission of the final plans to NHS England by 30 April ACTION Mrs Skidmore to present 2018/19 Finance Plan and Budget to April Governing Body meeting. Minute No. GB Corporate Performance Report 2017/ Dr Julie Davies presented the Corporate Performance Report 2017/18 which outlined the CCG s performance to date against the key performance indicators that the CCG was held accountable for with NHS England. The report also provided assurance on performance achievement against targets/standards at CCG and provider level as appropriate, and the delivery and contractual actions in place to address areas of poor performance 13.2 Key standards that had not been achieved were noted as follows: a) Cancer Targets The 62 day Referral to Treatment (RTT), screening, 2 week breast symptoms and 2 week wait cancer performance targets for the CCG were not being achieved, but SATH, its main provider, continued to achieve all targets except the 2 week breast symptoms which was just below target year to date (YTD) at Month 9 due to in month failure which was mainly due to cancellations as a result of the bad weather in early December. The CCG s overall cancer performance remained affected by out of county providers, which was continually being progressed through the corresponding lead commissioners via the contract team with support as required from NHS Improvement (NHSI). b) A&E 4 hour target A& A&E performance remained significantly challenged and January was the lowest performance YTD (66%), although there had been a slight improvement in the February performance. Demand remained on plan for Shropshire at Month 10. However, ambulance conveyances had increased and there were 30 >12 hour trolley waits reported in A&E at SATH in January. Root Cause Analysis (RCA) of these have been received by the CCG and were being reviewed in detail at the contract Clinical Quality Review Meeting (CQRM)with the Trust. Workforce and levels/timeliness of patient discharges remained the key underlying issues. Six priority action areas were agreed with the A&E Delivery Board in January. The draft work plans were presented back to the Delivery Board and NHSE in February. These were currently being updated following feedback from the Board and the regulators and would be used to mitigate risks over Easter. Additional expertise was continuing to be brought in from the national Emergency Care Improvement Programme (ECIP) team as required to support system recovery. Dr Davies particularly wished to record her thanks to Shropshire Council for their help in supporting complex discharges. c) Ambulance Handovers Although there had been an deterioration in the over 1 hour ambulance handovers in January, compared to the previous month, it remains better than the same period last year. This was as a result of improved working between the Hospital Ambulance Liaison Officers (HALOs), the SATH corridor nurses and Emergency Department (ED) staff. The deterioration was due to the sheer volume of ambulances at times presenting at the EDs which were more than they were designed to cope with for sustained period. d) Referral to Treatment (RTT) The CCG dipped below the RTT target in December despite SATH continuing to deliver the target. It was noted that this would continue to be at risk from January due to the nationally agreed extended period of cancellations during the month of January to allow the system to better manage winter pressures. e) >52 week waiters The CCG had 3 over 52 week waiters (2 at Wye Valley and 1 at Worcester) in December, all were related to trauma and orthopaedics. Full contractual levers were implemented against poor performance with any provider and the CCG performance lead received a forward look of all >40 weeks waiters at all providers to try and minimise such breaches in the future. Page 10 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

14 13.3 Mr Hutton referred to the Delayed Transfer of Care (DTOC) performance at Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (RJAH) which he felt was high (6.3%), given that the Trust mainly undertook elective procedures. Dr Davies reported that the issue related to a low number of spinal patients who had long length of stays and who required complex support packages from a number of different local authorities before they could be discharged Dr Rysdale referred to the significant pressure facing A&E and noted that although the RCAs did not show harm to individual patients, there was evidence that there was overall harm to patients due to toxic overcrowding, which was not just an issue for Shropshire but nationally. Dr Rysdale was concerned that demand did not appear to be decreasing and felt the that mitigating actions that had been identified may not have a significant impact in the short term. Dr Davies referred to the six priority actions that had been identified through the A&E Delivery Board, one of which she noted related to demand and capacity, and acknowledged that the although the impact may not be seen in the short term it would prepare the system for next Winter Ms Clarke concurred with Dr Rysdale s comments and highlighted the difficulty in quantifying the impact across the local health economy. Ms Clarke noted that a number of the patients who had breached 12 hours were later discharged home, therefore, Ms Clarke felt more work was required to look at the appropriateness of A&E attendances Dr Lynch referred to the NHS 111 data contained in paragraph 43 of the report and felt that there needed to be greater comparative data in order to understand the impact on A&E and ambulance service. Mr Shepherd endorsed Dr Lynch s comments. Dr Davies advised that the greater detail was presented to the Finance & Performance Committee and that she would include this in future performance reports presented to the Governing Body Dr Davies also advised that a piece of work was underway with the Regional Commissioner to look at ambulance demand and conveyance rates in order to mitigate the increase in demand Dr Sokolov referred to the additional expertise from the national ECIP team to support the urgent care system s recovery and asked when the output from their work would be known. Dr Davies advised that she would ask Mrs Claire Old, Urgent Care Director, to provide an update to the April Governing Body meeting. RESOLVE: THE GOVERNING BODY RECEIVED the CCG s Performance Report 2017/18 and NOTED the key standards that were currently not being met and the mitigating actions put in place to recover performance. THE GOVERNING BODY AGREED the following actions: Dr Davies to continue chairing monthly Planned Care Working Group meetings with RJAH and SATH to oversee recovery and sustainability of RTT and cancer performance. Dr Davies to be the Executive Lead for the system demand and capacity action area within the system A&E recovery plan. Dr Freeman to continue to attend A&E Delivery Board to ensure SCCG s contribution to the A&E recovery trajectory was delivered. ACTION Dr Julie Davies to include further NHS 111 comparative data in future Corporate Performance report. Dr Julie Davies to ask Mrs Claire Old, Urgent Care Director, to present Urgent Care update to April Governing Body meeting. Minute No. GB Contract Performance Report 14.1 Mr Millar presented the Contract Performance report to the Governing Body. The report summarised the current major contract performance reports detailing the activity as at Month 9 (December 2017) for the CCG s four main contracts: Shrewsbury and Telford Hospital NHS Trust (SATH) Page 11 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

15 Robert Jones and Agnes Hunt NHS Foundation Trust (RJAH) South Staffordshire and Shropshire Healthcare Trust (SSSFT) Shropshire Community Health Trust NHS Trust (SCHT) 14.2 Mr Millar highlighted the following key points from the report: Shrewsbury & Telford Hospital NHS Trust (SATH) a) SATH Activity was on plan, there was a slight over performance in day cases, first and follow up outpatient attendances. Elective, non-elective and critical care were all under plan. Robert Jones and Agnes Hunt Trust (RJAH) b) Day cases at RJAH were continuing to underperform by 20%. South Staffordshire & Shropshire Healthcare NHS Foundation Trust (SSSFT) c) A Contract Performance Notice (CPN) had been issued to SSSFT regarding the performance of the Early Intervention in Psychosis Pathway indicator. d) A CPN had also been issued to SSSFT due to concerns regarding the 0 to 25 service West Midlands Ambulance Service (WMAS) e) An Activity Query Notice (AQN) had been raised through lead commissioner following significant over performance in activity with West Midlands Ambulance Service (WMAS). Out of County Providers f) There was over-activity in the out of county providers particularly in Outpatients and Emergency Admissions notably at Wye Valley and Worcester Dr Lynch referred to point 39 of the report, in relation the ICS specification and asked when an agreement was likely to be reached, as was fundamental to the delivery of the Shropshire out of hospital model Mr Millar advised that collaborative work continued with SCHT and the local authority in order to agree the ICS specification, which would be robustly managed through the 2018/19 contract Dr Lynch also referred to point 50 of the report, in relation to out of hours medical cover in community hospitals, where it indicated that the service had continued to be provided by Shropdoc, when in fact there had been a break in cover arrangements. Dr Lynch sought assurance that this service would continue following contract negotiations with SCHT and Shropdoc. Mr Millar advised that he ensure this was picked up at the next contract meeting Mr Shepherd referred to the number of CPNs at SSSFT and noted that the Trust had submitted an expression of interest in acquiring SCHT, but their current performance gave him cause for concern and sought assurance that robust processes were in place to monitor their performance. Dr Davies advised that the Trust had developed a Remedial Action Plan (RAP) as a result of the CPNs and other performance issues that had been raised. Dr Davies advised that she would include an update on progress against the RAP in her next performance report. RESOLVE: THE GOVERNING BODY RECEIVED the Contract Performance Report for Month 9 (December 2017) and NOTED the current performance and actions being taken with each of the four main providers. ACTION Mr Charles Millar to ensure issue of out-of-hours cover at community hospitals was picked up at next Shropdoc contract meeting. Dr Julie Davies to include update on SSSFT performance against Remedial Action Plan in next Corporate Performance Report. Minute No. GB Quality Exception Report 15.1 Ms Clarke presented the Quality Exception Report which provided assurance to the Governing Body that processes were in place to monitor quality performance within the CCG s commissioned services, Page 12 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

16 ensure remedial action was in place where concerns had been identified and to escalate where appropriate Ms Clarke highlighted the following key points from the report: a) #EndPJ Paralysis Challenge - 10 days of bed rest in hospital (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80 (Graf 2006 Am J Nursing). Therefore, as part of the NHS 70 celebrations, NHS 70 had published the #EndPJ paralysis challenge beginning, 17 April to 26 June The aim was to focus on patients time by encouraging hospitalised patients to get up, dressed, moving and home first. This was aligned with other initiatives including #Red2Green, #Fit2Sit, the SAFER patient flow bundles, Sepsis Six, Discharge2Assess and #homefirst. It was noted that SATH has already committed to this challenge. b) SATH A&E (12 hour trolley breaches) - SATH had experienced increasing pressure in its Emergency Departments (ED). In January and 30 x 12-hour trolley wait breaches were reported. The CCG has received and reviewed the 72- hour reports for these patients. In all cases there were no immediate actions required to ensure the safety of patients, staff or the public. No harm to patients was identified. Due to the pressures in acute systems an unannounced joint visit with NHS Improvement, NHS England and CCG was undertaken in February to review the urgent care pathway at Royal Shrewsbury Hospital (RSH) to seek assurance that patients were safe. The team explored the views of staff on patient care and observed the ED, Acute Medical Unit (AMU), Surgical Assessment Unit (SAU) and Clinical Decisions Unit (CDU). The visiting team did not observe any patient safety issues whilst in ED, AMU, SAU or CDU. However, the team were concerned that patients remain boarded on these wards, although the appropriate assessments were in place to ensure patients were safe, the patient experience was affected by being boarded. The report was currently being finalised to be sent to the trust for comment and action. c) Getting it Right First Time Obstetrics and Gynaecology Review - The CCG had received SATH s NHS Improvement Getting It Right First Time (GIRTF) Obstetrics and Gynaecology Review report and implementation action plan. The GIRFT report provided evidence of the Trust s positive low percentage figures for instrument births, caesarean rates and episiotomies. d) 0-25 Emotional Health and Wellbeing Service - The CCG continued to raise concerns with the provider in the absence of quality and safety data reported to provide an acceptable level of assurance in terms of providing a safe and high quality service. A formal remedial improvement action plan was now in place to address the many concerns identified. Dr Davies agreed to present update on 0-25 Emotional Health and Wellbeing Service to the April Governing Body meeting. e) Looked After Children s (LAC) Services - Provision of LAC Services provided by SCHT continued to be raised as a concern with the provider. Progress had not been as timely as expected and a formal contracting information reporting breach notice had been issued by the CCG. A RAP had been received from the Trust in line with contractual requirements Dr Lyttle referred to the 12 hour trolley breaches and was concerned by the statement that in all cases there were no immediate actions required to ensure the safety of patients. Ms Clarke explained that a Root Cause Analysis (RCA) was undertaken for all cases and although no harm to patients was identified, it was acknowledged that patient experience was affected. Dr Rysdale gave assurance that the patients getting the care they required and given appropriate medication, food and drink, but acknowledged that it was not an ideal situation Mr Hutton referred to the staff absences and sickness levels identified following a visit to Bishops Castle Community Hospital and sought assurance that this was not replicated across other community hospitals. Ms Clarke gave assurance that regular announced and unannounced visits were undertaken at the community hospitals and that she was not aware of any issues at present Dr Lynch also raised concern with the lack of physiotherapy services at Bishops Castle Community Hospital at present, which she felt was fundamental to the rehabilitation of patients. Dr Davies reported that a full-time locum Physiotherapist had recently started at the community hospital and that recruitment for a substantive post was underway Ms Clarke acknowledged that there was workforce issues nationally and that the STP Workforce workstream was picking up the issues locally. Page 13 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

17 RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the key issues outlined in the Quality Report and actions being taken. ACTION Dr Davies to present an update on 0-25 Emotional Health and Wellbeing Service to April Governing Body meeting. GOVERNANCE Minute No. GB Healthwatch Report 16.1 Mrs Randall-Smith gave a verbal update in relation to the activities of Healthwatch Shropshire (HWS) during January and February 2018, as follows: a) Hot Topics For the Hot Topic in January, HWS participated in the Healthwatch England s Campaign, #SpeakUp. The purpose was to highlight the importance of sharing experiences and how they could be used to make a difference. For February and March the Hot Topic would be focusing on equipment services and assistive technology. Mrs Randall-Smith advised that HSW was keen to hear of people s experiences of NHS and Social Care equipment and aids. Any comments received would be shared anonymously with those who commission the service and the providers. Other intelligence - In January and February HWS received 54 comments. The 5 main topics covered by the feedback were: Access to services (15 comments: 12 negatives / 3 positives) Waiting time once arrived at appointment (5 comments: 4 negatives 1 positive) Information provision (5 comments: 3 negatives 2 positives) Medication (3 comments all negative) Waiting time and list for treatment (4 comments: 3 positive 1 negative) In terms of providers, HWS continued to receive comments on the Midwife Led Units (MLUs). Although the reopening of the three freestanding MLUs were welcomed, there were concerns due to the short notice closures. Mrs Randall-Smith noted that HWS was supporting the development and work of the Maternity Voices Partnership locally. b) Communications & Engagement HWS continued to support the preparation for the NHS Future Fit consultation. The Community Engagement Officer would be attending a Consultation Institute training course focused on the role of Local Healthwatch in consultation. In terms of engagement with community groups, it was clear that people wanted to know what was happening with NHS Future Fit and what it would mean for them. c) Enter & View Visits All Enter & View reports were published on the HWS website. Reports published in January and February 2018 included: Inhealth Pain Management Solutions New ophthalmology ward, Royal Shrewsbury Hospital Bishops Castle Medical Practice Radbrook Green Surgery, Shrewsbury The published reports also included the reports on the first Enter & View visits to General practices in Shropshire. d) Governance - Following the recommissioning process, HWS was working to implement the requirements of the new contract, which starts on 1 April The new contract integrates the HWS contract and that for the Independent Health Complaints Advocacy Services. Mrs Randall- Smith reported that both contracts were affected by the reduction in forward funding. Therefore, it was agreed at its February Board Meeting that from 1 April 2018 HWS would reduce its opening hours to four days per week and would close on Fridays. Page 14 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

18 16.2 Mrs Randall-Smith also reported that following feedback received in relation to SSSFT an issue had been identified with their admin hubs, in particular an answerphone service. Mrs Randall-Smith advised that remedial actions had now been put in place as a result and it was agreed that Mrs Randall-Smith should share the feedback with Ms Clarke Mrs Randall-Smith highlighted that forward planning was currently taking place for to identify HWS specific priorities, Hot Topics and more in-depth pieces of work and welcomed any feedback from Members in this regard Dr Povey acknowledged the significant work undertaken by HWS and noted that Enter & View reports relating to general practices would be presented to the CCG s Primary Care Commissioning Committee in future. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the verbal update on the activities of Healthwatch Shropshire (HWS) during January and February ACTION Mrs Randall-Smith to share intelligence and feedback received by Healthwatch relating to SSSFT with Ms Clarke. Minute No. GB Remuneration Committee (including revised Terms of Reference) 17.1 Mr Hutton presented his summary report which provide the Governing Body with the key issues arising from the 28 February 2018 Remuneration Committee meeting, which were noted as follows: a) Due to the Conflicts of Interest arising from the matters being discussed, the Remuneration Committee was held in a number of parts with different memberships in line with the Terms of Reference. b) The Remuneration Committee considered the Pay Review for Very Senior Manager (VSM) Directors, GP Governing Body Roles, Secondary Care Clinician and Lay Members and deferred any decisions pending the outcome of the national pay review of Agenda for Change staff. c) The Remuneration Committee considered matters regarding clarification of the contractual status and terms and condition for some Governing Body members and after lengthy discussion requested additional information before making any decisions. A further meeting was scheduled in early March and has met to consider this item again. d) The Remuneration Committee considered matters regarding the creation of a new post on the Governing Body and agreed that remuneration would be decided upon by the committee once the Governing Body had given formal approval. e) The Terms of Reference (TOR) for the Remuneration Committee were reviewed and it was agreed that minor changes would be made to reflect the current number of Lay Members in the CCG. The revised TOR were presented for approval by the Governing Body. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the summary report on the key issues arising from the 28 February 2018 Remuneration Committee meeting and the decisions made. THE GOVERNING BODY APPROVED the revised Remuneration Committee Terms of Reference. FOR INFORMATION ONLY/EXCEPTION REPORTING Minute Nos. GB to GB The following minutes of the Governing Body Committees were received and noted for information only: Clinical Commissioning Committee 17 January 2018 Quality Committee 31 January 2018 Finance & Performance Committee 7 February 2018 Primary Care Commissioning Committee 7 February 2018 A&E Delivery Board 23 January 2018 Locality Boards - North Locality Board 25 January South Locality Board 15 November 2017 Page 15 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

19 - Shrewsbury & Atcham Board 18 January There were no specific points raised in relation to the minutes. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the minutes as presented above. Minute No. GB Questions from the Public 19.1 Dr Povey advised that he had not received any written questions and, therefore, opened the meeting to verbal questions/comments from members of the public. The following questions were noted: a) Mr John Bickerton Mr Bickerton referred to the capital funding for NHS Future Fit and asked if the delay was due to waiting for funding from Project Phoenix. Dr Povey advised that the CCG did not have any responsibility or jurisdiction over the funding for Future Fit and that a decision was awaited from NHS England. b) Mr David Sandbach Mr Sandbach advised that he had a number of questions to raise but would formally write to Dr Povey in this regard. Although Mr Sandbach wished to note his concern with regards to the leadership of the STP locally, which he felt should have an Independent Chair. c) Mrs Sylvia Jones, Clunbury Parish Council Mrs Jones asked when the CCG was likely to come out of formal directions and be able to make its own decisions. Dr Freeman reported that it would be for NHS England to determine the timescale for removal of the CCG s formal directions and that this would be considered after the CCG had submitted its long-term financial plan. Dr Freeman advised that by being in directions had allowed the CCG to benefit from additional resources and support and that the CCG continued to be in a position to make its own decisions. Mrs Jones referred to the workforce issues at SATH, in particular maternity services, where she advised Mr Simon Wright, Chief Executive, had indicated that staffing levels were at full capacity, but asked if this was the case why the rural MLUs were closing at short notice. Dr Freeman advised that the CCG did not manage maternity services and, therefore, suggested Mrs Jones raise her concerns with SATH directly. Dr Freeman acknowledged that the CCG had raised concerns with the Trust about the frequency of the short-term closures of the MLUs. Mrs Jones also asked when SCHT would be making available transformation data available, particularly in relation to MSK. Dr Davies confirmed that the CCG had received the information from SCHT and that it was currently being analysed and an update would be presented to the Programme Board. d) Ms Gill George, Shropshire Defend Our NHS Ms George referred to the switching off of the out-of-hours Shropdoc number in favour of the NHS 111 service. Ms George noted that this was a nationally mandated change and asked if it would, therefore, constitute being a significant service change and if there would be a legal requirement to undertake a public consultation, as Ms George noted that this would apply to any local service change. Dr Freeman advised he was unsure if it would technically constitute a change in service and felt that the question should be directed to NHS England. Ms George noted that a Pre-Consultation Business Case (PCBC) had been developed following the MLU review and asked when this would be publically available. Dr Freeman reported that the PCBC would be considered at the next CCG s Executive Team meeting and presented to the April Governing Body meeting. Page 16 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

20 Ms George also advised that she had written to Dr Freeman asking if the local maternity campaigners could make a written submission to the Clinical Senate, but as yet had not had a formal response. Dr Freeman advised that he did have an answer in relation to the Clinical Senate submission and that would respond to Ms George in due course. e) Councillor Madge Sheinton Councillor Sheinton welcomed an update on the 0-25 Emotional Health and Wellbeing Service at the next Governing Body meeting, as she had concerns in relation to its current performance Dr Povey thanked members of the public for their comments and closed the meeting to public questions. ACTION Dr Freeman to include MLU Pre-consultation Business Case as an agenda item on next Governing Body meeting. Minute No. GB Any Other Business 20.1 There were no items of any other business raised. DATE OF NEXT MEETING The next scheduled meeting of the CCG Governing Body is: CCG Governing Body Meeting (open to the public) Wednesday 11 April time and venue to be confirmed. SIGNED.. DATE Page 17 Minutes of the CCG Governing Body Meeting 14 March 2018 TEJ Shropshire Clinical Commissioning Group

21 Shropshire Clinical Commissioning Group ACTIONS FROM THE CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY MEETING 14 MARCH 2018 Agenda Item Action Required By Whom By When Date Completed/ Comments GB Matters Arising GB Corporate Performance Report Ms Clarke to check that a copy of Appendix 2 of the Quality Strategy & Delivery Plan had been circulated to Governing Body Members. Ms Dawn Clarke Immediately GB Quality Strategy & Delivery Plan 2018/19 Dr Freeman to raise the issue of the Sustainability & Transformation Plan (STP) Programme Board meetings being held in public at the next meeting. Dr Simon Freeman Next STP Programme Board GB Questions from Members of the Public Dr Freeman to meet with Mr Sandbach, Mr Shepherd, Mrs Randall-Smith and Councillor Sheinton in relation to the ongoing work on the Out of Hospital Programme Dr Simon Freeman As soon as possible GB Acute Ophthalmology Services Dr Davies to raise issue of referral pathway for adult squint services at the next Ophthalmology Task & Finish Group Dr Julie Davies Next Ophthalmology Task & Finish Group GB /19 Finance Plan and Budget GB Corporate Performance Report Mrs Skidmore to present 2018/19 Finance Plan and Budget to April Governing Body meeting. Dr Julie Davies to include further NHS 111 comparative data in future Corporate Performance report. Mrs Claire Skidmore Dr Julie Davies April Governing Body meeting Corporate Performance Report presented to April Governing Body meeting On the agenda Completed Dr Julie Davies to ask Mrs Claire Old, Urgent Care Director, to present Urgent Care update to April Governing Body meeting. Immediately Deferred to May due to A&E Escalation Meeting 18

22 Agenda Item Action Required By Whom By When Date Completed/ Comments GB Contract Performance Report 2017/18 Mr Charles Millar to ensure issue of out-of-hours cover at community hospitals was picked up at next Shropdoc contract meeting. Mr Charles Millar Next Shropdoc contract meeting Dr Julie Davies to include update on SSSFT performance against Remedial Action Plan in next Corporate Performance Report. Dr Julie Davies Corporate Performance Report presented to April Governing Body meeting GB Quality Exception Report Dr Davies to present an update on 0-25 Emotional Health and Wellbeing Service to April Governing Body meeting. Dr Julie Davies April Governing Body meeting On the agenda GB Healthwatch Report Mrs Randall-Smith to share intelligence and feedback received by Healthwatch relating to SSSFT with Ms Clarke. Mrs Jane Randall- Smith As soon as possible GB Questions from Members of the Public Dr Freeman to include MLU Pre-consultation Business Case as an agenda item on next Governing Body meeting. Dr Simon Freeman April Governing Body meeting On the agenda 19

23 Agenda item: GB Shropshire CCG Governing Body meeting: 11 April 2018 Title of the report: Carer Experience Account Phlebotomy Service Responsible Director: Ms Dawn Clarke, Director of Nursing, Quality and Experience Author of the report: Ms Jane Blay, Patient Experience Lead Mr Phil Stredwick, Patient Insight Officer Presenter: Mr Meredith Vivian, Lay Board Member Patient and Public Engagement Purpose of the report: For the Board to receive an experience account which highlights the real experiences of the individuals who use and deliver the services for which we are responsible. Key issues or points to note: A powerful and insightful account which demonstrates just how, despite best intentions in terms of clinical effectiveness and safety, access to services can become fragmented with the resultant negative impact for all concerned. The potential for this account to be shared as part of the ongoing Phlebotomy and Out of Hospital reviews to ensure optimum effect and influence. Actions required by Governing Body Members: Board Members are asked to: Review their associated level of influence to ensure that services are commissioned to meet the needs of all service users in an efficient, timely and caring patient centred way, to avoid the potential for poor patient/carer experience as highlighted in this Account. Support the approach to routinely seek and consider patient experience feedback as an integral part of service re-design. Proactively address and ensure that all learning outcomes are systematically identified and acted upon to ensure improvements are made for the benefit of all. Ensure feedback is shared with the family concerned to provide assurance that their experience has not only been listened to but duly considered in the re-design process.

24 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required Yes/No 2 Health inequalities If yes, please provide details of the effect upon health inequalities 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement 5 Patient and public engagement If yes, please provide details of the patient and public engagement 6 Risk to financial and clinical sustainability If yes how will this be mitigated Yes/No Yes/No Yes/ No Yes/ No Yes/ No

25 Patient Experience Report issues with provision of the Phlebotomy Service in Shropshire Sybil is a 90 year old with severe learning disabilities which includes an inability to communicate verbally in any meaningful way because of speech defects which are now exacerbated by her age. She also has profound age related deafness, has had 3 hip replacements which render her unable to walk and is in significant pain from deterioration of her hip joints. Her sister, my mother, is Sybil s legal guardian. She has been a resident at a local Residential home for about 40 years and is very happy there. On Thursday 14 th December staff at the home noticed a lump on Sybil s leg and called the local GP to look at it. The GP visited at around 2.00 pm. There was a apparently some discolouration on her upper leg as well and the GP was concerned that this may be due to a blood clot but needed Sybil to have a blood test to confirm this before any medication could be started. The GP advised that an ambulance would need to be called to take Sybil to have the blood test and that there was a 4 hour window for this to happen. The home phoned my mother who is 86 years old, and she was on stand-by to attend the hospital with Sybil (she would have to drive there herself) to interpret and explain what was required to the medical staff and reassure her sister. I rang my mother at 6.00 pm for a chat and she told me that she could not stay on the phone because she would be getting a call at any moment to go to the hospital with Sybil as it was 4 hours since the GP had visited. It was a cold, wet winters night and I insisted that Mum who is frail herself was not going anywhere, and that I would go to the hospital to meet my Aunty and liaise with staff. Mum eventually agreed and I rang the home to tell them to ring me when the ambulance arrived. Meanwhile, I was really concerned that this was assumed to be the best way to proceed with someone so old and frail, particularly as I could not understand: 1. Why the GP had not taken the bloods herself 2. The district nurse who seems to visit the home most days was not asked to do the bloods and take them back to the hospital when she returned to Shrewsbury 3. There was an assumption that someone so old and frail was best served by being loaded into a transport ambulance and taken to the hospital for a simple blood test the costs of this seemed to me to be prohibitive and the patient experience of someone so immobile, with Severe Learning Disability and no understanding of what or why this was happening, could only be a negative one at that time of night. 4. The risk of exposure to infection and the taking up of valuable time in an A&E department for a routine procedure seemed not to be a sensible use of resource for anyone. 5. How, after hours, in a stretched A&E, there was going to be any chance that my aunt would be seen quickly, if at all, and my suspicion was that she would simply sit on a trolley all night until staff came in at 9.00 am to do the blood test routinely. I therefore rang 111 and asked for advice on whether this was indeed the way that blood tests were done in Shropshire and why they were not done by the GP or district nurse or a mobile phlebotomy team at the home for frail elderly patients. Unfortunately I got the new recruit who seemed

26 completely unable to understand what my concerns were or why I was asking if it was necessary for my aunt to be carted off to hospital at this time of night (it was now after 7.00 pm). Eventually, advice was sought and I was informed that Yes an ambulance has been ordered, but it wasn t actually ordered by the GP until about 4.30 and because they were so overstretched and there was no likely ETA to collect my aunt who was already totally bewildered because she was not being allowed to go to bed at her normal time at home. I was appalled, as it seemed my aunt would be waiting until the early hours and still unlikely to get the blood tests done and be returned to her home before morning. I therefore rang Shropdoc and insisted on speaking to a GP (by now it was close to 8.00 pm) to ask if they really thought that this was the best way to proceed with a 90+ year old frail lady with Learning Difficulties, and whether this was in the patient s best interests. Fortunately I spoke to a very sensible GP who appeared equally appalled at what was happening. However, as she quite rightly pointed out, there was a risk that there was a blood clot and to delay until the following day may result in my aunt dying. I explained that in my view, and the family s opinion, we would rather that Sybil died peacefully in her own bed, surrounded by people who knew her, following her usual routine, than in a bewildered state, probably in pain, on a trolley in A&E surrounded by strangers. I said that I felt it was a reasonable risk to wait until daylight and get this done in a timely way when services were available. The GP at Shropdoc agreed and offered to ring my mother and get her consent as Sybil s legal guardian, to cancel the transport and re-arrange it for the following morning. My mother confirmed that this was her wish and the transport was therefore re-organised for 9.00 am the following morning. Sybil was transferred to the hospital, my mother accompanied her, she was admitted to a bed in a unit near the A&E and was very well looked after with blood tests and x- rays being done in a timely way and Sybil returned to the home later that afternoon. Staff in the unit confirmed that there was no way the blood tests would have been done overnight and Sybil would indeed have sat in A&E. Conclusion: It seems to me that there are a number of questions that need to be asked about this experience and some consideration of whether there is a better way to arrange blood tests to be done without this use of expensive resources and unnecessary transfer to a hospital which is already overstretched. Sadly, I can say with confidence, that no-one will have fed back to the GP who unwittingly started this ridiculous process (in all innocence I am certain and asked that the implications of her decisions be discussed and reviewed to prevent this happening again. Will someone do this? I appreciate that much of the problem lies with the fact that services are managed by so many different bodies now and there is little or no meaningful communication because no-one has the time or energy to challenge anything outside their direct control. Perhaps consideration of cases like this, where patient experience came at the bottom of the pile in the way this was handled, might form the central pillar of any review of phlebotomy services. Noone appears to have asked that basic question Is this really the best way to do this when we have a

27 frail elderly patient with SLD and significant mobility issues? Surely someone should be asking this question at every step of the process. When the decision is made to request a blood test When the transport is ordered When the delays occur and someone is reviewing the list of transport requests Such a simple thing, taking blood, but it is turned into a major, costly, distressing exercise because someone has decided that the phlebotomy service needs to make savings. That may well be achieved in the Phlebotomy budget line, but someone else, in another team picks up the costs instead. I suspect any analysis of those costs would prove them to be prohibitive in comparison to some sort of flexible mobile service involving various health professionals who are out in the community every day. I was asked to provide this patient experience because there is to be a review of the phlebotomy service. I hope that this will inform that review and that managers who make these decisions about cost savings will actually consider the bigger picture rather than just focusing on the individual service. A simple requirement on your part to always ask What will be the impact on the range of patients that we provide this service for, and how have we assured ourselves that we have mitigated that impact and considered the wider cost implications in a considered and joined up service? I m sure you already ask the first part of this, but do you reflect on the whole?

28 Agenda item: GB Shropshire CCG Governing Body meeting: 11 April 2018 Title of the report: QIPP Update, M11: February 2018 Responsible Director: Claire Skidmore, Chief Finance Officer Author of the report: Kim Morris, Head of PMO Presenter: Claire Skidmore, Chief Finance Officer Purpose of the report: To inform the Governing Body of the performance of the QIPP programme to date as incorporated in the month 11 finance position. Key issues or points to note: At month 11, an outturn delivery of m against the target of 17.71m has been reported. The forecast outturn (FOT) net position has decreased slightly by 169k in month 11 from 16,224k reported at month 10 to 16,055k. Project managers are focusing energies on development of schemes for 2018/19 as the QIPP target for the year will be significant based on current budget projections. An update on 2018/19 plans is incorporated into a separate budget paper for Governing Body. Actions required by Governing Body Members: To note the reported Month 11 position. 1

29 Introduction 1 The purpose of this report is to provide information and assurance to the Governing Body on the progress of the 17/18 QIPP Programme. 2 Note that 2018/19 QIPP information is provided in a seperate budget paper. QIPP programme for 2017/18 3 At month 11, an outturn delivery of m against the target of 17.71m has been reported. 4 The Finance and Performance Committee noted that whilst the month on month change to the bottom line forecast was small, some line items that had driven this movement were more significant. 5 Underperformance in savings in Primary Care ( 673k down shift on earlier reported FOT) and Continuing Care Services ( 556k down shift on earlier reported FOT) have been offset in the main by improvements in the positions for VBC and MSK ( 896k). 6 Over the past quarter, the finance team have undertaken a thorough review of each project line. This has resulted in the resetting of some figures in order to more accurately reflect the delivery position. (Note that this is only a change to the reported delivery position, it does not impact on the finance position as savings manifest in the position as they occur and are forecast accordingly). 7 The table and graphs below demonstrate month on month progress against plan for 2017/18. 8 Table /18 schemes Year to Date and forecast outturn Graph 1 Monthly QIPP Delivery v s Plan Graph 2 Cumulative QIPP Delivery v s Plan 2

30 Table 1 3

31 Graphs 1 & 2 4

32 QIPP Performance and Monitoring 2017/18 9 During February there have been weekly Director sessions held by Simon Freeman supported by the Turnaround Director to review scheme finance profiles, risks and issues for escalation. Risks Project Risk - Finance 10 At month 11, Nil risk was reported in non ISFE, all risk has now been incorporated into the financial position. Programme Risk 11 Programme risks and issues were considered by the Finance and Performance Committee. Key areas of high risk are already known to the Governing Body via its consideration of the Board Assurance Framework. These are: (i) QIPP project delivery risk due to capacity restraints within CCG teams and (ii) The impact of QIPP slippage on the overall financial position of the CCG. Summary and Conclusion 12 Despite forecasting to not achieve the full 17.7m QIPP target for 2017/18, it should be recognised that the CCG has done well to deliver the level of savings that have been achieved this year. Particular successes in VBC, prescribing and CHC should be noted. 13 Delivery of an ongoing programme of QIPP at the current required levels does however remain challenging for the CCG. The organisation will therefore continue to remain proactive in delivering and developing schemes to drive savings. 14 The CCG will commence 2018/19 with a level of unallocated QIPP. The team remain committed to identifying additional projects that will close the QIPP gap and the risk associated with the unallocated figure is reported as a financial risk. Recommendations The Governing Body are asked to: note the reported Month 11 position. 5

33 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required No 2 Health inequalities If yes, please provide details of the effect upon health inequalities No 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement 5 Patient and public engagement If yes, please provide details of the patient and public engagement 6 Risk to financial and clinical sustainability The CCG is reliant on delivery of a substantial QIPP target to ensure that it meets its financial control total and as part of its trajectory to regain financial balance. No No No Yes 6

34 Agenda item: GB Shropshire CCG Governing Body meeting: Title of the report: Responsible Director: Update on the Remedial Action Plan raised for Child and Adolescent Mental Health Services (CAMHS) or the 0-25 Emotional Health & Wellbeing Service Julie Davies, Director of Performance & Delivery Authors of the report: Collen Manhuwa, Commissioning & Redesign Lead Lisa Wicks, Deputy Director of Performance & Delivery/Head of Out of Hospital Presenter: Lisa Wicks, Deputy Director of Performance & Delivery/Head of Out of Hospital Purpose of the report: The purpose of this paper is to inform the Governing Body of progress made in the remedial action plan for the services commissioned through South Staffordshire and Shropshire Healthcare Foundation Trust (SSSFT) for CAMHS (0-25 Emotional Health and Wellbeing Service). The Remedial Action Plan (RAP) was agreed with the Trust in January 2018 following a Contract Performance Notice issued on 30 th November Background to the issues: On the 1 st of May 2017 the CCG together with Telford and Wrekin CCG, awarded a new contract to South Staffordshire and Shropshire Healthcare Foundation Trust (SSSFT) for a 0-25 Health and Wellbeing Service, commonly known as CAMHS from Shropshire Community Trust. This service is not a mirror image of the previous CAMHs provision provided by Shropshire Community Trust but a very different and progressive portfolio of services which has very much been modelled together with the young people it serves. Fundamentally it is a different model of care, with an underlying core principle that emotional health and wellbeing services are provided as partnership across many different organisations. In May 2017 SSSFT quickly identified that there were issues within the service that required urgent action. These included; High consultant caseloads. Long waiting lists. The model of the service was based on a medical model. It was established that the staff skill mix, the practises and the change would take some time to embed and effect. 1

35 Key issues or points to note: Pre mobilization work with the service was inaccurate and the service has required substantial redesign due to the following issues: Robust management structures were not in place Clinical leadership was not an integral part of the service model Robust governance structures were not in place (incident reporting, insufficient clinical/management supervision, insufficient staff development/training etc) Lack of robust information system Multi-disciplinary working was not taking place in the service Lack of psychological treatment options available Formularies not following best practice guidelines Medical staffing caseloads were very high Physical health monitoring not routine Ineffective business processes Long waits for service users Skill mix within clinical teams not appropriate Ineffective discharge planning SSSFT have worked with staff to make a number of changes which include: Implemented an access team where initial assessments and brief interventions can be offered at first point of contact with the service. Clarified that the new model is a psychological model by appointing a Consultant Clinical psychologist as clinical lead for the service. Created clearly defined pathways for service delivery. Implemented electronic patient records which allows clinicians to have access to patient records at any location and allows risk assessments and care plans to be kept updated and shared with other clinicians working with that young person. Actions required by Governing Body Members: The Governing Body members are asked to note the prevailing issues in the service. It is important to note that whilst the Trust has not met all targets which were set as milestones for May 2018 this is linked to the ability to retain and recruit key personnel and the increased caseload from Looked After Children who were previously outside the scope of the contract. Monitoring of the RAP is taking place via the Contract Board Meetings and through the Operational Task and Finish Groups with key actions and contingencies agreed monthly. Due to the level of concern regarding this service monthly updates will be brought to the governing body until such time that the board is assured sufficient progress is being made. 2

36 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications n/a 2 Health inequalities n/a 3 Human Rights, equality and diversity requirements n/a 4 Clinical engagement Yes Engagement is required with primary care and GPs 5 Patient and public engagement Engagement is required with patients and the public in relation to the new service delivery model and challenges being faced by the Provider Yes 6 Risk to financial and clinical sustainability n/a 3

37 NHS Shropshire CCG Clinical Commissioning Group Update on the Remedial Action Plan raised for Child and Adolescent Mental Health Services (CAMHS) or the 0-25 Emotional Health & Wellbeing Service Author: Collen Manhuwa & Lisa Wicks Background 1 On the 30 th of November 2017, Shropshire and Telford and Wrekin CCGs raised a contract performance notice (CPN) to the contract provider SSSFT for the Child and Adolescent Mental Health Services/0-25 Emotional Health & Wellbeing Service around service issues which were affecting delivery of the service specification within the contract. Issues affecting the delivery of the Contract 2 Pre mobilisation work with the service was inaccurate and the service has required substantial redesign, namely: o Robust management structures were not in place o Clinical leadership was not an integral part of the service model o Robust governance structures were not in place (incident reporting, insufficient clinical/management supervision, insufficient staff development/training etc) o Lack of robust information system o Multi-disciplinary working not taking place in the service o Lack of psychological treatment options available o Formularies not following best practice guidelines o Medical staffing caseloads very high o Physical health monitoring not routine o Ineffective business processes o Long waits for services o Skill mix within clinical teams not appropriate o Ineffective discharge planning Progress made within the Service 3 The following progress has been made since the contract was awarded: New systems have now been implemented. Kooth have established their online offer and increasing numbers of young people are accessing this service. The Children s Society have established 2 drop in facilities and support groups. Healios are offering additional psychological assessments and interventions. Within the specialist mental health service there has been the following developments: o o o A clinical management of change has been completed to assign staff to core elements of the specialist service. Operational management roles have been advertised along with other clinical posts. Prescribing practices have been reviewed. 4

38 o o o An electronic patient record has been implemented and all children have been added to the open caseload. The service are now in the process of reviewing approximately 3,300 young person s cases in RiO to ensure that they have appropriate risk assessment, care plan and whether any further intervention is required. It is envisaged that this will take an additional 6-8 weeks to fully cleanse the data and review cases. From this work SSSFT will be able to identify fully the clinical need: including the number of assessments, estimated number of intervention packages, including individual psychological therapies, group work and family therapy. Alongside the clinical review, demand and capacity analysis will be undertaken to ascertain what additional capacity/time is required to address the backlog of work. This piece of work will then inform timescales for delivery around key actions. 7 Single Point of Access - Referral documentation and pathways are still being refined. There has been agreement that referrals can be made by GPs in letter format. Any GP referrals not accepted into the service will be escalated and investigated by the CCG`s MH Commissioner. The Provider has agreed to implement a letter back to the GP if any further information is needed. 8 Reporting - The reporting work has slowed due to recent reduced staffing levels which have limited development work. Agency, bank and internal staff from other areas within SSSFT have been used to maintain service provision pending commencement in post of new staff (from 3rd May) where an improvement in performance is forecast. 9 Communications Plan - A meeting was held with SSSFT to develop communication plans including website content. 10 Assessment and Treatment SSSFT confirm that casework reviews are ongoing and all outstanding cases have been identified and actions addressed. 11 The Single Point of Access team is currently receiving around 25 referrals per day with referrals some days as high as Job planning has commenced with practitioners to absorb activity levels. 13 All important Information relating to Looked After Children (LAC) has been updated on RiO (The Provider`s Clinical System). In addition SSSFT has requested RiO development to capture information relating to the placing authority to enable regular reporting. 14 As the scope of the service provision has increased to include Looked after Children, it is envisaged that access and waiting times will increase with the impact being a delay of between 4-6 weeks for children already in the system or awaiting assessment and treatment. Alternative service providers have been identified and choice is being offered to placing authorities following triage through SPA to manage the capacity within the service. 15 Recruitment update - 7 new staff due are to commence in access/crisis in April. 1 x LAC practitioner has been appointed and an advert is out for a second LAC and Youth and Justice post. A nurse (3 days per week in LD team) has been appointed. Whilst 1.5 Psychology posts are also out to advert. 5

39 16 However, 3 locum consultants resigned last week and have left the service. Prior to leaving, the psychiatrists reviewed their caseloads and identified priority cases and handed them over to the remaining psychiatrists. 17 The eating disorder service in Staffordshire is medically supporting the Shropshire eating disorder service. This will ensure that there is medical cover for this vulnerable group. 18 SSSFT have worked with local agencies and have identified three appropriate consultants who and their start dates which are 16 th April, 23 rd April and 30 th April. 19 SSSFT are working with our non-medical prescribers to support the consultants by managing routine prescribing this will enable the consultants to be focus on complex cases. 20 Due to the prioritising of the case load following the loss of the 3 locum consultants, some routine appointments have been cancelled (84). Therefore, requests for repeat prescriptions is being managed by implementing a strict repeat prescription request policy, this will ensure that all prescriptions can be produced in a timely way and ensure that existing doctors have dedicated time to complete these 21 Each day one of the consultants has an urgent appointment slot which can be used. So far only one of these slots has been used for patients who currently don t have a consultant. 22 Data and Activity Reporting is still a challenge. Almost 12 months into the contract the Trust has not reported performance and activity, citing the need to move to electronic records and legacy issues. RiO implementation is ongoing in terms of training/support for staff to improve quality of information being captured. Summary 23 This paper has outlined the progress and remaining challenges to date against each of the short term remedial actions for the service. These are high priority actions which were agreed for implementation by May Psychiatrists with specialist skills in treating young people are very difficult to recruit (this is a national issue). However, these posts are required and to cover the gap, locums are used when necessary. There is however, four psychiatrists working full time within the service and a lead psychiatrist who is working alongside them. In addition a further substantive consultant is commencing in post on 7 th May and interviews are taking place for a further substantive post in April. Recommendations 25 The Governing Body is asked to note the progress to date on the actions taken since December 2017 when the CPN was raised. 26 It is important to note that whilst the Trust has not met all targets which were set as milestones for May 2018 this is linked to the ability to retain and recruit key personnel and increased caseload from Looked After Children who were previously outside the scope of the contract. 6

40 27 Monitoring of the RAP is taking place via the Contract Board Meetings and through the Operational Task and Finish Groups with key actions and contingencies agreed monthly. 28 Due to the level of concern regarding this service monthly updates will be brought to the CCG governing body until such time that the board is assured sufficient progress is being made. 7

41 Agenda item: GB Shropshire CCG Governing Body meeting: 11 April 2018 Title of the report: Responsible Director: Author of the report: Presenter: Out of Hospital Transformation Programme Update Julie Davies, Director of Performance & Delivery Lisa Wicks, Head of Out of Hospitals Commissioning & Redesign Lisa Wicks, Head of Out of Hospitals Commissioning & Redesign Purpose of the report: To provide an update on the Out of Hospital Transformation Programme. Key issues or points to note Stakeholder event held on 28 th February 2018 to collaboratively shape and agree the comms and engagement plan that will support the programme. Locality task and finish groups were held on 7 th March to commence the collaborative design across all providers of the programme. The inaugural meeting of the Programme Board was held on 22 nd March. Further task and finish groups are planned for the end of April to demonstrate the case management and hospital at home models within Simul8 for further refinement. Actions required by Governing Body Members: Members of the Governing Body are asked to note the progress of the programme. Page 1 of 4

42 Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications No 2 Health inequalities No 3 Human Rights, equality and diversity requirements An equality and privacy impact assessment will be required as part Yes of the program. Monitoring form Agenda Item: GB Clinical engagement Clinical engagement is required through the programme 5 Patient and public engagement Engagement is required with patients and the public in relation to the new service delivery model. 6 Risk to financial and clinical sustainability Yes Yes No Page 2 of 4

43 NHS Shropshire CCG Out of Hospital Transformation Programme Author: Lisa Wicks Purpose 1 The purpose of this paper is to provide an update on the Out of Hospital Transformation Programme since the last meeting of the Governing Body in February. Progress 2 On 28 th February, a stakeholder event took place involving the CCG, providers across the local health and social care economy, and patient representatives, to collaboratively develop, shape and agree the comms and engagement plan that will support the programme. 3 On 7 th March locality task and finish groups were held to develop potential models for: Phase 2 Primary Care Development including Case Management Phase 3 Hospital at Home 4 All providers worked within the groups on the following: The business intelligence provided by Optimity (2017) was reviewed by the groups which categorised patients that sometimes and usually could be managed at home providing an opportunity for avoiding an acute admission. This information was derived from the data from the acute for 16/17. Work was undertaken to establish what a case management model within primary care could achieve to support admission avoidance and the development of Primary Care. A hospital at home approach was discussed to ascertain what interventions could be undertaken to achieve admission avoidance, what skills were required in the service, digital technology needs and where the service would operate from etc. All information has been developed into themed analysis in readiness for model and pathway work. 5 The CCG has purchased modelling and scenario generation software (Simul8) to enable the long-list of options to be refined and tested in a wider stakeholder group meeting. This will be demonstrated in terms of model and pathways. 6 Feedback on the events were rated as follows: 56% of delegates rated the event as very good 25% of delegates rated the event as good 19% of delegates rated the event as fair 7 The inaugural meeting of the Programme Board was held on 22 nd March. The agenda focused on ratification of the terms of reference and a presentation on the work to date. Page 3 of 4

44 8 An agenda item at the meeting was a proposal to establish alliance demonstrator sites across localities to start to move the out of hospital new ways of working forward. 9 The CCG website now has a page dedicated to the Out of Hospital programme with all information contained within the page. Next Steps 10 Development, refining and testing of long-list of model options (pre-consultation) 11 Wider stakeholder event to explore and consider the long-list of options 12 Ongoing locality task and finish groups 13 Meetings will be held with all providers to establish the terms of an alliance agreement. 14 Once agreed, expressions of interest will be sought from the localities and a panel held to agree the demonstrator sites, the priorities, outcomes etc. 15 An engagement strategy will be developed from the feedback received at the Stakeholders event on 28 th February Assurance meeting requested from NHSE to plan the process and links with the clinical summit. Recommendations 12 Members of the governing body are asked to note the progress to date of the Out of Hospital Transformation programme. Page 4 of 4

45 Governing Body Meeting Agenda item: GB Shropshire CCG Governing Body meeting: 11 April 2018 Title of the report: Finance and Contract Report to 28 th February 2018 Responsible Director: Claire Skidmore - Chief Finance Officer Author of the report: Tony Uttley Interim Deputy Chief Finance Officer Presenter: Claire Skidmore - Chief Finance Officer Purpose of the report: The purpose of this report is to articulate the year to date and forecast finance position and highlight any areas of risk within the reported figures. Key issues or points to note: Shropshire CCG continues to be in Directions and in formal financial recovery. The CCG, with the support of NHS England, has invited PWC to conduct a financial deep dive during March in order to review the CCG s finances prior to year-end. This is intended to support delivery of a robust year-end position and associated working papers for the external auditors to review. The cumulative financial position for 2017/18 shows a forecast deficit of 59.5m which includes 32.6m brought forward from previous years. The overall financial position to 28 th February 2018 is forecasting an in year deficit of m. The position has deteriorated by a further 2.851m since Month 10, primarily due to additional cost pressures identified for Continuing and Complex Healthcare Services. The deficit reflects the gap between the CCG s current plan and the excess of expenditure over resource allocation. The CCG has achieved the Better Payment Target for this month, exceeding 95% of the volume of invoices paid within 30 days. The CCG is achieving the cash target to date.s are asked to: Actions required by Governing Body: Members are asked to: Note the contents of this report o Note the content of this report. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 1

46 Governing Body Meeting Executive Summary and Actions Required Shropshire CCG continues to be in Directions and in formal financial recovery. The financial position at 28 th February 2018 is forecasting a full-year deficit of m. The position has deteriorated by a further 2.851m since Month 10, primarily due to additional cost pressures identified for Continuing and Complex Healthcare Services. The CCG entered 2017/18 with a number of known significant risks and has a QIPP target of 17.71m. It should be noted that a number of unforeseen pressures have materialised since the beginning of the Financial Year and these were not included in the financial plan. The main areas that have created pressures are; HRG4+ tariff increases, challenges within the Shropdoc Out of Hours provider, specific drug pressures on NCSO (No cheaper stocks obtainable) Prescribing and additional Running Costs incurred during Senior Management transition. The CCG, with the support of NHS England, has invited PWC to conduct a financial deep dive during March in order to review the CCG s finances prior to year-end. This is intended to support delivery of a robust year-end position and associated working papers for the external auditors to review. Actions required by Governing Body Members: Members are asked to: o Note the content of this report Introduction The purpose of this report is to articulate the year to date and full year forecast finance position and highlight any areas of risk within the reported figures. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 2

47 Governing Body Meeting Main Body of the Report Overall Financial Position The table below gives the summary level financial position to 28 th February This position has been reported to NHS England and is consistent with the position held within the Integrated Single Financial Environment (ISFE), the ledger system. Appendix 1 provides information on detailed service lines. 2017/18 Budget Year to Date - Month 11 Actual Year to Date - Month 11 Variance Year to Date - Month 11 Annual Budget Outturn Expenditure Outturn Variance Residual Risk Revenue Resource Limit Recurrent Allocations 353, , , , Non Recurrent Allocation ,482 2, Deficit Brought Forward (29,905) (29,905) 0 (32,624) (32,624) 0 0 Co-Commissioning Allocation 38,920 38, ,919 42, Total resource limit 362, , , , EXPENDITURE Commissioning 358, ,512 14, , ,670 15,971 0 Corporate 3,534 4, ,044 4, Reserves 2,589 (774) (3,363) 12,516 2,134 (10,382) 0 Healthcare Sub Total 364, ,796 11, , ,282 6,023 0 Running Costs 6,036 7,356 1,320 6,546 8,177 1,631 0 Co-Commissioning 39,341 39,211 (130) 42,919 42,767 (152) 0 Total Expenditure 409, ,363 12, , ,226 7,502 0 (Surplus)/Deficit 47,416 60,099 12,683 52,025 59,527 7,502 0 Deficit Brought Forward (27,202) (27,202) (32,624) (32,624) In Year Deficit 20,214 32,897 12,683 19,401 26,903 7,502 Income and Expenditure Resources The current CCG revenue resource is m. This includes (32.624m) deficit brought forward from previous years. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 3

48 Governing Body Meeting Acute Services The following is a summary of the contract position. It draws upon month 10 data to inform the month 11 position. Ytd Budget '000 Ytd Actual '000 YTD Performance M11 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Shrewsbury and Telford Hospitals NHS Trust 132, , ,499 3, ,268 5, ,084 Robert Jones and Agnes Hunt FT 30,010 27,319 30,688 3,369 33,655 3, ,453 West Midlands Ambulance Service Contract 11,417 10,467 11, , Other Acute Contracts 24,179 22,164 24,135 1,971 26,486 2, ,211 Acute NCA's 4,250 3,896 4, , (214) 879 Acute Special Placements (14) 35 (16) 0 (16) Winter Resilience 1,973 1,809 1, , Future Fit (201) (223) 22 Acute services - Other (69) 412 (78) 6 (84) Acute Services Team Acute Services Total 205, , ,402 11, ,070 12, ,882 Note 1: The Shrewsbury and Telford Hospitals NHS Trust position includes both Contract and Non Contract values. (Activity and Finance Tables reported elsewhere may reflect the contract position only) Shrewsbury and Telford Hospitals Trust YTD 3.627m over-spend: FOT 5.085m over-spend 1. The Shrewsbury and Telford Hospitals contract is showing a year to date overspend of 3.627m and a full-year forecast over-spend of 5.085m. As in Month 10 this reflects the year-end deal and will therefore not change in Month 12. Shrewsbury and Telford Hospital Trust Shropshire CCG Position at Month 11 - Finance (Per Month 10 SATH Monitoring adjusted) POD Ytd Cost Plan Ytd Plan v Actual ( ) FOT Plan v Actual ( ) Ytd Cost Actual Ytd Cost Variance Cost Variance as % of Total Cost Variance Cost Plan Cost FOT FOT Cost Variance FOT percentage Variance above Plan (01) Day Case 13,281,251 13,403, , % 14,580,263 14,714, , % (02) Elective 6,676,644 6,519,453 (157,191) (2.4%) 7,245,540 7,074,955 (170,585) (2.4%) (03) Emergency 47,727,834 50,173,256 2,445, % 52,443,620 55,130,664 2,687, % (04) Non Elective Other 7,405,874 6,187,259 (1,218,615) (16.5%) 8,099,281 6,766,569 (1,332,713) (16.5%) (05) Regular Admissions % % (06) Critical Care 2,857,677 2,105,967 (751,711) (26.3%) 3,150,655 2,321,877 (828,778) (26.3%) (07) Outpatient Firsts 8,538,875 8,505,809 (33,066) (0.4%) 9,352,773 9,316,556 (36,218) (0.4%) (08) Outpatient Follow Ups 6,477,237 6,463,905 (13,331) (0.2%) 7,058,634 7,044,106 (14,528) (0.2%) (09) Outpatient Procedures 6,442,997 6,153,772 (289,225) (4.5%) 7,005,319 6,690,852 (314,467) (4.5%) (10) Accident and Emergency 6,968,684 7,110, , % 7,636,399 7,791, , % (11) Non PBR Variable 12,688,843 17,125,868 4,437, % 13,822,835 18,656,393 4,833, % (12) Non PBR Block 959, , % 1,047,219 1,047, % (13) CQUIN 1,701,115 1,701, % 1,855,762 1,855, % Total 121,726, ,410,687 4,683, % 133,298, ,411,589 5,113, % Emergency Threshold 0 (2,824,176) (2,824,176) 0 (3,132,416) (3,132,416) QIPP (2,358,000) (1,050,204) 1,307,796 Risk Assement (Critical Care) 0 366, , , ,000 IR Reconciliation Adjustment (106,026) 0 0 (121,617) 0 121,617 CQUIN Reserve 1,133,917 1,133, ,237,000 1,237,000 0 Q1 CQUIN Reconciliation (23,000) (23,000) Prisoners 116, ,250 23, , ,000 26,135 Total Over/(Under) performance 122,871, ,227,344 2,250, % 132,182, ,995,969 3,813, % Year End Deal Adjustment 0 1,271,328 1,271, ,271,328 1,271,328 Year End Deal 122,871, ,498,673 3,627, % 132,182, ,267,297 5,084, % Originator of Report: Claire Skidmore Author of Report: Tony Uttley 4

49 Governing Body Meeting Shropshire CCG Position at Month 11 - Finance (Per Month 10 SATH Monitoring adjusted) POD Ytd Activity Plan Ytd Plan v Actual (Activity) Ytd Activity Actual Ytd Activity Variance Activity Variance as % of Total Activity Variance Activity Plan FOT Plan v Actual (Activity) Activity FOT FOT Variance FOT percentage Variance above Plan (01) Day Case 21,991 22, % 24,142 24, % (02) Elective 2,606 2,164 (442) (17.0%) 2,830 2,349 (481) (17.0%) (03) Emergency 24,391 24, % 26,801 26, % (04) Non Elective Other 3,785 2,989 (796) (21.0%) 4,139 3,269 (871) (21.0%) (05) Regular Admissions % % (06) Critical Care 2,548 2,094 (454) (17.8%) 2,810 2,309 (501) (17.8%) (07) Outpatient Firsts 53,007 53, % 58,060 58, % (08) Outpatient Follow Ups 82,300 81,976 (324) (0.4%) 89,687 89,334 (353) (0.4%) (09) Outpatient Procedures 46,770 45,085 (1,685) (3.6%) 50,852 49,020 (1,832) (3.6%) (10) Accident and Emergency 52,724 52, % 57,775 57, % (11) Non PBR Variable % % (12) Non PBR Block % % (13) CQUIN % % Total 290, ,628 (2,496) (0.9%) 317, ,382 (2,715) (0.9%) Total 290, ,628 (2,496) (0.9%) 317, ,382 (2,715) (0.9%) Robert Jones and Agnes Hunt NHS Foundation Trust YTD 3.369m over-spend : FOT 3.645m over-spend 1. The Robert Jones and Agnes Hunt NHS Foundation Trust contract is showing a forecast full-year over-spend of 3.645m, a small increase of 0.192m since Month10. Robert Jones and Agnes Hunt Hospital Trust Shropshire CCG Position at Month 11 - Finance (Per Month 10 RJAH Monitoring adjusted) Ytd Cost Plan Ytd Plan v Actual ( ) FOT Plan v Actual ( ) Ytd Cost Actual Ytd Cost Variance Cost Variance as % of Total Cost Variance Cost Plan Cost FOT FOT Cost Variance FOT percentage Variance above Plan POD (01) Day Case 5,143,380 5,196,145 52, % 5,636,903 5,694,731 57, % (02) Elective 10,091,745 11,120,480 1,028, % 11,060,080 12,187,525 1,127, % (04) Non Elective Other 875, ,837 (80,169) (9.2%) 958, ,105 (87,861) (9.2%) (05) Regular Admissions 193, ,521 59, % 212, ,847 65, % (07) Outpatient Firsts 2,279,789 2,081,292 (198,497) (8.7%) 2,441,242 2,228,688 (212,554) (8.7%) (08) Outpatient Follow Ups 3,143,119 3,128,322 (14,797) (0.5%) 3,366,291 3,350,443 (15,848) (0.5%) (09) Outpatient Procedures 564, , , % 619, , , % (10) Accident and Emergency % % (11) Non PBR Variable 4,607,075 4,647,501 40, % 5,049,139 5,093,443 44, % (12) Non PBR Block 2,293,327 2,455, , % 2,653,636 2,840, , % (13) CQUIN 660, ,266 16, % 723, ,252 18, % Total 29,852,648 31,115,665 1,263, % 32,721,641 34,121,096 1,399, % Anticipated QIPP Delivery (2,533,784) 0 2,533,784 (2,712,000) 0 2,712,000 CVs Pending Contract Challenges 0 (427,208) (427,208) 0 (466,045) (466,045) Total position 27,318,864 30,688,457 3,369,592 12% 30,009,641 33,655,050 3,645, % Originator of Report: Claire Skidmore Author of Report: Tony Uttley 5

50 Governing Body Meeting Shropshire CCG Position at Month 11 - Finance (Per Month 10 RJAH Monitoring adjusted) Ytd Plan v Actual (Activity) FOT Plan v Actual (Activity) Activity Variance as % of Total Activity Variance FOT percentage Variance above Plan POD Ytd Activity Plan Ytd Activity Actual Ytd Activity Variance Activity Plan Activity FOT FOT Activity Variance (01) Day Case 2,391 2,317 (74) (3.1%) 2,621 2,539 (82) (3.1%) (02) Elective 1,924 2, % 2,109 2, % (04) Non Elective Other (41) (18.1%) (45) (18.1%) (05) Regular Admissions % % (07) Outpatient Firsts 18,642 17,994 (648) (3.5%) 20,063 19,268 (795) (4.0%) (08) Outpatient Follow Ups 48,104 49,404 1, % 51,434 52,912 1, % (09) Outpatient Procedures 2,855 3, % 3,129 3, % Total 74,381 75,735 1, % 79,865 81,317 1, % Other Acute Contracts 1. Other Acute contracts are showing a forecast full-year over-spend of 2.307m, which has increased slightly since Month 10 (by 0,096m), of which 533k relates to the prior financial year Community Health Services - YTD 1.031m over-spend: FOT 0.997m over-spend Ytd Budget '000 Ytd Actual '000 YTD Performance M11 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Shropshire Community Trust 40,125 36,781 36, , (4) 104 Other Community Services 3,506 3,214 4, , Palliative Care 2,343 2,148 2,139 (9) 2,333 (10) 0 (10) Childrens Special Placements Community Health Services Total 45,974 42,143 43,174 1,031 46, Within the main community contract which is with Shropshire Community Trust we have seen a slight improvement in the forecast full-year position. The expected full-year position reflects unidentified QIPP of 300k, mitigated by underperformance within the PbR element of the contract. In relation to the other community services (the main contract being with Wye Valley) we have seen over-performance in several of our PbR community providers with the primary driver at Wye Valley being Podiatry. Continuing Healthcare YTD 2.849m over-spend FOT 2.701m over-spend Ytd Budget '000 Ytd Actual '000 YTD Performance M11 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Complex Care 25,618 23,483 25,466 1,983 27,474 1,856 2,024 (168) Funded Nursing Care 7,534 6,907 7, , Complex Care Team , , (132) 323 Reablement Continuing Healthcare Total 34,374 31,457 34,306 2,849 37,075 2,701 1, During Month 11, the reported year to date over-spend increased from 1.208m in Month 10 to 2.849m in Month 11, an increase of 1.641m. The forecast for CHC has also moved adversely by 1.957m in the current Month 11 (at Month m over-spend was reported). Originator of Report: Claire Skidmore Author of Report: Tony Uttley 6

51 Governing Body Meeting 2. A number of issues contributing to this significant swing were identified in-month, and a number of additional checks have been initiated to identify any remaining areas of risk to be reported before the end of the financial year. The CHC area has also been flagged to the PWC review team as an area of high risk. 3. In Month 11 a number of patient care packages, with an estimated cost of 0.6m, were approved by the CHC Team with care start dates and therefore costs dating back to earlier months. However, because the expected cost of these care packages was not included in the Broadcare system earlier, or otherwise identified, no financial provision for these costs had been made either in earlier months actual position or the forecast full-year out-turn position. 4. Further accruals have been made in-month for 0.2m of current year invoices that were identified within a suspense account and not included within Broadcare. 5. Through a review of actual financial ledger transactions for the full-year, 0.9m of prior year invoices were identified within a suspense account that had not been previously identified and were therefore excluded from the forecast full-year position which was accordingly set too low as a result. 6. The accrual for estimated continence spend was increased by 0.3m in-month. Additionally, a new provision was established in Month 11 of 0.1 relating to settlement of an outstanding appeal. Year on year trends for both finance and patient activity numbers are detailed in the two graphs below. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 7

52 Governing Body Meeting Note 1: The above table has been generated from a single cumulative report from the Broadcare system. In previous months reports the table was based on previous reports updated with the current s month s Broadcare data. This report will in future highlight any significant trends in month and cumulatively based on latest cumulative Broadcare data. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 8

53 Governing Body Meeting Mental Health Services YTD 0.012m over-spend FOT 0.025m under-spend YTD Performance M11 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 South Staffordshire and Shropshire FT 30,026 27,523 27,501 (22) 30,001 (25) 13 (38) Other NHS Mental Health Contracts (619) 32 (676) 0 (676) Mental Health NCA's , , Mental Health Special Placements Mental Health - Winter Resilience Mental Health - Other 1,457 1,335 1,246 (89) 1,362 (95) (44) (51) Mental Health Services Total 32,802 30,067 30, ,777 (25) 119 (144) 1. At month 11, Mental Health services are forecasting an under-spend of 0.25m. 2. Over-performance within the Mental Health NCAs line is being offset by underspends in other areas. Primary Care Services (Non Delegated) YTD Performance M11 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 Prescribing 50,167 45,869 45,453 (416) 49,318 (849) 14 (863) Central Drugs 1,252 1,147 1,087 (60) 1, Oxygen Enhanced Services 2,044 1,749 2, , Out Of Hours 4,233 3,880 4, , Primary Care Commissioning Schemes 1,272 1,166 1, , (16) 106 Hospice Drugs (10) (10) 0 Prescribing Incentives (131) Care Home Advanced Scheme Primary Care Team 2,511 2,136 1,813 (323) 2,072 (439) 51 (490) Primary Care Services Total 62,809 57,165 57,162 (3) 62,759 (50) 94 (144) Primary Care Services YTD 0.003m under-spend: FOT 0.050m under-spend 1. According to the ninth monthly detailed report from the Business Support Agency (BSA), prescribing expenditure has come in at levels that are lower than budget profile. This is consistent with measures that are being put in place to secure efficiencies. 2. Nationally, there are significant increases in prices for commonly prescribed, and usually very inexpensive, drugs. The Department of Health (DOH) places certain items on an increased price list when there are deemed to be No cheaper stocks available (NCSO). As per the PMD reports, the CCG has seen increases in the cost of 6 drugs which the prescribing lead will continue to monitor closely. The net cost of this increase is currently assessed at 2.1m the impact of this cost pressure was factored into the forecast out-turn from Month Graphs comparing monthly costs and number of scripts issued for this year and last year are presented below for information. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 9

54 Governing Body Meeting Originator of Report: Claire Skidmore Author of Report: Tony Uttley 10

55 Governing Body Meeting Enhanced Services Out of hours 1. The forecast outturn for Enhanced services includes 0.325m to reflect the additional 1/head of population payment agreed for practices for 2017/18 only. 1. For Month 11, the out-of-hours forecast outturn shows an over-spend of 0.560m. This is a reflection of the current agreement between the CCG and Shropdoc, to sustain service delivery whilst contract discussions take place. Other YTD 0.174m under-spend FO 0.185m under-spend YTD Performance M11 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 Patient Transport 3,123 2,863 2,820 (43) 3,084 (39) 207 (246) NHS (1) 21 Referral Assessment Service Team (115) 423 (103) 17 (120) Community & Care Co-ordinators NHS Property Services Better Care Fund 8,005 7,338 7,254 (84) 7,908 (97) (97) 0 Other (6) 212 (8) (94) 86 Other Total 12,678 11,621 11,447 (174) 12,493 (185) 32 (217) 2. At month 11, other services are reporting an under-spend of 0.174m and forecasting an under-spend of 0.185m. The forecast outturn reflects latest available information for this area. Primary Care (Delegated) YTD Performance M11 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Ytd Annual Budget '000 Budget '000 Dispensing & Prescribing 2,301 1,976 1, , Enhanced Services (105) 864 (90) 0 (90) General Practice APMS 1,799 1,645 1,613 (32) 1,788 (11) 0 (11) General Practice GMS 26,542 24,177 24,161 (16) 26,433 (109) 0 (109) General Practice PMS (16) 352 (18) 0 (18) Other GP Services 1,008 1,701 1, , Premises Costs Reimbursements 5,335 4,951 4,660 (291) 5, QOF 4,087 3,746 3, , Reserves 523 (31) (484) 0 (484) Co Commissioning Total 42,919 39,341 39,211 (130) 42,767 (152) 0 (152) Co-Commissioning YTD 0.130m under-spend: FOT 0.152m under-spend 1. Primary Care Co-Commissioning was 0.130m under-spent year to date to M11. The main areas of under-spend relate to premises costs associated with Rates rebates, plus prior year Enhanced services savings and the release of an unallocated reserve and part of the delegated contingency. These savings are partly offset by cost pressures relating to Dispensing charges, Locum fees, and QOF payments. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 11

56 Governing Body Meeting 2. It is expected that the year-end position will show a 152k underspend which mainly relates to unallocated prior year accruals. Running Costs YTD 1.320m over-spend: FOT 1.633m over-spend YTD Performance M11 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 Corporate Costs 2,587 2,371 3, , Strategy & Service Redesign 1,721 1,578 1,479 (99) 1,692 (29) 79 (108) Governance (126) 202 (144) (12) (132) Finance 1,729 1,619 2, , Nursing & Quality (33) 132 (31) 17 (48) Running Cost Total 6,546 6,036 7,356 1,320 8,177 1, , The Running Cost element of the CCG allocation is showing a year to date overspend of 1.320m with full-year forecast over-spend of 1.633m. One area of over-spend is expenditure relating to a number of senior interim appointments in the first part of pending the commencement of substantive Executives. 2. Running costs continue to be subject to stringent review by Executives. Reserves YTD Performance M11 In Month Movement '000 o(u) Previous Month FOT Variance '000 o/(u) Annual Budget '000 Ytd Budget '000 Ytd Actual '000 Variance '000 o/(u) FOT Actual '000 FOT Variance '000 Commissioning Reserve 8,672 2,589 (774) (3,363) 213 (8,459) 308 (8,767) 0.5% Non Recurrent Reserve 1, , % Contingency 1, (1,922) 0 (1,922) Reserves Total 12,516 2,589 (774) (3,363) 2,135 (10,381) 308 (10,689) 1. A summary of all reserves budgets are provided in the table above. The 0.5% contingency and 0.5 % of the 1% non-recurrent reserve (discretionary element) have been released to support the financial position. Statement of Financial Position (SOFP) 1. The Statement of Financial Position has been prepared in accordance with International Financial Reporting Standards (IFRS), the Treasury Financial Reporting Manual, and DoH requirements. The Month 11 position is summarised in Appendix 2. Cash 1. The CCG is required to estimate its cash requirement prior to the start of each month and drawdown cash funding. In line with guidance, the CCG must ensure cash levels each month remain below 1.25% of the monthly draw down. 2. The actual level of cash held in the bank at the end of February was 0.084m. This is within the levels required by NHS England and demonstrates a successful management of cash balances which is detailed in the cash report at Appendix 3. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 12

57 Invoice Value '000 No. of Invoices Governing Body Meeting Better Payment Policy Statistics 1. The requirement of the Better Payment standard is that 95% of invoices should be paid within 30 days of receipt by an organisation. 2. In February 2018 both NHS and Non NHS BPPC was above target for the invoices processed. Total Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total NHS ,848 Non NHS 2,126 2,091 1, ,003 1,257 1,029 1,166 2,093 2,082 2,174 17,034 Total 2,418 2,308 1,284 1,285 1,218 1,589 1,221 1,448 2,314 2,315 2, ,882 Passed NHS ,779 Non NHS 2,120 2,070 1, ,232 1,008 1,133 2,034 2,060 2,156 16,731 Total 2,407 2,282 1,273 1,246 1,150 1,551 1,196 1,411 2,246 2,285 2, ,510 Pass Percentage Total NHS 98.3% 97.7% 99.2% 99.3% 92.6% 96.1% 97.9% 98.6% 95.9% 96.6% 99.7% 97.6% Non NHS 99.7% 99.0% 99.1% 96.3% 94.8% 98.0% 98.0% 97.2% 97.2% 98.9% 99.2% 98.2% Total 99.5% 98.9% 99.1% 97.0% 94.4% 97.6% 98.0% 97.4% 97.1% 98.7% 99.2% 98.1% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% NHS 23,369 23,184 23,634 22,628 24,611 21,865 22,568 23,167 24,354 23,756 26, ,831 Non NHS 11,868 9,838 9,679 9,699 8,831 11,111 9,676 9,937 10,741 12,212 8, ,033 Total 35,237 33,022 33,313 32,327 33,442 32,976 32,244 33,104 35,095 35,968 35, ,863 Passed NHS 23,364 23,086 23,589 22,384 24,386 21,846 22,533 23,029 24,351 23,027 26, ,290 Non NHS 11,775 9,826 9,672 9,627 8,425 10,552 8,877 9,522 10,365 10,959 8, ,979 Total 35,139 32,912 33,260 32,012 32,811 32,398 31,410 32,550 34,717 33,987 35, ,269 Pass Percentage NHS 100.0% 99.6% 99.8% 98.9% 99.1% 99.9% 99.8% 99.4% 100.0% 96.9% 100.0% 99.4% Non NHS 99.2% 99.9% 99.9% 99.3% 95.4% 95.0% 91.7% 95.8% 96.5% 89.7% 99.3% 96.4% Total 99.7% 99.7% 99.8% 99.0% 98.1% 98.2% 97.4% 98.3% 98.9% 94.5% 99.8% 98.5% Risk and Mitigations 1. The CCG is required to provide an analysis of potential risks and mitigations as part of the monthly Non ISFE return to NHS England. For month 11, all risks have now been reflected in the position. Any further cost pressures arising during Month 12 as part of year-end preparation or as a result of the PWC review will be reported in due course. Summary and Conclusions 1. The overall financial position to 28th February 2018 is forecasting an in year deficit of m. The position has deteriorated by a further 2.851m since Month 10, primarily due to additional cost pressures identified for Continuing and Complex Healthcare Services. 2. CCG risks have been reflected in position for month 11. Any Additional risks arising during the final Month 12 will be reported in due course. Originator of Report: Claire Skidmore Author of Report: Tony Uttley 13

58 Governing Body Meeting Appendix /18 Financial Summary Position as at Month 11 RESOURCES 2017/18 Annual Budget Budget Year to Date - month / /18 Actual Year to Date - month 11 Variance Year to Date - month 11 Outturn Expenditure Outturn Variance Recurrent Allocation 390, , , ,922 0 Non Recurrent Allocation 2, ,482 0 Deficit Brought Forward 16/17 (32,624) (29,905) (29,905) 0 (32,624) 0 Co-Commissioning Allocation 42,919 38,920 38, ,919 0 Total resource limit 403, , , ,699 0 EXPENDITURE Acute Services Shrewsbury and Telford Hospitals NHS Trust 132, , ,499 3, ,267 5,084 Robert Jones and Agnes Hunt FT 30,010 27,319 30,688 3,369 33,655 3,645 West Midlands Ambulance Service Contract 11,417 10,467 11, , Other Acute Contracts 24,179 22,164 24,135 1,971 26,486 2,307 Acute NCA's 4,250 3,896 4, , Acute Special Placements (14) 35 (16) Winter Resilience 1,973 1,809 1, ,973 0 Future Fit (201) Acute services - Other (69) 412 (78) Acute Services Team Acute Services Total 205, , ,402 11, ,069 12,963 Community Health Services Shropshire Community Trust 40,125 36,781 36, , Other Community Services 3,506 3,214 4, , Palliative Care 2,343 2,148 2,139 (9) 2,333 (10) Community Health Services Total 45,974 42,143 43,174 1,031 46, Continuing Healthcare Complex Care 25,618 23,483 25,466 1,983 27,474 1,856 Funded Nursing Care 7,534 6,907 7, , Complex Care Team , , Reablement Continuing Healthcare Total 34,374 31,457 34,306 2,849 37,075 2,701 Mental Health Services South Staffordshire and Shropshire FT 30,026 27,523 27,501 (22) 30,001 (25) Other NHS Mental Health Contracts (619) 32 (676) Mental Health NCA's , , Mental Health - Other 1,457 1,335 1,246 (89) 1,362 (95) Mental Health Services Total 32,802 30,067 30, ,777 (25) Primary Care Services Prescribing 50,167 45,869 45,453 (416) 49,318 (849) Central Drugs 1,252 1,147 1,087 (60) 1,252 0 Oxygen Enhanced Services 2,044 1,749 2, , Out Of Hours 4,233 3,880 4, , Primary Care Commissioning Schemes 1,272 1,166 1, , Hospice Drugs (10) Prescribing Incentives (131) Care Home Advanced Scheme Primary Care Team 2,511 2,136 1,813 (323) 2,072 (439) Primary Care Services Total 62,809 57,165 57,162 (3) 62,759 (50) Other Patient Transport 3,123 2,863 2,820 (43) 3,084 (39) NHS Referral Assessment Service Team (115) 423 (103) Community & Care Co-ordinators NHS Property Services Better Care Fund 8,005 7,338 7,254 (84) 7,908 (97) Other (6) 212 (8) Other Total 12,678 11,621 11,447 (174) 12,493 (185) Reserves Commissioning Reserve 8,672 2,589 (774) (3,363) 213 (8,459) 0.5% Non Recurrent Reserve 1, , % Contingency 1, (1,922) Reserves Total 12,516 2,589 (774) (3,363) 2,135 (10,381) Running Costs Corporate Costs 2,587 2,371 3, , Strategy & Service Redesign 1,721 1,578 1,479 (99) 1,692 (29) Governance (126) 202 (144) Finance 1,729 1,619 2, , Nursing & Quality (33) 132 (31) Running Cost Total 6,546 6,036 7,356 1,320 8,177 1,631 Co-Commissioning 42,919 39,341 39,211 (130) 42,767 (152) Co Commissioning Total 42,919 39,341 39,211 (130) 42,767 (152) Total Expenditure 455, , ,362 12, ,226 7,502 Budget (Surplus) / Deficit 52,025 47,415 60,098 12,683 59,527 7,502 Total Resource Limit 403, , , ,699 0 Total Expenditure 455, , ,362 12, ,226 7,502 Total 52,025 47,415 60,098 12,683 59,527 7,502 Deficit Brought Forward (32,624) (27,202) (27,202) (32,624) In Year Deficit 19,401 20,213 32,896 12,683 26,903 Originator of Report: Claire Skidmore Author of Report: Tony Uttley 14

59 Governing Body Meeting Appendix /18 SOFP Trends Month 2016/17 Apr17 May17 Jun17 Jul17 Aug17 Sep17 Oct17 Nov17 Dec17 Jan18 Feb18 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Property, Plant & Equipment IT P&M Networked Assets Total PP&E Receivables Accounts Receivable Ledger 3,364 3,603 2,819 2,231 2,110 1,438 1, ,002 1,277 3,658 1,795 Accrued Income 1, ,057 2,568 1,715 2, Bad Debt Provision (136) (136) (357) (34) (34) (34) (34) (34) (34) Other Receivables (12) (55) (43) 66 (208) (8) Payments on Account 3, ,628 1,036 1,717 3, , Prepayments ,613 7,920 6,511 2,493 1,537 1, Total Receivables 5,162 7,676 6,796 5,413 5,362 8,133 10,773 11,387 3,955 4,929 5,449 2,512 Cash & Bank Cash & Bank Accounts Payable Accounts Payable Ledger (1,593) (1,591) (2,118) (2,496) (3,788) (3,784) (1,997) (3,313) (2,718) (3,077) (3,999) (5,048) Accruals (11,181) (11,047) (11,071) (9,724) (9,562) (12,667) (17,357) (18,951) (16,508) (16,302) (18,339) (15,229) Accrued Liabilities (104) Prescribing (8,491) (4,643) (8,807) (8,846) (8,847) (8,755) (8,618) (8,712) (8,719) (8,868) (8,765) (8,365) Prescribing Incentive (378) (369) (835) (626) (332) (512) (534) (526) (511) (505) (464) (415) Deferred Income (405) (575) (508) (491) (405) (405) (355) (593) Payroll Related - PAYE (45) (49) (66) (53) (61) (58) (58) (99) (64) (67) (63) (68) Payroll Related - NI (52) (58) (66) (62) (68) (72) (70) (74) (74) (82) (81) (81) Payroll Related - Pension (314) (354) (368) (382) (339) (385) (367) (437) (379) (395) (411) (381) Payroll Related - Other (8) (7) (6) (5) (26) (34) (31) (30) (31) (32) (34) (33) Partly Completed Spells (1,368) (1,368) (1,368) (1,368) (1,367) (1,367) (1,367) (1,367) (1,367) (1,367) (1,367) (1,367) Total Payables (23,430) (19,486) (24,705) (23,562) (24,795) (28,209) (30,907) (34,000) (30,776) (31,100) (33,878) (31,684) Total Assets (18,062) (11,459) (17,476) (18,018) (18,946) (19,954) (20,042) (22,482) (26,472) (25,964) (28,284) (29,049) General Fund B/fwd 2016/17 (14,455) (18,064) (18,064) (18,063) (18,063) (18,063) (18,063) (18,063) (18,063) (18,063) (18,063) (18,063) Allocation 36,153 71, , , , , , , , , ,169 B/fwd Deficit Allocation (5,440) (8,156) (10,875) (13,593) (16,312) (19,031) (21,749) (24,468) (27,187) (29,905) Net Allocation 36,153 66,024 98, , , , , , , , ,264 Timing Adjustments\ Deficit Funding 32,626 2,391 8,873 12,426 15,678 18,823 23,354 26,655 31,263 36,959 41,743 49,112 Net Parlimentary Funding 446,575 38,544 74, , , , , , , , , ,376 YTD Net Expenditure (450,184) (31,939) (74,309) (111,123) (148,613) (186,073) (223,411) (262,458) (303,777) (342,271) (382,681) (422,362) Cumulative Surplus\(Deficit) (32,624) 4,214 (8,285) (12,381) (16,561) (20,714) (25,333) (31,074) (39,672) (44,860) (51,964) (60,098) In Year Surplus\(Deficit) 4,214 (2,845) (4,225) (5,686) (7,121) (9,021) (12,043) (17,923) (20,392) (24,777) (30,193) Total Equity (18,062) (11,459) (17,476) (18,018) (18,946) (19,954) (20,042) (22,482) (26,472) (25,964) (28,284) (29,049) Originator of Report: Claire Skidmore Author of Report: Tony Uttley 15

60 Governing Body Meeting Appendix /18 Shropshire CCG Month 11 - Cash Report Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD YTD Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Forecast Plan Actual,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000 C/fwd ,437 Drawdown 32,679 35,346 33,158 32,697 32,674 32,869 33,158 32,869 33,158 32,869 32,675 33,545 33,549 32,869 33,067 33,769 33,539 35,369 33,542 34,369 32,099 35,369 37,878 37, , ,940 Council BCF Receipts Other Receipts , , ,315 Total Reciepts 32,740 36,132 33,219 33,989 32,735 33,961 33,219 33,379 33,219 33,996 32,736 33,780 33,610 32,947 33,128 34,125 33,600 35,677 33,603 36,762 32,160 35,944 37,939 37, , ,693 Expenditure RFT Runs 20,610 23,816 21,090 23,748 20,606 20,467 21,090 19,477 21,090 21,434 20,607 18,464 21,089 19,646 20,607 20,061 21,089 21,186 21,090 20,601 19,647 23,535 21,139 21, , ,435 BACs & Pos 8,203 5,309 8,202 5,751 8,202 8,784 8,202 8,489 8,202 8,163 8,202 8,765 8,594 8,276 8,594 9,312 8,584 8,386 8,585 9,817 8,585 8,320 12,863 12,863 92,156 89,373 BCF CHAPS / Faster Payments 0 2, , , , , , ,164 Co Commissioning 3,456 3,456 3,456 3,456 3,456 3,456 3,456 3,456 3,456 3,461 3,456 3,461 3,456 3,461 3,456 3,461 3,456 3,461 3,456 3,461 3,456 3,461 3,465 3,465 38,016 38,051 Cheques Salaries ,585 2,959 Pensions Tax & NI ,133 1,395 Total Expense 32,679 35,865 33,158 33,640 32,674 33,930 33,158 33,093 33,158 33,949 32,675 33,760 33,549 32,888 33,067 34,081 33,539 35,544 33,542 36,684 32,099 35,860 37,878 37, , ,293 Total Cleared Cash ,400 BACs not Cleared Total Cleared Cash , BSA Cash Prescribing 4, , , , , , , ,166 3,564 4,305 3,598 4,305 3,665 3,890 3,474 4,310 4,310 46,382 38,874 Oxygen

61 Governing Body Meeting Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications Turnaround support sourced to year-end. PWC team engaged to provide additional assurance over Month Health inequalities If yes, please provide details of the effect upon health inequalities 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements Yes No No 4 Clinical engagement If yes, please provide details of the clinical engagement No 5 Patient and public engagement If yes, please provide details of the patient and public engagement No 6 Risk to financial and clinical sustainability Yes As noted in the report 17

62 Agenda Item GB CCG Governing Body Shropshire Clinical Commissioning Group MINUTES OF THE FINANCE & PERFORMANCE COMMITTEE HELD IN ROOM 2, OAK LODGE, WILLIAM FARR HOUSE, SHREWSBURY, SY3 8XL ON THURSDAY 8 MARCH 2018 AT 3.00PM Present Mr Keith Timmis (Chair) Mr William Hutton Mrs Claire Skidmore Mr Kevin Morris Dr Jessica Sokolov In Attendance Mr Barry White Mr Meredith Vivian Mr Charles Millar Ms Sarah Porter Mrs Faye Harrison Apologies Mrs Gail Fortes-Mayer Dr Julie Davies Ms Kim Morris Lay Member Lay Member and Audit Chair Chief Finance Officer GP Board Representative Deputy Clinical Chair Interim PMO Lead Lay Member Head of Contracting (Part) Lay Member Personal Assistant/Minute Taker Director of Contracting Director of Performance & Delivery Head of PMO FPC Apologies 1.1 Apologies were received as listed above. FPC Members Declaration of Interests 2.1 There were no declarations of interest. FPC Minutes of Previous Meeting held on 7 February The minutes from the previous meeting were agreed as a true and accurate record. FPC Matters Arising/Action Tracker 4.1 The Action Tracker was discussed and updated as appropriate. Please see attached. 4.2 With regards to the CHC Independent Review Cases Mrs Skidmore updated members that NHS England have offered some support from Deloitte under the QIPP 4 Programme to include a Deep Dive around CHC generally. Mr White informed members that Interim Nurses have been brought in to decrease the backlog and a review is currently on going around Broadcare. It was felt that bringing a CHC update to the Committee each month would be beneficial. FPC Work Plan 5.1 The proposed Work Plan was discussed and agreed. 1

63 FPC Terms of Reference 6.1 The Terms of Reference were discussed. It was felt that a few minor amendments were required around the numbering, wording and formatting. It was agreed to make these amendments and then take to the Governing Body in April for approval. FPC Performance Report 3.25pm Charles Millar joined the meeting 7.1 Mr Millar attended the meeting to present the Performance report in the absence of Dr Julie Davies. Mr Millar updated that it has been identified that there is no significant impact of the Winter Elective Pause at SaTH however the activity was slightly higher this January from the previous year. 7.2 Mrs Skidmore reported that there is currently a dispute regarding one of the figures which has been added to the Contract negotiation around RTT Catch Up. 7.3 Ambulance Service handovers were discussed. There is ongoing work with ECIP Consultants and the clarification of the timeline is awaited; it is expected to run over into the next financial year. Staffing issues were a contributing factor to the ongoing issues, however Shropshire s length of stay and DTOC was considered good. 7.4 With regards to ShropDoc the reported numbers relate to the 999 Service and it was felt that this could be looked at in more detail as currently marrying up the data sets is proving a challenge. It would be beneficial to enhance the data to clarify a true position. It would be important to continue monitoring the situation and to obtain benchmarking figures and up to date figures. Action: Charles Millar to provide up to date conversion rates to the next Committee. 7.5 Query was raised around the DTOC figures provided by RJAH as the majority of their workload is elective. This is another area which would require close monitoring. 7.6 The issue around the cancer 2 week wait window was discussed as appointments were being offered late; the process would need to be explored and a timescale for this would need to be clear. Action: Charles Millar to provide information on how and when appointments are offered to cancer patients to the next Committee. FPC Contracting Report 8.1 This agenda item was brought forward as Mr Millar was also presenting this report in the absence of Mrs Fortes-Mayer. 8.2 Clarification was requested around the ICS Specification. ShropCom have raised the issue that there is currently no clear Service Level Agreement (SLA) with the Local Authority (LA) and that the LA have withdrawn some of the service so therefore cannot sign up to the specification as it is and have requested an adjustment. Discussion was held around this issue and it was agreed that greater detail would be 2

64 required therefore an update to demonstrate stability including evidence was needed. Despite this being requested there appears to be some delay. 8.3 Mrs Skidmore gave further update around an historical issue with the contracts. It has been agreed with Telford & Wrekin that a full investigation into these agreements will take place this will then, in turn force the issue with ShropCom in order for the new contract in 2019/20. Action: Update report to address ShropCom Contract issues to be included in the Contracting Report for June Committee. 8.4 Dr Sokolov requested more information regarding the joint investigation into activity levels at SSSFT. Mr Millar commented that this would be added to next months report. Action: Mr Millar to add more information around the joint investigation into activity levels at SSSFT to next month s contracting report. 8.5 Mr Millar updated that a plan to improve DTOC performance had been received from ShropCom which details the target being achieved by August There was an Executive Team to Executive Team Meeting held recently with SSSFT and it was felt that the level of engagement had improved and that the Trust has a clearer idea of its position. 8.7 A discussion was held regarding ShropDoc and it was felt that the contract was currently not in the right format as there are quite a few red areas in the report. An improvement plan would need to be agreed to move this forward. It would be beneficial to describe the agreed remedies for the improvement plan in next month s report. Action: Charles Millar to describe remedies for the ShropDoc Improvement Plan into next month s report. 8.8 Discussion was held around the IAPT tariff as this is currently considered a risk. There is a group looking into the currency to understand the real impact. 8.9 An enquiry was made as to whether there is a representative from the CCG who attends the contract meetings with Falck Medical Services. Charles Millar commented that he would expect someone to attend and would find out and confirm at next month s meeting. Action: Charles Millar to confirm who attends the contract meeting with Falck Medical Services It was discussed whether the Contracting work area was adequately captured in the Terms of Reference. Mr Timmis agreed to re-visit these and update if appropriate. Action: Mr Timmis to re-visit TOR to ensure contracting work area was appropriately captured and circulate to members for comment. 4pm Charles Millar left the meeting 3

65 FPC QIPP Update 9.1 Mrs Skidmore reported that the Month 10 figures were holding firm as per the forecast and Month 11 numbers were also looking stable at this point. 9.2 A Risks and Issues Log has been introduced; this would be used at the QIPP Programme Board and be brought to this Committee for information. 9.3 Concern was raised that the forecast has not changed over the past 3 months and that this might be evidence of poor forecasting. Mrs Skidmore reported that the numbers are set in terms of delivery. Next month more rigor will be applied to the exercise and some of the presentation on individual lines will be different. More variation will be apparent however there is no shift in the bottom line. FPC QIPP PMO Review Lessons Learnt 10.1 Mrs Skidmore reported that this was a useful piece of work in order to move things forward, set the plan of action and the pace at which this would be rolled out Mr Timmis wanted it to be made clear that the role of the Finance and Performance Committee would be to gain assurance that the actions are being carried out and it would be Executive responsibility to complete the actions Concern was raised on the numerous PMOs and Turnaround Directors who had been in post, the repetitive work which had been carried out and the negative impact this had caused. Further discussion was held and it was felt that a better grip was still required in order to move things forward Mr White informed members that it was the role of the PMO to provide support and mentor staff within the organisation. It would be important to adopt a consistent way of working where the outcome would be key. A pragmatic approach would be beneficial A dashboard is being developed along with a new version of the tracker for staff to access; this can be taken to the various sub-committees as required for discussion. Examples of solutions would be included along with an embedded process Levels of capability within the team were discussed and it was felt that setting up a skills profile and offering support and training where required would be appropriate. Guidance notes are in the process of being developed. Discussion was held regarding the benefits of the PMO function and how best to use this moving forward Mr Timmis commented that a potential crossover with the Audit Committee would be useful. It was agreed that Mr Timmis, Mr Hutton and Mrs Skidmore would meet to follow this up. Action: Mr Timmis, Mrs Skidmore and Mr Hutton to meet to agree how to align a crossover with Audit Committee around the lessons learnt paper 10.8 Mrs Skidmore reported that the next steps would be for Mr White to attend an Executive Team Meeting for update and discussion. Action: Mrs Skidmore to arrange for Mr White to bring the Lessons Learnt paper to Executive Team for discussion. 4

66 10.9 Kevin Morris has been invited to become a member of the QIPP Programme Board. The Schedule of meetings is currently being looked at. FPC Finance Report 4.40pm Mr Barry White left the meeting 11.1 Mrs Skidmore highlighted the concern she raised at the previous committee around the shift in numbers. She reported that as of Month 10 before any adjustments the Control Total would be missed by approximately 4.6m In Month 12 the ½% of national reserve will be released to cover the NCSO cost pressure this will reduce the overspend to around 2.5m She informed members that when she reports the Month 11 figures at the next committee there will be a further shift of 3m on top of the 4.6m already reported. This is due to forecasting methodology and concerns with the Balance Sheet as a number of invoices with a suspense code had not been counted; a big chunk of these invoices relate to CHC Mrs Skidmore further reported that as of 7 March 2018 NHS England have agreed to pay for a Financial Due Diligence with PwC carrying out the work to look at forecast and balance sheet to ensure nothing else has been missed. This should be completed by the end of March Where further issues have been discovered it is being ensured process is put into place so that these mistakes do not happen again Mr Timmis felt this should be seen as a positive to help with the accounts and ensure the root of the problem is found. PwC can also identify any other problems which may arise. They will require meetings with the Chair of Audit Committee and the Accountable Officer. Once the report is complete and available it will be taken to the Audit Committee and will therefore be in the public domain Mrs Skidmore highlighted an issue around expenditure coming through in 2017/18 which should have been paid in the previous year. She has raised this with the Team as this problem cannot afford to be carried forward again. FPC DEEP DIVE Budget and Plan for 18/ Mrs Skidmore talked through the presentation with members and updated on items which had moved on since the slides were created and discussed with the budget sub-group last Friday In order to look at the impact for 18/19 Mrs Skidmore highlighted the underlying deficit for this year. A lot of the expenditure for this year are one-off costs and this would need to be taken into consideration. The underlying deficit now stands at 22.2m with an extra 1m of recurrent costs from the most recent shift in position A further complication is that plans need to be on a basis that the national percentage uplifts for growth will be bought for the acute contracts. Mrs Skidmore confirmed that although there had been extra money to allow for this and the 1% reserve has been released this only enables us to break even with the extra deficit. 5

67 12.4 The Control Total for next year is now 13.3m deficit again; this is further challenged by the extra expenditure which has recently been discovered There are further on going challenges with the messages that have been received as these are repeatedly changing. The plan which Mrs Skidmore will now submit is stating that there will be an 18.3m deficit and not 13.3m as previously thought At this point the draft plans are up for discussion and are not definitive. Mrs Skidmore commented that she preferred to flag this as the bigger number until more information is received. Members agreed with this decision. If nothing else changes Mrs Skidmore will update the numbers to show hitting the bottom line before taking to Governing Body and will provide the same update The net QIPP which will need to be delivered in order to hit the 13.3m will be 19.7m. It will still need to be proved how the QIPP will be delivered. National debate is ongoing Mrs Skidmore pointed out that the plan that has been made is not without risk and even though some of it can be mitigated there is still 5m of unmitigated risk. The majority of the risk is around the confidence of QIPP deliverability Brief discussion was held regarding Activity Growth and Trends. A plan needs to be set and a timeline put in place. The initial plan being submitted today, further plans will be submitted in April as all contracts have not yet been signed Mental Health Investment Standard was discussed as there will be no concessions and this will need to be met next year. The same level of growth of 2.9% will need to be included. There are a number of contributing factors to consider including SSSFT, Prescribing, Complex Care and Learning Difficulties With regards to QIPP Mrs Skidmore reported that she had initially included the NCSO spend as recurring but has since been advised by NHS England that this needs to be non-recurring which will improve the unidentified QIPP by 2.1m Mrs Skidmore explained the confidence scales to members and gave examples however; these are subject to change and are continually being updated It was discussed that it would be beneficial to hold a Governing Body Development Session to look at the unpalatable options and sliding scale of projects. A table top exercise of models would be helpful along with focused debate and benchmarking. This could be added to the Development Session next week if appropriate The signing of contracts also creates an area of impact. The different categories and outcome were explained and discussed for each provider. Agreement has been reached for the SCHT contract. Although there are some discrepancies with RJAH our position can be proven and evidenced. Once the contracts have been signed they can be made public Work is on going with Telford and Wrekin CCG around the rebasing of the SSSFT contracts. Telford have agreed to support the transition to the sum of 500,000 in 2018/19 pending full resolution for the following year There are still areas of disagreement with SaTH as they are still not recognising the areas of QIPP. Discussions are continuing with the Director of Finance at SaTH and 6

68 signatures are required by 23 March. Winter monies is also an area of discussion with SaTH along with the maternity money Mrs Skidmore agreed to keep members updated if there are any changes prior to the Governing Body meeting next week. She would share the key messages which would be discussed the day before the meeting and would welcome any feedback so that a united approach at Board could be seen. FPC Any Other Business 13.1 There were no items of any other business discussed. Meeting closed 5.45pm 7

69 Agenda item: GB Shropshire CCG Governing Body meeting: 11 April 2018 Title of the report: Responsible Director: Terms of reference for the Finance and Performance Committee Claire Skidmore, Julie Davies, Gail Fortes-Mayer Author of the report: Keith Timmis, Lay Member - Performance Presenter: Keith Timmis Purpose of the report: To present revised terms of reference for the Finance and Performance Committee (FPC). Key issues or points to note: FPC reviewed its terms of reference at its meeting on 8 March A number of amendments were agreed to the original document that dated from December The changes were designed to: Simplify the description of Committee responsibilities. Remove one responsibility for reviewing reports from external bodies that the Committee concluded was more relevant to the Audit Committee. Formalise the revised membership of the Committee. Actions required by Governing Body Members: The Governing Body is asked to approve the revised terms of reference for FPC. 1

70 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required No 2 Health inequalities If yes, please provide details of the effect upon health inequalities No 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement 5 Patient and public engagement If yes, please provide details of the patient and public engagement 6 Risk to financial and clinical sustainability If yes how will this be mitigated No No No No 2

71 APPENDIX 2 NHS SHROPSHIRE CLINICAL COMMISSIONING GROUP FINANCE & PERFORMANCE COMMITTEE Terms of Reference Constitution 1 The Clinical Commissioning Group s Governing Body hereby resolves to establish a Committee of the Governing Body known as the Finance & Performance Committee. The Committee is established in accordance with NHS Shropshire Clinical Commissioning Group s Constitution, Standing Orders and Scheme of Reservation & Delegation. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the group and shall have effect as if incorporated into the CCG s constitution. Purpose 2 The Finance Committee shall undertake on behalf of the CCG Governing Body objective scrutiny of the CCG s financial plans and decisions. The Committee shall review the CCG s monthly financial performance and identify the key issues and risks requiring discussion or decision by the CCG Governing Body. 3 The Committee shall oversee the delivery of organisational Quality, Innovation, Productivity and Prevention (QIPP) plans. 34 The Committee and will also review the contracting and performance of the main services commissioned by the CCG as directed by the Governing Body. Responsibilities 45 Scrutinise the development of the CCG s annual financial plan and medium term financial strategy, including underlying assumptions and methodology used, ahead of review and approval by the CCG Governing Body. 56 Review the CCG s monthly financial performance (including performance against savings programmes) and identify the key issues and risks requiring discussion or decision by the CCG Governing Body, recognizing that the primary ownership and accountability for the CCG s financial performance rests with the full CCG Governing Body. 67 Review at the request of the CCG Governing Body specific aspects of financial performance where the Governing Body requires additional scrutiny and assurance and has the right of access to obtain all the information and explanations it considers necessary to fulfill its remit. 7 Advise the Governing Body on relevant reports by NHS England, regulators and other national bodies, and, where appropriate, management s response to these. 8 Oversee and evaluate the development of a CCG performance management framework which allows the CCG to performance manage. 9 Monitor organisational performance against strategic objectives, important milestones, national, regional and local targets, specific obligations placed upon the CCG, and particular priorities which the Governing Body asks the Committee to monitor.

72 108 Receive regular commissioning contracting and performance reports (covering activity and cost) for each of the CCG s main areas of commissioning expenditure, working in partnership with the CCG Clinical Commissioning Committee, and undertaking detailed reviews as directed by the Governing Body. 11 Receive performance reports from the CCG s Commissioning Support Unit in respect of delivery of these services. 129 Review clinical programmes delivery, ensuring delivery of clinical objectives and value for money, including the delivery of QIPP objectives, and the appropriate management of risks and opportunities Ensure that where possible the performance of the CCG is benchmarked against that of equivalent or similar organisations, or organisations facing similar challenges Review and monitor action plans relating to areas of under-performance Address particular performance matters referred to it by the Governing Body, and provide reports to the Governing Body on areas of performance as requested In addition, the committee will ensure that equality and diversity is proactively considered and promoted as part of the committee s business and its decision making. Membership 17 The membership of the Finance & Performance Committee will be: Independent Lay Member (Committee Chair) Independent Lay Member (Committee Vice-Chair) Director of Finance Deputy Clinical Chair Director of Performance & Delivery Director of Contracting & Planning Director of Corporate Affairs Director of Primary Care Locality Chairs x 3Practice Governing Body member. 18 Other members of the CCG will be invited to attend to discuss areas of responsibility as required. 19 Membership will be reviewed regularly to adjust for changes as required by the purpose of the Committee. 20 Members who cannot attend should send a named deputy only if approved by the Committee Chair or Vice Chair. Deputies will have the decision-making rights of the person he/she is representing. Quorum 21 A minimum of three members will constitute a quorum, so long as this includes either the Chair or Vice Chair of the committee, a minimum of two one Executive Directors and a minimum of one Locality ChairClinical or Practice Governing Body member.

73 Reporting Arrangements 22 The minutes of the Finance & Performance Committee shall be formally recorded and submitted to the Governing Body on a monthly basis.. Administration 23 Secretarial support will be provided by the corporate affairs office. Frequency 24 The Finance and Performance Committee will meet on a monthly basis with extraordinary meetings to be held as required. Conduct of the Committee 25 The Committee shall conduct its business in accordance with national guidance, relevant codes of practice including the Nolan Principles and the Policy for Conflicts and Declarations of Interest (Incorporating gifts, hospitality and commercial sponsorship). 26 An annual report of its performance, membership and terms of reference will be submitted to the governing body. Equality Statement Formatted: Font: Bold 27 Shropshire CCG is committed to promoting equality in all its responsibilities as commissioner of services, as a partner in the local economy and as an employer. All committees of the Governing Body have a duty to ensure that it contributes to ensuring that all users and potential users of services and employees are treated fairly and respectfully with regard to the protected characteristics of age, disability, gender, reassignment, marriage or civil partnership, pregnancy and maternity, race, religion, sex and sexual orientation. Review 28 These Terms of Reference will be reviewed on an annual basis or sooner if required with recommendations made to the CCG Governing Group for approval. -Ends- Date approved: Review date:

74 Agenda item: Gb Shropshire CCG Governing Body meeting: 11 April 2018 Title of the report: Governing Body SCCG Performance Report 2017/18 Responsible Director: Julie Davies, Director of Performance & Delivery Author of the report: Julie Davies, Director of Performance & Delivery Presenter: Julie Davies, Director of Performance & Delivery Purpose of the report: To update the governing body on the CCGs performance to date in 2017/18 against the key performance indicators that the CCG is held accountable for with NHS England. This overview provides assurance on performance achievement against targets/standards at CCG and provider level as appropriate, and the delivery and contractual actions in place to address areas of poor performance. Key issues or points to note: The attached report sets out Shropshire CCG s performance against all its key performance indicators for early 2017/18. They key standards that are not currently being met YTD for SCCG are :- 62 day cancer RTT 62 day wait screening 2wk wait (Breast) A&E 4hr target Ambulance handovers >30mins and >1hr RTT >52 wk waiters The 62 day RTT, Screening and 2wk Breast symptoms performance targets for the CCG are not being achieved but SaTH, its main provider, continues to achieve all targets except the 62 day RTT which is just below target (84.8% YTD at Month 10. As expected their 2wk performance bounced back in January after the weather related issues in December. The CCGs overall cancer performance remains affected by out of county providers and this is continually progressed through the corresponding lead commissioners via our contract team with support as required from NHSI & NHSE. A&E performance remains significantly challenged, although a slight improvement In February over January s lowest YTD performance it continues to be of significant concern. Demand remains broadly on plan for Shropshire at Month 11. Workforce and 1

75 levels/timeliness of patient discharges remain the key underlying issues. Six priority action areas are now progressing via the fortnightly A&E delivery group reporting to the A&E Delivery Board monthly. Additional expertise is continuing to be brought in from the national ECIP team as required to support our system s recovery. A focused period of improvement in the two weeks either side of Easter has showed some early signs of success and contributed to an improvement in the A&E performance at the end of March. Over 1hr ambulance handovers improved in February after the challenges in January and remains better than the same period last year. This is as a result of improved working between the HALOs, the SaTH corridor nurses and ED staff. The deterioration was due to the sheer volume of ambulances at times presenting at the EDs which were more than they are designed to cope with for sustained period s The CCG had 2 over 52 wk waiters (1 at Wye Valley and 1 at RJAH) at the end of January, both T&O. The one at RJAH will remain a breach until the summer due to the choice of timing of the procedure to coincide with school holidays. Full contractual levers are implemented against poor performance with any provider and the CCG performance lead now receives a forward look of all >40wks waiters at all providers to try and minimize such breaches in the future. The CCG remained below the RTT target in January once again in spite of SaTH continuing to deliver the target. This will continue to be at risk from February due to the nationally agreed extended period of cancellations during the month of January to allow the system to better manage winter pressures. Actions required by Governing Body Members: J.Davies to continue chairing monthly planned care working group meetings with RJAH and SaTH to oversee recovery and sustainability of RTT and cancer performance. J.Davies is the Exec lead for the system demand and capacity programme within the system A&E recovery plan. S.Freeman to continue to attend A&E Delivery Board to ensure SCCGs contribution to the A&E recovery trajectory is delivered. 2

76 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: A: CCG Aims and Objectives Yes/ No 1 Objective 1 Deliver continually improving Healthcare and Patient Experience Yes Achievement of the performance metrics will improve outcomes and patient experience 2 Objective 2 Develop a true membership organization (active engagement and clinically led organization) No 3 Objective 3 Achieve Financial sustainability for future investment 4 Objective 4 Visible leadership of the local health economy through behavior and action 5 Objective 5 Grow the leaders for tomorrow (Business Continuity) No No No B: Governance Yes/ No 1 Does this report: Provide Shropshire CCG with assurance against any risk in the BAF? Have any legal implications? Yes Promote effective governance practice Risk no. 73/16 NHS Constitution 2 Additional staffing or financial resource implications The CCG would fail to get its full Quality Premium Payment if it fails any of its key performance premium indicators. 3 Health inequalities The action taken by the CCG to deliver all its constitutional targets will address any health inequalities currently present in the areas the performance targets are not being met 4 Human Rights, equality and diversity requirements 5 Clinical engagement 6 Patient and public engagement Yes Yes N/A N/A N/A 3

77 Governing Body Shropshire Clinical Commissioning Group (CCG) Performance Report April 2018/19 INTRODUCTION 1. This performance report provides an overview of the key performance indicators (KPIs) that the CCG is held accountable for with NHS England during 2017/18. They are part of the CCG s Improvement and Assessment Framework (IAF) for 2017/18 detailed under the Better Care section and linking in with the six national clinical priorities. These are mental health; dementia, learning disabilities, cancer, diabetes and maternity. 2. The monthly data reported is for January 2018 and February 2018 where data is available. 3. Some of the CCG Improvement and Assessment Framework indicators have been updated where new data has been made available. 4. The overview provides assurance on performance achievement against targets/standards at CCG and provider level as appropriate, and the delivery and contractual actions in place to mitigate. DASHBOARD 5. The dashboards below provide details of indicators and their RAG rating against national and local standards within service areas. Following these, there are details of the high risk indicators and the mitigation in place. 6. Where key standards were not achieved in 2016/17, trajectories have been set as part of the Sustainability & Transformational Fund (STF), in the 2017/18 planning round. For Robert Jones and Agnes Hunt Hospital and Shrewsbury and Telford Hospital Trust, these included; A&E 4 Hour Wait 18 Weeks RTT Incompletes Cancer 62 day Waits Page 1

78 Cancer Latest Baseline Position Outturn/St andard Standard/ Target Shropshire CCG KEY PERFORMANCE INDICATORS Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Cancer Diagnosed at Early Stage - % of cancers diagnosed at Stage 1 & 2 Cancer 62 Day Waits - % of patients receiving first definitive treatment for cancer within 62 days of an urgent GP referral for suspected cancer Cancer 62 Day Waits - % of patients receiving first definitive treatment for cancer within 62 days of referral from an NHS Cancer Screening Service Cancer 62 Day Waits - % of patients receiving first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status Cancer 2 Week Wait - % of patients seen within two weeks of an urgent referral for suspected cancer Cancer 2 Week Wait - % of patients seen within two weeks of an urgent referral for breast symptoms 2016/ % 85% 89.2% 89.2% 76.2% 82.6% 79.0% 81.9% 77.9% 89.3% 88.8% 78.6% 83.1% 2016/ % 90% 100.0% 100.0% 60.0% 80.0% 100.0% 100.0% 86.7% 85.7% 85.7% 84.6% 87.8% 2016/ % No National Standard % (England 52.4%) 86.1% 87.8% 88.5% 93.1% 86.1% 83.9% 84.8% 87.8% 86.8% 91.2% 87.5% 2016/ % 93% 94.2% 93.5% 92.5% 93.0% 92.0% 93.1% 94.2% 93.6% 89.9% 93.9% 93.0% 2016/ % 93% 92.1% 91.8% 92.6% 92.9% 90.0% 92.6% 93.5% 91.9% 87.5% 91.3% 91.8% Cancer 31 Day Wait - % of patients receiving first definitive treatment within 31 days of a cancer diagnosis 2016/ % 96% 98.5% 98.0% 97.9% 99.4% 99.5% 98.7% 100.0% 100.0% 98.8% 98.7% 99.0% Cancer 31 Day Wait - % of patients receiving subsequent treatment for cancer within 31 days where that treatment is surgery Cancer 31 Day Wait - % of patients receiving subsequent treatment for cancer within 31 days where that treatment is anti cancer drug regimen Cancer 31 Day Wait - % of patients receiving subsequent treatment for cancer within 31 days where that treatment is radiotherapy treatment course One-year survival for all cancer Cancer patient experience of responses, which were positive to the question "Overall, how would you rate your care?" 2016/ % 94% 90.9% 100.0% 100.0% 97.5% 95.2% 100.0% 97.7% 97.5% 95.8% 96.7% 97.3% 2016/ % 98% 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.8% 2016/ % 94% 100.0% 98.1% 100.0% 97.8% 100.0% 100.0% 98.6% 98.1% 100.0% 100.0% 99.2% (England) % (England 70.4%) (CCG) Page 2

79 CANCER 9. As at January 2018, 3 cancer indicators did not achieve the standard in the month: 62 week wait GP Referral, 78.6% against 85% standard 62 week wait Screening Service, 84.6% against 90% standard 2 week wait Breast, 91.3% against 93% standard 10. SaTH failed 2 cancer targets in January: Urgent 62 day RTT and extended 62 day treatment (screening). Complex cases and patient choice continue to be key factors in determining the number of breaches. The CCG continues to work with SaTH and other providers to improve pathways for vague symptoms which currently do not fall neatly into existing pathways. 11. The cancer dashboard also details 3 further indicators, which are all reported on an annual basis. As national data becomes available this will be updated. These indicators are; diagnosis at early stage 1&2, one year survival and cancer patient experience. Baselines and the latest position are shown. The patient experience RAG rating is based on a survey where patients are rating their care (excellent or very good) the overall care rating for Shropshire CCG is 8.7 compared to 8.7 for England 12. There were day cancer breaches reported for January All long wait cancer patients are reviewed through CQRM to ensure processes are not likely to cause harm and that any systemic reasons for delay should be investigated, understood and remedied. Page 3

80 Mental Health Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD IAPT Roll Out - Proportion of people that enter treatment against the level of need in the general population (CCG/SSSFT) 2016/ % 15% 1.2% 1.3% 1.1% 1.1% 1.6% 1.3% 1.1% 1.1% 1.1% 1.5% 12.4% IAPT Recovery Rate (CCG/SSSFT) 2016/ % 50% 60.7% 59.6% 53.3% 52.9% 56.6% 51.7% 52.7% 52.4% 54.7% 54.3% 55.6% 75% of people with relevant conditions to access talking therapies in 6 weeks (CCG/SSSFT) 95% of people with relevant conditions to access talking therapies in 18 weeks (CCG/SSSFT) New target 2016 ** SSSFT 75% 95.6% 98.7% 98.8% 93.8% 96.4% 94.1% 94.7% 93.7% 98.4% 95.8% 93.8% 95% 95.6% 98.7% 100.0% 99.5% 99.5% 98.7% 98.2% 99.5% 100.0% 99.0% 98.5% 50% of people experiencing first episode of psychosis to access treatment within 2 weeks (CCG/SSSFT) Children & Young People's Mental Health Services Transformation Crisis Care & Liaison mental health services transformation Out of Area placements for acute mental health inpatient care - transformation Mental Health - Care Programme Approach (CPA) - % of patients under adult mental illness on CPA who were followed up within 7 days of discharge from psychiatric patient care 2016/17 68% 50% 50% 0% 50% 50% 0% 100% 50% 33.0% 100.0% 100.0% 54.0% 5 Questions: 2 fully Compliant 2 Partially Compliant 1 Not Compliant 15 Questions: 6 fully Compliant 3 Partially Compliant 6 Not Compliant 3 Questions: 3 fully Compliant 5 Questions Fully Compliant 15 Questions Fully Compliant 3 Questions Fully Compliant Q4 2016/17 85% Q4 2016/17 50% Q4 2016/17 100% 2016/ % 95% 100.0% 96.2% 97.9% Page 4

81 MENTAL HEALTH IMPROVED ACCESS TO PSYCHOLOGICAL THERAPIES (IAPT) 13. Performance for IAPT is as follows: Roll Out standard 15%. Performance for February is reported as 1.4%, slightly lower than the previous month, with a year to date position of 14.7% which is on target to achieve the year end target. Other IAPT activity occurs through GP counsellors, but this is not recorded in national monitoring. SSSFT, as the main provider, is currently contracted to achieve 15% at the year end. The Recovery rate dropped to 51.9% in February but is still above target for Q There are now three indicators in the Mental Health Dashboard where a service baseline has been set, and progress is due during 2016/17. These relate to children s and young people s mental health, crisis care and liaison and out of area placements. MENTAL HEALTH CARE PROGRAMME APPROACH (CPA) 15. As at Q3, 2017/18, 96.4% patients on CPA were followed up within 7days against the 95% standard. The YTD position is 97.3%. MENTAL HEALTH EARLY INTERVENTION IN PSYCHOSIS (EIP) 16. As at February the CCG is achieving 54% against a target of 50%. The numbers of cases each month is small, so month on month percentage achievement is subject to variability due to small numbers. MENTAL HEALTH Under 25 Service 17. A Remedial Action Plan is in place with SSSFT for this service. A Single Point of Access has been established for the service and a clear position achieved in respect of numbers of clients waiting service provision. 18. SSSFT reported at the March contract meeting that they would be losing 3 locum consultants. The CCG has asked for a statement from the Trust regarding the risk assessment they have done on impact of this loss and the resulting contingency plans. They are in the process of recruiting substantive consultants and have the first starting on the 7 th May and interviews for a second later in April. They will need to continue to use locum consultants until all the required posts are substantively recruited to. Page 5

82 Dementia Latest Baseline Position Outturn/ Standard Standard /Target Maternity Latest Baseline Position Outturn/ Standard Standard /Target Learning Disability Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Reliance on specialist inpatient care for people with a learning disability and/or autism (per million pop) Monitoring commenced in 2016/17 Trajectory 1.19% Q4 2016/17 68 Proportion of people with a learning disability on the GP register receiving an annual health check 2015/ % (England) 46.5% (2015/16: CCG) Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Jan-18 Feb-18 Mar-18 Neonatal mortality and still births per 1,000 population 2015 Women's experience of maternity services (2015: CCG) 82.1 (2015: CCG) Choices in Maternity Services Monitoring commenced in 2016/ % (2015 CCG) Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Maintain a minimum of two thirds diagnosis rates for people with dementia 2016/ % 67% 69.4% 69.8% 69.8% 68.0% 70.1% 70.3% 71.4% 71.1% 69.9% 69.5% 69.8% 69.8% The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months 2015/16 80% (2015/16: CCG) Page 6

83 LEARNING DISABILITIES (LD) 19. There are two indicators relating to LD: At Q2, 2017/18, the rate for reliance on specialist inpatient care for people with a learning disability and/or autism was reported as 200 per 1m population. In absolute terms this is 62 patients. 20. The CCG is constructing a plan for 2018/19 to achieve the required improvement in the percentage of patients on GP LD registers receiving an annual health check. MATERNITY 21. The maternity indicator position is reported annually. There are three indicators in the dashboard, with data now populated. These have not yet been updated from 2015 data and show the CCG in the middle range of the national distribution. DEMENTIA 22. Dementia diagnosis continues to perform above the national standard. Page 7

84 Urgent and Emergency Care Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Achievement of milestones in the delivery of an integrated urgent care service 6 Inequality in unplanned hospitalisation for chronic ambulatory care sensitive conditions Q3 2016/ (England) Q3 2016/ A&E Waiting Time - % of people who spend 4 hours or less in A&E (SaTH) 2016/ % 95% 84.5% 77.5% 79.6% 78.6% 76.6% 77.6% 73.3% 73.7% 69.3% 66.0% 67.6% 75.3% Trolley Waits in A&E - Number of patients who have waited over 12 hours in A&E from decision to admit to admission (SaTH) 2016/17 17 Zero Tolerance Ambulance Handover time - Number of handover delays of >30 minutes (RSH + PRH) 2016/ Zero Tolerance Ambulance Handover time - Number of handover delays of > 1 hour (RSH + PRH) 2016/ Zero Tolerance Page 8

85 URGENT & EMERGENCY CARE A&E 4 HOUR WAIT & AMBULANCE HANDOVERS 23. The SaTH A&E 4 Hour Wait target has not been achieved and is reported as 66.0% in January and 67.6% in February. This is significantly below the target trajectory. 24. Performance in January and February still was below the planned STF trajectory at SaTH. Actual attendances at A&E are below the expected numbers in the STF trajectory, but breaches are higher than expected. Performance on Delayed Transfers of Care (DToC) in SaTH improved in January to 2.0% which is ahead of the target of 3.5%. 25. The action plan agreed through the A&E Delivery Board has identified 6 key action areas: Frailty Stranded patients ED Processes Getting SAFER as standard including red to green Capacity and demand Working towards an integrated discharge team Specific work plans are being formulated to take each of these action areas forward. 26. CDU at PRH is currently expected to become operational from 2 nd April following some delays due to provision of Medical Gasses. Tracking of progress against the NHSI recommended actions is in place and improvements are being made to FFA documentation. SaTH have undertaken a Perfect Week exercise at the end of March/beginning of April to deliver a step change in internal systems and processes. The initial learning from this will be presented at the A&E Delivery Group on the 4 th April. 27. Stranded patients remains a problem with generally around 350 patients with lengths of stay of over 7 days. Clinician behaviour is increasingly being challenged concerning discharges. The Frailty project will continue beyond 31 st March and an evaluation report is currently being prepared within SaTH. This will then be reviewed by the CCG and finalised to go to the Clinical Commissioning Committee in April. 28.There have been twelve 12 hour trolley waits reported in A&E at SaTH in February. RCA analysis of these are reviewed at the contract CQRM meeting with the Trust. Page 9

86 Urgent and Emergency Care Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Category 1 (mm:ss): 90th Percentile WMAS 00:11:22 00:11:45 00:11:48 00:11:47 00:12:21 00:11:59 00:11:19 00:11:41 00:12:10 00:11:44 00:12:46 00:11:36 New 15mins metric SCCG 00:17:44 00:18:31 00:18:34 00:19:56 00:19:56 00:20:35 00:20:04 00:20:22 00:19:55 00:19:14 00:20:12 00:20:33 Category 2 (mm:ss): 90th Percentile WMAS 00:16:43 00:18:39 00:18:10 00:19:21 00:19:52 00:22:17 00:21:09 00:21:36 00:24:16 00:22:26 00:24:22 00:21:38 New 36mins metric SCCG 00:25:16 00:29:40 00:28:18 00:32:14 00:30:55 00:34:05 00:31:32 00:33:58 00:34:50 00:34:31 00:34:38 00:32:37 Category 3 (mm:ss): 90th Percentile WMAS 00:28:59 00:39:53 00:38:01 00:44:57 00:46:05 00:76:27 00:64:15 01:07:15 1:32:57 01:22:47 01:36:47 00:69:48 New 90mins metric SCCG 00:36:29 00:45:17 00:41:27 00:46:17 00:49:06 00:68:06 00:57:03 1:02:13 1:15:13 01:00:59 01:13:23 00:62:54 Category 4T (hh:mm:ss) : 90th Percentile WMAS 01:00:32 01:20:12 01:18:45 01:35:33 01:30:59 01:34:53 01:27:17 1:21:06 1:66:15 01:45:57 02:02:23 01:31:34 New 180mins metric SCCG 00:41:07 01:08:07 01:04:21 01:06:27 01:20:44 01:08:57 01:15:55 1:32:19 1:03:17 01:17:57 01:24:59 01:13:25 Crew Clear delays of > 30 minutes (RSH + PRH) 2016/ Crew Clear delays of >1 hour (RSH + PRH) 2016/ Delayed Transfers of care attributable to the NHS (LA) 2016/ Zero Tolerance Zero Tolerance Reduction 2016/17 Outturn DTOC Rate (SaTH) 3.5% 2.3% 2.9% 2.8% 3.3% 3.1% 2.4% 3.0% 3.7% 2.5% 2.0% 2.4% DTOC Rate (RJAH) 3.5% 4.8% 4.3% 4.2% 4.2% 3.2% 2.3% 0.5% 3.2% 5.9% 6.2% 2.3% Population use of hospital beds following emergency admission Q3 2016/ (England) Q3 2016/ (Rolling Year) Page 10

87 URGENT & EMERGENCY CARE AMBULANCE RESPONSE TIMES, CREW CLEAR AND DELAYED TRANSFERS OF CARE 29. New performance standards have been defined for the 4 categories of call and are planned to be formally introduced to national monitoring form 1 st April WMAS have reported these new measures since September. The standards are shown below. Call Category Standard (mean) 90 th Percentile Category 1 Mean 7 minutes 90 th Percentile 15 minutes Category 2 Mean 18 minutes 90 th Percentile 36 minutes Category 3 90 th Percentile 90 minutes Category minutes 30. The CCG failed to meet the standards for the Category 1 calls and for the average target response time for Category 2 calls in January but, continues to achieve the standards for all other Call category standards. Category 1 calls account for around 5% of total calls to the ambulance service 31. DTOC (SaTH) In January 2018, the number of delayed days was 2.0% of occupied bed days. This is below the 3.5% target at SaTH. The position at RJAH in January was 6.2%, affected by problems in arranging complex support packages with a number of local authorities. At SCHT, the January value was 7.0%, a deterioration from the previous month. The Trust has re-calibrated its DTOC improvement plan and is now targeting achieving the 3.5% aim by August Target levels for delayed transfers of care have been agreed with the Local Authority. These are expressed as a rate per day per 100,000 population over the age of 18. The January attainment for this was a rate of 5.6 per day per 100,000 population which is ahead of target. Whilst the overall rate is on target, there are some difficulties in ensuring that patients requiring NHS packages of care are being progressed through the system quickly enough to avoid delays. Page 11

88 Elective Access Latest Baseline Position Outturn/Stand ard Standard/Targ et Primary Medical Care Latest Baseline Position Outturn/S tandard Standard/ Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Inequality in emergency admissions for urgent care sensitive conditions Q3 2016/17 1,758 (England) Satisfaction with the quality of consultation at a GP practice (Jan-Mar & Jul- Satisfaction with the overall care received at the surgery Sept15) - Published 89.8% Satisfaction with accessing primary care Jan % Extended access to GP services on a weekend and evening Primary care workforce: Number of GPs and Practice Nurses (full-time equivalent) per 1,000 weighted patients by CCG March 2017 Sep % (England) 1.04 (England) Q3 2016/ (Jul-Sept15 and Jan-Mar16) Published July % (Jul-Sept15 and Jan-Mar16) Published July % This is based on a bi-annual survey undertaken in March and September March 2017 (CCG): 9.3% 1.15 (September 2016: CCG) Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD RTT - incompletes (CCG) 2016/ % 92% 88.6% 89.4% 89.4% 88.9% 89.8% 90.7% 92.0% 92.2% 91.2% 90.9% 90.5% RTT - incompletes (SaTH) 2016/ % 92% 85.8% 87.8% 88.2% 88.9% 90.8% 93.2% 94.5% 94.9% 93.9% 93.1% 90.2% RTT - incompletes (RJAH) 2016/ % 92% 91.3% 91.5% 90.1% 89.2% 88.7% 88.1% 89.1% 89.2% 89.0% 89.0% 89.7% No. of 52 Week Waiters (CCG) 2016/17 56 Zero Tolerance Diagnostic Test Waiting Time < 6 weeks (CCG) 2016/17 1.8% 1% 0.3% 0.5% 0.4% 0.5% 0.6% 0.9% 0.7% 1.0% 0.7% 0.7% 0.6% Diagnostic Test Waiting Time < 6 weeks (SaTH) 2016/17 1.7% 1% 0.0% 0.1% 0.0% 0.0% 0.1% 0.7% 0.7% 1.0% 0.4% 0.5% 0.3% Diagnostic Test Waiting Time < 6 weeks (RJAH) 2016/17 0.2% 1% 1.0% 0.1% 0.3% 0.5% 0.4% 0.7% 0.3% 0.5% 1.4% 0.6% 0.5% Cancelled Operations - no. of patients re-admitted within 28 Zero 2016/17 5 days (SaTH) Tolerance Cancelled Operations - no. of patients re-admitted within 28 days (RJAH) 2016/17 2 Zero Tolerance Page 12

89 PRIMARY MEDICAL CARE 33. Access to, and satisfaction with, Primary care services continues to be rated highly by Shropshire patients and compares well with the overall England position. 34. Extended access at weekends and evenings is an area where improvement is indicated for the CCG as it is below the national average and therefore is a section within the GP 5yr forward view work stream. ELECTIVE ACCESS 18 WEEKS RTT, 52 WEEK WAITERS, AND < 6 WEEKS DIAGNOSTICS 35. The CCG s RTT performance was 90.9% in January, which is below the target. This was made up of 93.1% achievement at SaTH, 90.4% at RJAH and 89.3% at all other providers. This indicates that all providers continue to struggle to achieve the target. 36. SaTH achieved their overall RTT target in January for the fifth time this year at 93.1% and is now achieving in all specialties apart from T&O. 37. RJAH have indicated they anticipate achieving between 91% and 92% by the end of the current financial year. 38. At the end of January there were 2 52 week waiters reported for the CCG. These were one patient at Wye Valley and one at RJAH. Both patients are T&O. The RJAH patient will remain a 52 week breach until July due to patient choice of date of surgery. 39. Performance against the 99% standard for waiting time for a Diagnostic Test was achieved by the CCG in January with a level of 99.3%. Page 13

90 Additional Indicators Requiring Focus Latest Baseline Position Outturn/ Standard Standard /Target NHS Continuing Healthcare Latest Baseline Position Outturn/ Standard Standard /Target Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD People eligible for standard NHS Continuing Healthcare per 50,000 population. Consistent application across the country is the measurement 2016/17 Q (England) Q3 2016/ Indicator Description Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Healthcare acquired infection (HCAI) measure (MRSA) 2016/ Healthcare acquired infection (HCAI) measure (Clostridium difficile infection) 2016/ E coli bacteraemia 2016/ Page 14

91 NHS CONTINUING HEALTH CARE (CHC) 40. Performance for CHC at CCG level for Q is at 42.7% against a national figure of 45%. This national data has been recently published as part of My NHS dashboard. HEALTH ACQUIRED INFECTION MRSA AND CDIFF 41. For 2017/18 there have been no incidences of MRSA reported at CCG level in Q1, Q2 & Q3 2017/ C Difficile for 1718 to January 58 incidences were reported which may put the year end position at risk. 43. E Coli infections were slightly below target in February. The annual target for the CCG is 205 with the final year position having now failed. The anonymised data of these cases will be analysed and shared with the Local Health Economy E coli BSI Reduction Group and the Local Health Economy IPC Group to identify opportunities and potential interventions to reduce the risk of E. coli BSI in the CCGs population and achieve the ambition to reduce all E coli BSI reported at CCG level by 10% or greater by March NHS The CCG is now receiving data direct from the regional commissioning lead for NHS 111. There were 2973 calls triaged by NHS 111 registered to Shropshire in January Of these 26.67% (793) were triaged by CA. Of the triaged calls 36.46% were referred to OOH service and 16.3% to the ambulance service. 45. The surge in activity that was seen in December and January now appears to have reverted to levels more consistent with the average of earlier months. The lead commissioner has reported some recent improvement in call response times though there is still some concern around adequacy of shift coverage at peak times. 46. Care UK, the service provider, are reviewing procedures and operation of NHS Pathways which are expected to reduce the number of dispositions to the ambulance service. RECOMMENDATIONS 47. The Governing Body is asked to NOTE the contents of the report and the CCG actions contained within to recover performance in those areas which are currently below target. Page 15

92 Agenda item: GB Governing Body Meeting: 11 April 2018 Responsible Director: Gail Fortes-Mayer, Director of Contracting & Planning Author of the report: Charles Millar, Head of Contracting, Planning & Performance Meryl Flaherty, Head of Contracting Presenter: Gail Fortes-Mayer, Director of Contracting & Planning Purpose of the report: This report summarises the current contractual position at Month 10 for the CCG s four main contracts; highlighting key contractual issues for review by the Governing Body. Key issues or points to note: SaTH Activity is on plan, there is slight over performance in Daycases and First Outpatient attendances. Elective, Non-Elective and Critical Care are all under plan. Daycase at Robert Jones and Agnes Hunt Trust is continuing to underperform by 14% A Contract Performance Notice is in place with SSSFT regarding the performance of the Early Intervention in Psychosis Pathway indicator. A Contract Performance Notice is in place with SSSFT due to concerns regarding the 0 to 25 service An Activity Query Notice (AQN) has been raised through lead commissioner following significant over performance in activity with WMAS ; Actions required by Members: To note the current performance and actions. 1

93 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications Yes/No 2 Health inequalities 3 Human Rights, equality and diversity requirements 4 Clinical engagement 5 Patient and public engagement 6 Risk to financial and clinical sustainability There is over-activity in the out of county providers particularly in Outpatients and Emergency Admissions notably at Wye Valley and Worcester Yes/No Yes/No Yes/ No Yes/ No Yes/ No 2

94 NHS Shropshire CCG Governing Body January 2018 Major Contract Performance Month 10 (January 2018) Authors: Charles Millar, Head of Planning & Performance and Meryl Flaherty, Head of Contracting Executive Summary and Actions Required 1 This report summarises the current contractual position at Month 10 for the CCG s main contracts; highlighting key contractual issues for review by the Finance & Performance Committee. Members are asked to note the current performance and actions. Introduction 2 This report summarises Shropshire CCG s (SCCG) position with respect to its contracts with its main providers outlining the actions underway. Note: This paper should be read in conjunction with the Finance and Contract Report. Contracts Overview Shrewsbury and Telford Hospital NHS Trust (SaTH) Activity 3 The overall the contract activity is slightly under plan. The areas of over performance are similar to the contract from 16/17, namely: Daycases and First Outpatient attendances. 4 There are also areas of underperformance that have continued in Elective, Nonelective and Critical care, bringing the activity back in line with plan. Elective activity in January was slightly higher than the same month last year, so the Winter Elective pause seems to have had little impact. Table 1. SaTH Activity Month Point of Delivery (POD) Plan Actual Variance % Variance Day cases % Elective % Emergency % Non Elective % Critical Care % First Outpatients % Follow Up Outpatients % Outpatient Procedures % A&E Attendances % Total % Emergency Figures 1 & 2. Emergency activity 5 The charts below show a 34 month activity and cost trend. 3

95 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Emergency Actual Activity 2,600 2,400 2,200 2,000 1,800 1,600 Emergency Actual Cost 5,500,000 5,000,000 4,500,000 4,000,000 3,500,000 3,000,000 6 The over performance is predominately case mix driven. The chart above indicates that cost has slowly been increasing over the last 34 months. November 17 case mix being particularly high. Sepsis Counting and Coding Notice The 2018/19 National Sepsis guidance impact has been released and should see around a 190k savings. This will form part of the Challenges for 18/19 if SaTH do not correct the coding. 4

96 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Referrals 7 SATH referrals continue to be on a slight downward trajectory. The referral data is analysed in detail at the Activity & Finance Group and discussed at a speciality level. There is particular focus on the consultant to consultant referrals to ensure they are within the CCG Policy. Figure 3. Referrals to SaTH SaTH Referrals Referrals Linear (Referrals) Finance 8 At month 10 position, Shrewsbury and Telford Hospitals contract is reporting a year to date overspend of 3.016m and a forecast overspend of 5.085mat the year end, this is part of Year End deal and as such will not change in subsequent months. Contractual Actions Contractual Challenges Raised 9 Flex and Freeze is being fully operated within the SaTH contract in line with the National Secondary Uses Service (SUS) timetable. The CCG will not fund activity that has not been reconciled through SUS, or in the case of activity or payments not liable for SUS submission. The CCGs will pay only on reconciliation of Service Level Agreement Manager data (SLAM) with Patient Level Data. Challenges Raised 10 The formal Month 9 challenge position is as follows: 5

97 Table 2. Challenge Values Month Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Full challenge value 463, , , , , ,186 Month Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Full challenge value 336, , , Month 10 formal challenges will be issued on 3 rd April 2018 Activity Query Notices (AQN) 12 The Trust has raised an Activity Query Notice with regards to data issues supplied by the CSU contained in the month 2 challenge letter. The CSU have acknowledged there were duplicates contained in the backing data supplied with the challenge letter. Additional validation took place in September to ensure the Month 3 backing data was accurate; the CGG is now expecting the notice to be closed. Contract Performance Notices 13 There is now only one Contract Performance Notices (CPN) currently open with SaTH for failure to achieve the constitutional targets: The percentage of A&E attendances where the Service User was admitted transferred or discharged within 4 hours of their arrival at an A&E department. 14 It should be noted that financial sanctions attributed to A&E performance cannot be applied under the contract as part of the national STF (Sustainability and Transformation Fund) process Contractual Prior Approvals - Value based Commissioning (VBC) 15 Contractual prior approvals have been in place for the treatments contained in the VBC Policy since October Contractually the commissioner is not required to pay for activity carried out without an appropriate prior approval. 16 Key actions summary from Monthly Contract Meetings Activity Plan for 2018/19. The Activity plan for 2018/19 is currently being negotiated with the Trust for sign off. A&E Potential closure of Princess Royal Hospital, Telford Meeting is being arrangement between the CCGs and Trust to discuss the potential closure of the A&E Department at the Princess Royal Hospital. 6

98 Midwife Lead Units Services at Oswestry Midwife Led Unit are suspended until 25 th February 2018 to remove the uncertainty that short notice suspension of services causes. Workforce Vacancy The Trust current has nursing vacancies of 22%. This causes the need to agency staff and the additional cost pressure brought by these Roof at Maternity Unit RSH Following the snow damage at RSH the Maternity Unit is closed to deliveries. Further damage has occurred and the service has now moved to a different ward within the Hospital. Repairs to the roof are ongoing Robert Jones and Agnes Hunt NHS Foundation Trust (RJAH) Activity 17 Month 10 activity at RJAH is 3% below plan. The largest variance in activity is Day cases where activity is 14% below plan. Follow-Up Outpatients are also below plan but there remains a significant number of patients on the Follow Up backlog list. Table 3. RJAH Month 10 Activity Point of Delivery (POD) Plan Actual Variance % Variance Day cases % Elective % Non Elective % Regular Day cases % First Outpatients % Follow Up Outpatients % Outpatient Procedures % Total % Outpatient Procedure 20% over plan 18 The charts below show the 20 month activity and cost trend Figures 4 & 5. Outpatient Procedure Activity N Outpatient Procedure Activity 7

99 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 05N Outpatient Procedure Activity 100,000 80,000 60,000 40,000 20,000 0 Elective YTD variance over plan 19 The over performance is largely due to the impact of the VBC process removing some less complex types of activity which shifts the balance on the waiting list to more complex cases. These are more likely to require inpatient admission rather than treatment as a daycase. Referrals 20 There was a sharp decrease in the number of referrals during December 2017 which was due to a combination of the normal slowdown over the Christmas period plus the impact of the period of snow during the month. The trend is monitored at the monthly contract meetings and at the Planned Care Working Group. Figure 6. RJAH Referrals RJAH Referrals Total Linear (Total) Finance 21 For Month 10. Robert Jones and Agnes Hunt NHS Foundation Trust contract is forecasting an overspend of 3.453m at the end of the year, which is an increase of 60k compared to the previous month. 8

100 Contractual Actions Contractual Challenges Raised 22 Flex and Freeze is being fully operated in line with the National Secondary Uses Service (SUS) timetable. The CCG will not fund activity that has not been reconciled through SUS, or in the case of activity or payments not liable for SUS submission, the CCG will pay only on reconciliation of Service Level Agreement Manager, data (SLAM) with Patient Level Data. 23 The formal Month 9 challenge position is as follows: Table 4. Challenge Values Month Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Full challenge value 223, , , ,365 68,825 99,796 Month Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Full challenge value 113,019 60,402 80, Month 10 formal challenges are being issued on 3rd April 2018 Activity Query Notices (AQN) 25 There are currently no Activity Query Notices open at RJAH. Contract Performance Notices 26 The contractual action relating to the achievement of the RTT target agreed under the STF arrangements remains in place. Value based Commissioning (VBC) 27 Contractual prior approvals have been in place for the treatments contained in the VBC Policy since October Contractually the commissioner is not required to pay for activity carried out without an appropriate prior approval. 28 Key actions summary from Contract Meetings SOOS (Shropshire Orthopaedic Outreach Service) The funding for SOOS has been agreed and the update has been made to the contract. Shropshire Community Health Trust 29. The Month 10 financial position shows a 174k underspend. 9

101 Area Activity Plan Activity Actual % Variance (Activity) Value Variance ( ) PBR 28,047 27,496 -% - 177,339 Non 430, ,558 % 3,350 PbR Total 458, ,054 % 173,989 PbR YTD 44.6% Inpatient under-activity against plan (-107) = - 100, % under-activity against plan in Outpatients (-1,321) = - 141, % under-activity against plan in Radiology (-331) = - 13, % over-activity against plan in MIU (727) = 47, % over-activity against plan for Welsh patients in MIU (482) = 31,364 Inpatient and outpatient under activity is mainly due to reductions in capacity as a result of workforce issues across the health economy. 30. Contractual Actions A Contract Variation has been raised to remove the age restriction within the service specification for the Community Neuro-Rehabilitation Service, to ensure compliance with Age Discrimination Laws. 31. Contractual Challenges Raised No Contract Challenges have been raised. 32. Activity Query Notices (AQN) No activity query notices were open at the end of January Contract Performance Notices Two Contract performance Notices have been issued in January 2018 concerning Unplanned closure at MIUs due to be closed on receipt of the staffing plan from the Community Trust The failure to deliver the Out of Hours District Nursing service The CCG and the Community Trust have agreed to complete a joint investigation to understand the demands for Out of Hours District Nursing and the resources that may be required to deliver the service. 34. Key actions summary from Contract Meetings ICS Specification Collaborative work is being completed in order to agree the ICS specification. IDT Specification There are issues about the delivery of District Nursing services and the eligibility criteria for the service. The CCG is working with the Community Trust to resolve them 10

102 Physiotherapy Waiting Times - The Trust has supplied a monthly report of waiting times for Physiotherapy at each clinic and this is being circulated in the G.P. Newsletter. Physiotherapy waiting times at Whitchurch have recovered based on the most recent reporting. DTOC - SCHT have submitted a plan to achieve the 3.5% target for Delayed Transfers of Care by August The Trust reported 5.59% for January 18. As part of the contractual agreement for the 2018/19 year, the CCG, SCHT and Telford and Wrekin CCG have agreed to undertake an exercise to re-structure the contract so that it: More accurately reflects the current range and shape of services provided; The production of an up to date price/activity matrix for service lines; The development of an updated activity schedule which will reflect the current nature and relativities of services. This work is planned to be completed within the first 6 months of the 2018/19 financial year. South Staffordshire and Shropshire Healthcare Trust 35. Month 10 Activity The contract is currently 9.4% under the activity target at Month 10 with a 31,857 underspend once the financial adjustments are applied. The financial adjustment is the application of the 5% cap and collar and the upper and lower tolerances. Activity plan Activity Actual 11 % Variance Activity YTD Finance Variance YTD Financial adjustment M9 MH Admitted Care 18,823 14,436 (23.3.%) ( 26,014) ( 26) MH Non Admitted Care 1,030, ,692 (6.2%) ( 1,298,836) ( 30,310) MH Non PbR 19,196 20, % 52,680 9,092 Specialist & Family Services 1,625 1,465 (9.8%) ( 44,865) ( 2,584) Learning Disability Service 7,345 8, % 175,934 ( 8,029) Other 33,815 0 Total 1,077,000 1,009,867 (9.37%) ( 1,107,286) ( 31,857) PICU % PICU Nurse Specialling * * Nurse specialling is where a patient requires 2:1 nursing (or more) and is included in the price of PICU. The marginal rate does not apply to PICU but there is an upper tolerance limit of 20%. 36. Contractual Actions

103 None to report. 37. Contractual Challenges Raised No Contract Challenges have been raised. Activity Query Notices (AQN) The AQN issued in relation to the significant under activity in community services has now been closed following a joint investigation into activity levels. This concluded that the underperformance was due to internal changes within SSSFT whereby activity undertaken by social work staff was no longer being recorded within the contract. The nature of the cap and collar arrangement within the contract means that the financial impact of this is diluted. The CCG is discussing with the trust and Telford and Wrekin CCG a re-structuring of the contract for the 2019/20 year to recognise the true levels of activity Contract Performance Notices A Contract Performance Notice remains open due to concerns about the ability to achieve the Early Intervention in Psychosis (EIP) target that 50% of Service Users experiencing a first episode of psychosis should commence a NICE-concordant package of care within two weeks of referral. SSSFT are implementing a remedial action plan to rectify the situation which is being monitored by Commissioners in the monthly Contract meetings. SSSFT have also produced a Reporting Assurance Process in association with NHS Digital. An investigation was undertaken into apparent differences between activity numbers reported locally and those reported through national routes. This concluded that there was in fact no difference between these numbers, the issue being the rounding of numbers in the national reporting to the nearest 5 as a result of small cell count rules in national reporting. A Contract Performance Notice has been issued concerning the 0-25 Emotional Health and Well-being Service. SSSFT are implementing an agreed Remedial Action Plan which will be closely monitored by Commissioners. There are monthly operational meetings between all Commissioners and the SSSFT to provide a forum to agree solutions for operational problems and to alleviate any communication issues. 38. Key actions summary from Contract Meetings New model for Learning Disabilities Services - A new model for Learning Disability services and service specifications are in development. Commissioners are in discussions with SSSFT to progress. IAPT Service Tariff Development A group of stakeholders currently including Staffordshire CCGs are working together with the Trust to develop tariffs for the IAPT services. It has been agreed to build the tariff based on real costs of individual services and compare to national reference costs. The CCG is appraised of the national work to identify a non-mandatory price for IAPT services. Out of Area Placements A task and finish group is to be set up to address Out of Area placement management. Shropshire Doctors Co-operative Ltd. (Shropdoc) 12

104 39. The Out of Hours service is commissioned on a block contract basis from Shropdoc. Month 10 - Shropshire LQR In-time Total % 1 % calls abandoned % 2 % answered in 60 seconds % 4 % calls passed to 999 within 3 minutes % 12 % calls triaged within 20 mins (urgent) % 13 % calls triaged within 60 mins (routine) % 9 % emergencies consulted within 1 hour % 10 % urgent consulted within 2 hours % 11 % routines consulted within 6 hours % 9 % emergencies visited within 1 hour % 10 % urgent visited within 2 hours % 11 % routines visited within 6 hour % 40. The performance in relation to these KPIs does not currently carry any penalty payment consequences. The KPIs are currently being reviewed for appropriateness and sensitivity and will be restructured as a result of this. LQR In-time Total % 9 F2F All - 1 hour % 10 F2F All - 2 hours % 11 F2F All - 6 hours % 41. Contract Actions Shropdoc have shared their model of service delivery implementing the use of Urgent Care Practitioners as well as GPs. The Commissioners are monitoring the impact of the new model. The CCGs have agreed to revise some of the targets for home visits for in recognition of the rural nature of Shropshire and the travelling times that may be incurred for home visits. 42. Activity Query Notices There are no Activity Query Notices open. None 43. Contract Performance Notices 44. Key Actions Summary from Contract Meetings Out of Hours Medical Cover in Community Hospitals Shropdoc noted that this element of the service was not in the service specification of the current contract and, therefore, they could not provide the service. Following discussions, Shropdoc are continuing to provide the service. Out of Hours District Nursing Shropdoc gave notice to Shropshire Community Health Trust on delivering this sub-contracted arrangement as it was no longer viable once Telford and Wrekin CCG had given notice on the service. Whilst negotiations take 13

105 place between the two Providers and the CCG, Shropdoc are continuing to provide the service on behalf of the Community Trust. Provider 45. Table 9 Falck Finance Position Planned Budget YTD (M11) Actual Cost YTD (M11) Variance % Variance Falck Medical Services 2,733,566 2,808,020 74, % 46. The committee is asked to note the current performance of the provider. Falck Medical Services are currently over performing by 2.72% against budgeted plan. Contractual Actions 47. Indicative Activity and Expected Contract Values will be remodelled based on outturn for this financial year to reflect current performance. A contract variation will be issued to action these changes. 48. A previous agreement required the CCG to fund NEPT costs for out of area patients and then reclaim from the relevant commissioners. The current position for this is shown in Table 10. Table 10 Out of Area Costs Out Area Activity Top 5 Highest Costs Actual Cost (M1-M11) Powys LHB 137,782 NHS Stafford and Surrounds CCG 4,060 NHS Stoke on Trent CCG 2,926 NHS Herefordshire CCG 2,869 NHS South East Staffordshire and 2,327 Seisdon Peninsula CCG Other CCGs (84 in total) 26,383 Total Cost 176,347 Contractual Actions 49. To mitigate this cost Finance has raised invoices to recharge Powys LHB for their responsible cohort of patients. Moving forward Powys will become a party to the current contract with Falck Medical Services. The provider will then charge Powys directly for their cohort of patients. It has also been agreed with the provider from 1 st April 2018 the responsibility of charging out of area patients who are the responsibility of other English commissioners will be with the provider. 50. Key Performance Indicators are currently being reviewed. 14

106 51. Contract Notices None open. Other Providers 59. Table 11 - Other providers activity Provider Planned Activity Actual Activity Activity Variance Betsi Cadwaladr University Health Board Daycase & Regular Day Admissions Elective Emergency and Non-Elective st Outpatient Follow Up Outpatient Other The Royal Wolverhampton NHS Trust Daycase & Regular Day Admissions Elective Emergency and Non-Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other University Hospitals Birmingham NHS Foundation Trust Daycase & Regular Day Admissions Elective Emergency and Non-Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other University Hospitals of North Midlands NHS Trust Daycase & Regular Day Admissions Elective Emergency and Non-Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other Worcestershire Acute Hospitals NHS Trust Daycase & Regular Day Admissions Elective

107 Emergency and Non-Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Wye Valley NHS Trust Daycase & Regular Day Admissions Elective Emergency and Non-Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other Mid Cheshire Hospitals NHS Foundation Trust Daycase & Regular Day Admissions Elective Emergency and Non-Elective st Outpatient Follow Up Outpatient Outpatient Procedure PbR A&E & MIU Attendances Other Grand Total The following are the major out of county contracts that are over performing: Worcestershire Acute Over performance is mainly in 1 st outpatients and follow up outpatients Mid Cheshire Over performance is mainly in 1 st outpatients and follow up outpatients University Hospitals of North Midlands Over performance is mainly in Emergency and non-electives and First Appointments. 61. Detailed reports for all Out of Area contracts are now reviewed by contracts and performance team internally. West Midland Ambulance Service Table 12 WMAS Activity Provider Planned Actual Variance % Variance Activity Activity Activity West Midland Ambulance Service 36,185 39, % Contractual Actions 62 An activity query notice has been raised through the lead commissioner in respect of over-performance on the WMAS contract. This investigation is ongoing with the provider. The lead commissioner has requested the provision of an additional data set 16

108 which will help identify any issues around calls which do not result in an allocation of a treatment resource. Recommendations 63 The committee is asked to note the current performance and actions. 17

109 Agenda item: GB Shropshire CCG Governing Body meeting: 11 April 2018 Title of the report: Quality Exception Report Responsible Director: Dawn Clarke, Director of Nursing, Quality and Patient Safety Author of the report: Nursing, Quality and Safeguarding Team Presenter: Dawn Clarke, Director of Nursing, Quality and Patient Safety Purpose of the report: The CCG must ensure that commissioned services, including joint-commissioned services are being delivered in a high quality and safe manner, ensuring that quality sits at the heart of everything it does. A wide range of reports pertaining to the quality agenda are received and considered at the Quality Committee in accordance with the terms of reference of the Committee. The purpose of the report is to provide assurance to the Governing Body that the processes are in place to monitor quality performance within our commissioned services, to ensure remedial action is in place where concerns are identified and to escalate where appropriate. Key issues or points to note: The Quality Team at Shropshire CCG is working in collaboration with Telford and Wrekin CCG and Shrewsbury and Telford Hospital NHS Trust (SaTH) jointly to hold the 'Partners in Care' Conference on 15 May The Partners in Care Nursing Conference on 15 May 2018 is open to all Primary Care and Community Care colleagues (nursing and allied health professionals) from across the local health economy. It is timed to coincide with International Nursing Day and to mark the occasion of NHS70 celebrations. The event is designed to help nurses, midwives and healthcare professionals to share good practice and showcase innovative and new ways of working. The conference is built around Leading Change, Adding Value, a framework for nursing, midwifery and care staff, launched by Professor Jane Cummings, Chief Nursing Officer for England. With a focus on nursing and healthcare of the past, present and future, a host of speakers has now been confirmed for this event: Professor Mark Radford - Director of Nursing for Improvement, NHS Improvement Dr Jacqueline McKenna MBE - Director of Nursing for Professional Leadership Andrea Bailey - Associate Dean, Students, Staffordshire University 1

110 Elizabeth Beech - National Project Lead for Healthcare Acquired Infections and Antimicrobial Resistance, NHS England Julia Holding - Co-Production Patient Experience (specifically re Support for Carers), NHS Improvement. To support safer care for patients, SaTH has seen a number of improvements during the Let s Crack It a positive change fortnight that aims to improve patient journeys through the hospitals and ensure patients are discharged as soon as they are medically fit to leave. The Trust coped well with the Bank Holiday period and a review of the success of this programme is being undertaken. Workforce issues in its Emergency Departments, however, remain a constant challenge for the Trust and further testing of the Trust s business continuity plan will take place in the first week of April Shropshire Community Health Trust Looked After Children Health Team has formulated a service recovery plan to assist with assurance around progression of work related to monitoring around the health of looked after children. As progress had not been as timely as expected, a remedial action plan has been received from the Trust in line with contractual requirements and additional operational standards to meet the quality requirements have been drafted for inclusion within the contract. The Trust is reviewing its systems around statutory health assessments for all children under 5 years and over 5 years and the data is expected at the forthcoming CQRM. Actions required by Governing Board Members: Board members are asked to note the key issues above, to note the actions being taken and to receive the report. 2

111 Monitoring form Agenda Item: GB Does this report and its recommendations have implications and impact with regard to the following: 1 Additional staffing or financial resource implications If yes, please provide details of additional resources required No 2 Health inequalities If yes, please provide details of the effect upon health inequalities 3 Human Rights, equality and diversity requirements If yes, please provide details of the effect upon these requirements 4 Clinical engagement If yes, please provide details of the clinical engagement No No Yes Medical and non- medical clinical input routinely provided 5 Patient and public engagement If yes, please provide details of the patient and public engagement Yes Healthwatch are members of the Quality Committee 6 Risk to financial and clinical sustainability If yes how will this be mitigated No 3

112 Quality Committee Governance 1 The CCG must ensure that commissioned services, including joint-commissioned services, are being delivered in a high quality and safe manner, ensuring that quality sits at the heart of everything it does. 2 A wide range of relevant reports pertaining to the quality agenda is received and considered at the Quality Committee in accordance with the terms of reference of the Committee. 3 As part of the revised reporting arrangements, in January, the Quality Committee received the revised Quality Strategy for The Quality Strategy and the supporting delivery plan will be presented at the February Governing Body. CCG Quality and Safeguarding Assurance The CCG is responsible for securing the quality of services we have commissioned and hold all our providers to account for their responses to serious incidents to ensure they are investigated and managed in accordance with national guidance. In April 2018, Dr Finola Lynch- GP Clinical Lead, is providing Quality Committee members with a short training session to support a wider understanding of the serious incident review process, A Quality Account is a report about the quality of services offered by an NHS healthcare provider. The reports are published annually by each provider, including the independent sector, and are available to the public. The CCG s Quality Leads were invited to participate in the Quality Account Stakeholder Events for both SaTH and SCHT in March 2018, and have received SSSFT s suggested priority quality improvement indicators for consideration. A report will be prepared for the Quality Committee in April to ensure that all provider accounts are appropriately reviewed and feedback given. As previously reported, the CCG Quality team, in collaboration with Telford and Wrekin CCG and SaTH, is continuing to progress the preparations for the Partners in Care nurse conference to be held on Tuesday 15 May This will be an exciting opportunity to showcase our work on the National Framework for nursing, midwifery and care staff (May 2016), Leading Change, Adding Value, and there will be an open invitation to all our nursing and allied health professionals across the Health and Social Care Economy within the STP. Quality, Equality and Diversity and Privacy Impact Assessments The CCG is committed to ensuring that commissioning decisions, business cases and any other business plans are evaluated for their impact on quality. An impact assessment is a continuous process to ensure that possible or actual business plans are assessed, the potential consequences on quality, privacy and equality and diversity are considered, and any necessary mitigating actions are outlined in a uniformed way. A quality named lead has been identified for each of the Quality, Innovation, Productivity and Prevention (QIPP) schemes for , to support the CCG commissioners and providers ensure that quality and safety of care is not compromised during service change. 4

113 Quality in Commissioned Services Shrewsbury and Telford Hospital NHS Trust (SaTH) In February 2017, Deirdre Fowler, Director of Nursing, and Dee Radford, Associate Director for Patient Safety, attended the CCG Quality Committee meeting to provide members with an update on how their Serious Incident systems and processes are compliant with the National Serious Incident Framework. The CCG GP Clinical Lead and Director of Nursing and Quality have also been invited to attend the Trust s internal Serious Incident Committee To support safer care for patients the Trust has seen a number of improvements during the Let s Crack It a positive change fortnight that aims to improve patient journeys through the hospitals and ensure patients are discharged as soon as they are medically fit to leave. Let s Crack It is aimed at reducing clinical risk in the Emergency Departments, Assessment Units and on the Wards and the Trust coped well with the Bank Holiday period. A review of the success of this programme is being undertaken with CCG involvement. Workforce issues, however, remain a constant challenge for the Trust in its Emergency Departments and further testing of the Trust s business continuity plan will take place in the first week of April In March, the Trust received a letter of commendation from Ruth May, Executive Director of Nursing, Deputy CNO & National Director for Infection, Prevention and Control, in recognition of its contribution to reducing Escherichia coli bloodstream infections, based on the Quality Premium The Trust is one of 59 to have achieved a 10% or greater reduction in the hospital onset Escherichia coli bloodstream infections. The Trust s baseline numbers were 46 in 2016 and 41 in 2017, equivalent to a 10.9% reduction in cases. This directly contributes to better outcomes for patients and is part of the Shropshire and Telford-wide E.Coli reduction collaborative led by the CCG Infection Prevention and Control Team. The external investigation into the Maternity Service Serious incidents reported since November commissioned by NHS England and NHS Improvement was expected to be completed by March The CCG, to date, has not received the final report. The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (RJAH) The Care Quality Commission report following the recent inspection has not yet been published. The Trust was inspected in March 2016 and was given an overall rating of Requires Improvement. A great deal of work has been undertaken by the Trust to implement the recommendations of the 2016 report and the CQC has not reported any concerns to the CCG following this recent inspection. The Trust was recently awarded the Talent Match Mark award for the work it does to provide exploration, employment and experience opportunities for young people. Shropshire Community Health NHS Trust (SCHT) Shropshire Community Health Trust Looked After Children Health Team has formulated a service recovery plan to assist with assurance around progression of work related to monitoring around the health of looked after children. As progress had not been as timely as expected, a remedial action plan has been received from the Trust in line with contractual requirements, and additional operational standards to meet the quality requirements have been drafted for inclusion within the contract. The Trust is reviewing its systems around statutory health assessments for all children under 5 years and over 5 years and the data is expected at the forthcoming CQRM. 5

114 The risks as outlined above have been reported to the Corporate Parenting Group, recorded on the CCG s risk register and to the CCG Quality Committee. Concerns have been raised about the availability of the District Nursing Service and impact on patient care. This is being reviewed further with the Trust and will be considered at the forthcoming CQRM The CCG Quality team undertook a patient safety and quality visit to Bishops Castle Community Hospital on 31January and in February. As reported previously, there were no major concerns observed from a patient safety and quality perspective. However, further concerns have been raised and a further visit is to be undertaken in April. South Staffordshire and Shropshire Healthcare NHS Foundation Trust (SSSFT) The CCG Quality Team has completed the deep dive analysis of the unexpected deaths reported by SSSFT during 2016 and This work has been undertaken in collaboration with the Director of Public Health. The DPH has met with SSSFT to share the findings and recommendations. Issues concerning access to the 0-25 Emotional Health and Wellbeing Service for out of area looked after children placed into Shropshire and Telford & Wrekin has continued to be a major concern in terms of locally addressing the needs of hosted children. Further key actions are being taken in partnership with the Trust, as highlighted within the Board performance report. A proposal to work collaboratively between CCG and LA commissioners and the Trust in relation to high volume, high risk areas of the mental health and CHC provision in Shropshire has been agreed. An Open Book process across Provider and Commissioner has been established to identify solutions that meet the needs of the population of Shropshire in a sustainable way, whilst supporting the Commissioner to deliver statutory obligations of financial balance. This process will begin in April. Conclusion The Governing Body is asked to note the key issues above, to note the actions being taken and to receive the report. 6

115 Agenda Item GB CCG Governing Body Shropshire, Telford & Wrekin STP STP Directors Monthly Report March 2018

116 How the new NHS Planning Guidance supports our STP key points to consider Integrated System Working, the transition from STP to ICS In 2018/19, all STPs are expected to take an increasingly prominent role in planning and managing system-wide efforts to improve services. Integrated Care Systems System working will be reinforced in 2018/19 through STPs and the voluntary roll-out of Integrated Care Systems. Integrated Care Systems are those in which commissioners and NHS providers, working closely with GP networks, local authorities and other partners, agree to take shared responsibility The term Integrated Care System as a collective term for both devolved health and care systems and for those areas previously designated as shadow accountable care systems. An Integrated Care System is where health and care organisations voluntarily come together to provide integrated services for a defined population. Integrated Care Systems are seen as key to sustainable improvements in health and care Integrated Care Systems will be supported by new financial arrangements It is anticipated that additional systems will wish to join Integrated Care System development programme during 2018/19 as they demonstrate their ability to take collective responsibility for financial and operational performance and health outcomes. It is envisaged that over time Integrated Care Systems will replace STPs As systems make shifts towards more integrated care, they are expected to involve and engage with patients and the public, their democratic representatives and other community partners. Engagement plans should reflect the five principles for public engagement identified by HealthWatch and highlighted in the Next Steps on the Five Year Forward View. Further Information: 2

117 Shropshire, Telford & Wrekin Our vision for health and care services in Shropshire, Telford & Wrekin

118 Our ambition is simple: We want everyone in Shropshire, Telford and Wrekin to have a great start in life, supporting them to stay healthy and live longer with a better quality of life. Our STP is the culmination of a wide range of local organisations, patient representatives and care professionals coming together to look at how we collectively shape our future care and services. This strong community of stakeholders is passionate, committed and realistic about the aspirations set out in this document. Our thinking starts with where people live, in their neighbourhoods, focusing on people staying well. We want to introduce new services, improve co-ordination between those that exist, support people who are most at risk and adapt our workforce so that we improve access when its needed. We want care to flow seamlessly from one service to the next so that people don t have to tell their story twice to the different people caring for them, with everyone working on a shared plan for individual care. Prevention will be at the heart of everything we do from in the home to hospital care. In line with the GP Five Year Forward View priorities, we plan to invest in, reshape and strengthen primary and community services so that we can provide the support people in our communities need to be as mentally and physically well as possible. 4

119 Its all about integration 5

120 Commissioner Led System Improvements Plan on a page

121 Out of Hospital Programme - Shropshire Delivery of Integrated Care in the community The Golden thread Improvement in Community Care & Admission Avoidance Admission avoidance Case Management Crisis Resolution Programme needs to: Using all available resources to commission integrated health and care services that are clinically effective and cost effective and as close as possible to where people live with the greatest needsa System needs to: 1. Collaborate and co-produce 2. Agree alliance working across providers 3. Agree pathways to support admission avoidance 4. Reduce occupied bed days by impact of F1&2 and F3 & 4 The progress: Stakeholder workshops held Patient and engagement workshops held Task & Finish groups formed to co-produce Governance in place Admission avoidance modelling complete Engagement strategy in development Interventions and process changes Primary Care Development including risk profiling, case management, enhanced service delivery Development of a Hospital at Home service to support admission avoidance Development of a Rapid Response and Resolution team to manage patients prior to and during crisis Development of DAART and Community Bed Provision Enhancement of the Frailty Front Door/Community Pull Team Risks to delivery Risks 1. Culture of bed based care persists, and risk aversion preventing people being managed at home 2. Needs assessment to inform future design (JSNA) 3. Workforce limitations and reluctance to develop one team approach 4. Contract negotiations and reluctance to risk share 5. Sustainability of current services Data The work completed by Optimity (2017) and Deloitte (2016) illustrates Shropshire s over dependency on in-patient resources secondary to historically commissioned services which have grown organically and failed to take into account key factors such as demographic changes. Optimity (2017) suggest that through shifting secondary service utilisation by a 5 year age band will reduce emergency usage of secondary services by 385 cases per 5,000 head of population within the 65+ age band equating to 4586 admission avoidances. 7

122 Out of Hospital Programme Telford & Wrekin Delivery of Integrated Care in the community The Golden thread Improvement in Programme needs to: 1. Improve access to activities that will prevent the development of poor health 2. Improve early identification of illness to stop further deterioration 3. Promote self-care/self-management 4. Demonstrably increase effective community support available 5. Strengthen Primary care 6. Reduce dependency on statutory services 7. Develop a sustainable workforce 8. Reduce social isolation System needs to: 1. Services and activities to be available closer to home 2. Prevention to be promoted throughout all work 3. Optimal use of technology 4. Introduction of new roles and ways of working 5. Well connected services and communities 6. Robust information accessible for communities and the professionals working with them 7. Empowerment for people and professionals 8. Consideration of mental health embedded The progress: Community resilience and prevention Social prescribing within Newport and Central East Telford Healthy Lifestyle service Neighbourhood Teams Diabetes improvement in patient outcomes has been achieved Hypertension An increase in the number of individuals being screened has resulted in more diagnosis of hypertension and people referred for further support to manage this. Branches feedback is demonstrating that a number of Section 136 are being avoided. Citizens Advice - outcomes achieved include an estimated 15,200 in welfare benefit gains Cancer Detection 2 pilots have taken places with practices, both achieved an increase in screening for bowel cancer. Reduction in demand on social care Interventions and process changes Encouraging healthy lifestyles Promoting community resilience Direct care in the community Speciality review Risks to delivery Risks What next using data to drive change Actions: Develop enablers as detailed below Community Information Portal which holds information on services and groups in the area Robust and practical communication and engagement plan Strong, well represented working groups to progress development Strong leadership within the organisations involved Proactive working relationships between stakeholder 8

123 Urgent & Emergency Care Programme Frailty Programme The Golden thread Improvement in the A&E Quality Standard a) MDT at front door b) Reduce Care Home admissions c) Reduce bed days Programme needs to: 1. F1 Implement the MDT Frailty Team at RSH ED front door in line with AFN model 2. Adopt comprehensive Frailty Assessment Tool for use by MDT and wider hospital 3. Avoid all avoidable admissions by MDT assessment/rapid care plan for ongoing care in community 4. If admitted ensure frail patients have a clear time limited care/treatment plan with an EDD to minimise Length 5. F2 Replicate at PRH 6. Keep patients mobile at all times to reduce de-compensation and rehabilitation needs 7. Discharge frail patients home on the agreed EDD System needs to: 1. Implement the following schemes::- 2. F3 Reduce admissions/re-admission from Care Homes by a) focus on high admitters; b) Care Home team (T&W) 3. F4 Reduce admissions/re-admission from Care Homes by a) focus on high admitters;) b Trusted Assessors (Shrops) to reduce Los 4. Reduce occupied bed days by impact of F1&2 and F3 & 4 The progress: Frailty MDT in RSH piloted since Sept Model redesign following support from AFN 333K invested in new Care Home Team (T&W) 3 Trusted Assessors appointed by SPIC to work with Shropshire Care Homes Both CCGs to work with SPIC to focus on high admitting homes CHAS being reviewed as part of Out of Hospital service design Care Home Pharmacists appointed in both SC and T&W Practices using Frailty Index to identify/risk stratify patients next steps will be ensuring all Care Home residents have advanced care plans/chas; and then all >75s Interventions and process changes F1 Move Frailty Team to the front door PDSA February 2018 to ensure earlier decisions F2 Replicate model at PRH with Community Matron/Rapid Response Resolve payment for Frailty Teams from F3 Agree actions with 10 Care Homes and SPIC F4 Agree metrics for Care Home Team F5 Agree actions with Primary Care clinicians across both Shrops and T&W for practices to prepare care plans for all patients on Frailty Index Risks to delivery 1. F1 & 2 ED teams will not support the AFN model and allow Frailty MDT to make early decisions at front door before the ED Clinicians this will waste time and opportunities for turn around on same day/avoid admissions 2. Insufficient awareness of the harm admissions can cause/understanding that de-compensation adds to delays/failure to embed rapid care/treatment/discharge to reduce LoS and discharge needs 3. Culture of bed based care persists, and risk aversion to sending patients home first 4. Lack of ownership of all hospital staff to keep patients mobile risk aversion re Falls 5. F 3 & 4 risk of insufficient engagement from Care Home managers/proprietors, and risk of hospital staff over-prescribing on going care needs on discharge. 9 Data 75+ admissions account for 25% of emergency admissions, and c75% of OBDs. Average LoS = 9.5 days F1 & F2 will reduce admissions of Frail patients >75 by 7% (half the Frailty modelling number) i.e.2205 fewer admissions (1483 SCCG 722 T&W) equivalent to 6/day. After 90 days the target will be revised and will rise to 9/day 3,285/year. F1 & F2 will also result in corresponding reduction in OBDs of 20,897 (14,261 SCCG/6626 T&W), rising to 31,345 Impact of F1 & F2 on breaches will be X% from rising to y% after 90 days F3 & F4 will reduce admissions and LoS of Care Home residents 2 fewer per day = 14/week = 728/year, with corresponding OBD reducing bed occupancy by 6,899. This will increase to 3 fewer admissions /day; 21/week; 1092/year after 90 days with corresponding OBDs reducing by 10,374. Impact of F3 & F4 on breaches will be X% from rising to y% after 90 days

124 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Cancer The Golden thread Improving Cancer survivorship Programme needs to: Deliver all Cancer Waiting Times (CWT) standards consistently, including the forthcoming 28 days from referral to diagnosis standards Monitor and scrutinise performance for individual tumour sites and challenge the system where needed Pilot innovative ideas to improve cancer service and patient outcomes, such as Telford and Wrekin pilots to trial vague symptoms and FIT testing Interventions and process changes System needs to: Make sure that processes and pathways are in place to deliver Cancer Waiting Times standards consistently Implement remaining parts of the NICE NG12 suspected cancer guidance for upper GI, vague symptoms and FIT testing for lower GI Benchmark against optimal pathways produced by NHSE ACE programme to identify areas where improvements could be made Implement remaining areas of the national cancer strategy Achieving World Class Cancer Outcomes, such as the new CWT standards for confirmed diagnosis within 28 days of referral Improve 1 year survival for all cancer patients to achieve the overall target of 75% The progress: Cancer Waiting Times standards generally met and performance good for SaTH as the main cancer centre Majority of NG12 pathways in place, with those outstanding in advanced stages of development Replacement of SaTH LINACs Representation at tertiary centre contracting meetings to make sure that our issues are addressed Recovery package implementation for all cancer patients - SaTH funded by Macmillan Cancer Support 2018 for 2 posts over 3 years The Local Health Economy established an STP local cancer group which continues to focus on objectives linked to STP: Preventing cancer Diagnosing more cancers early Improving cancer treatment and care. Develop health economy wide cancer strategy based on National Cancer Taskforce priorities in the national strategy Use of Digital Health solution to develop new whole population models of care Investment from NHSE to support tertiary centres to improve performance against cancer waiting times Plan capacity needs to implement GP direct to test aspects of NG12 guidance Development of a whole health economy cancer strategy and action plan linked to STP priorities Risks to delivery Diagnostic capacity needed to deliver NG12 and optimal pathways Poor performance at tertiary centres Workforce development needed to meet future demand Lack of funding to further develop and roll out Cancer app and digital technologies to all cancer patients (particularly for treatment and recovery stages) Insufficient focus and capacity locally to drive and support earlier patient presentation and diagnosis through public awareness and community engagement Data Day RTT 2016/ /18 - SaTH % 50% % 10 Breaches Within Target % Achieved Target National %

125 End of Life The Golden thread Improvement in Quality of Care Improved communication & coordination to provide best end of life care possible. Programme needs to: Develop a whole systems direction of travel for EOL care that all partners and organisations are working towards together. This direction of travel is to shift care further upstream from the last few weeks and days of life to at least the last 12 months. Consider EOL /palliative care for children and young people and where this fits into the STP System needs to: 1. Shift approach to eol care further upstream. This means recognising earlier when a person is in at least the last 12 months of life. 2. Reduce demand on acute trust by enhancing anticipatory care and planning ahead; reducing the amount of inappropriate and non beneficial treatments/interventions of for some patients. 3. Recognising that planning ahead ( Advance care planning) is a positive intervention. Including preferences and options and should be included in all care interventions/pathways. 4. Develop new models of working to support neighbourhoods- use of voluntary sector and communities to support eol care. The progress: Development and agreement by all partners on the strategic direction of travel for eol care across the whole system. Interventions and process changes Facilitate effective personalised care planning and planning ahead and support those important to the dying person Ensure equal access to palliative and end of life care. Develop systems to identify when a person is in the last year if life Establish concept of living well supporting advanced and anticipatory planning and access to services Ensure skilled and compassionate workforce. Identify education needs across the county Work in partnership to ensure that care is co-ordinated between systems. 11 Risks to delivery Risks Capacity and demand- a growing elderly population, impacts on workforce Multimorbidity including frailty. Rural and urban models affecting care access and support. Social care provision inconsistent across the county, worse in rural areas. Inconsistent understanding of the term end of life- has different meanings for different organisations and professionals. A shift in culture for many aspects: upstream working, stopping treatments that aren t beneficial, introducing the concept of planning ahead. This will be for all organisations Data Data is required to quantify this for example: Those attending AE and the nature of emergency admissions and interventions The types and numbers of high cost LTC interventions where the patient dies within a certain time limit when other care and treatment options could have been used. Those attending AE and the nature of emergency admissions and interventions used. Those being admitted 3 times a year or more( particularly those patients with severe frailty). Those attending AE and the nature of emergency admissions and intervention used inappropriately; The types and numbers of high cost LTC interventions where the patient dies within a certain time limit when other care and treatment options could have been used. Those being admitted 3 times a year or more( particularly those patients with severe frailty).

126 Referral to Treatment The Golden thread Improvement in Quality of Care Improvement in referral to Treatment, access & Waiting Times Programme needs to: 1. Maintain progress made to date in achievement of standard 2. Mange transition at SaTH back to opening challenged services to referrals. 3. Manage the transformation of pathways (MSK) to improve RTT performance System needs to: 1. Manage impact of winter capacity limitations and protect capacity where appropriate 2. Address pathway issues around diagnostics and reporting 3. Manage out of county provision 4. The STP/Ffit plan requires a reduction of 28,000 out patient appointments as part of the transformational change programme. 5. In 2016/17 there were almost 38,000 first appointments and almost 65,000 follow up appointments in the local acute provider. Work is being developed to reduce this by approximately 2,500 first appointments and 5,000 follow up appointments during 2018/19. The progress: SaTH achieving RTT standard RJAH expect to be close to standard at year end 52 week waits reduced in year The Incomplete target was not met for 16/17 but performance improved by the third quarter of 2017/18 and the target was met. This has been achieved by: Continued outsourcing of services which including ophthalmology, gynaecology and Orthopaedic for both outpatient and elective activity. Demand management plans aimed at reducing referrals by working with primary care services. Agreed recovery plans with existing providers moving forward. TRAQS continuing to offer patient choice while enabling accurate monitoring of referral and trends. Interventions and process changes MSK Pathway being redesigned MRI Direct Access pathway being reviewed Service provision being augmented in challenged specialties e.g Neurology Risks to delivery Risk Mitigation Performance of out of county providers is main risk to overall CCG achievement of RTT standard MSK pathway redesign may increase pressure at RJAH for RTT achievement Reducing the number of follow up appointments to benchmarked levels for key specialties Increased use of advice and guidance as an alternative Increased use of telephone clinics Increased use of telemedicine and technology to enable patients to self care Managing levels of consultant to consultant referrals Managing PLCV policies application through the contract Data Month 9 RTT performance Shropshire CCG 91.2% SaTH 94% RJAH 88.8% 52 Week waiters - 3 (Worcester Acute and Wye Valley) 12

127 Primary Care Programme GPFV - Workforce The Golden thread Programme needs to: The Shropshire Primary Care Workforce Plan has 15 Projects: 1. GP Recruitment 2. GP International recruitment 3. GP Retention/Career Plus 4. GP Fellowships 5. Tier 2 Visas 6. Impact of Workflow Optimisation Training 7. Targeted Enhanced Recruitment Scheme (TERS) 8. Clinical Pharmacists 9. Physician Associates 10. Nurses 11. Upskilling HCAs 12. Other clinical groups e.g. Urgent Care Practitioners, Mental Health Therapists, Physiotherapists, Occupational Therapists and Psychologists 13. Organisational Development Training and Education 14. Engagement 15. Marketing and Communications Interventions and process changes System needs to: 1. Focused Prevention 2. Enhanced Primary & Community Care 3. Effective & Efficient Planned Care 4. Simplify Urgent & Emergency Care 5. Reduce cost of services 6. Improve Cancer & End of Life Services Improvement in Capacity & Capability of Primary Care Workforce The progress: Practice engagement to develop a diversified workforce. The key progress made to date is as follows: Data on GP and other clinicians (current numbers, anticipated numbers, trajectories) has been submitted to NHS England The Primary Care Workforce Plan has been refreshed and re-submitted to NHS England. The first 12 of the projects are aimed at recruiting and retaining GPs and non-doctor clinicians the final three projects are cross-cutting enablers. An STP footprint Workforce working group has been set up with STP PMO membership Plans have been agreed, with both CCGs, to work with practices/groups of practices over the coming three months to develop local versions of the Plan i.e. plans which will indicate which of the projects are a priority for the practices/groups of practices and what actions will be taken to deliver a more diverse workforce. These plans involve working with the NHS England Staffordshire and Shropshire workforce project manager. Milestone 1: Interest in/appetite for GP International Recruitment identified and linked to the STP GP IR bid (May 2018) Milestone 2: Locality/Practice Group workforce plans produced (June 2018) Milestone 3: STP-wide workforce event held to identify emerging themes from the Locality/Practice Group workforce plans and plan next steps (June 2018) Milestone 4: At-scale bids for Clinical Pharmacists submitted (where identified by the localities/practice groups) - ongoing Milestone 5: Primary Care Workforce Plan reviewed in the light of the Locality/Practice Group workforce plans (October 2018) Risks to delivery of the bids Risks 1. The lack of engagement by practices with the CCGs when developing bids for the national Clinical Pharmacists scheme may adversely affect the quality of the bids Mitigation: Information to be provided to practices about the importance of engagement with the CCG over potential CP bids Data 2. IR application is not approved and cannot be used to mitigate requirement to recruit additional GPs by 2020 Mitigation: Application shared with NHSE prior to submission for comment. Increased engagement with GPs planned to gain buy in to scheme 13

128 Mental Health The Golden thread Parity of Esteem Programme needs to: 1. Deliver the implementation plan for the Mental Health Forward View, ensure delivery of the mental health access and quality standards, increase baseline spend on mental health; 2. work to eliminate out of area placements and reduce PICU spend 3. Improve access to psychological therapies and ensure at least 16.8% of the population access IAPT in 2018/19 rising to 19% in 19/20 and 25% by 20/21 a key milestone under 5YFV 4. Eradicate legacy issues in CAMHS around access, backlogs and reduce waiting lists whilst also providing specialist help to Looked After Children placed in the area and overall improve delivery and efficiency 5. Provide one stop coordinated service for Adult Autism and stepdown beds for Learning Disability patients from Tier 4 Interventions System needs to: 1. Work across all systems to consider mental health needs of individuals 2. Ensure services all are trauma aware 3. Focus on prevention and early intervention 4. System has a clear understanding of reasonable adjustments for individuals with mental health or learning disabilities issues 5. Close gaps in provision of Autism services for adults as there is no commissioned pathway in Shropshire 6. Improve provision and support for out of area Looked After Children 7. Eliminate inappropriate access arrangements,improving multi-agency working and enhance understanding amongst other agencies of role of core CAMHS team and lead overall improvement of service 8. reduce treatment time in Early Intervention In Psychosis, reduce inequity in LD services 9. Have provision of both acute and PICU MH beds locally to avoid spot purchasing out of area based on competitive tariffs The progress: 1. Extra Funding has been extended to current Provider to enable increase of Mental Health patients receiving employment support (IPS) under 5YFV 2. Scoping is now complete for the Commissioning of a clear integrated pathway for Adult Autism Disorder Spectrum, next stage will be moving into procurement process (April 2018) 3. Equity access to LD respite agreed with Local Authority 4. Scoping underway to reduce PICU bed use out of area and improve quality, QIPP benchmarking in progress 5. Delivery issues in CAMHS being addressed via a Remedial Action Plan with clear milestones and objectives. Operational Group in place monitoring progress 6. Dementia diagnosis rate for Shropshire is presently at 69.9% against the national benchmark of 66.7%. 7. CCGs meeting entry, recovery and waiting times targets for Access to Psychological services System wide approach to delivery and. Contractual talks pencilled for March 18 with aim to increase IAPT access Implementation of Community Mental Health Hubs joining the Main Provider and Third Sector Organisations almost complete Implementation of Community Mental Health Hubs joining the Main Provider and Third Sector Organisations almost complete Development and delivery of new models of integrated care for MH and LD services Benchmark and scope likelihood of having local PICU beds to reduce OOA placements Risks to delivery Risks 1. Legacy issues and backlogs in CAMHS require more resource in terms of workforce to eradicate. Provider currently running extensive recruitment process, Risks of serious incidents, safeguarding issues as a result of service problems with recruitment. 2. NHSE requirement that IAPT interventions be clustered and each treatment be tariff based will likely push contract prices up based on national reference costs which means there is a financial risk to the CCG to meet the required IAPT access targets mandated under the Five Year Forward View 3. Burden on financial resources due to spot purchasing of beds for female PICU 4. Gaps in provision, adult ASD (no LD), some patients might not receive required support. Data Mental health MDS (MHMDS) - difficult to manipulate IaPTUS- IAPT service only 14

129 Mental health will be integral to our ambitions around improving population wellbeing. We will put services in place to support individual needs and in the most appropriate settings by transforming services and focusing on early education and prevention. At the same time, we agree that everyone should have improved access to high quality specialist care in hospitals and that no matter where people live they get the same standards, experience and outcomes for their care and treatment. Key to this success will be developing innovative, integrated models of care, this will ensure care is provided in the right place, at the right time and by the most appropriate staff. Developing a part of a system networked approach to services across Shropshire, Telford and Wrekin, will improve the quality and efficiency of services for our patients, in areas such as Frailty and will simplify the urgent and emergency care system so that it is more accessible. 15

130 Acute & Specialist Programmes Musculoskeletal Services The Golden thread Improvement in Workforce Capacity Workforce Capability Culture & Leadership to deliver Transformation Programme needs to: Implement the national high impact MSK triage intervention Improve patient outcomes through improved access to conservative management Reduce surgical interventions to normalised rates Deliver a vertically integrated local care model Interventions and process changes System needs to: Support implementation of evidence based Value Based Commissioning (VBC) policy across the full pathway from referral to treatment Ensure the MSK triage service is the single point of access to secondary care for all routine MSK referrals Support the implementation of the single MSK physiotherapy specification and treatment pathways for Hips, knees, shoulders, spines and ankles. Collaborate to maximise the effective utilisation of local physiotherapy, conservative management and secondary care capacity and capability Better interface tier T3 and T4 health services with T1 and T2 social care physical activity services and maximise the opportunities for supported self management through shared decision making Supporting Primary Care to implement evidence based care of osteo arthritis, providing early advice, education and management prior to any onward referral The progress: Specialist MSK triage assessment and treatment service (SOOS) live in North and Shrewsbury localities, expansion into the South 10 th March 2018 Appointment of SEM consultant to lead SOOS 1 April 2018 Working with PHE to introduce effective local physical activity interventions Implemented prior approval for the VBC policy, with agreed schedule for future updates Signed up to the Shared decision making collaborative, with patient participation Jan 2018 Improvement reported in the NJR PROMs CQUIN for MSK health questionnaire outcome measure developed and currently being piloted MSK Physiotherapy specification developed and with local providers for implementation 2017/18 QIPP FOT of 3m from reduced secondary care intervention rates Timely direct access to MSK therapies operating under a single specification (April 2018) and central booking (Sept 2018) Shropshire Patients have access to services compliant with NICE OA Quality Standards, in Primary Care from September 2018 SOOS established as Countywide community based specialist MSK assessment and treatment service from March 2018 & providing MSK triage by April 2018 All routine MSK direct access to be coordinated through SOOS, the specialist access route April 2018 Aligned incentives contract in place with RJAH from 1 st April 2018 Risks to delivery Risks 1. Lack of GP/provider engagement and support for the agreed pathways and associated compliance issues 2. Availability of conservative management 3. Patient expectation /acceptance of non surgical interventions Data Actions: 1. Communication and engagement plan and targeted practice visits 2. Mapping of demand and capacity. Action plan to maximise utilisation and MSK business case to increase capacity 3. Patient and public involvement. Active engagement with and support from Health Watch and Shropshire Patient Group. Implementation of Shared decision making and partnership working with PHE. 16

131 Acute & Specialist Programmes Future Fit The Golden thread Programme needs to: Ensure safe progress towards a formal public consultation, including developing effective relationships with scrutiny bodies Once approval received, deliver a formal public consultation, analysis of data, final report and decision making process Ensure implementation of the action plans arising from the Clinical Senate Review and NHSE Assurance Panel feedback Co-ordinate the development and delivery of a robust IIA Mitigation Plan before the end of the consultation period Ensure the completion of a ambulance and patient transport impact modelling exercise prior to the end of the consultation period At the end of the consultation period, ensure robust analysis and full report to inform next phase of decision making System needs to: Support the effective delivery of the consultation with relevant clinical and managerial support to key events Contribute to the development of the IIA Mitigation Plan Ensure delivery of actions to timescale arising from external review exercises where individual stakeholder organisations are nominated as lead officers Develop and implement robust out of hospital/neighbourhood models which will support the required reduction in demand on acute hospital services in line with the Future Fit Activity and Capacity modelling and which also delivery effective and seamless integrated pathways between acute and community The progress: Improvement in NHSE assurance process undertaken Consultation materials developed and approved IIA Workstream established and held first meeting, next meeting scheduled for , chaired by RJAH Director of Nursing Ongoing monitoring of progress in implementation of the action plans from external reviews Interventions and process changes Approval to proceed to formal consultation by NHSE (date tbc) Consultation exercise completed and results analysed and report available to inform DMBC (date tbc) IIA Mitigation Plan and Ambulance Impact Modelling completed prior to the end of the consultation period in order to inform DMBC All key actions arising from external reviews of the programme completed Development of DMBC (date tbc) Risks to delivery Risks Lack of resource to effectively deliver a public consultation, including programme management, patient and public involvement and communications, impacting on ability to receive QA from external assessor Insufficient non-pay budget to deliver a public consultation of this scale Significant political and campaign opposition to the proposals, impacting on programme reputation in the media Uncommissioned activity, including travel and transport analysis, therefore impacting on planning public involvement in the process Continuing delay in progess ing to formal consultation risks damaging the reputation of the programme and the increasing workforce challenges in SATH with recruitment and retention of ED clinicians risks decision to close PRH A&E overnight to maintain safe services has to be taken which could be viewed as predetermination ahead of completion of the consultation exercise Data Actions: 17

132 Urgent & Emergency Care System Improvements Plan on a Page 18

133 Shrewsbury and Telford Hospitals NHS Trust Urgent & Emergency Care Programme - overview The Golden thread Improvement in the A&E Quality Standard Reduction in the stranded patient metric SATH needs to: 1. Fully implement the SAFER patient flow bundle and Red2Green days. This incorporates the Alex Knight work by 31 st March (Slide 1) 2. Improve ED Systems and processes as plan by 31 st march 2018 (Slide 2) 3. Decrease the stranded patient metric from 360 to 180 by March 31 st 2108 (Slide 3) System needs to: 1. Implement the frailty model of care as per plan with acute frailty network (Slide 4) 2. Support the Capacity and Demand project and discuss the recommendations when received at the end of March 2018-(Slide5) 3. Develop towards an integrated discharge team using the guidance on the High Impact Change Model, Jan2018 (Slide 6) The progress: Ian Surgess has been in three times now and has trained five of the SATH members of staff to perform AEP. Check, Chase and Challenge is happening daily. Stranded patient review in place from Mid December and taking place every week. Length of stay review commences on the 15 th of February Plans for Perfect Week commenced 9 th February- assisted by STP Plans to implement Ben Owen s recommendations being led by COO, Medical Director and Nurse Director( more detail on slides) Plans to join End PJ Paralysis 70 day challenge commenced- start 28 th April. Interventions and process changes Complete LOS reviews on all bedded environments by the end of February 2018 Complete the Appropriateness Evaluation Protocol on every inpatient ward by 31 st March 2018 Perfect Week/Stop the line to address stranded patient metric to be completed end March 18 Support to SAFER start week 1 st March 2018 Move Frailty Team to the front door PDSA February 2018 Risks to delivery Risk The medical workforce challenge including the number of junior doctors is the biggest risk in this environment Actions: The chief executive officer has met with and negotiated with HEE for an expanded cohort by Feb this has been declined The emergency department is recruiting to fill vacant posts. The clinical lead and workforce lead are attempting to mitigate the risk through the appointment of long term agency staff ahead of the recruitment plan delivering any substantive appointments. The trust recognises the financial risk associated with this decision. Data 19

134 Pathway Over View Delivering 90% by September 2018 The Golden thread System overview Avoiding Admission 1. Optimity 2. Care Homes 3. Frailty 4. Readmissions 5. WMAS AED Process 1. ECIP recommendations 2. Workforce 3. Control/Leadership 4. ED Value Stream (transformation) 5. WMAS: Reduction in conveyance Handover delay reduction plan In-Hospital Process 1. Stranded patients 2. Ambulatory pathways 3. Pride & Joy constraints programme 4. SAFER Discharge 1. Hospital discharge 2. Complex discharge 3. Pathway 1, 2, & 3 beds 4. Powys delays/capacity 5. Pre 12 discharge 6. Mental health pathways The System Capacity and Demand review for the system External supporters: Dr Sturgess, Gary Swann, Emergency Care Improvement Programme (ECIP) KPO for urgent care pathway Interventions and process changes Complete LOS reviews on all bedded environments by the end of February 2018 Complete review of percentages of simple and complex discharges by 7 th March 2018 and compare with national average Review findings of the Appropriateness Evaluation tool to add intelligence Complete Length of Stay review in the acute Trust- end March 2018 Dennis Holmes to complete interviews with identified system leaders and staff end March 18 Risks to delivery Risk 1. Operational pressures prevent full engagement and involvement in review and development of an action plan and implementation. 2. Financial pressures prevent implementation of the review recommendations. 3. Workforce gaps and affordability 20

135 Urgent & Emergency Care Programme Stranded Patients Programme needs to: Reduce the number of stranded patients with a length of stay of Daily / weekly review process in recording and reporting Management of 7 day patients Escalation and management of 21 day patients Use of AEP audit to identify baseline data repeat bi-annually Identify top 5 reasons for patient delay and develop action plan to address System needs to: System support for super stranded patient work including attendance at weekly escalation meeting and delivery of agreed actions System plan to address external reasons for delays identified via AEP audit The progress: Established daily check, chase, challenge process across both sites Established super stranded patient (over 21 days) escalation process including executive triumvirate AEP audit completed for USCG and top 5 reasons for delay identified : Pathway plans, doctor reviews, pathway 2 beds, POCs, Pathway 3 beds Action plans to address SATH s identified areas (pathway decision and Doctor review) developed. Interventions and process changes Establish daily check, chase challenge process Establish super stranded patient escalation process Complete AEP audit for USCG and identify top 5 reasons for delay Development and implementation of action plan to address internal delays Support system to address external delays identified via audit Risks to delivery Risks 1 Medical workforce constraints 2. Medical ownership of AEP audit outputs 3. Engagement of therapy department in required changes to working practices 4. Achievement of SP plan requires change in custom and practice for clinical staff over prescription of social input noted 5. Engagement with local authority and Community Trust 21 Data reduce LoS per pt No of pts LoS greater than 6 days Av LoS for stranded pts beddays beds at 100% occupancy % Delivery of 180 target reduction in beds required OR If beds maintained % occupancy % 0 100% % 9 97% % 19 94% % 29 90% % 38 87% % 48 84% % 58 80% % 68 77% % 77 74% % 87 71% % 97 67% % % % % current beds used by stranded patients based on data best practice occupancy rate Target 180 beds for stranded patients

136 Urgent & Emergency Care Programme ED Systems & Processes Programme needs to: Improve ED Systems and processes as plan by 31 March 2018 by: Implement recommendations from internal and external reviews to improve non-admitted pathway Open CDU at PRH Review and revise operating plan CDU s across both sites Rapid Process Improvement Week (RPIW) for AEC unit at RSH March Improve data quality issues associated with ECDS ED specific Value Stream 16 March (Sponsor day), with RPIW April Re-launch internal governance forum System needs to: Review ambulance conveyance rates including: Care homes via GP referrals Batching of ambulance arrivals Use of alternative pathways Ensure effective out of hours service provision to avoid unnecessary acute referrals 10 areas of focus national priorities (cross-reference) Improve and embed escalation processes The progress: Detailed action plan that incorporates outputs from both internal and external reviews developed and in place 2 DQC s appointed and commenced in post ED Patient Flow Co-ordinators appointed in post from March CDU build on PRH site completed Planning underway for ED RPIW Planning underway for AEC RPIW Interventions and process changes Change in working practices within ED departments Revise operational plan for CDU and implement Undertake RPIW for AEC and embed improved processes following the Kaizen event Undertake RPIW for ED value stream and embed improvements at 30/60/90 days Revise and re-launch internal SaTH governance to oversee improvements Risks to delivery Risks: 1. Clinical ED workforce constraints failure to appoint to doctor and nursing workforce gaps associated with ED business continuity 2. Financial affordability associated with ED workforce plan 3. Volume of external assurance visits impacting upon staff morale 4. Pace of change required to deliver improvement 5. Capability of teams to implement required changes 6. Engagement of WMAS 7. Impact of 111 and Shropdoc service changes Data Potential improvement on ED performance 4.6% 22

137 Urgent & Emergency Care Programme SAFER - Red to Green Programme needs to: Fully implement the SAFER patient flow bundle and Red2Green days. This incorporates the Alex Knight work by 31 March 2018 Board rounds & EDD R2G Criteria led discharge Pre 10 am/1600 ward huddle Pre 10am and 12pm discharges Average LOS System needs to: SATH governance process for major work streams ED workforce improvement plan 10 areas of focus national priorities (cross-reference) Escalation Whole Trust clinical communication Medical leadership Job planning Data and reporting Clinical pathways Pride and Joy The progress: Patient journey facilitators now on 14 wards across both sites Completed various promotional events and have a regular slot on the trust s corporate induction Highlighted key delays and areas for improvement Work underway to integrate Red2Green on the PSAG board Interventions and process changes Complete the Strategic Workforce Baseline data gathering Develop a consistent and streamlined FFA completion process Gain visibility around LOS and changes to EDD Develop consistent electronic process for Dr to Dr referrals Gain assurance that Board Rounds are adding value and are action orientated Risks to delivery Data Risks 1. Ward staff engagement and capacity to support 2. Lack of engagement from medical staff 3. Ineffective board rounds and lack of standardisation 4. Duplication with other initiatives 5. Capacity of patient journey facilitators Top 3 delays 1) Social/therapy delays 2) Dr Review 3) Residential/ Nursing Home 23

138 Shrewsbury and Telford Hospitals NHS Trust Integrated Discharge Team The Golden thread Improvement discharge practice Improved integrated discharge practice in Telford Health and social care system needs to: 1. Ensure an integrated team discharge team approach continues to develop. 2. Continue to support the admission avoidance pathway provided by Rapid Response nursing and social care teams. 3. Review current team scope to further improve performance. 4. Improve flow through discharge process to maintain performance by improving the level of rigour particularly in the intermediate care bed process. 5. Haver a single narrative in the form of a system wide operational framework for intermediate care in Telford. Interventions and process changes System needs to: 1. Increase membership and increase input to the current integrated discharge processes particularly enabling SaTH therapy directed transition planning for discharge. 2. Further develop towards an integrated discharge team using the guidance on the High Impact Change Model, Jan2018 (Slide 6) 3. Support the current demand and capacity modelling across the system. 4. Implement the aspiration target of 21 days length of stay inn the intermediate care beds to improve flow and access. 5. Further develop the system wide assistive technology offer. The progress: 1. Review day held 5/2/18 for all system partners in discharge and intermediate care planning including; SaTH/SSSFT/SCHT/TW CCG/TWC/third sector/independent sector. 2. System wide operational refresh intermediate care framework agreed by all partners. 3. Review of intermediate care beds provision and process carried out by CCG quality Lead Nurse and improvement action plan developed as a result. 4. Visit booked to Warwickshire to view best practice model. 5. From 26/2/18 British Red Cross will be seeing all PW 1 patients before discharge on the ward and once home if required. 6. Since Jan 18 specific OT to support patients being discharged from intermediate care to prevent re-admission. 7. Well-being sessions being offered to those on GP Frailty list following MDT to prevent urgent admissions to hospital. 8. NHS Digitial bid submitted to join up partner discharge planning Set criteria met nurse discharge especially at weekends Operational intermediate process and framework review and system wide agreement to new framework. Training across all partners regarding new intermediate care process. Red, amber, green process for all intermediate care pathways with twice weekly monitoring and MDT s. tracker post out to advert. Point prevalence/audit to review progress against new framework SaTH therapists to goal set for minimum 72 hours post discharge Transfer by relative/red Cross should be default unless otherwise indicated Anticipatory equipment planning and prescribed meds with person day before discharge Risks to delivery Data Risk Provider failure dom/bed based care. Mitigation plan in place Lack of collaboration between partners. Framework in place across all partners including trainng and routine consultation and collaboration. BCF sufficiency to meet demand. New governance structure to support BCF board to monitor performance. 24

139 Urgent & Emergency Care Demand and capacity review The Golden thread Improvement in the A&E Quality Standard Reduction in the stranded patient metric SATH needs to: 1. Chris Green to visit the Trust to discuss acute modelling. Date to be confirmed (aim for before Mid- March) 2. Develop an acute plan using data and intelligence provided 3. Task and Finish Group to be set up to implement findings System needs to: 1. System needs to support Dennis Holmes in the review of all out of hospital capacity by the end of March In April 2018, used the refreshed D2A group to develop the action plan based on report recommendations. 3. Julie Davies to ensure that Powys are informed and engaged with system review. 4. System lead to visit Wye Valley to discuss implementation of SOP with Powys. 5. Draft TOR to April A&E Delivery Board 6. Final plan to A&E Delivery Board in May The progress: Initial acute modelling performed by Chris Green Review of P2 and P3 for Shropshire, Telford and Wrekin completed by 23 rd February Interventions and process changes Complete LOS reviews on all bedded environments by the end of February 2018 Complete review of percentages of simple and complex discharges by 7 th March 2018 and compare with national average Review findings of the Appropriateness Evaluation tool to add intelligence Complete Length of Stay review in the acute Trustend March 2018 Dennis Holmes to complete interviews with identified system leaders and staff end March 18 Risks to delivery Data Risk 1. Operational pressures prevent full engagement and involvement in review and development of an action plan and implementation. 2. Financial pressures prevent implementation of the review recommendations. 25

140 Transformation Enablers System Improvements Plan on a Page

141 Digital Enabling Programme The Golden thread Improvement in use of technology enabled care Appropriate information securely available to the appropriate person at the appropriate time. Programme needs to: Connectivity : Provide seamless access networks and efficient procurement of new connections wifi access for staff and citizens at all locations. Populate Information sharing Gateway with agreements to allow sharing of information between organisations. Formulate an STP-wide plan for Cybersecurity: Ensure records and systems are secure. Licensing: future proof and cost efficient route for Microsoft and Office upgrades (towards O365 and CloudFirst) Support digital requirements for all other programme groups Improve Digital Maturity Assessment scores to support programme success. Develop funding bids for possible future funding availability Analyse options for an Integrated care record across health and social care settings. Identify the capability for Interoperability across the STP area. Interventions and process changes (milestones) System needs to: 1. Clarify the end vision and the level of commitment required from organisations. 2. Act as One! Agree the objectives of the enabling group with in the strategic governance process at exec level 3. Standardise on clinical coding (SNOMED-CT) for all organisations. 4. Provide resource (inc funding, project management etc) to define and plan programmes and projects 5. Involve digital solutions in all workstreams. Promote the modernisation and efficiency of paperless processes to increase efficiency through a digital programme 6. Conform to cyber-security requirements and resource specialist support 7. Provide Strategic direction for an STP solution to enabling a system wide approach to an infrastructure that enables the use of all modern technologies to improve frontline patient care. The progress: Universal Capabilities: most on target to be significantly delivered by March-18, with enhanced delivery going forward. Digital Maturity Assessment improved over previous year (except for medicines management, and where the requirement changed e.g. B.I.) Information Governance ISG signed up to by all agencies, and becoming operational Funding Bids ETTF for GP wi-fi and Voice over IP telephony - implementation in progress LMS bid for user kit and software development - bid submitted Electronic discharge to social care bid submitted Online consultations - part of GP5YFV - going to procurement ETTF money secured for video consultations and telehealth Data Sharing Agreements on Electronic register across the LHE May 2018 Universal Capabilities significantly delivered by end of March 2018 (on target) Electronic Patient Record systems need to be procured for SaTH and RJAH to support shared access to Integrated care records. Risks to delivery Risks Resources (lack of funding, governance and leadership to progress strategic planning, and availability. commitment from senior management to release or increase resources) Lack of Technology standardisation - Action :Identify interoperable platforms and recommending their use across the STP Licencing costs are set to increase with a requirement to migrate to a supported set of office applications with revenue costs instead of capital. Executive Strategic Direction Lack of clear co-ordinated approval processes for schemes with a cross-organisation impact. Complex governance arrangement (STP is not an executive group with delegated authority. ) Lack of consistent engagement from social care and mental health trust. Uncertain leadership of the DEG. No consistent CCIO appointment process and no DEG CCIO position defined. Actions: Creation of 3 supporting groups 27 Data DMA graph?

142 Strategic Estates Programme The Golden thread Improvement in Systems Estates Planning Community Centric Approach. People rather than building focused. Partnership approach the norm. Programme needs to: Use data in geographic layers at a very local level as evidence of emerging community need, & how or if they are being addressed Identify opportunities for developing community hubs, housing solutions or projects to support economic growth, where a local need is present. Inform the requirements for future service provision and ultimately guide the utilisation of the public estate Ensure estate is accessible, efficient and safe. Engage the expertise and knowledge of public sector delivery leads in developing community needs-based projects stemming from opportunities created by the One Public Estate work-stream. Interventions and process changes System needs to: Provide an integrated and co-ordinated healthcare estate relevant to redesigned patient /service user and staff pathways under the STP Deliver a reduction in estate Reduce / plan removal of backlog maintenance Support Estate aligning with and utilising the One Public Estate agenda Utilisation aligned with Carter review Deliver a Reduction in annual revenue costs Provide flexible estate that will enhanced a dynamic healthcare economy Develop local solutions drawing on all the assets and resources of an area Build resilience of communities The progress: SHAPE database validation undertaken by all partner organisations. Estates Workbook & Disposal produced, now a living document Initial Community Needs workshop 27 Feb 18 to inform future Estates projects delivered with engagement from senior reps inc. Public Health England, CCG's Providers; VCSA, Adult & Social Care, DH, Early Help, Shropshire Council, Keele Uni, Housing, Economic Growth, Community Health FT, Nature Partnership, Data Analyst/Intelligence, Similar repeat workshop planned for Telford localities 17Apr18* Project Manager & Project Group in place for Whitchurch Project, following successful OPE bid. Now moving from strategic planning to delivery Asset Mapping & data layering work with Shropshire Council going well, producing evidence base & assisting to inform opportunities Circulate workshop outcomes, feedback through STP/Council/OPE partners/local Councillors. Market Town specific Workshops to inform next steps Run Telford & Wrekin Workshop, identify opportunities and then bring together all opportunities into one whole system approach Overarching and adopted estate strategy aligning with the estate outcomes and key STP outcomes Outline rationalisation plan, with better use of void space, shared/bookable space, joint utilisation, extended opening hours, energy efficient Evidence using Geographical Intelligence Systems applied in layers ; to include Voluntary Sector services Risks to delivery Data Risks Timelines for funding bids vary across different organisations; aligning for cross-organisational estate projects difficult to achieve. Aligning existing projects and agreement on potential future opportunities Engagement not fully embraced Actions: Transparency and awareness of funding timelines between organisations Agreed approach to partnership working Identify and Plan for interim arrangements 28 Validation and updates of SHAPE database (Health Service Estates) by all relevant organisations; ongoing requirement to maintain accuracy Property and Estates (Shropshire and Telford), Freehold land, Leasehold land, Leased land; Transport, Shropshire and Telford Bus routes 2016, Car and Van ownership (2011 Census); Demographic (covers Telford and Shropshire) (2016 MYE ONS), Deprivation (2015 IMD, DCLG) Community Facilities (e.g. libraries/schools) Older People, Health, including long-term illness & disability; health deprivation Planning Themes (Planning and Land Use Monitoring systems, Planning Policy Team Economy Housing Affordability

143 Strategic Back Office The Golden thread Improvement in shared resources & risks STP Long Term Financial Sustainability Programme needs to: Update the planning assumptions made in the 5 year STP financial plan and identifying a more robust view on the scale of savings in the following areas; Corporate services savings in the health economy, using recent benchmarking data, Shared recruitment processes (being developed by the Workforce Work stream Procurement savings through model hospital and PPIB data Estate rationalisation (developed by the STP Estates Work stream) Develop an over view that makes it clear what exists in plans already and whether the programme can stretch the thinking to gain more operational and financial value ( e.g. target set to drive costs to the national median). Interventions and process changes System needs to: 1. Support a level of ambition proposed by the programme ie. drive costs to the national median (where there is one or other agreed benchmark where there isn t), 2. Sponsor and support the collaboration on key priorities, initially by sponsoring the CSU s diagnostic and option appraisal process. 3. Have an open book approach to data and information to enable opportunity assessment, 4. Develop the relationship with other STP stakeholders to assess the opportunity for wider public sector benefits, 5. Agree a change programme in due course. The progress: The work stream has demonstrated good practice in collaborating and sharing information between NHS providers. Underpinning case for change still holds true. Individual STP work streams are working on discrete aspects of rationalisation or collaboration (estates and workforce) All providers are using benchmarking data to support decision making Initial exploration of the Model Hospital opportunities for Providers, including corporate services and ambition set February 18 Initial discussion with Midlands and Lancashire CSU Value Add proposal to pump prime further review and option appraisal March 18 Commence CSU diagnostic April 18 Evaluate CSU diagnostic conclusions and agree programme of change Summer 18 Implement change programme Autumn 18 onwards Risks to delivery Risks The scale of opportunity will not be realised due to; 1. Lack of collaboration beyond health on procurement. 2. Capacity to drive ideas forward across organisations at pace 3. Lack of willingness to collaborate on a joint agenda and give or pass on sovereignty by individual organisations. 4. A Shropshire centric preference not accessing the opportunity where it is at its greatest on a wider footprint (ie out of STP boundaries) Data Model hospital (Carter) Corporate services data (Model Hospital) NHS Efficiency Map Procurement data (PPIB).. Actions: A review of the effectiveness of the existing county wide Procurement Group Using the CSU diagnostic and option appraisal process to increase pace, draw conclusions and propose a change programme which will require 29 tangible agreement.

144 Strategic Workforce Programme The Golden thread Improvement in strategic workforce development Workforce Capacity Workforce Capability Culture & Leadership to deliver Transformation Programme needs to: 1. Develop a system-wide Strategic Transformation Workforce Plan. 2. Develop and implement a system Organisational Development Plan to support new ways of working. 3. Develop workforce sustainability through the identification of learning and development, education and training needs and through supporting system programmes to implement change. Interventions and process changes System needs to: Work closely to share workforce intelligence, undertake workforce modelling and strengthen system ownership of workforce strategies. Work collaboratively to attract, recruit and retain the current and future health and care workforce. Agree system-wide requirements in order to maximise the education, development and training opportunities for our workforce. Lead a system programme that delivers transformation and sustainability. Lead cultural change through health and care that supports integrated working which prioritises patients resulting in improved population health and wellbeing. Deliver system-wide workforce solutions and improvements in response to the system workforce challenges. The progress: Agreement between STP partners on priority areas. System-wide Workforce Strategy initial stages begun. Mental Health Workforce Plan March submission on schedule OD plans and Workshops with King s Fund underway. Local Maternity Services (LMS) Transformation Plan developed with workforce analysis being undertaken. GP Forward View Workforce Plan and delivery of GPFV primary care workforce projects underway. West Midlands agreement for consistent /shared statutory and mandatory training across NHS organisations. 2017/18 workforce investment programme of 817,600 covering both primary care and acute services. Complete the workforce profile data gathering and individual specialist workforce plans. Leadership and OD Programme with the King s Fund ongoing. STP Partner attendance on TCSL Programme. Development of Shared Recruitment project and Collaborative Bank. Implementation of a pilot Rotational Apprenticeship Programme. Delivery of STP/LWAB funded priority areas and development of a shared training/learning offer to meet system needs and promote integrated working. Risks to delivery Risks: Planning without knowledge of future finances and service redesign/configuration. Varying levels of stakeholder engagement driven by different approaches to Workforce and access to data. Ability to fund workforce development activities both in terms of finance and time. Risk to quality of STP submissions due to a lack of clarity around requirements. Timely decisions in respect of funding which affects education, development and recruitment. Actions: Ensure strong workforce links with STP clinical /service priorities reporting into the Strategic Workforce Group. Continue to build relations through working together on identified projects/ task & finish groups. Identify priority development areas and align through STP PMO processes. Collaborating with HEE to access support and align programmes. Piloting areas of work to test outcomes. 30 Data Shropshire Workforce Baseline: HEE are developing an STP dashboard for workforce data which will use NHS organisations workforce data submitted to NHSI as part of the operating plan submission on 8th March along with social care data from the NMDS. There is also the potential for Skills for Health to undertake some analysis on behalf of the STP. Individual areas of workforce: Mental Health Workforce data included in the submission of the MH Workforce Plan in March. Maternity workforce data being developed as part of the LMS Plan Primary Care workforce data has been collated as part of the GPFV Workforce Plan Future plans to include Cancer Workforce.

145 Strategic Communication & Engagement Programme The Golden thread Improvement in Communication & Engagement A single message and understanding of the STP Programme of work Programme needs to: Create a comprehensive communications and engagement strategy, building on the wider vision and values OD activity, to encompass all workstreams of the developing STP, ensuring coproduction with all stakeholders Provide communications and engagement support to STP priorities Develop channels for communication of STP activity Provide advice, support and guidance to individual workstreams, facilitating two-way communication and identifying content for communicating across the STP partners and beyond System needs to: 1. Work together to utilise each organisations limited resource for patient involvement and communications 2. Ensure synergy across core delivery partners - such as providing additional assurance that the delivery of the plans is embedded within the sponsoring organisations own activities, but also provide insights on how to best deliver across the wider community that the programme impacts 3. Develop and embed a cohesive vision and values for the STP footprint that each organisation and their staff recognise and understand, thereby facilitating the production of a meaningful communications and engagement strategy The progress: Communications and engagement workstream meets monthly and includes representation from all partner organisations, including Healthwatch Communications and engagement leads aligned to each of the workstreams, to offer support and advice and gather progress articles Interventions and process changes Gain a clear understanding of the vision and values of the STP that have been signed up to by all partners Map activity across workstreams to understand timing of potential service changes Develop a comprehensive communications and engagement strategy Develop and deliver channels for communication of STP priorities Support service reconfiguration activity Risks to delivery Risks Lack of building blocks in place to effectively resource (pay and non-pay) the activity required lead to an inability to develop and maintain external, internal communications Lack of understanding of the proposed overall plan for the STP leads to public objections. Limited system wide resource may lead to failure of workstreams to adhere to required processes leading to assurance test issues going forward. Inadequate patient, citizen, stakeholder involvement in proposed service transformations, leads to public opposition and a potential failure to meet assurance tests moving forward. Lack of coordination or necessary timings lead to service reviews and potentially consultations taking place at the same time, leading to public confusion and opposition. Negative presence in the media undermines confidence in the programme which may lead to distraction, unnecessary excess utilisation of resources and finances. 31 Data Plan is to use Comms & Engagement data to inform 1. Public perception of service changes 2. Confidence levels in strategies and plans 3. How well we are including stakeholders in our redesign and service changes 4. Measure responses from websites and surveys

146 Population Health & Prevention Improving population health The Golden thread Embedding prevention through all the work we do The programme needs to: 1. Develop our wider workforce to make every contact count (MECC+) / proactive identification of people at risk of ill health and behaviour change conversations, brief interventions 2. Prevent harm due to alcohol, obesity and CVD 3. Support culture change and new working practices that help people at the earliest opportunity 4. Support active signposting and develop a good understanding of how communities support people linking to Social Prescribing 5. Work across organisations (including the VCSE) to prioritise support for key population groups address inequity and inequalities 6. Support and embrace the role of the VCSE and communities to drive forward prevention activity 7. Focus on developing a good understanding of need continual information provision for the JSNA 8. Improve communication between organisations Interventions and process changes Improve access and use of population health and wellbeing data from across the system to support decision making Develop and Deliver System CVD & Diabetes Strategy The system needs to: Deliver the prevention expectations of cancer strategy Develop and Deliver System Obesity Strategy The progress: 1. Systematically raise awareness and deliver lifestyle advice, signposting and referral by healthcare and other professionals, e.g. through MECC +, PHE s One You, including for: Stop Smoking Support Weight management Physical activity programmes Immunisation opportunities, e.g. flu 2. Improve the prevention, detection and diagnosis of CVD, specifically diabetes and hypertension 3. Radically upgrade the role of the NHS in tackling harmful alcohol consumption, through screening, identification, brief advice and referral into treatment services 4. Deliver prevention expectations of the national Cancer Strategy 5. To ensure the systematic delivery of mental wellbeing services, including identification of mental ill health and prioritisation of emotional support 6. Work together to make best use of resource and expertise Shropshire Healthy Lives Develop system social prescribing infrastructure STP Mobilisation of the National Diabetes Prevention Programme March-May Neighbourhood working to build community capacity- focus on Healthy places, Active and Creative communities Delivery of Social Prescribing initiatives and infrastructure Supporting Carers through all age strategies and Dementia Companions Delivery of Fire Safe and Well Visits (since July 17) Develop and deliver a system prevention framework for all pathways Developing very positive joint working across health and care Individual Placement Support Service for those in secondary MH services Telford & Wrekin Healthy Telford Borough-wide lifestyle offer Twitter and blog using social media to inspire behaviour change Developing and nurturing our community health champions Public Health Midwife, stop smoking support and maternal health advice Development of an Integrated Care Navigation Programme Delivery of Healthy Lives Programme and prevention services Development of a system plan to reduce harm related to alcohol Develop the system MECC Plus proactive approach, including training and delivery plan Opportunities Smoke free hospital and brief interventions in hospital Connecting to workforce (and funding) to support development of staff (link to MECC plus) Mental health hubs, MH support in Local Maternity hubs, Early help for children and young people, link to Estates Healthy hubs and social care support/ advice and guidance in hospital Risky behaviour CQUIN - link to MECC Plus Risks to delivery 1. Lack of buy in by partner organisations Risk to strategy delivery Risk to culture change needed 2. Investment in prevention programmes (national and local) Local Authority Public Health Grant challenges Lack of NHS investment in prevention 3. Medical and nursing capacity NHS Trusts (SaTH, SSSFT, ShropCom, RJAH) Primary Care 32 Outcomes how do we know it s working? DRAFT Public Health Outcomes Framework Healthy life expectancy Health Equity Smoking rates Obesity children and adults Physical activity Wellbeing measures Social Prescribing Reduction in GP attendances Reduction in unplanned hospital admissions Cancer rates Harm due to alcohol alcohol admission rates Connecting to other programmes Health and Wellbeing Boards Strategic Planning (both T&W and Shropshire) Better Care Fund (T&W and Shropshire) Rightcare STP Neighbourhoods and Out of Hospital Programmes community development, GP 5 Year Forward View Mental Health 5 Year Forward View preventing Maternity Services Transformation Workforce developing our Estates Partnership Musculoskeletal and Falls System Planning

147 System Strategic Finance Programme Programme needs to: Provide clear, timely, accurate and relevant financial information and reporting to internal and external stakeholders including NHSE/NHSI, member organisations, Executive groups and individual work stream programmes and enabling work streams Support individual and collective work stream program managers, provider and commissioner finance teams to provide financial guidance to achieve defined outcomes and benefits including specific programme targets and timelines Support identify the optimum decisions with pertinent financial information. Increase the financial profile and raise financial understanding amongst non-financial management Better understand the objectives and congruence with each work stream to advise most appropriate action/outcome. Provide clear financial overview of each work stream, timing and planned gap to achieve overall financial control total. Interventions and process changes System needs to: Clearly define objectives, activity, resource, milestones within each program work stream to enable accurate assessment of financial impact and timings of each work stream quantifying target financial benefit / cost. Clearly define current financial position for each work stream Share all pertinent current financial information. Organisations needs to appoint and advise of financial resource (personnel) for each project. Greater financial transparency; Organisation needs to share financial information sufficient to be able to identify potential double counts for QIPP/CIPS and identify any performance / activity / demand / income / expenditure gaps. Identify additional cost savings to recover adverse in year FOT performance Include a suitable provision (target over-performance) to cover performance slippage and help protect control total target attainment Improvement in System Financial Position The progress: The Golden thread Provide improved financial support and probity through impartial, transparent, accurate, timely, complete and relevant financial information across the Integrated Care System. Identifying current financial gaps in STP outturn group performance Started to work with LMS projects to understand project objectives, milestones and financial impact with timings (process needs to be completed for all work streams) Supporting Estates work stream improving financial transparency and congruence with the members strategic capital investment plan Establishing a credible portfolio of executive reporting tools for financial transparency to aid control and improve relevant response Developing a risk register that includes valuations of risk, pre and post mitigation potential Building strong links with CCG and provider finance teams to aid transparency and consistency to help provide a congruent financial footing for effective decision making Understand and report control gap Support work streams, providing financial management, help define and achieve financial and quality goals Work with the Integrated Care System and work streams to: 1. attain / retain identified financial and quality benefits 2. Identify additional opportunities to recover the reported control deficit 3. Establish a work plan provision for a robust trading position (aim for over delivery) Develop and deliver channels for communication of STP priorities Identify capital requirements and ensure full disclosure (link with estates strategy Risks to delivery Risks 17/18 FOT negative variance from control totals; achieving underlying financial performance targets. Additional plans required to recover this forecast deficit. Future CIP, QIPP and STP double counts between commissioners / providers Co-operation and necessary disclosure between all member organisations. Triangulation and accuracy of contract activity and income assumptions between CCG and provider. Availability and timing of capital for strategic change e.g. Future Fit requirements. Resource; STP finance support available throughout project life. Extended double running; timings of inter-connected and enabling work streams essential to ensure efficient transformation and full financial benefit attainment. Data 1. System Data in relation to finances will be shared via the following routes Strategic Leadership Group Organisational Board Meetings System Finance Group All data in relation to system finance will need to be consolidated and checked for accuracy 33

148 STP PMO Resource STP PMO Support STP PMO are a flexible system resource allocated across a number of Transformation Enabling & Delivery programmes Their key role is to support existing system staff: Programme Management, including project set up, engagement, reporting, risk mitigation, benefits realisation. STP PMO can provide standard templates and methodologies where those don t already exist and support the system as required. They hold a system wide view and can help identify interdependencies and risks across system programmes of work STP PMO are NOT leaders for programme delivery, they support coordination and facilitation to drive change. The leaders come from within the system itself. The PMO will hold the System Project register Current Support Provided The next slide shows the STP Team Resource and allocated area of work Where STP Partners have existing resource, the ethos is to work in a matrix approach to avoid duplication and to ensure added value Collaborative working will be facilitated through SharePoint shared files and virtual working practices using Skype and Microsoft teams STP Governance STP has no authority and is bound by current governance arrangements, it relies on partnership and trust between STP Partner Organisations through the STP Strategic Leadership Group (System CEO s) STP Priorities are driven nationally & locally and are influenced by System Leadership and STP Clinical Strategy Group Patient & Public involved is required in Every Delivery & Enablement Group, it s a requirement of individual workstreams to ensure this occurs as required. STP Programme Board is where system Programme Delivery and Enabling Workstreams come together to share progress and mitigate / escalate risk as required (this Group is due to be reconvened in April 18)

149 To contact a member of the team or ask any questions please contact: STP Programme Director Phil.Evans1@nhs.net Programme Leadership STP Urgent Care Director Claire.Old1@nhs.net System Urgent & Emergency Care STP Head of PMO Jo.Harding1@nhs.net PMO Transformation & Enablement STP Communication & Engagement Lead pam.schreier1@nhs.net System Communication & Engagement STP Senior Project Administrator J.Knott@nhs.net STP Diaries, Meetings, Requests, STP Programme Manager Andrea.Webster5@nhs.net Transport, Telford Neighbourhoods STP Programme Manager Penny.Bason@nhs.net Future Fit, Population Health, Prevention, STP Programme manager Robgray@nhs.net Digital Enablement STP Programme Manager sara.edwards3@nhs.net Strategic Workforce STP Programme Manager Maggie.durrant@nhs.net Estates, Back Office STP Programme Manager Paul.gilmore1@nhs.net System Finances STP Programme Manager Jill.barker4@nhs.net Urgent Care, MSK Future Fit Programme Support haley.barton1@nhs.net Future Fit Programme Project Support Future Fit Senior Communication & Engagement niki.mcgrath@nhs.net Future Fit Programme Future Fit Communication & Engagement kathryn.smith37@nhs.net Future Fit Programme All Resource is coordinated through STP Programme Leadership and PMO and area s of responsibility may change according to STP priorities. The team work across all sites and are a combination of full and part time staff. If you have a programme of work not already identified in this slide pack that you would like to see developed across our system that has clear SYSTEM benefits: Please contact jo.harding1@nhs.net Existing governance arrangements will still apply to all programmes of work in terms of approvals 35

150 Updated Version 3.0 Feb 2018 Shropshire, Telford and Wrekin Sustainability & Transformation Programme Governance Structure STATUTORY ORGS Requirement to adhere to own governance procedures Provider Boards Commissioner Boards Local Authority Cabinets Telford & Wrekin CCG Telford & Wrekin LA SaTH RJAH ShropCom SSSFT Shropshire CCG Shropshire LA STP System Leadership Group (System CEOs) Health & Wellbeing Boards Joint Health Overview Scrutiny Committee STP Clinical Strategy Group (System Clinical Leads) STP Transformation Programme Delivery Board System Enablers Strategic Workforce Group Communication & Engagement System Back Office Strategic Estates Group Digital Enablement Group System Finance Group Telford & Wrekin 1. Community Resilience & prevention 2. Neighbourhood Teams 3. Systematic Speciality Review System Cancer Local Maternity Services Muscular Skeletal Services Future Fit Sustainable Services Programme Frailty Development of Primary Care Mental Health UEC High Impact Changes System End of Life programme Shropshire Neighbourhoods & Prevention Out of Hospital Programme 1. Frailty Front Door 2. Primary Care Development 3. Hospital at Home / Crisis intervention System Partners On Programme Delivery Board Health Watch Telford & Wrekin Shropshire Partners in Care Severn Hospice West Midlands Ambulance Service Voluntary Sector Wider independent organisations Health Watch Shropshire Local Pharmacy Committee Powys Teaching Health Board ShropDoc Patient Groups Welsh Ambulance Service System Neighbours Subject Matter Experts