Governing Body Meeting Held in Public

Transcription

1 Governing Body Meeting Held in Public Governing Body (Public) Holiday Inn,Farnborough 29 June :00-29 June :00 Overall Page 1 of 160

2 Governing Body meeting held in Public Wednesday 29 June 2016 from 3pm to 5pm Holiday Inn, Lynchford Road, Farnborough GU14 6AZ Time 3.00pm 1 Item no AGENDA Item Lead Attachments Introduction Chairman s Welcome & Apologies Andy Whitfield Verbal Welcome to the newly appointed members of the Governing Body with brief description of their role. 2 Register of Interest To receive and note the register of interests of members ensuring that members do not participate in making decisions on an issue where a conflict of interest is established. To receive any verbal updates on the interests of members. Andy Whitfield Paper 3 Governing Body Assurance Framework To note the paper Andy Whitfield Paper Presentations 3.15pm 4 Working in partnership with local people - engagement and co-production Ros Hartley & Edward Wernick Presentation 3.30pm 5 CCG 2016/17 Objectives and Progress Andy Whitfield & Ros Hartley Presentation Papers for decision 3.45pm 6 Primary Care Strategy For approval Mike Attwood Paper 4.00pm 7 Any Qualified Provider Direct Access Musculoskeletal Physiotherapy Services For approval Alison Edgington Paper 4.10pm 8 Unapproved Minutes of the Governing Body meeting held in Public on Wednesday 20 April 2016 To approve the minutes of the Clinical Commissioning Group s Governing Body meeting held in Public on 10 February 2016 Andy Whitfield Paper 9 Action Tracker from the Governing Body meeting held in Public on Wednesday 20 April 2016 To receive the Action Tracker and any verbal updates Andy Whitfield Paper 4.15pm 5 Minute Break Matters for Governing Body to discuss and note 4.20pm 10 Quality Report To note the paper Page 1 of 2 Emma Holden Paper 1. GB Agenda Public 29 June v7 20 June.pdf Page 1 of 2 Overall Page 2 of 160

3 4.35pm 11 Integrated Performance Report Quality Performance Quality, Innovation, Productivity and Prevention (QIPP) Finance To note the paper Information to note and not for discussion 12 Sub-Committees of NHS North East Hampshire and Farnham Clinical Commissioning Group s Governing Body To receive summary updates from recent meetings of the Governing Body Committees: Clinical Executive Committee Finance and Performance Committee Quality Improvement Committee Audit and Risk Patient and Public Engagement Committee Delegated Primary Care Commissioning Committee Roshan Patel Steven Clarke Elaine Budd Emma Holden Peter Cruttenden Kathy Atkinson Mark Hammond Paper Paper Paper Paper Verbal Paper Verbal 4.50pm 13 Questions received from the Public in advance of the meeting To respond to the questions received from the public. 5pm 14 Close The next Governing Body Meeting in Public Governing Body meeting in public is scheduled to take place on Wed 21 September 2016 between 2pm and 5pm Farnham Town Council Offices, Farnham All Andy Whitfield Verbal Verbal Page 2 of 2 1. GB Agenda Public 29 June v7 20 June.pdf Page 2 of 2 Overall Page 3 of 160

4 Corporate Register of Interests 2016 version 23 June 2016 Name Relevant and Material Interests Governing Body Finance and Performance Audit & Risk Clinical Executive Remuneration & Nominations Quality Improvement Patient & Public Engagement Delegated Primary Care Commissioning Whitfield, Andy (Dr) Clinical Lead & Chair GP Principal at Southwood PMS Practice Provider of private Occupational Health Services Shareholder in Salus Medical Services Ltd Governing Body Clinical Directors Bibawy, Peter (Dr) GP partner in Southlea Group Practice, Aldershot, Hampshire Private practice that deals with medico-legal claims and Healthchecks Shareholder in Guildford Physiotherapy and Sports Clinic Wife is a psychiatrist working for Southern Heath Shareholder in Salus Medical Services Ltd Updated 23 June 2016 Key A= Attendance = Member 2. Register of Interest v 23 June 2016.pdf Chair MacIsaac, Maggie No interests to declare A A - - Chief Officer Lay Members Atkinson, Kathy Voluntary Chairman of Guildford Symphony Orchestra Chair Lay Member with Patient and Public Involvement Portfolio Budd, Elaine No interests declared Cruttenden, Peter Councillor in the Parish of Steep, near Petersfield Chair Chair Lay Member with Company-Nominated Trustee of the Horizon Housing Group Pension Scheme Governance Portfolio the pension scheme of a Croydon-based social housing provider Hammond, Mark Palfrey, Ed (Dr) Secondary Care Consultant Directorship Georgetown Associates Ltd (family consultancy company) Trustee Council for AT Risk Academics (Charity) NED- General Pharmaceutical Council (starting from April) Penna (global people management business) member of the Public Sector Advisory Board Part time consultant to Frimley Health FT undertaking medical revalidation as an appraisal lead. Private practice at Clare Park (non NHS patients) Private practice advice given to Medical Directors of NHS acute trusts Chair - - Page 1 of 7 Overall Page 4 of 160

5 Name Relevant and Material Interests Governing Body Finance and Performance Audit & Risk Clinical Executive Remuneration & Nominations Quality Improvement Patient & Public Engagement Delegated Primary Care Commissioning Clarke, Steven (Dr) Dempster, Jane (Dr) Fairbairn, Olive (Dr) Wernick, Edward (Dr) CCG Directors Hartley, Ros Director of Strategy and Partnerships Holden, Emma Director of Quality and Partner at Branksomewood Healthcare Centre Working in partnership with Lloyds Pharmacy who have established an onsite pharmacy at Branksomewood Healthcare Centre Wife is GP Partner, River Wey Medical Practice, Farnham Health Centre. Wife is shareholder in Inside View company providing some diagnostic services such as ultrasound and echocardiograms. Member of NHUC, a provider of out of hours services for North East Hampshire and Farnham Clinical Commissioning Group. Lead GP for Fleetwood Lodge care home, Fleet Shareholder in Salus Medical Services Ltd Lives in Farnham and registered with Farnham practice GP Partner at Farnham Dene Medical Practice Shareholder in Salus Medical Services Ltd Occasional locum at Alexander House Surgery, Farnborough Employed at Jenner House Surgery, Farnborough as a regular locum Trustee of RHL (Rushmoor Healthy Living) a local charity involved in providing services that improve the health and well-being of the local population Trustee and Chairman of the Broadhurst Welcome Home Community Ltd a trust fund which provides grants for providers and individuals with mental health problems in Rushmoor and parts of Surrey Heath and Hart Shareholder in Salus Medical Services Ltd GP Principal in Downing Street Group Practice, Farnham Wife is a physiotherapist at Basingstoke Hospital Shareholder in Salus Medical Services Ltd Shareholder in Farnham Integrated Care Services Ltd - Chair No interests to declare No interests to declare A Page 2 of 7 2. Register of Interest v 23 June 2016.pdf Page 2 of 7 Overall Page 5 of 160

6 Name Relevant and Material Interests Governing Body Finance and Performance Audit & Risk Clinical Executive Remuneration & Nominations Quality Improvement Patient & Public Engagement Delegated Primary Care Commissioning Nursing McBride, Sarah Director of Transformation Patel, Roshan Chief Finance Officer Alison Edgington, Interim Director of Delivery Husband is employed by Ashley Lodge, an independent care home for people with learning disabilities in North Hampshire CCG area (Winchfield) A A Riverside Meadows Management Company Limited Director Director AE executive Interims Ltd. Associate Directors and Managers No interests to declare - - A Lawrence, Kirsten Deputy Director of Delivery Pettman, Mary Deputy Director of Finance Fiona Hoskins Deputy Director of Quality & Nursing Husband is Director of Strategy Poole Hospital NHS Foundation Trust - A A No interests to declare A - - Trippner, Gillian No interests to declare Lisa Mercer Assistant CFO Oliver White Assistant CFO Charlotte Keeble, Associate Director of Integrated and Urgent Care School Governor, Henry Tyndale School (County Council SLD), Ship Lane, Farnborough, Hampshire A A No interests to declare A - A Husband works for Surrey County Council A Clinical Leads Ahmed, Arfan (Dr) GP at Monteagle Surgery, Yateley Page 3 of 7 2. Register of Interest v 23 June 2016.pdf Page 3 of 7 Overall Page 6 of 160

7 Name Relevant and Material Interests Governing Body Finance and Performance Audit & Risk Clinical Executive Remuneration & Nominations Quality Improvement Patient & Public Engagement Delegated Primary Care Commissioning Ballard, Martin (Dr) Professional development and workforce Bennett, Karl (Dr) IT Boylett, Sharon (Dr) Introducing new models of integrated health & social care Couderc, Ushadevi (Dr) Improving Quality and productivity of planned care Elliott, Jane (Dr) Targeted prevention and earlier prevention Hoff, Hanne (Dr) Children s Services Work Stream Targeted prevention and earlier prevention Shareholder in Salus Medical Services Ltd GP Downing Street GP Tutor HEKSS employee since 2012 Trustee on PGEC Board FPH GP Advisor to Clare Park Hospital One session per month advising on GP education and engagement OOH Regular sessions worked for NHUC. Shareholder in Salus Medical Services Ltd Partner in Hartley Corner Surgery which is currently in negotiation to merge with two local practices in the Yateley area (Oaklands Medical Centre and Monteagle Surgery). The same locality is currently in negotiation with North East Hampshire and Farnham CCG to participate in an integrated care pilot which will involve development of IT systems to support this activity Wife is senior partner at Station Road surgery, part of Surrey Heath CCG and a GP member of the Surrey Heath CCG board with no specific portfolio. Shareholder in Salus Medical Services Ltd Nurse Practitioner at Alexander House Surgery, Farnborough Nurse Practitioner in North Hampshire Urgent Care out of hours service GP Principal at Victoria Practice, Aldershot Co-opted LMC member Shareholder in Salus Medical Services Ltd GP Partner in Holly Tree Surgery, Farnham Husband is Consultant Ophthalmologist at Frimley Health NHS FT Shareholder in Salus Medical Services Ltd GP in Crondall New Surgery, Farnham Husband is a senior GP Partner in Crondall New Surgery and Medical Director of NHUC Locum GP in North Hampshire Urgent Care out of hours service Page 4 of Register of Interest v 23 June 2016.pdf Page 4 of 7 Overall Page 7 of 160

8 Name Relevant and Material Interests Governing Body Finance and Performance Audit & Risk Clinical Executive Remuneration & Nominations Quality Improvement Patient & Public Engagement Delegated Primary Care Commissioning King, Nelly (Dr) Cancer Lead Micklethwaite, Glen (Dr)Improving Quality & productivity of planned care Rishworth, Viv (Dr) Improving Quality & productivity planned care Robinson, Karen (Dr) Empowering individuals to take control of their health Rosling, Lesley (Dr) Mental Health Russell, Kate (Dr) Children Project Clinical Auditor of North Hampshire Urgent Care Honorary tutor in the department of Pharmacology, Toxicology and Therapeutics at the University of Cardiff NHUC Employed as Clinical auditor Shareholder in Salus Medical Services Ltd Southlea Practice - Register of Interests Form to be completed Shareholder in Salus Medical Services Ltd Senior GP Partner in Milestone Surgery, Farnborough Shareholder in Salus Medical Services Ltd GP Downing Street - Register of Interests Form to be completed Shareholder in Salus Medical Services Ltd GP Southlea Practice GP Partner Shareholder in Salus Medical Services Ltd GP Southlea Practice Register of Interests Parochial church council member St Mary Church Frensham no conflict Trustee Ridgeway School(Special needs school) Farnham no conflict Shareholder in Salus Medical Services Ltd GP Downing Street Practice Register of Interests Form to be completed Shareholder in Salus Medical Services Ltd Page 5 of Med Management Melinda Veck, Med No interests to declare. Management Pharmacist Clare Watson, Med No interests to declare. Management Jennifer Fynn, Head Husband is Pharmacy manager at Fernhurst Pharmacy Ltd A A 2. Register of Interest v 23 June 2016.pdf Page 5 of 7 Overall Page 8 of 160

9 Name Relevant and Material Interests Governing Body Finance and Performance Audit & Risk Clinical Executive Remuneration & Nominations Quality Improvement Patient & Public Engagement Delegated Primary Care Commissioning of Medicines Management Inderpal Chheena Locum Pharmacist for Boots Sarah Ellis-Martin Married to North East Hants and Farnham CCG employee Emily Dewey No interests to declare. Other Organisations Boddy, Jean No interests to declare A Surrey County Council Claire Hooke Employed by Hampshire County Council A Area Director North & East Hampshire, Hants County Council Pears, Robert No interests to declare A - - Consultant in Public Health, Hampshire County Council Ed Walton Employed by Hampshire County Council Vamplew,Tim Research Policy and Performance, Surrey County Council Elspeth Griffiths Associate Director of HR Central, South Associate member of the Asian Welfare and cultural Association, Eastleigh No interests to declare No interests to declare A and West CSU David Brown (Dr) GP at Farnham Dene Practice Chair of the Practice Council Shareholder with Salus Shareholder in Farnham Integrated Care Services Ltd Firmin, Christina Practice Manager at Giffard Drive Surgery Secretary of the Practice Council Page 6 of Register of Interest v 23 June 2016.pdf Page 6 of 7 Overall Page 9 of 160

10 Name Relevant and Material Interests Governing Body Finance and Performance Audit & Risk Clinical Executive Remuneration & Nominations Quality Improvement Patient & Public Engagement Delegated Primary Care Commissioning Samantha Hudson Employed Hampshire County Council as Head of Communities and Wellbeing Sue Hathaway Work capacity - RUS is the Umbrella operation supporting the voluntary sector in Rushmoor Kefford, Sharon (GP) Safeguarding Children Employed by West Hampshire CCG as named GP for Safeguarding Children assigned to NEHF CCG Nigel Watson (Dr) Chief Executive Officer, Wessex Local Medical Committee (LMC) Page 7 of 7 2. Register of Interest v 23 June 2016.pdf Page 7 of 7 Overall Page 10 of 160

11 Governing Body Date of Meeting 29 June 2016 Agenda Item 3 Paper Number 3 Strategic Objective Number Author Justina Jeffs Head of Governance Sponsor 13. Governance systems and processes Andy Whitfield, CCG Chair and Clinical Lead Title: Executive Summary: Governing Body Assurance Framework The attached Governing Body Assurance Framework identifies the key risks as well as the controls in place to reduce, mitigate and manage these risks, and assurance, in order to determine whether these controls are working. Points to note: Risk 1: Constitutional Targets Accident and Emergency (A&E) 4 hour wait has been added to this strategic risk. Risk 2: Financial Targets the score has decreased due to the revised contract in place with Frimley Health (capped contract) Risk 3: There is a note included regarding Southern Health NHS Foundation Trust s warning notice issued by the Care Quality Commission. Risk 5: Delegated Commissioning this risk has been extended to include two local practices receiving requires improvement outcomes following Care Quality Commission inspections. Risk 7: Robust systems and processes (Business Continuity). The score of this risk has decreased as the Business Continuity Plan has been revised to include primary care. The Governing Body are asked to note the Governing Body Assurance Framework. Actions/ Recommendations Other Committee(s) where this paper or supporting information have been considered To Approve To Ratify - An item of business where the Governing Body is required to ratify the action(s) taken of behalf of the Governing Body, for example by a formal committee established by the Governing Body. To Discuss - An item of business that requires discussion by the Governing Body prior to agreement of a formal resolution or a general policy steer to the executive officers. To Note - An item of business for which the Governing Body is required to give due regard to but for which there is not expected to be discussion. X Date 12 May 2016 Version 3 3. (FINAL) Draft GB GBAF.pdf Page 1 of 5 Overall Page 11 of 160

12 Governing Body Assurance Framework High Risk Summary: Chart Ref Risk Current Score Score Trend Consequence Likelihood Current Previous month 3 months ago 6 months ago General direction 1 = Negligible 1 = Never Score of Travel 5 = Catastrophic 5 = Almost Certain 1 Constitutional Targets Financial Targets 3 Provider/Partner failure impacting on Service Delivery 4 Engagement with Member Practices Delegated Commissioning 9 9 N/A N/A Vanguard programme N/A N/A 7 System Resilience and Business Continuity CCG Sustainability Conflicts of Interest Management of collaborative arrangements for Mental Health & Learning Disability Services N/A N/A 3. (FINAL) Draft GB GBAF.pdf Page 2 of 5 Overall Page 12 of 160

13 Chart Ref Risk Name & Description Risk Owner & Clinical Lead/Risk Manager Assurance Committee Current Risk Rating Consequence x likelihood Actions Key Controls Assurance Source 1 Risk: Performance against Constitutional Targets a) Ambulance Response Times b) Increased number of delayed transfers at Frimley Park Hospital (nursing home placements, home care packages and Patient & Family choice) c) Increase in Continuing Health Care Expenditure (CHC) d) A&E 4 hour wait Interim Director of Delivery Alison Edgington Governing Body 15 (3x5) a1) A new recovery plan and trajectory is being negotiated with North West Surrey CCG a2) SECAmb are implementing their Immediate Handover Procedure a3) NEHF CCG working with Frimley Park A&E to reduce handover times. b1) NEHF CCG have developed an action plan which will be used in planning discussion with the Frimley System Resilience Group b2) The CCG have developed a trajectory to reduce the rate of delayed transfers of care from 3.5% to 3.9%. c1) A deep dive presentation planned for the Finance & Performance Committee in June c2) Two fixed term posts starting in June 2016 c3) Monthly Performance & Governance meetings introduced by West Hampshire CCG for escalation and this group will lead of drafting a CHC service specification. c4) a performance scorecard has been developed and can be accessed to run reporting by the CCG. Finance and Performance Committee established to review monthly Integrated Performance Report which includes performance against Constitutional Targets. a1) Contract monitoring meetings with providers a2) Monthly face-to-face meetings with SECAmb a3) CQC inspection undertaken and active monitoring by Monitor and NHS England. b1) regular monitoring of the Discharge to Assess beds c1) Local CHC working group overseeing performance and evaluation of planned projects. c2) CHC Governance & Performance group and plans. d2) Contract Quality review meetings with Frimley NHS England quarterly Assurance Meetings Integrated Performance Report and key issues raised at each Governing Body meeting Internal and External Audit reports NHS England requirement d1) Vanguard and System Resilience Group developing a range of projects designed to target key areas of challenge including Out of Hours and local authorities to reduce delays and increasing GP support to Frimley to help improve discharge. d2) The Quality team are working with Frimley Health to determine reasons for 12 breaches of patients waiting longer than 12 hours in A&E 2 Risk: Failure to meet financial obligations and requirement. Chief Finance Officer Roshan Patel Finance & Performance 9 (3x3) Vanguard programmes designed to deliver savings CCG actively imbed Right Care CCG actively manage GP referrals Deliver QIPP (savings) schemes Contract Review Meetings Robust scrutiny of chargeable activity Finance & Performance Committee Integrated Performance Report Internal audits carried out on financial business NHS England 3 Risk: Significant impact on North East Hampshire & Farnham CCG due to Providers and or Partner failure (in particular; Financial, Quality or Performance) In April the Care Quality Commission issued Southern Health NHS Foundation Trust with a warning notice to improve governance arrangements in particular around investigations and learning from incidents and deaths. Monitor subsequently put an additional condition on the Trusts License to provide NHS Services. Directors Roshan Patel Emma Holden Alison Edgington Governing Body 12 (3x4) Further development of the Quality Strategy Quality Insight Visits being rolled-out across all practices Board to Board meetings with providers. Signed Contract with all providers Monthly contract review meetings and use of contractual incentives and levers System-wide established networks e.g System Resilience Group Contract Quality Schedules in place for all providers Clinical Quality Review, Serious Incident and Learning Panel Meetings in place Regular CQRM meetings Quality report to Governing Body. Quality exception dashboard to Quality Improvement Committee NHS England Quarterly Assurance meetings. Internal Audit Reports for services provided by partner organisations (e.g Safeguarding, Continuing Health Care etc.) CCG Internal Audit Reports 3. (FINAL) Draft GB GBAF.pdf Page 3 of 5 Overall Page 13 of 160

14 Chart Ref Risk Name & Description Risk Owner & Clinical Lead/Risk Manager Assurance Committee Current Risk Rating Consequenc e x likelihood Actions Key Controls Assurance Source 4 Risk: There is insufficient engagement with Member Practices which may impact on relationships, and CCG programme development & delivery. Interim Director of Delivery Alison Edgington Governing Body 6 (2x3) Work continues on the separation of the Communications and Engagement Strategies to include internal communications and engagement Reinstate regular meetings between the Chair and Secretary of the Practice Council and Chief Officer and Chair. Further development of the CCG Intranet to provide as an additional resource and means of communication with Member Practices. Regular locality meetings established & taking place CCG website operational Engagement and working together is a key enabler of the Vanguard programme which the CCG is a key member CCG processes have been developed to gain Member Practice engagement with decision-making. 5 Strategic Risk: Delegated Primary Care Commissioning. a) Insufficient allocations to CCG to support historic commitments. b) there is no early warning system in place to identify vulnerable practices in advance. c) failure to build a sustainable model of integrated primary care at scale d) two local practices have received requires improvement outcomes following Care Quality Commission inspections. Interim Director of Delivery Alison Edgington Governing Body 9 (3x3) The Primary Care Strategy will include primary care sustainability. Determine the criteria and intelligence monitoring to support an early warning system. The Delegated Primary Care Commissioning Committee are overseeing these risks and determining ways of working with practices for the future. Delegation and Collaboration Agreements in place between CCG and NHS England. Model terms of reference for delivery of statutory functions and duties. Delegated Primary Care Commissioning Committee now established NHS England Chart Ref Risk Name & Description Risk Owner & Clinical Lead/Risk Manager Assurance Committee Current Risk Rating Consequenc e x likelihood Actions Key Controls Assurance Source 6 Risk: Vanguard fails to deliver in the following areas: Savings Transformation Sustainability Interim Director of Delivery Alison Edgington Chief Finance Officer Roshan Patel Director of Strategy & Partnerships Ros Hartley Governing Body 9 (3x3) Regular reporting to Governing Body in order to determine any issues or areas of concern started in April Vanguard Steering Group in place to oversee programme delivery. Governing Body and its Sub-Committees overseeing any national requirements as they arise Reporting to National Vanguard team on progress NHS England Quarterly Assurance meetings Work stream leads providing Work stream reports for Vanguard Steering Group 7 Risk: There is a lack of robust systems & processes in respect of Business Continuity Emergency /Operational Planning Interim Director of Delivery Alison Edgington Chief Finance Officer Roshan Patel Governing Body 6 (3x2) Business Continuity systems and process to include primary care commissioning responsibilities have been undertaken and are currently out for review. Emergency Preparedness Resilience and Response Plan Daily system resilience process On call system On call planning across the geographical patch Emergency Preparedness Resilience and Response Plan Assurance via checklist and NHS England assessment of CCG and Lead commissioner organisations with action plan regularly monitored Positive assurance from NHSE Wessex on winter preparedness Internal Audit Report NHS England requirement 3. (FINAL) Draft GB GBAF.pdf Page 4 of 5 Overall Page 14 of 160

15 Chart Ref Risk Name & Description Risk Owner & Clinical Lead/Risk Manager Assurance Committee Current Risk Rating Consequenc e x likelihood Actions Key Controls Assurance Source 8 Risk: The CCG is not sustainable due to lack of required resources in place to deliver strategic change including: workforce to deliver new models of care; training and development for future workforce; organisational development programmes that challenge the status quo, communicate the change needed, shape the culture and values needed and empower staff; 9 Risk: reputational damage due to a failure to manage conflicts of interest effectively. Director of Strategy & Partnerships Ros Hartley Chief Finance Officer Roshan Patel Remuneration & Nominations Governing Body 12 (4x3) 6 (3x2) Learning Agreement to be finalised and approved. Operational Leadership Group reviewing mandatory training requirements for each team Review and revision of the management of declaration of Interests and conflicts of interest documentation to reflect requirements of new NHS England guidance. Interests determined for Vanguard Steering Board Service Level Agreement with the Commissioning Support Unit for delivery of CCG mandatory training monitored Organisational Development Plan in place Recruitment into teams Leadership Programme Induction programme in place Annual Declaration of Interests Procedure Standing Orders detail process of management of conflicts of interests Committee Terms of Reference Standards of Business Conduct and Conflicts of Interests Policy CCG Mission Statement and Objectives used in staff objective-setting and appraisals. Monthly Workforce data which is reviewed at Remunerations and Nominations Committee. Review of the Register of interests at each Governing Body and sub-committee meeting. Internal Audit report with reasonable assurance. NHS England approved Standards of Business Conduct and Conflicts of Interests policy Conflicts of Interests declared at each Governing Body and subcommittee meeting NHS England announcement 31 March 2016 Chart Ref Risk Name & Description Risk Owner & Clinical Lead/Risk Manager Assurance Committee Current Risk Rating Consequenc e x likelihood Actions Key Controls Assurance Source 10. Risk: failure to manage collaborative commissioning arrangements for: Mental Health Director of Strategy & Partnerships Ros Hartley Governing Body 15 (3x5) 16/17 Collaborative SLAs to be reviewed and signed MH Collaborative changes to be agreed with current CCG members Transition arrangements for MH collaborative to be mapped and agreed with CCG members Impact and risk assessment to be completed on MH Collaborative options and changes identified Agreement to be made with member CCGs on management of risks and liabilities linked to changes in collaborative arrangements Communication and management of change with affected staff and partners to be planned and implemented as appropriate to level of change agreed SLA for each collaborative to be in place with relevant CCGs Regular collaborative meetings to take place Terms of reference for the collaborative meetings to be reviewed annually and agreed by members Annual plan contributions and contract negotiation mandates for respective area coordinated and produced with agreement of members by collaborative teams Monthly reports to CCGs on agreed work programme, contract activity, performance and finance Integrated Performance Report and key issues raised at each Governing Body meeting Internal and External Audit reports Relevant decision papers to be submitted to relevant CCG clinical executives and governing bodies by collaborative leads Regular attendance and reporting to Surrey Collaborative forums by collaborative executives and managers Governing Body meeting discussion March (FINAL) Draft GB GBAF.pdf Page 5 of 5 Overall Page 15 of 160

16 Governing Body Date of Meeting 29 June 2016 Agenda Item 4 Paper Number 4 Strategic Objective Number Author Edward Wernick, Director Sponsor Clinical Director and Sharon Ward, Associate Clinical Sponsor Director of Communications and Engagement All Ros Hartley, Director of Strategy and Partnerships All Clinical Directors Title: Working in partnership with local people engagement and co-production Executive Summary: This paper provides a briefing of the organisational objectives which relate to patient and public engagement for North East Hampshire and Farnham Clinical Commissioning Group. Our engagement priority for 2016/17 is to strengthen and embed robust processes to engage and co-design with the local community, ensuring that their views and experiences directly influence priorities, plans and delivery North East Hampshire and Farnham Clinical Commissioning Group (the CCG) is committed to working with the community in a different way: so that people are involved in discussions and decisions which affect their health and social care. This means getting the community involved at the start of projects, not just asking them what they think of something that s already been decided. We believe that better decisions are made when the general public and professionals work together. Through the work of the CCG and our Vanguard workstreams we have two clear priorities. To: 1. Deliver meaningful citizen engagement in the new care model programme: completing a co-design and engagement project on the primary care strategy by October 2016 and a consultation on the community bed provision by March Embed a new culture and ways of working which places collaboration with patients and the community at the heart of how we work: This paper aims to provide the Governing Body with assurance around the actions we have undertaken through quarter /17 to meet these priorities and to provide the Governing Body with an opportunity to discuss how we are meeting our engagement values. Actions/ Recommendations To Approve - An item of business that requires the Governing Body to take a formal decision To Ratify - An item of business where the Governing Body is required to ratify the action(s) taken of behalf of the Governing Body, for example by a formal committee established by the Governing Body. To Discuss - An item of business that requires discussion by the Governing Body prior to agreement of a formal resolution or a general policy steer to the executive officers. To Note - An item of business for which the Governing Body is required X 4. (FINAL) Working in partnership local people GB June 16.pdf Page 1 of 13 Overall Page 16 of 160

17 to give due regard to but for which there is not expected to be discussion. Other Committee(s) where this paper or supporting information have been considered Date 15 June (FINAL) Working in partnership local people GB June 16.pdf Page 2 of 13 Overall Page 17 of 160

18 Working with local people Engagement and co-production 4. (FINAL) Working in partnership local people GB June 16.pdf Page 3 of 13 Overall Page 18 of 160

19 We have a legal duty to consult: The Health and Social Care Act (2012) introduced amendments to the NHS Act (2006). Within the act all Clinical Commissioning Groups (CCGs) were given a legal duty to ensure that patients, carers and general public are involved in decision making. The 2015 Patient and Public Participation Policy reinforces these messages TheNHS five year forward plan also outlines how services should be designed with those who use them, harnessing the renewable energy represented by patients and communities' and the need to 'engage with communities and citizens in new ways, involving them directly in decisions about the future of health and care services. Ultimately it is not about the plan but delivering real change for patients. 4. (FINAL) Working in partnership local people GB June 16.pdf 2 Page 4 of 13 Overall Page 19 of 160

20 Our involvement duties: There are three involvement duties for CCGs; to ensure patients participate in planning, managing and making decisions about their individual own care and treatment and that CCGs promote that involvement (patient choice, personalised care planning, shared decision making, self-care opportunities, information with targeted support etc.) the public involvement duty which is aimed at enabling the effective participation of the public in the commissioning process itself, so that services reflect the needs of local people. This includes the duty to ensure that people to whom services are being provided (or may be) are involved in the planning commissioning arrangements(including consideration of allocation of resources, needs assessment and service specification), the development and any proposals for changes and decisions affecting or having an impact on the way that services are delivered or range of services that are available the requirement to report on this as a minimum annually within the Annual Report 4. (FINAL) Working in partnership local people GB June 16.pdf Page 5 of 13 Overall Page 20 of 160

21 And we have made a genuine commitment to co-designing and engagement: Locally, we believe that by working in partnership with services users, carers, families and the general public we can learn about peoples experiences and views to help us prioritise and shape the delivery of local services, reducing inequalities and improving access and quality for all. Patient and carer stories bring a different perspective to our understanding of our services; and can challenge our view of how we think services are received and what we think people think is important We are committed to working with the community in a different way: so that people are involved in discussions and decisions which affect their health and social care. This means getting the community involved at the start of projects, not just asking them what they think of something that s already been decided. We believe that better decisions are made when the general public and professionals work together. 4. (FINAL) Working in partnership local people GB June 16.pdf Page 6 of 13 Overall Page 21 of 160

22 The CCG has an Engagement and Partnership Objective for 2016/17: To strengthen and embed robust processes to engage and co-design with the local community, ensuring that their views and experiences directly influence priorities, plans and delivery 4. (FINAL) Working in partnership local people GB June 16.pdf Page 7 of 13 Overall Page 22 of 160

23 Our Priority Actions: 1) Deliver meaningful citizen engagement in the new care model programme: completing a consultation on the primary care strategy by October 2016 and on community bed provision by March ) Embed a new culture and ways of working which places collaboration with patients and the community at the heart of how we work: a) developing a sustainable Community Ambassadors Programme; b) investing in collaborative leadership; c) fully introducing the Patient Involvement Assessment Framework; d) ensuring we have sufficient skills and capacity to support co-production. 4. (FINAL) Working in partnership local people GB June 16.pdf Page 8 of 13 Overall Page 23 of 160

24 We have three enabling priorities to support these priorities: To align the Happy Healthy at Home and North East Hampshire and Farnham Clinical Commissioning Group Engagement and Communication priorities and bring together as one sustainable work plan Undertake a review of how we work collaboratively with stakeholders in the system, including the third sector to make best use of all available resources Develop and deliver a strategy and plan to support an embedded culture of engagement throughout, to include knowing how to measure success 4. (FINAL) Working in partnership local people GB June 16.pdf Page 9 of 13 Overall Page 24 of 160

25 Priority 1 Deliver meaningful engagement on the primary care strategy and community bed provision: Engagement project plan developed, aligned to the Happy Healthy at Home PMO office format to ensure effective reporting and compatibility The plan includes a series of locality engagement and engagement for hard to reach groups and/or specific demographics events and deliverables A Farnham event on the Primary Care Strategy engagement has already taken place, with follow up to introduce Community Beds and finalise the engagement plan for that locality in July The Yateley eventwill have an engagement event by end of July 2016, with the others planned to follow shortly We are currently working with our third sector colleagues to utilise their existing general public forums to help us to engage. 4. (FINAL) Working in partnership local people GB June 16.pdf Page 10 of 13 Overall Page 25 of 160

26 Priority 2 Embed a new culture and ensure we have sufficient skills and capacity to support co-production: a) Develop a sustainable Community Ambassadors Programme b) Implement the Patient Involvement Assessment Framework c) Deliver the Collaborative Trios Programme by March 2017 d) Ensuring we have sufficient skills and capacity to support co-production 4. (FINAL) Working in partnership local people GB June 16.pdf Page 11 of 13 Overall Page 26 of 160

27 Priority 2 actions: There are now 80 Community Ambassadors in place. Working with the third sector we have developed and implemented a post to support this exciting volunteer pool. We now have in place an induction programme, training and sustainability tools. The Patient Involvement Assessment Framework has now been approved and is being piloted for three months this is the first of its kind in CCGs locally. The framework will support us to ensure we follow through on our commitment to engagement and do nothing about us without us. The Communications and Engagement team are developing a series of tools to support co-production, to support engagement in a meaningful way. The collaborative trio modelis being developed to ensure it delivers best value locally and is aligned to the key engagement priorities 4. (FINAL) Working in partnership local people GB June 16.pdf Page 12 of 13 Overall Page 27 of 160

28 Actions to implement the enablers: We have just finalised the strategy for engagement based on these priority areas, and are in the process of developing a simple to read and access 1- page accessible summary We aim to develop a series of KPIs for engagement, with patients, the general public and carers to measure our success Using the work of the organisational values, we aim to work with the staff forum to develop ways to embed the engagement values and be able to generate examples of good practice We are now prioritising key communication tools to support engagement; a) Happy Healthy at Home Newsletter now back in place, with a plan to update monthly; b) Happy, Healthy at Home website under review; c) Reviewing how we share our successes more frequently, looking at developing our social media and networking systems further. 4. (FINAL) Working in partnership local people GB June 16.pdf Page 13 of 13 Overall Page 28 of 160

29 Governing Body Date of Meeting 29 June 2016 Agenda Item 5 Paper Number 5 Strategic All Objective Number Author Ros Hartley Director Sponsor Ros Hartley Clinical Sponsor All Clinical Directors Title: North East Hampshire and Farnham Objectives 2016/17 Executive Summary: The GB is asked to note Quarter 1 progress against our North East Hampshire and Farnham objectives for 2016/17. There are 13 overall CCG objectives organised around key themes. These objectives and Q1 progress include the work within both the CCG and Vanguard work programme within one document. Progress against the objectives will be reported against on a quarterly basis. Actions/ Recommendations Other Committee(s) where this paper or supporting information have been considered Date June 2016 To Approve - An item of business that requires the Governing Body to take a formal decision To Ratify - An item of business where the Governing Body is required to ratify the action(s) taken of behalf of the Governing Body, for example by a formal committee established by the Governing Body. To Discuss - An item of business that requires discussion by the Governing Body prior to agreement of a formal resolution or a general policy steer to the executive officers. To Note - An item of business for which the Governing Body is required to give due regard to but for which there is not expected to be discussion. Senior Management Team 5. (FINAL) GB - objectives.pdf Page 1 of 17 Overall Page 29 of 160

30 CCG Objectives for 2016/17 Objectives Priority Actions 2016/17 Leads A: Improved Services, Outcomes and Care Quality for our Population 1. Ensure local people receive high quality services that are safe, improve outcomes for people, and are delivered with kindness and compassion. Where care does not meet required standards, take action to improve the quality of these services 2. Deliver the actions within our improvement programmes to improve the quality, outcomes and performance of services. Our improvement programmes include: (1) prevention and selfcare, (2) primary care, (3) integrated community care, (4) urgent and emergency care, (5) planned care, (6) specialist care 3. Ensure that all constitutional standards are achieved for the North-East Hampshire & Farnham population. a) Implement a system wide quality improvement programme with clear and measureable outcomes b) Build upon existing approaches and frameworks to measure, improve and publish information on quality in local health and social care c) Continue to embed robust systems and processes that safeguard vulnerable people in the local population d) Agree and deliver a system wide programme of action to address clinical variation in order to improve the quality and cost effectiveness of service delivery e) Enhance prevention and self-care by implementing the Recovery College; expanding Making Connections; improving how we respond to the needs of carers; and falls prevention f) Agree and begin implementation of the primary care strategy to increase the sustainability of, and extend access to general practice to 8am-8pm, in all localities by March 2017 g) Further develop existing Integrated Care Teams (ICTs), fully implementing the ICT model in all localities by March 2017 h) Ensure we have a single service for people with more complex needs who require specialist support to avoid a crisis, to come home from hospital or to decide what is next for them following treatment, which joins up existing services, and identifies a clear plan for Continuing Health Care i) Bring together out-of-hours primary care and 111 services into a single offering integrated with other urgent care services. j) Implement the plan to deliver the NHS Seven Day Services Clinical Standards for the local population k) Improve planned care services, implementing the Orthopaedics Extended Scope Physiotherapy (ESP) Pathway; increasing the proportion of non-surgical interventions for people with chronic pain, and transferring ophthalmology services into the community where it is appropriate to do so l) Proactively manage operational performance to ensure constitutional standards are delivered throughout the year, including leadership of the Frimley System Resilience Group Page 1 of 16 Emma Holden & Ed Wernick Emma Holden & Ed Wernick Emma Holden & Jane Dempster Andy Whitfield Alison Edgington & Olive Fairbairn Alison Edgington & Steven Clarke Alison Edgington & Jane Dempster Alison Edgington & Jane Dempster Alison Edgington & Peter Bibawy Alison Edgington & Peter Bibawy Alison Edgington & Steven Clarke Alison Edgington & Peter Bibawy 5. (FINAL) GB - objectives.pdf Page 2 of 17 Overall Page 30 of 160

31 Objectives Priority Actions 2016/17 Leads 4. Through the delivery of the New Care Models Programme and through the development and delivery of the Frimley and Hampshire & Isle of Wight Sustainability and Transformation Plans (STPs), accelerate the pace and scale of delivery of new models of care a) Put in place a clinical leadership programme through which clinicians across the whole system come together to provide leadership and direction to the delivery and transformation of health and care services for the North East Hampshire and Farnham population b) Lead the development and introduction of an accountable care system by April 2017 in which a single leadership team comprising providers and commissioners takes responsibility for the outcomes, operational and financial performance of local health and social care services Andy Whitfield, Peter Bibawy & Emma Holden Maggie MacIsaac & Andy Whitfield B: System Reform 5. Develop, agree and put in place revised contracting, payment and governance arrangements with providers to support delivery of the system strategy, and the creation of a place-based system of care. c) Develop and agree a procurement strategy that supports the system to deliver the new care models d) Improve the way we commission services: develop a system wide quality framework that improves outcomes for local people, and a new Quality Assurance Framework for new care models introducing longer term outcome based contractual arrangements with providers, and creating a single population budget with Hampshire County Council and Surrey County Council for our population e) Develop and agree a plan to extend our collaboration with other CCGs where this offers greater benefits for patients and better value for money Roshan Patel Emma Holden & Ed Wernick Roshan Patel & Alison Edgington Maggie MacIsaac f) Agree Sustainability and Transformation Plans for the Hampshire & Isle of Wight and the Frimley systems by June 2016 and begin implementation Ros Hartley & Andy Whitfield g) Deliver the priority IT deliverables: all GP practices on single system, increase the use and scope of the Hampshire Health Record, expand the use of e-referrals and e-prescribing Roshan Patel h) Deliver the priority estate deliverables: ensuring that Integrated Care Teams have the appropriate premises to fully operate, maximising the use of Aldershot Centre for Health and Farnham community hospital, and assessing the estate impact of the community bed consultation Roshan Patel Page 2 of (FINAL) GB - objectives.pdf Page 3 of 17 Overall Page 31 of 160

32 Objectives Priority Actions 2016/17 Leads C: Engagement & Partnerships 6. Strengthen and embed robust processes to engage and codesign with the local community, ensuring that their views and experiences directly influence CCG priorities, plans and delivery 7. Further improve and embed the arrangements through which member practices operate within and contribute to the work of the CCG, in order to accelerate planned service improvements 8. Further develop and strengthen the partnerships we need to improve health and health services for our population 9. Effectively discharge our responsibilities leading the commissioning collaborative for children s and maternity services and for mental health and learning disability services a) Deliver meaningful citizen engagement in the new care model programme: completing a consultation on the primary care strategy (by Oct 16) & on community bed provision (by Mar 17) b) Embed new ways of working which place collaboration with patients and the community at the heart of how we work: investing in collaborative leadership, developing a sustainable Community Ambassadors Programme, fully introducing the Patient Involvement Assessment Framework and ensuring we have sufficient skills and capacity to support co-production c) Deliver a thriving programme of member practice engagement d) Through the children and maternity services collaborative - agree and begin implementation of a new model of children s integrated care teams across Hampshire - agree a sustainable community paediatric service across the CCG e) Agree a revised model for commissioning mental health and learning disability services for our local population, by Sept 16 f) Ensure parity of esteem for Mental Health and Learning Disabilities is further developed including support to primary care and integrated care teams Ros Hartley & Ed Wernick Ros Hartley & Ed Wernick Ros Hartley & Andy Whitfield Ros Hartley & Olive Fairbairn Ros Hartley & Olive Fairbairn Ros Hartley Ros Hartley & Olive Fairbairn Page 3 of (FINAL) GB - objectives.pdf Page 4 of 17 Overall Page 32 of 160

33 Objectives Priority Actions 2016/17 Leads D: Financial Sustainability 10. Continue to refine and implement our five-year financial plan which ensures the sustainability of services for our population and ensures that CCG has the resources and resilience it needs to deliver its strategy 11. Deliver our annual financial plan, achieving value for money and meeting our financial obligations a) Deliver the CCG financial plan b) Proactively manage contracts with providers and ensure that the CCG has the ability to deliver activity and financial plan, resulting in hospital utilisation levels (admissions, A&E activity and bed days) being maintained at or below 2015/16 outturn levels c) Deliver the agreed Quality, Innovation, Productivity and Prevention (QIPP) schemes for 2016/17 d) Develop and agree, by September 2016, a balanced financial plan for 2017/18 Roshan Patel Roshan Patel Roshan Patel & Alison Edgington Roshan Patel Objectives Priority Actions 2016/2017 Leads E: CCG People and Organisation 12. Refresh and implement our organisational development plan, developing our people, culture and clinical leadership to enable innovation and excellence, managing within our running costs 13. Ensure that the necessary internal systems, processes, constitutional and governance arrangements are in place to enable the CCG to deliver its duties and responsibilities a) Deliver our CCG Organisational Development programme b) Ensure clinical leadership roles are agreed and that these roles are deployed for maximum benefit in the system c) Deliver our multi-professional workforce development programme d) Ensure effective internal and external communications e) Improve our risk management processes and ensure they are driving CCG priorities and activity f) Ensure key indicators and reporting processes are in place that enable monitoring of performance across all objectives g) Improve the management of conflicts of interest Maggie MacIsaac Andy Whitfield & Peter Bibawy Emma Holden Ros Hartley Roshan Patel Roshan Patel Roshan Patel Page 4 of (FINAL) GB - objectives.pdf Page 5 of 17 Overall Page 33 of 160

34 Priority Actions in relation to Children s & Maternity, and Mental Health & Learning Disability Collaborative Commissioning As described in objective 9 above, our CCG is also responsible for commissioning children s and maternity services on behalf of Hampshire CCGs and mental health and learning disabilities services on behalf of Surrey CCGs. The table below summarises the priority actions in relation to these two Collaborative Commissioning Functions. Children s and Maternity Collaborative Working in partnership provide the best possible start in life through high performing maternity and children s healthcare from pre-birth to adulthood Priority Actions 2016/17 a) Respond to the recommendations of the National Maternity Review Better Births, ensuring all antenatal and postnatal maternity pathways deliver timely access to services, support choice and personalised packages of care; and ensuring appropriate healthy infant feeding practices are applied consistently across the county b) Design locally based models of integrated paediatric care across the community and acute providers c) Working in partnership, commission responsive and flexible mental health, learning disability and autism services that are supported by early intervention services and deliver the priorities of the Future in Mind plans d) Continue to implement the requirements of the Children & Families Act ensuring families have access to a single Education, Health & Care Plans; timely and relevant information promoted through the Local Offer; development of personal budgets and ensure the process is supported by designated medical officers within the Acute Trusts e) Continue to implement Transitions protocols and implementation of the Preparing for Adulthood strategy f) Develop a strategy, in partnership with Public Health, to reduce obesity levels in children Mental Health and Learning Disability Collaborative Working in partnership to achieve parity of esteem for mental health and improve the health and wellbeing of adults with mental health or learning disabilities across the Surrey and North East Hampshire populations through high quality services that are equally accessible to all. Priority Actions 1 April 31 July 2016 a) Discharge our responsibilities as lead commissioner for the Surrey and North East Hampshire Integrated Commissioning Strategy for Emotional Wellbeing and Adult Mental Health b) Deliver the Mental Health Crisis Care concordat plan with the roll out across the collaborative of Crisis Cafes, development of urgent integrated/single point of access and completion of the adult mental health bed review c) Complete the review of Surrey and Borders Partnership NHS Foundation Trust Learning Disability inpatient and community services and initiate the service redesign that aims to prevent inappropriate admissions by providing intensive support in a crisis d) Work with our local authority and NHS England partners and providers to develop appropriate robust co-commissioning arrangements around the delegated, Section 117, and specialist areas of mental health and learning disability e) Develop and implement plans that will deliver against the new access requirements for mental health f) Source the data to enable commissioners to report against the new framework for people with learning disabilities g) Develop and procure a perinatal service Page 5 of (FINAL) GB - objectives.pdf Page 6 of 17 Overall Page 34 of 160

35 CCG Objectives for 2016/17 Q1 Progress Priority Actions 2016/17 Q1 Progress A: Improved Services, Outcomes and Care Quality for our Population a) Implement a system wide quality improvement programme with clear and measureable outcomes. b) Build upon existing approaches and frameworks to measure, improve and publish information on quality in local health and social care. c) Continue to embed robust systems and processes that safeguard vulnerable people in the local population. System-wide Pressure Damage inaugural workshop completed. Scoping for Care Home Quality Improvement Programme underway and entered the system wide Care Home Forum into the Health Service Journal Awards. Agreed the CCG Sign Up to Safety pledges and developed delivery plan for 16/17. Agreed the 16/17 Quality Contract schedules with Providers helping to secure high quality and safe services for local people. Revised Governing Body Quality Reports to streamline quality reporting from Quality Improvement Committee to Board. Established Quality Reporting project and held inaugural meeting with Commissioning Support Unit to identify the range of metrics and Key Performance Indicator (KPIs) available. Date agreed for quality reporting workshop to redesign the CCGs quality reporting approach and framework. Continue to build on the CCGs Safeguarding Committee, meeting monthly to manage the agenda and gain assurance on Provider and CCG safeguarding arrangements. Engaged with the relevant adult and children s Safeguarding Boards sub groups for Hampshire and Surrey. Completed Section 11 Safeguarding Children s Audit Hampshire and Surrey. Agreed mitigating actions with the 5 Hampshire CCGs to agree cover for the vacant Looked After Children s Doctor role. Ensured access to Primary Care safeguarding training in local practices through the named GP for Safeguarding. Page 6 of (FINAL) GB - objectives.pdf Page 7 of 17 Overall Page 35 of 160

36 d) Agree and deliver a system wide programme of action to address clinical variation in order to improve the quality and cost effectiveness of service delivery. Discussion and agreement of joint approach with CCGs in Frimley South system regarding implementation of Right Care methodology. The use of RightCare will be a key element of the Frimley System STP submission. A: Improved Services, Outcomes and Care Quality for our Population e) Enhance prevention and self-care by implementing the Recovery College; expanding Making Connections; improving how we respond to the needs of carers; and falls prevention. Clinical Leadership discussion within the CCG to enable sufficient clinical expertise is applied to clinical variation. Review and renewal of Practice Support Program for 2016/17. Establish a primary care referral management process in Farnham in quarter one. Redesign practice support visits to incorporate the key dimensions of quality. Establish the new Time for Audit, Research, Governance, Education & Training (TARGET) primary care education programme. Identified 5 therapeutic areas to focus on for Right Care across the system - circulation, neurology, genito-urinary, musculoskeletal & respiratory. Contract for the Making Connections (social prescribing) has been awarded and is expected start receiving referrals from July The Recovery College programme has been published and is being published. Co-production meetings are underway for carers. The falls project, Walk and Live Confidently (WALC), is now established. Recovery College is running well, 38 courses are being delivered and completed with 200+ attendees. GPs are being made aware as are borough councils and the voluntary sector. Making Connections across the area is being established. A steering group has been set up to drive the work forwards and support the implementation. Coordinators have been appointed and are visiting the localities. First patients will be seen by 1 July Carers groups are being consulted with the support of Healthwatch about what is the best approach to help carers. Healthy living pharmacies are being developed. 1 has started and 1 is being developed. Page 7 of (FINAL) GB - objectives.pdf Page 8 of 17 Overall Page 36 of 160

37 f) Agree and begin implementation of the primary care strategy to increase the sustainability of, and extend access to general practice to 8am-8pm, in all localities by March Primary Strategy has been further developed to include future clinical model for primary care in response to reducing urgent and emergency care system pressure. This will be submitted to the Governing Body for approval in June A: Improved Services, Outcomes and Care Quality for our Population g) Further develop existing Integrated Care Teams (ICTs), fully implementing the ICT model in all localities by March h) Ensure we have a single service for people with more complex needs who require specialist support to avoid a crisis, to come home from hospital or to decide what is next for them following treatment, which joins up existing services, and identifies a clear plan for Continuing Health Care. i) Bring together out-of-hours primary care and 111 services into a single offering integrated with other urgent care services. j) Implement the plan to deliver the NHS Seven Day Services Clinical Standards for the local population. k) Improve planned care services, implementing the Orthopaedics Extended Scope Pathway (ESP) Pathway; increasing the proportion of non-surgical interventions for people with chronic pain, and transferring ophthalmology services into the community where it is appropriate to do so. l) Proactively manage operational performance to ensure constitutional standards are delivered throughout the year, including leadership of the Frimley System Resilience Group. The ICT workstream has developed activity performance reporting to provide a comparison of how each ICT is developing and having an impact on reducing acute activity. The plans to implement an Enhanced Recovery Team have been fully worked up and approved. Frimley Health NHS Trust and Southern Health NHS Trust are working in partnership to recruit to the team. The commencement date is 1 st September North East Hampshire & Farnham is participating in a Hampshire-wide collaborative procurement for the call-handling element of the 111 system. A Clinical/ stakeholder workshop has taken place and the emerging model is about to be debated by a stakeholder Task and Finish Group. Action to take forward this objective is yet to commence. The Orthopaedics Extended Scope Pathway (ESP) pathway has been in place for several months and is successfully treating higher numbers of patients without surgical intervention. The number of patients with chronic pain having a surgical intervention continues to decrease. A community glaucoma service is transferring patients from an acute environment to a community based environment. An interim Lead for System resilience has been appointed and the recruitment process for a permanent appointment has commenced. The System Resilience Group (SRG) has agreed a workplan for coming year and is working jointly with the Frimley North SRG to develop a co-ordinated SRG response across the Frimley Sustainability and Transformation Plan. Page 8 of (FINAL) GB - objectives.pdf Page 9 of 17 Overall Page 37 of 160

38 Priority Actions 2016/17 a) Put in place a clinical leadership programme through which clinicians across the whole system come together to provide leadership and direction to the delivery and transformation of health and care services for the North East Hampshire and Farnham population. b) Lead the development and introduction of an accountable care system by April 2017 in which a single leadership team comprising providers and commissioners takes responsibility for the outcomes, operational and financial performance of local health and social care services. c) Develop and agree a procurement strategy that supports the system to deliver the new care models. Q1 Progress Building on success of CCG Clinical Leads Programme work has started on the development of a Sustainability and Transformation Plan wide multi-agency, multiskilled clinical leadership programme. Support for this has been secured & work is starting in the next few weeks to design & recruit to the programme. This will also include working with TVWLA - Thames Valley & Wessex Leadership Academy. Discussions on different models being considered as part of Vanguard Work Programme. Full strategy developing alongside Vanguard new care model. B: System Reform d) Improve the way we commission services: develop a system wide quality framework that improves outcomes for local people, and a new Quality Assurance Framework for new care models introducing longer term outcome based contractual arrangements with providers, and creating a single population budget with Hampshire County Council and Surrey County Council for our population e) Develop and agree a plan to extend our collaboration with other CCGs where this offers greater benefits for patients and better value for money. f) Agree Sustainability and Transformation Plans for the Hampshire & Isle of Wight and the Frimley systems by June 2016 and begin implementation. g) Deliver the priority IT deliverables: all GP practices on single system, increase the use and scope of the Hampshire Health Record, expand the use of e-referrals and e-prescribing. Full population budget created. The CCG is receiving accelerate support from the New Care Models team to support payment and pricing reform required for the introduction of an accountable care system. Engaged with the Hampshire and Isle Of White Sustainability and Transformation Plan Quality assurance and framework workshop. As part of our Sustainability and Transformation Plans (STPs), further development of collaborative working is being considered and tested, eg. maternity across Hampshire and Isle of Wight. The CCG has had a key role in shaping both Frimley and Hampshire Isle Of White STPs. Both STPs have identified financial and non-financial gaps and have agreed high level priorities for the next 5 years. Plans will be further developed by next milestone (Sept 16) Digital projects scoped and projects underway. All GP practices to be on same system by the end of Q2 rollout of Hampshire Health Record version 3 underway. h) Deliver the priority estate deliverables: ensuring that Integrated Care Teams have the appropriate premises to fully operate, maximising the use of Aldershot Centre for Health and Farnham community hospital, and assessing the estate impact of the community bed consultation. Development of Integrated care teams at Farnham Hospital. Estate building works to commence June 16. Yateley development also due to commence in the summer. Page 9 of (FINAL) GB - objectives.pdf Page 10 of 17 Overall Page 38 of 160

39 Priority Actions 2016/17 Q1 Progress a) Deliver meaningful citizen engagement in the new care model programme: completing a consultation on the primary care strategy (by Oct 16) & on community bed provision (by Mar 17). The Engagement Strategy is being finalised. The focus of this will be to ask patients, carers and the general public to support us to co-design future services for Primary Care and Community Beds with local patients, carers, and the general public. Supporting this, a draft engagement plan has been developed. C: Engagement & Partnerships b) Embed new ways of working which place collaboration with patients and the community at the heart of how we work: investing in collaborative leadership, developing a sustainable Community Ambassadors Programme, fully introducing the Patient Involvement Assessment Framework and ensuring we have sufficient skills and capacity to support co-production. A Farnham event on the Primary Care Strategy engagement has taken place, with follow up session to finalise the engagement plan for that locality in July. Further locality events are either in place (such as Yateley in July), or being developed with local clinical teams. We are actively working with third sector colleagues to utilise and maximise the opportunities to engage with their existing general public forums to help us to engage and be able to tap into places where people already go. The CCGs communication priorities include the Vanguard Newsletter, Vanguard website, and supporting the development of an easy to read document for the Out of Hospital Care Project and a summarised version of the Annual Report. We have appointed 80 Community Ambassadors. There is a Community Ambassador support role now in place, designed with and supported by Rushmoor Healthy Living. We have designed a new Patient Involvement Assessment Framework which has been designed with patients and the general public. The framework is intended to ensure that the CCG prioritises engagement and puts people first i.e. do nothing about us without us. Page 10 of (FINAL) GB - objectives.pdf Page 11 of 17 Overall Page 39 of 160

40 c) Deliver a thriving programme of member practice engagement. We have reshaped our GP practice forum and developed it into a wider practice education and engagement. The GP Council which engages practices as commissioners was re-launched in April A clinical engagement programme to seek input on the development of the primary care strategy is underway. The CCG's primary care and Vanguard teams are collaborating to shape a future programme of primary care development and service redesign to support localities from September C: Engagement & Partnerships d) Through the children and maternity services collaborative agree and begin implementation of a new model of children s integrated care teams across Hampshire agree a sustainable community paediatric service across the CCG e) Agree a revised model for commissioning mental health and learning disability services for our local population, by Sept 16. We have established a Children s Vanguard programme where we will be designing in partnership with families integrated teams across health and social care. A new Programme lead has commenced which has been joint funded between the CCG and Hampshire County Council. Two geographical areas have been selected (Basingstoke and North East Hampshire) to test out new models of care and to design new integrated teams. Community Paediatric services are currently out to tender. The procurement is led by Guildford & Waverley CCG in partnership with Surrey County Council are developing a fully integrated model. A revised model for commissioning Mental Health and Learning Disabilities across our population is being finalised. New arrangements will commence August 16. The Safe Haven model has been rolled out in 2 schools in Rushmoor. f) Ensure parity of esteem for Mental Health and Learning Disabilities is further developed including support to primary care and integrated care teams. We have developed a well-integrated dementia pathway agreed with primary, secondary, community providers and voluntary sector to allow more care at community and primary care level with good access to secondary care when needed. Work has started to develop an improved service for adult Attention Deficit Hyperactivity Disorder and Autism with discussions with Surrey and Borders Partnership (SABP) and potential GP training in Mental Health. Learning Disability awareness training for Primary care is under development. Page 11 of (FINAL) GB - objectives.pdf Page 12 of 17 Overall Page 40 of 160

41 Priority Actions 2016/17 Q1 Progress a) Deliver the CCG financial plan. b) Proactively manage contracts with providers and ensure that the CCG has the ability to deliver its activity and financial plan, resulting in hospital utilisation levels (admissions, A&E activity and bed days) being maintained at or below 2015/16 outturn levels. On-going. The CCG at the end of Q1 is currently forecasting to meet the financial plans. All material contracts are agreed. All contract management processes have been reviewed and updated (end of Q1). Executive contract management reviews with Frimley Health underway. D: Financial Sustainability c) Deliver the agreed Quality, Innovation, Productivity and Prevention (QIPP) schemes for 2016/17. d) Develop and agree, by September 2016, a balanced financial plan for 2017/18. e) Deliver our CCG Organisational Development programme. Quality, Innovation, Productivity and Prevention (QIPP) schemes for continuing health care and prescribing are high priority. Finance and Performance committee has undertaken a deep dive into both areas in May. End of Q2 deliverable. Leadership cohorts for bands 7 and up and bands 3 6 are currently taking place and will continue over a six month period. A follow up workshop bringing together the cohorts from last year is planned for September/October. An organisational development plan will be produced during quarter 2. Health and Wellbeing programme mindfulness and yoga sessions have taken place and further sessions are planned/lunch and learn sessions in place. Staff Partnership Forum: the forum was established in April providing staff with an opportunity to express their views and ideas. Page 12 of (FINAL) GB - objectives.pdf Page 13 of 17 Overall Page 41 of 160

42 Priority Actions 2016/17 Q1 Progress a) Ensure clinical leadership roles are agreed and that these roles are deployed for maximum benefit in the system. Thirteen clinical leads are now in post & working on a range of CCG priority areas. A support & development programme has been established to ensure maximum delivery against priorities. Objectives have been agreed & work is underway to review priorities. E: CCG People and Organisation b) Deliver our multi-professional workforce development programme. c) Ensure effective internal and external communications. d) Improve our risk management processes and ensure they are driving CCG priorities and activity. e) Ensure key indicators and reporting processes are in place that enable monitoring of performance across all objectives. Designed and delivered the inaugural Practice Nurse programme linked to the CCGs Target Days as part of primary care workforce development. Internal and external newsletter for staff, patient and general public has been refreshed. We are currently reviewing our website and social media for additional opportunities to support people with prevention messages. Risk Register rolled out to all CCG Committees for inclusion as standing agenda items at each meeting. Work continues on the development of team risk registers and the update of the Risk Management Policy. Cover sheets for Committees have been amended to reflect risk issues as part of the consideration on the submission of papers. This will be launched during the June Committee meetings. Reporting of all constitutional and key performance measures via the CCG Integrated performance report to the Finance and Performance Committee and Governing Body. f) Improve the management of conflicts of interest. Declarations of Interest have been expanded during the first quarter to include the Vanguard Steering Group members. The CCG were informed that the Chair of the Audit Committee will be the Conflicts of Interest Guardian and a draft policy has been developed in preparation for launch following the publication of the national guidance in June Page 13 of (FINAL) GB - objectives.pdf Page 14 of 17 Overall Page 42 of 160

43 Priority Actions in relation to Children s & Maternity, and Mental Health & Learning Disability Collaborative Commissioning As described in objective 9 above, our CCG is also responsible for commissioning children s and maternity services on behalf of Hampshire CCGs and mental health and learning disabilities services on behalf of Surrey CCGs. The table below summarises the priority actions in relation to these two Collaborative Commissioning Functions. Priority Actions 2016/17 Q1 Progress Children s and Maternity Collaborative a) Respond to the recommendations of the National Maternity Review Better Births, ensuring all antenatal and postnatal maternity pathways deliver timely access to services, support choice and personalised packages of care; and ensuring appropriate healthy infant feeding practices are applied consistently across the county. b) Design locally based models of integrated paediatric care across the community and acute providers. c) Working in partnership, commission responsive and flexible mental health, learning disability and autism services that are supported by early intervention services and deliver the priorities of the Future in Mind plans. Hampshire, Southampton, Portsmouth and Isle of Wight have been selected as one of six Pioneer sites for the delivery of the Better Births recommendations. North East Hampshire & Farnham CCG will be the lead for the programme. We are working closely with NHS England to implement the infrastructure and identifying the resource requirements. The bid put forward is to create a single point of access to maternity services, with standardised systems and processes that will enable choice and personalisation for women. We have established a Children s Vanguard programme where we will be designing in partnership with families integrated teams across health and social care. A new Programme lead has commenced in post which has been joint funded between the CCG and Hampshire County Council. The initial work programme will look at opportunities of integrated working for professionals who provide services for children with disabilities and complex health needs. We have successfully launched the new Child & Adolescent Mental Health contract with Sussex Partnership. The new contract has been developed to ensure swifter access to assessment and treatment 4 weeks and 8 weeks respectively; a single point of access in partnership with the third sector; improved communications; increased work within schools. Page 14 of (FINAL) GB - objectives.pdf Page 15 of 17 Overall Page 43 of 160

44 Children s and Maternity Collaborative d) Continue to implement the requirements of the Children & Families Act ensuring families have access to a single Education, Health & Care Plans; timely and relevant information promoted through the Local Offer; development of personal budgets and ensure the process is supported by designated medical officers within the Acute Trusts. e) Continue to implement Transitions protocols and implementation of the Preparing for Adulthood strategy. f) Develop a strategy, in partnership with Public Health, to reduce obesity levels in children. All education, health and care plans have been approved. The children s commissioning collaborative have been working to implement a Transition (childhood to adulthood) service specification over the past year. Partnership working with Public Health is being developed to produce an obesity strategy alongside this work at a local level has commenced. Two areas of focus are the Daily Mile and a Better Me programme. Page 15 of (FINAL) GB - objectives.pdf Page 16 of 17 Overall Page 44 of 160

45 Priority Actions 2016/17 Q1 Progress a) Discharge our responsibilities as lead commissioner for the Surrey and North East Hampshire Integrated Commissioning Strategy for Emotional Wellbeing and Adult Mental Health. Following a review of the collaborative arrangements across the 6 Surrey CCGs change has been signalled and preparation is taking place to agree the change, transition and timescales. Mental Health and Learning Disabilities Collaborative b) Deliver the Mental Health Crisis Care concordat plan with the roll out across the collaborative of Crisis Cafes, development of urgent integrated/single point of access and completion of the adult mental health bed review. c) Complete the review of Surrey and Borders Partnership NHS Foundation Trust Learning Disability inpatient and community services and initiate the service redesign that aims to prevent inappropriate admissions by providing intensive support in a crisis. d) Work with our local authority and NHS England partners and providers to develop appropriate robust co-commissioning arrangements around the delegated, Section 117, and specialist areas of mental health and learning disability. e) Develop and implement plans that will deliver against the new access requirements for mental health. f) Source the data to enable commissioners to report against the new framework for people with learning disabilities. The Surrey Crisis Concordat plan has been refreshed and re-submitted to the national website. Crisis cafes have now been rolled out and gone live in each CCG area across the county. The Single Point of Access foundation work is taking place with interface work with 111 and mental health staff recruited to police call centre full crisis Single Point of Access (SPA) go live date 2 April 2017 on track. Review and identification of new service design. A unified pathway including the intensive support service has been agreed and a single Service specification has been completed and approved by the Mental Health and Learning Disability Collaborative to go forward for sign off. Regular interface meetings and reports take place with delegated commissioning and a quarterly meeting is being initiated to include each tier of commissioning. Final draft joint S117 policy has been completed between Health and Social Care in Surrey and is going forward for sign off. Improving Access to Psychological Therapies has gone forward to opening selfreferral route by all CCGs and reprocurement has taken place and mobilisation of an extra provider being negotiated. Early intervention in Psychosis (EIP) increase in funding and recruitment and training by the provider has taken place to be compliant with the access standards for people from 14 to 60 years. Data is sourced and has been routinely reported through the quarter. g) Develop and procure a perinatal service. Perinatal MH Network has been established and has drafted a local pathway and specification for community specialist service. Dashboard on access standard reporting has been developed for CCGs. Page 16 of (FINAL) GB - objectives.pdf Page 17 of 17 Overall Page 45 of 160

46 Governing Body Date of Meeting 29th June 2016 Agenda Item 6 Paper Numbers 6 Strategic Objective Number System reform 4. Through the delivery of the Vanguard Programme and through the development and delivery of the Frimley and Hampshire & Isle of Wight Sustainability and Transformation Plans (STPs), accelerate the pace and scale of delivery of new models of care and transformation. 5. Develop, agree and put in place revised contracting, payment and governance arrangements with partners to support delivery of the system strategy, and the creation of a place-based system of care. Author Michael Attwood Director Sponsor Alison Edgington/Mike Attwood Clinical Sponsor Steven Clarke Title: Executive Summary: Primary Care Strategy Approving the Strategy and Key Messages for the Public The Governing Body is being asked to approve the Primary Care Strategy today. The draft Action Plan which is work in progress is attached here. This means signing it off as a firm direction of travel and offering for formal engagement and further feedback with clinicians, patients/public and our partners, the latter now increasingly through the Strategic Transformation Plan arrangements as well as Vanguard, Health & Wellbeing Boards and Health scrutiny and Overview Panels. We are also setting up patient/public locality engagement networks with dates set for Farnham (the second one) and Yateley so far, with agreement to arrange one for Farnborough. An engagement plan has been mapped out and produced. Much early, informal engagement has happened as reported previously through practice locality meetings, GP Forum and Practice Council, 1:1 and group conversations with Governing Body members and clinical leads, the Area Patient Group, some local Patient Participation Groups, Third Sector umbrella bodies, Community Ambassadors and a range of other partners. The recommended timetable from here is to bring back the final strategy, together with the final action plan together with draft 2017/18 primary care commissioning intentions to Governing Body in September. The primary care commissioning intentions would then be finalised and signed off in the autumn as a full part of the CCG s wider commissioning intentions/delivery plan for 2017/ (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 1 of 48 Overall Page 46 of 160

47 These commissioning intentions will be defined by 10 foundation design principles which will be our essential decision-making criteria that all future primary care development and investment proposals will need to meet see page 25 of the strategy. The key messages for the patients and public the people we serve, are set out below. We will need to work with the communications team to develop them further. General Practice is the foundation of the NHS delivering 90% of contact with the public. List based primary care is at the centre of our vision and in NHS England s 5 year and GP Forward View GPs are working harder than ever we are very grateful for all they do and they need our support to deliver the changes set out in the strategy we want our share of the 2.4 billion from the GP Forward View to get true growth in resources behind general practice and we are working with Salus, our local GO federation to begin to address the very real workforce pressures that face GPs nationally as well as locally The Primary Care Strategy has to be a partnership between clinicians and the CCG, reaching out to patients, the public and our partner organisations to redesign services together as we create a new model of care. As a Vanguard we know that we can t do more of the same - we have to transform general practice in order to stabilise and sustain it for the future. This is for the same reasons as our Vanguard programme in which GPs are at the front-line: - there is a gap in outcomes for our population; 6 years life expectancy gap - people are living longer and demand is rising - local people tell us they believe that health and social care services need to be more integrated, and need to bring together people, communities and the public, private and voluntary sectors - if we don t take action our financial gap will be 73 million by 2020 GPs are already changing what they do. The strategy seeks to capitalise on this and help development to happen at pace and consistently for our whole population The main developments will be: - a population approach practices really understanding their population as a whole so that they can profile need and plan different programmes of care for different needs. We see four programmes: prevention and self-care; long-term conditions and frailty; urgent care; routine care - a really significant shift in primary care service delivery towards more prevention and self-care helping people to adopt healthy lifestyles in the first place and manage their symptoms where they have developed a lifelong condition - continuing to develop integrated care teams serving patients with complex needs, frailty and multiple long term conditions - reducing need for urgent care as prevention, self-care and integrated care teams increase their impact - extending access to routine GP care we are testing whether we can deliver 8-8 Monday to Friday and 9-12 Saturday by April 2018 The practical signs of change will be:- - GP practices working together on a common locality plan for general practice in our five localities of Aldershot, Farnborough, Farnham, Fleet and Yateley. Possible examples include: one locality on the day urgent care hub for same day GP appointments, already about to be trialled in Farnham and Yateley to improve urgent access; one locality plan for practices to achieve 8-8/9-12 routine access. We are just starting work with the localities to develop these plans. 6. (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 2 of 48 Overall Page 47 of 160

48 - GPs working together with the rest of the NHS in stable integrated care teams to support people with more complex needs so that care is well co-ordinated through one overall care plan with a named professional in overall charge of your care - more support for prevention and self-care e.g. our carers hubs and recovery college programmes to help people manage their conditions and keep well - a wider multidisciplinary team in general practice who will sometimes be the first point of contact e.g. physiotherapists for back pain; more counselling for mental health support. The GP will still be leading the clinical team and overseeing the quality of care - one care record, with your permission, so that the range of professionals caring for you can see your whole picture of needs and the care you re getting - better technology people who like technology will be able to have on-line consultations and access to apps to help them self-care A commitment to work with you to shape the model of care in your locality if you would like to be involved in our new local engagement networks. To do this, contact your local practice s Patient Participation Group of become a Community Ambassador A clear timetable, with the strategy finalised and signed off by the Governing Body in September together with an action plan and draft commissioning intentions (our plan for GP investment and priorities from April 2017) Links to Strategic Objectives - Delivery of a Primary Care Strategy that supports Vanguard aspirations, connecting service strategy, model, and the annual contracting round Risks: 1) ensuring capacity for effective clinical and patient/public engagement in a period of rapid change now mitigated by appointment of an Associate Director for Communications and Engagement and a project manager for both the Primary Care Strategy and Community Beds review. 2) supporting general practice through a period of significant change the two main support mechanism being a workforce development package being shaped at present and offering support to help each locality develop its plan Financial/Cost Implications the Strategy includes an updated finance chapter. We are working through the implications of the GP Forward View which will need to be clear in the 2017/18 Commissioning Intentions. The aim remains to invest CCG growth in primary and wider services outside hospital wherever possible. The Sustainability and Transformation Plan collaborative approach will assist a system-wide investment common agreed approach Equality & Quality Impact Assessment to be completed by October Legal concerns/implications formal consultation will be conducted as required e.g. community bed review Patient engagement Locality Engagement Networks are now being actively established. The Governing Body is asked to approve the Primary Care Strategy for formal engagement, noting the commissioning foundation design principles on page 25 of the strategy and approve the timetable set out above. To Approve - An item of business that requires the Governing Body to take a formal decision. 6. (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 3 of 48 Overall Page 48 of 160

49 Other Committee(s) where this paper or supporting information have been considered Previous versions of the strategy have been considered by all Governing Body sub-committees, the Vanguard Engagement Work Stream, GP and Practice Managers Forums Date 16th June (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 4 of 48 Overall Page 49 of 160

50 Stabilising, Shaping and Sustaining Primary Care OUR PLAN FOR GENERAL PRACTICE (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 5 of 48 Overall Page 50 of 160

51 Contents Foreword 3 1 Stabilising General Practice - Why is this strategy so important? 4 2 Context and Direction 5 3 Shaping General Practice - Our Guiding Vision and Principles 6 4 A Snapshot of Local General Practice 8 5 What does the Future Look Like? 9 6 How will the Model of Primary Care Change? 10 7 Sustaining Future General Practice Quality Development - including Prescribing Building a Stong, Dependable and Creative workforce Developing the Primary Care Estate Information and Communication Technology (ICT) Financial Resources and a New Approach to 17 Commissioning Primary Care 7.6 Provider Development 22 8 Engaging for Success 25 9 Next Steps 27 Appendix 1 - Access to primary care 29 Appendix 2 - Working in Collaboration and at scale 32 Appendix 3 - GP list sizes and locality map 34 Appendix 4 - Strong and dependable workforce 35 Appendix 5 - Information and communication technology 38 Appendix 6 - Commissioning and contracting models 40 Appendix 7 - Our approach to engagement (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 6 of 48 Overall Page 51 of 160

52 Foreword 90% of people s contact with the health service is through their General Practitioner (GP). Its role as first port of call and the sheer level of coverage it offers means that it really is the foundation of our National Health Service (NHS). A stable and sustainable NHS therefore relies on stable and sustainable general practice. As a Vanguard site testing out new approaches to care for the NHS in England, we know that we can t carry on as we are because: The population is growing and people are also now living longer and have more complex needs that require more support. we need to make a step change in how we prevent the growing health problems associated with lifestyle factors like drinking, smoking and obesity from arising in the first place we need to help people who already have a complex health problem to self-care better so that they can manage their symptoms and keep well despite their illness people want services across general practice and the wider NHS and social care system to be better integrated, more person-centred, accessible and easier to use GP practice workload is higher than ever before, made more difficult by the fact it is very hard to recruit GPs and other practice staff we are at a new technology tipping point where patients need a single electronic care record to support the whole NHS and social care system to care consistently for them wherever they are in that system. We need to break down information sharing barriers safely and with confidence need is growing faster than the resources we have to meet it and so greater efficiency and value for money will be crucial to how we develop services Much good work is already underway; to develop self-care and preventive services; to build deeper collaboration between GP practices; to support integration between primary care and other NHS and social care services; to extend access and increase opening hours - whilst building the sustainability we will need to succeed in practice in terms of resources, workforce, estate and new technology plans. We welcome the recent publication in April of the General Practice Forward View by NHS England. We need to capture this moment by engaging systematically and thoroughly with patients and the public on how general practice could look in future and giving general practices and their NHS and social care service partners the support they need to interpret, design, adapt and implement our Vanguard model of care to suit the local circumstances in each of our five localities in Aldershot, Farnborough, Farnham, Fleet, and Yateley. This strategy is now ready for approval by the CCG s Governing Body as our agreed future direction. It will continue to benefit enormously from input - both support and challenge - from patients, the wider public, clinicians and our partner organisations over the summer as we now move on to develop the practical action plan to deliver the changes. The next step is to develop an action plan covering the next five years and to produce our year one commissioning intentions for 2017/18 by November Thank you for continuing to work with us to shape the future. Dr Andrew Whitfield Dr Nick Hughes Dr David Brown Dr Steven Clarke Chair Chair Chair Clinical Director CCG Salus Medical Services GP Practice Council CCG June (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 7 of 48 Overall Page 52 of 160

53 1. Stabilising general practice - Why is this strategy so important? This General Practice Primary Care Strategy sets out our vision and, more importantly, our practical plans for stabilising, shaping and sustaining general practice here in North East Hampshire and Farnham. 90% of people s contact with the health service is through their General Practitioner (GP). Its role as first port of call and the sheer level of service coverage it offers means that it really is the foundation of our National Health Service (NHS). People s expectations of the service they wish to access from their GP practice are growing. It has been reported nationally that demand for appointments has significantly increased in recent years; with GPs seeing an estimated 1 million people per day nationally. In a 2014 tracker survey by the BMA 74% of GPs described their workload as not manageable or unsustainable. Locally, 56% of GPs cite their workload difficult or intolerable. 40% of GPs feel that they are suffering personally because of workload. Set against this are public expectations of more on-line access to services, extended opening hours and a new generation of patients who expect to be engaged as an active partner in their treatment and care. A stable and sustainable NHS relies on stable and sustainable general practice. For some patients this service comes in the form of regular, planned support to manage a complex long term condition like diabetes or depression. For others it is the ability to access routine or urgent advice and help when they are feeling unwell. More often now it is about offering a proactive plan of care to a frail older person with multiple health and social care needs. Whatever the reason for accessing primary care, local residents greatly value the care our GP practices provide to them from cradle to grave. With growing need and demand, the growth in the older population and long term conditions such as diabetes, the financial pressure on public services and a workforce crisis, general practice has to transform itself to survive and be sustainable into the future. According to a recent survey by Salus, the local GP Federation, in January 2016, some 85% of local GPs believe that the current model of general practice now has to change in order to be sustainable for the future. Our primary care strategy will talk about stabilising, shaping and sustaining general practice into the future. We can only do this by engaging openly with GPs and their teams, patients and the public and the other partners in health and social care. It means: Short-term work now to stabilise very high workload and workforce pressures; Development work at the same time now to shape and describe the future model of care; and Focused planning of the money, staffing, buildings and technology that will make the changes real and sustain primary care into the future. Keeping the best of the present whilst reshaping for the future needs serious and honest conversations. We all need to be able to trust in and see a solid, better future in order to let go of those things that aren t working now. Although 85% of GPs locally see the need for change, around 15% are less certain. This 15%, together with patients and the public, can be our best critical friends to help us get it right. For many GP practices, working as an independent small business has been a conscious choice and way of working that is deeply held and valued. The cultural difference needed to collaborate more formally in localities is very significant and needs strong, sensitive and sympathetic clinical leadership and facilitation. Change by primary care for primary care is likely to be more successful than being done to (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 8 of 48 Overall Page 53 of 160

54 On 1 st April 2016 we took a step forward in leading the communities we serve by taking on full delegated responsibility from NHS England for primary care commissioning. This means that we now manage all contracts with local GP practices to complement our existing responsibilities for primary care development. This is good news, because we can now join up our commissioning of general practice with wider health and social care services to support our vision for general practice as a full partner in a locally integrated health and social care system. This strategy is an important complimentary feature to our role as delegated commissioners of primary care services. 2. Context and direction The NHS Five Year Forward View (5YFV) for the NHS in England, published by NHS England in October 2014, reinforces our determination to work openly with GPs and local people to design a better future for primary care together. You can read more here: It makes clear that: 1. Population based, list based, general practice is the foundation of the NHS into the future 2. There needs to be a radical upgrade in the approach to prevention 3. People will need to be helped to have far more control over their health and care 4. The NHS must take decisive steps to break down the barriers in how care is provided 5. Urgent care must be better integrated, especially to prevent unnecessary hospital admissions 6. Frail people in nursing homes need better support 7. The future model of care for the NHS cannot be one size fits all, but a small number of tried and tested Vanguard models of care are needed, rather than letting a thousand flowers bloom. The challenge is clear:- Demand for health and social care is rising at an unsustainable rate. We celebrate the fact that people are living longer, however the ageing population creates serious service pressures. We want all people as they age to lead lives are that healthy and fulfilling. Consultation with local people provides a strong mandate to change. People rightly have high expectations of health and care services, and the way we deliver care doesn t always consistently meet those expectations. In particular people tell us that they believe services need to be more joined up, and need to bring together people and communities with public, private and voluntary sector services. Lifestyle factors including smoking, poor diet, lack of exercise and excessive drinking remain the most significant risk factors for chronic ill health in our area and contribute to reduced life expectancy and reduced quality of life. Cancer, circulatory disease and respiratory disease account for 70% of deaths in North East Hampshire and Farnham. You can find out more about our population trends in our public health Joint Strategic Needs Assessment here - The cost of delivering services in the current model is rising more quickly than the available resources. Our estimate is that the gap between available funding and projected spending requirements for the whole system will reach 73m per year, by 2019/20, unless we act. The challenge nationally and locally is to improve GP funding which has reduced from 11% to 8% of the NHS budget. We hope that NHS England s General Practice Forward View, published in April will help us to improve this 5 6. (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 9 of 48 Overall Page 54 of 160

55 The General Practice Forward View confirms that nationally general practice is vulnerable and must be safeguarded. It sets out plans that should begin to help it to stabilise and reform. This is not indication of a return to past practice it recognises that significant change has to occur. You can read more about the General Practice Forward View here: 3. Shaping general practice our guiding vision and principles The Primary Care Strategy has to connect the CCG s vision for commissioning with the vision of the Vanguard, which is the vehicle for all health and social care system of providers and commissioners working together to create a new model of care. It unites under the banner of Healthy Happy at Home and is set out in the picture below. It means that we have to improve health as well as health services by expanding support for prevention and helping patients to self-care more. The population approach means that practices will be helped to plan ahead for their whole population. Overall services need to be delivered closer to home in the community as much as possible to free up the hospital to use its expertise for the people who are most ill or need their specialist expertise This Primary Care Strategy aims to help by creating a narrative that: Spells out the vision and role of primary care in delivering the Vanguard Model of Care Describes how we will help primary care clinicians to work with local people and their partner service providers in practice to interpret, adapt and implement the model of care flexibly to suit each locality s local circumstances For a locality map and practice population sizes see Appendix 3. Sets out practical plans at a North East Hampshire and Farnham-wide level to address the enablers of primary care, particularly workforce, money, buildings and new technology 6 6. (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 10 of 48 Overall Page 55 of 160

56 It is important for us to set out clear commissioning principles that make the CCG and Vanguard vision for primary care a reality, as shown in the picture below: We are using the analogy of a house to represent the health and care system in North East Hampshire and Farnham, where primary care is the sustainable foundation that underpins the overall NHS model of care. It does this in the new world in two new ways: By general practices working together at scale either in localities, CCG wide and across the wider Frimley or Hampshire patch By forming an Integrated Care Team in each of those localities where community, mental health and the wider range of community based services wrap around general practice to serve a common population. The walls that sustain the house are the two aspects of the population approach, segmenting different needs and planning ahead, and At Home, where the combination of locality Integrated Care Teams and building named locality clinical consultant links with acute hospital teams both join up and intensify the service offer outside hospital. The rooms of the house show the changing shape of primary care provision to deliver preventive health and wellbeing at a new scale on new equal terms with health and care services. This is delivered through a shift in the availability of prevention and self-care programmes. The roof of the house encapsulates the principles that hold the collaborative primary care new system together. These are explained in the diagram below which shows how the twin drivers of the population approach and At Home are supported by the wider commissioning 7 6. (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 11 of 48 Overall Page 56 of 160

57 principles. We will use these principles to guide the ongoing development of this strategy. 4. A snapshot of general practice locally Our 23 GP practices are spread across approximately a 15 mile area and care for diverse populations. Our towns of Aldershot, Farnborough, Farnham, Fleet and Yateley present different patterns of need for the clinicians providing care to local people. The cross-county boundaries of Hampshire and Surrey also continue to pose challenges to the delivery of consistent models of integration of social care with health services. The average number of patients registered in each one of the 23 GP practices size is 9,755 but this ranges from the smallest at 3,276 in Aldershot to the biggest at 22,299 in Yateley. Our GP practices are spread across 5 geographical localities and are increasingly choosing to work more closely together. For a locality map and practice population sizes see Appendix 3. In many of the localities a natural hub has developed from which to deliver centralised and collaboratively provided services. In Farnborough, however, this is currently missing owing to the limited available estate in the locality. Locality plans for Farnham and Yateley are further advanced at this stage with plans for shared acute GP hubs and a range of other collaborative work. Our GP practices have solid reputations for the quality of the services they deliver to patients. They are generally highly regarded by the people living in North East Hampshire and Farnham. The recent national GP patient survey results for 2015 show that people are more satisfied with the service provided by their GP practice than the national average. 88% rate their GP as good, compared to 85% nationally. See for fuller details (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 12 of 48 Overall Page 57 of 160

58 Salus, the local GP Federation, conducted an opinion survey amongst local GPs in January Some 85% of GPs agree that change is needed with 15% being less sure. Staffing is very fragile with just over 60% of GPs are planning to retire or go part-time in the next 5 years. There were some GP vacancies in May 2016, around 15% and locum fees are very high. The retirement profile for practice nurses is even more marked 71% within 5 years. The vast majority of GPs feel that their workload and stress levels are far too high, with them not being able to spend the time that they think is needed with their more complex patients. There is a strong desire for a more multidisciplinary workforce model, for collaboration between practices on issues such as appointment systems and recognition that many GP premises are not now sustainable into the future. We know that GP workload is continually rising, although we are not yet able to routinely quantify this in the way that we can for example with our acute hospital contracts. We rely on national trend data which we cannot link to local contract negotiations. The Information Technology section of the strategy proposes rolling out the Alamac system locally so that we can more easily demonstrate the true scale of workload increase as we grow our investment. Alamac is an information technology tool that can help practices to track workload and pressure in real time. GPs are also telling us that the amount of work moving into primary care from hospital is growing without resource to undertake it, for example monitoring of drugs initiated in hospital. The routine pressures of working with primary/secondary care interface issues are a major source of concern alongside a range of other transactional issues that are seen as time consuming e.g. housing letters. Despite this, around one third of GPs either only tend to agree that change is needed or, indeed, disagree that change is needed, with around 80% tending to agree or agreeing that GPs must maintain independent contractor status. Only just under half would be willing to consider practice mergers and 80% believe that the partnership model is still the right model, although this seems to be gradually changing as more newly qualified GPs choose to be salaried or work part-time. 5. What does the future look like? We are clear that the foundation of NHS care in our area must be founded on list based GP services. We are using the following description of primary care. The aim of primary care is to provide an easily accessible route to care, whatever the patient s problem. Primary health care is based on caring for people rather than specific diseases. An important role is acting as the patient s advocate and co-ordinating the care of the many people who have multiple health problems. Since primary care practitioners often care for people over extended periods of time, the relationship between patient and doctor is particularly important. Primary health care involves providing treatment for common illnesses, the management of long term illnesses such as diabetes and heart disease and the prevention of future ill-health through advice, immunisation and screening programmes. (University of Bristol Centre for Academic Primary Care) Broadly the services provided for patients can be categorised into four programmes of care. The diagram below shows the programmes and what they cover (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 13 of 48 Overall Page 58 of 160

59 Prevention and self-care Educating and supporting patients: - to keep well in the first place, supporting them to maintain healthy lifestyles..and Routine treatment for common illness Providing a comprehensive range of services to patients addressing known health needs and delivering support services - to manage their symptoms if they do already have a health problem Management of long term conditions Giving intensive support to elderly patients and to patients of all ages who have an increasing number of complex long term conditions Urgent treatment for common illness Providing time critical access to services where the patient requires immediate care It is these four programmes of care that need to drive how primary care is reshaped to meet the needs of different groups of patients with differing needs, moving away from what has been a reasonably standard approach to appointments of ten minutes or so at the local surgery. General practice will need to enhance its support for prevention and self-care. We also believe that planning care further ahead for in a year of care approach for patients with more complex needs will reduce the need for urgent appointments. Key to this is will be how our five localities decide which services to provide at individual practice level and which through a collaborative, shared hub approach. Practices are already working on many of these issues already, but this strategy needs to promote consistency across our whole population and deliver the new model of care comprehensively. 6. How will the model of primary care change? We believe that delivering these four programmes of care has a number of specific implications for primary care. These are:- Primary care will need to establish a new population approach based on a deep understanding of each locality s public health Joint Strategic Needs Assessment, but taking it a stage further to use it to profile, segment and plan care ahead for the four different need groups. This means that primary care needs to be routinely using risk stratification, linking it to the predicted activity and workforce capacity required. A really significant shift in primary care service delivery towards more primary prevention and self-care helping people to adopt healthy lifestyles in the first place and manage their symptoms where they have developed a lifelong condition. Alongside their own direct role in prevention, for example through immunisation and screening, we are creating a range of preventive services for GPs to access for their patients, such as healthy living pharmacies and social prescribing. There are also big opportunities to build links with the voluntary sector and to take a community asset-based approach to unlock the care and support often on offer from faith and other community groups. We also need to take a systematic and strategic approach to public education to support them in going to the right place for help e.g. using pharmacies much more for minor ailments (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 14 of 48 Overall Page 59 of 160

60 A new model of access to primary medical care services is required. o The model of appointments of ten minutes or so in general practice does not easily support these programmes of care. It needs to be redesigned and a new way of working, based on planning ahead and delivering services for known population needs to be implemented. This has been changing for some time as practices introduce triage systems, nurse-led clinics, double appointments, longterm condition reviews for more complex needs. We believe that in the future extended appointments will become routine for the neediest of our population. o o o One shared plan for extended opening hours giving access to routine primary care appointments as a minimum between 8am - 8pm Monday to Friday and 9-12 on a Saturday. As a Vanguard, extended opening hours in 2017/2018 must be core aspect of our operating plans and commissioning intentions. We need rapidly to assess how the resources to implement this will work following publication of the GP Forward View. Additional workforce and resources are needed here. One plan in each locality for delivering acute on the day GP access, supported by a plan across the Frimley System to integrate the approach with 111, out of hours GP, district nursing and social care services rather than each individual practice attempting to meet same day/urgent need. Other pathways need to be formally introduced at the point of triage in the surgery e.g. to pharmacies and social prescribing as these are often more appropriate for self-care as well as taking pressure off practices. For a more detailed look at urgent and planned access development see Appendix 1 o Currently there is no method of collating demand data. GP practices clearly understand demand trends, but they cannot easily quantify this. This makes it difficult make the local case for investment in GP practices and operationally to alert other providers to pressure in primary care. We will work with GP practices during 2016 to implement a tool to map existing demand, measure capacity and utilise a trigger system for times of pressure. This is likely to be the Alamac system. It also needs to help quantify financial investment needed based on workload as we are able to do with other providers GP practices will need to work collaboratively and at scale. o Collaboration between GP practices to work at scale is essential for sustainability. Localities need to define this for themselves based on how services should look to best suit their communities. Services still need to meet the principles set out in the Vanguard model of care, but with local freedom about how best to do this. This will need to include deciding which services practices will deliver together and which services need the relationship-based continuity of care from someone s own GP o GP practices will need to forge sustainable alliances with community, mental health, social care and other closer to home service teams, delivered through active and consistent participation in an integrated care team (ICT) in each locality, to support frail older people and those with multiple long term conditions, keep them out of hospital wherever possible and get them home as soon as possible (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 15 of 48 Overall Page 60 of 160

61 o Building alignment of acute hospital teams to localities with named linked consultants for key specialties such as geriatrics, paediatrics and diabetology is needed. This should enable GPs to access referral and admission clinical advice much more easily, agree local pathways in and out of hospital and strengthen training and clinical education on secondary care in primary care. For a more detailed look at collaboration between GP practices see Appendix 2 This shift in the model of care points to important changes needed in the so called enablers, such as buildings and IT. The key changes are:- Shaping a comprehensive approach to quality in primary care that draws together the three dimensions of safety, clinical outcomes and patient outcomes rethinking the pattern of premises to create a hub and spoke model in each locality and being transparent about the barriers to be overcome, given the mix of building ownership and lease arrangements in general practice and the need to share financial risk and broker joint solutions that support a localitywide pattern of service finding creative workforce solutions - extending primary care teams to share power with other clinicians working autonomously e.g. practice pharmacists, physiotherapists and counsellors. It also means new staff roles; physician assistants; care navigators and co-ordinators as well as health coaches helping patients own their health conditions and manage symptoms better. maximising the power of new technology in order to: o o o share patient records safely to make shared care and collaboration across practices in the interests of population-based care the new standard enable easily accessible clinical advice from and shared care with hospital based secondary care find new virtual methods of consulting with patients work with applications that will support patients to keep healthy and self-manage. This means that primary care will continue to grow and extend around the individual general practices. Important and respected though they are, we believe that services will only be sustainable into the future if practices can now commit to working more closely with each other to plan a mutually agreed pattern of service - usually in each of our five localities of Aldershot, Farnborough, Farnham, Fleet and Yateley - and sometimes across a wider area within the CCG or beyond. This has started, but we know that we need to do this more consistently. The geographical footprint of our Frimley System Sustainability and Transformation Plan area gives us a natural way of building the wider partnerships beyond the CCG s own geography where that is needed for more durable services such as GP Out of Hours provision (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 16 of 48 Overall Page 61 of 160

62 This shift for general practice towards programming, co-ordinating and delivering care for their population is significant and is shown in the graphic above. Increasing the scale of two of these programmes of care prevention/self-care and care for long term conditions and frailty - should reduce the need for urgent care. Patients will be offered continuity of care by a named GP where needed, with rapid access and turnaround for people with routine needs. GPs will have a wider range of preventive services to refer to and the support of the locality based Integrated Care Team to support people with more complex needs. As GPs work more closely together in the five localities, they will be supported by a locality population profile to assist them plan care ahead. They will collaborate on a locality plan in common for estates and extended opening hours. Across the CCG as a whole, access to a single shared electronic heath record will be rolled out, a single workforce plan will be developed, and in due course, supported by the Vanguard Programme, a capitation based commissioning financial model will be created. Many Practices already recognise that they need to go beyond how they work with each other currently to shape and implement consistent and extended primary care teamwork with the full range of other health and social services to support people who have more complex needs - at home or in the community wherever possible. For other practices though there is concern and reticence to embrace this new way of working. Supporting practices to develop the capacity to develop and own meaningful locality plans for themselves that are based on a good understanding of the local profile of population needs will be essential (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 17 of 48 Overall Page 62 of 160

63 7. Sustaining future general practice How can general practice be supported to change their model of service delivery? In the following 6 ways: Quality Development including Prescribing Building a strong, dependable and creative workforce Developing the primary care estate Information and Communication Technology Financial resources and a new approach to commissioning primary care Provider Development 7.1 Quality Development including prescribing We have been reviewing our approach to quality development in primary care following the delegation of primary care commissioning from NHS England in April Generally our patients access high quality primary care services with satisfaction ratings of good or above at 88% compared to 85% in the 2015 national GP survey. There are a number of improvement areas that we would like to pursue e.g. early cancer diagnosis, increased diagnosis rates of long term conditions such as diabetes and continuing to open up access to primary care through extended hours and encouraging the development of extended multidisciplinary primary care teams. Measurement of quality in primary care needs further development locally and nationally. The main mechanism is the Quality and Outcomes Framework which is a reward and incentive programme introduced nationally in The budget for the CCG is just under 2 million and practices on average achieved 96.8% of the 559 points available in the programme. Care Quality Commission visits are another key indicator. Up to December 2015, 12 of practices had been inspected, of which 6 were classed as good, with 4 requiring improvement in one area, 4 requiring improvement in two areas and one deemed inadequate in one area. The Friends and Family test, which is a real time national feedback tool, indicated in February 2016 that 82% of patients would recommend their practice compared to 88% nationally. The would not recommend figure was 6% compared to 7% nationally. Numbers using this test are quite small 856 patients and we need to develop this further. In terms of prescribing, the prescribing of medicines is the most common intervention in the healthcare system and in an era of significant economic, demographic and technological challenges, it is imperative that patients get the best quality outcomes from medicines. Medicines optimisation is a fundamental change in approach to medicines use that centres on the individual patient and their experiences. Medicines optimisation is a national priority cited in key policy documents such as the NHS Five Year Forward View and the NHS Outcomes Framework. Our aim is to optimise the use of medicines across the local community to ensure that people receive the right choice of medicine at the right time to: improve their outcomes avoid taking unnecessary medicines (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 18 of 48 Overall Page 63 of 160

64 improve medicines safety reduce the wastage of medicines Our key medicines management priorities are: - respiratory - Improving the use of inhaled medicines in chronic obstructive pulmonary disease and asthma to reduce the number of hospital admissions and re-admissions - diabetes focusing on the use of medicines in type 2 diabetes - antimicrobial stewardship - reducing inappropriate antimicrobial prescribing. We aim to enhance patient safety by reducing the risk of antimicrobial resistance and healthcare infections such as clostridium difficile. - cardiovascular care -Improving anticoagulation therapy in patients with atrial fibrillation at risk of stroke. Our overall strategic approach to quality is based on three dimensions clinical safety; clinical outcomes and patient outcomes. As a commissioner our key role is to work with general practices to agree quality priorities, monitor the results and outcomes of these though our contracts and ensure that the required improvements are implemented. In the past, we have had more of a role in quality development, helping practices to build their systems, to provide education and to develop their own capacity to learn and improve services. We are now in a period of transition where we have a role in the shorter term to support primary care to develop its own embedded capacity for quality improvement. The role of the GP Federations such as Salus and Farnham Working Together is crucial here as they will need to grow to be the agents of sustainable development and improvement long term. Some of the key prerequisites of a strong approach to quality in primary care are:- - a safety culture for example safeguarding of children & vulnerable adults and sound infection control systems - a commitment to openness systematic reporting of and learning from incidents, errors and near misses - effective prescribing - patient engagement being at the heart of primary care and building patient aspirations into measures of quality - understanding variation - building capacity for research and clinical audit We will work with localities over the next 21 months to ensure that, by April 2018, primary care has the capacity to define, collect, monitor and review the main dimensions of quality through our regular programme of Practice Support Visits. Over this period our main priorities as a commissioner are: to assume responsibility for the NHS England Quality Workstream as a delegated commissioner of primary care to ensure that practices action plans following Care Quality Commission inspections are robust and effective to maximise practices use of the NHS England Primary Care Intelligence Tool to extend our programme of Practice Support Visits to encompass quality to encourage practices to report all incidents onto the National Reporting and Learning system to encourage practices routinely to use the system for Clinical Concerns Reporting to build our intelligence about the quality issues facing other NHS providers (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 19 of 48 Overall Page 64 of 160

65 to embed the use of the Family and Friends Test alongside other means of engaging patients, especially practices Patient Participation Groups and our Vanguard Community Ambassadors to roll out a comprehensive approach to medicines management 7.2 Building a strong, dependable and creative workforce The pressures across the primary care workforce have already been described, with recruitment, retirement, expensive locum fees and flexible working trends all pointing to a need for a radical rethink in the approach needed for future sustainability. Time for training, updating and personal development is also at a premium and stress levels are high. The existing primary care team needs to be upskilled and fully utilised, creating an optimum primary care team. By providing the opportunity to ensure all health care assistants and nurses are trained to their full potential GP time will be released to concentrate on chronic and complex care. Building the extended care primary team by making better use of existing wider clinical roles such as pharmacists, physiotherapists and counsellors is vital. In addition exploring new clinical roles such as physician assistants and exploring new non-clinical roles such as patient coaches and the voluntary sector both have an important part to play. Once these new teams are in place, building a longer term recruitment, retention training and development strategy will be vital to ensure job satisfaction, career progression and maintenance of a resilient workforce. As we move towards a new workforce model, this is likely to require pump-priming and double-running financial support to support practices in a transitional period. A primary care workforce stabilisation package is currently being developed by the CCG with Salus to support practices. This will provide the opportunity to test new models of workforce and prove their benefits. More details on workforce development can be found in Appendix Developing the Primary Care Estate We understand that community estate is a vital component in the successful change of a model of care. The CCG has developed an outline Local Estates Strategy to identify the estate opportunities within each locality. It is built on the principle that the estates model should support the Vanguard model of care in essence a hub and spoke approach that enables the right collaborative activities to be delivered once by practices working together with each other and with wider community providers, as well as services that need to be more personalised and delivered by each GP practice individually. Locality-based Hub services beginning to develop already include, acute on the day GP appointments, a setting for locality-wide services such as the locality Integrated Care Team, shared GP home visiting services and a joint team supporting frail older people. Aldershot Centre for Health and Farnham Hospital are natural hubs, with options to develop Fleet Community Hospital also likely to be viable. Yateley is developing a hub, but it will be important that the pattern of services is agreed by all three practices in the locality as soon as possible now that two of the three have agreed to formally merge.it is likely that a new locality hub will need to be created in Farnborough to provide the primary care estate (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 20 of 48 Overall Page 65 of 160

66 required to deliver high quality and sustainable services and to enable further integration in the community. Decisions about individual primary care premises will not be made in isolation but will be considered alongside the wider requirements for estate within the locality based on achieving the new model of care. Maximum use will be made of the various funds available including a bid to the national Estates and Technology Transformation Fund by June The current estimate is that 2million capital spend is required alongside an ongoing increase in revenue running costs of just under 1million. The revised and updated estates strategy will be published in September Information and Communication Technology (ICT) The CCG already has a published primary care information technology strategy and is a full player in the delivery of the Surrey and Hampshire Digital Strategies. More details can be found in Appendix 5 General practice needs to maximise the power of new technology in order to: Share patient records safely to make shared care and collaboration across practices in the interests of population-based care the new standard Enable easily accessible clinical advice from and shared care with hospital based secondary care Find new web-based virtual methods of offering primary care consultations to patients e.g. WebGP Work with digital applications that will support patients to keep healthy and selfmanage Understand GP capacity and activity in real time 7.5 Financial resources and a new approach to commissioning primary care The overall approach we wish to take financially is to grow our investment in general practice to support the transformation of primary care. We recognise and support this locally and it is the national direction as set out in the GP Forward View. We believe that it can be done if we can work together to achieve this strategy. It will be sustainable to increase the general practice share of the local NHS Budget if we can agree the approach to transformation. Financial growth and transformation do need to happen together to make sure that services are viable for the longer term. The combination of our Vanguard work, the Frimley System Sustainability and Transformation Plan and the money attached to the GP Forward View, all taken together, now make this more possible as we can work clearly with general practice to agree the new model of care. Clearly the sooner we can do this the more quickly we can manage the transition as we know that the service and the workforce are under very great pressure. In practical terms, we are therefore working hard to get to a position where the Vanguard (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 21 of 48 Overall Page 66 of 160

67 new model of care enables us to stabilise our acute care spend in hospital at or slightly below the current 2016/17 level, so that we can invest the CCG s future financial growth from 2017/18 onwards in general practices and other closer to home services. We will set out this transformation for growth plan and how this will work financially in our primary care Commissioning Intentions by November The following paragraphs set out the wider assumptions that can make this possible. Working with our individual GP practices as commissioners to balance best use of precious hospital resources will be as critical as GP transformation as providers. If we can do both, then there is no reason why we cannot rebalance the share of investment between acute and primary/community programmes in a way that grows general practice without destabilising our hospitals. The provision of publically funded health and social care to local people are currently divided between four commissioning bodies: North-East Hampshire and Farnham CCG; NHS England; Hampshire County Council and Surrey County Council. The total health and social care commissioning budget for the North-East Hampshire and Farnham population is an estimated 410 million. The CCG s own budget is around 230 million, which includes around 36 million of primary care budgets, including the pure GP element of 5 million and prescribing at around 31million. The split of funds is set out in the table below. 2016/17 Full Year Budget 000 Enhanced 1,764 Services Out of Hours 1,870 Prescribing 31,230 GP 569 Information Technology Other 615 Total 36,048 The delegated budget for primary care contracts from NHS England is 26.5 million. This is shown in more detail in the table below. 2016/17 Full Year Budget (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 22 of 48 Overall Page 67 of 160

68 General Practice General Medical Services 14,128 General Practice Personal Medical Services 5,754 Enhanced Services (Local Service Contracts) 1,755 Quality and Outcomes Framework 1,459 Premises (including NHS Property Services) 3,001 Other 404 Total 26,501 It is important to understand the main building blocks in our commissioning budgets because the Vanguard approach to funding is to move to a single, population-based, capitated budget and to commission services using a so-called accountable care approach. This means that we will move away from multiple contracts with many providers to the provider system working together as one joint venture, working to one outcome based contracting vehicle. This will increasingly include our budgets for commissioning GP services. Any accountable care system is based on trust and will need to be clear and transparent about the individual financial building blocks that comprise the total system budget and we would continue to work with practices and our Local Medical Committees transparently as we do now. During 2015/16 the Vanguard developed a whole system activity and financial model to demonstrate what the financial impact of introducing the new model of health and social care would be, looking at this from three perspectives the taxpayer, the CCG s budget as commissioner and the providers of services. It sets out the impact on both the quantum of care to be provided as well as the cost. It covers four scenarios do nothing, best case, worse case and likely case. It includes the impact of future population growth, housing development, changes in admission rates and hospital lengths of stay under the new model of care and a number of other anticipated trends. The financial gap for the system as a whole if we do nothing has reduced from 90 million to 73 million by 1919/20. Around 86% of this gap or around 63 million is the responsibility of the providers such as Frimley Health, Southern Health and Virgin to handle. The total cost base of our providers plus the County Councils social care element for our population is around 410 million on which they would need to make efficiency savings of around 3.8% from the year 2017/18 onwards. This assumes that; growth for all continues to rise by around 3% per year over and above population change based on historical trends; that the NHS predicted inflation funding modelled by NHS England continues and that the population needs reflected by new housing are funded nationally. The costs of primary care rise by 24% in this do nothing scenario, although this modelling was conducted before the publication of the national GP Forward View in April 2016 and the impact on the model will need to be updated by September 2016 to reflect its welcome growth proposals by general practice. Nationally, NHSE has plans to increase investment by 2.4 billion per year in general practice by 20/21 with a 500 million turnaround package to support stabilisation. We (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 23 of 48 Overall Page 68 of 160

69 understand that this money has to be bid for rather than being allocated on a population basis. Our weighted population in 2015/16 represented 0.37% of the total for CCGs in England which would equate to 1.85 million of this 500 million if were to bid successfully for an amount based on population. The CCG will review the local impact of these plans on the overall financial model by September 2016, publishing its primary care commissioning intentions, (annual investment/contracting plans for general practice) in November This primary care strategy explains the wider financial context because primary care development is essential to delivering the new model of care which must strengthen services in the community and lead to:- - reducing urgent and unplanned appointments in primary care - reducing emergency hospital attendances, admissions and length of stay - reducing referrals by primary care to secondary care - reducing admissions to care homes This is challenging and stabilising acute activity at current levels would be a solid achievement. Again investment with transformation together is what is needed to go further. The Vanguard Value Proposition for 2016/17 sets the other scenarios out in more detail. Overall, whilst the CCG as commissioner would expect to save the full tariff cost of the activity avoided above, we know that providers are unlikely to be able to release an equivalent cost due to their cost base including fixed and stepped costs. In reality any freedup capacity and resources will be needed to meet new demand caused by demographic change. This means that we do not expect a reduction in either the size or costs of our provider sector, but we do expect our new models of care to help the system avoid additional future costs. The finance and activity model as set out in the Vanguard 2016/17 Value Proposition document also assumes that new recurrent investment will be made to build new model of care as follows: - prevention services 430,000 per year - integrated care teams in our five localities 2.6 million per year - enhanced recovery at home 450,000 per annum - GP in A&E and consultants in primary care 300,000 per annum If we invest as above without reducing the other areas as planned, the gap rises to just under 78 million by 2019/20. The scenarios in the finance and activity model assume that through the new investment in the model of care, we can improve our benchmarked position on key dimensions of care such as emergency admissions and length of stay compared to other parts of the NHS as well as implementing aspects of best international practice in other publicly funded health services such as Valencia in Spain. If the new model of care reduces activity by 15-20%, then the financial gap reduces to between 50 million and 57 million. The remaining financial gap would need to be reduced further in two ways: 1) a more manageable annual 2% efficiency saving by providers which (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 24 of 48 Overall Page 69 of 160

70 would not however apply to general practice (2% equals 28 million total) and 2) further collaboration between the CCG as commissioner and the providers to close the so called taxpayer gap of 18 million. The advantage of being a Vanguard area is that we have short-term national funding to establish or pump-prime the new services in advance and double-run them. This means that the new services to support people closer to home rather than in hospital are starting to deliver the new activity to deliver the new model of care now. We hope to be able to enhance this up-front Vanguard investment to achieve the transformation of services further as our Strategic Transformation Plan (STP) for the wider Frimley System covering east Berkshire, North East Hampshire and Farnham and Surrey Heath is approved by NHS England. The Vanguard and STP non-recurring investment together could represent a nonrecurring boost of around 6 million to bridge the change and get the new services up and running early. The Vanguard is also working towards a new commissioning approach, known as an Accountable Care organisation which would adopt one single commissioning approach to delivering health and social care services for the people of North East Hampshire and Farnham though one population capitation based, outcome-based contract mechanism where our providers move to deliver services working together in one overall collaborative arrangement, rather than through separate contracts as now. What does this mean for primary care commissioning? The primary care services being commissioned from our GP practices are being commissioned within this wider context, now by the CCG under full delegation from NHS England from April General practice funding currently stands at about 8% of the total NHS budget, having slipped from around 11% in The General Practice Forward View published by NHS England in April 2016 aims to address this between now and Locally, as set out above we want to increase our investment in general practice as it transforms. If we can work with our 23 practices to stabilise acute spend at or below 2016/17 levels then it becomes possible to invest future CCG growth money form 2017/18 in primary and community services. The total budgets that we have to commission primary care consist of two complementary pots as already described: - the CCG s own primary care development budgets-around 31million, including prescribing at 30 million of this total - the delegated budgets for GP contracts for our 23 practices million The way that primary care is traditionally funded through many discrete elements does not create sustainable providers. The disadvantages of this commissioning approach are: the commissioning split between a practice s own GP contract and the other specific pots of money such as Local Service Contracts and the Quality and Outcomes Framework create an artificial distinction between normal expectations of a GP practice versus above the normal expectations instead of unifying all commissioning budgets to create one overall stable and resilient primary care service (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 25 of 48 Overall Page 70 of 160

71 the annual commissioning cycle does not support GP practices to forward plan and invest; it requires significant management resource from the GP practice to submit claims for payment; It requires significant management resource from the commissioner to monitor claims for payment; it can result in the withdrawal of services by practices upon removal of funding; and it does not allow for services to adapt and change quickly as patient needs alter. Recognising these disadvantages of the current commissioning approach, the CCG will work with our 23 practices and the Local Medical Committees to move to commissioning on a population or outcomes basis wherever possible. Individual pots of funding will be joined together to create this approach. Services over and above the NHS England funded GMS and PMS contracts will be increasingly commissioned at locality or CCG level. Where possible, services will be commissioned over a longer period of time than the traditional one year planning cycle. We need to work together on the pace of this approach. As we assume full delegated responsibility, we will each year shift the proportion of primary care spend away from individual budget streams into a single, integrated primary care capitated, population-based budget that can take its place within the overall Vanguard capitated budget that is also being developed. This will start from 2017/18. We have already taken two small but clear steps by allocating Personal Medical Service (PMS) contract premium resources to all 23 GP practices on a weighted population basis in return for agreed services outcomes. PMS premium reinvestment investment also sets the principle that practices have to make certain services available for their population, but that these can be delivered through another practice or on a locality, shared basis. This promotes consistency of services across the area. Three key factors are therefore driving the commissioning of primary care in future: - stabilising acute activity and append to free up CCG future growth to invest in primary and community care - implementing NHS England policy to equalise funding per head of weighted registered population across the two types of GP contract (General Medical services and Personal Medical Services) by 31 st March increasingly unifying the CCG s own primary care development allocation and commissioning services on a locality-wide base rather than through individual practices. This impact of this approach is twofold: 1) All practices will be funded equitably for their main practice contract by the end of 2020/21. We will also consider with our practices a move to the new national voluntary GP contract in 2018 once the six national pilots that start in 2016 are evaluated. We will invest nationally agreed growth under the GP Forward View in the GP contract as required. All (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 26 of 48 Overall Page 71 of 160

72 further growth beyond this will be invested though the mechanism in 2) below. 2) A gradual joining up of the funding over and above the GP contract. We will continue to combine resources currently spent on Local Service Contracts, Designated Enhanced Services and the Quality and Outcomes Framework over the period 2017/ /21 and use them to commission against five locality plans that see GP practices working together at scale and collaborating with community and mental health providers to deliver a local version of the Vanguard model of care that suits local circumstances. 7.6 Provider Development The challenge is for general practice is to operate at scale, through practices collaborating with each other in localities and integrating services to create extended primary care viable teams with community, mental health and other closer to home services. This is a very significant shift for practices, many of whom have actively chosen the partnership model of small business with a contract for services to the NHS. Localities are a good place to have the debate between practices who already work together, but we need to flexible about the different approaches to collaboration and alternative models of employing the new, extended primary care team to enable general practice to identify solutions for itself with our support. General practice is unusual in that so-called provider development has tended to be delivered by the various primary care commissioning organisations that have existed since 1999 onwards; Primary Care Groups, Primary Care Trusts and now Clinical Commissioning Groups. This was also the case even earlier with GP Fundholding in the late 1980s and into the 1990s. Larger NHS organisations provide their own development in the main. The responsibilities for delivering the changes required to build sustainable general practice and build the Vanguard model of care need to be set out clearly. At the centre of this sits the need for each locality to develop a Locality Plan. This will developed in two stages:- - stage 1 - covering 2016/17 initial actions and developments towards the model of care - stage 2 - covering a three year sustainable plan 2017/18-19/20 This is set out in the graphic below (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 27 of 48 Overall Page 72 of 160

73 For Stage 1, the CCG as commissioner will set out a framework for what we believe a good one year Locality Plan delivering the new model of care should look like. This will cover three aspects: - core objectives to be delivered e.g. reduction in admissions and referrals - the service design building blocks for dialogue and consideration e.g. effective development of the locality Integrated Care Team - the development support available to each locality and how the Vanguard and CCG Primary Care Teams will work with the GP Federation (Salus) and the Farnham Working Together GP collaborative to help with the drawing up of the plan by the end of July 2016 The Stage 2 plan would be delivered by December 2016 as a three year locality development plan to respond to the CCG s commissioning intentions. A draft example of suggested objectives is shown below. This includes a viability health check to make sure that each locality understands the main vulnerability and sustainability issues faced by their fellow practices (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 28 of 48 Overall Page 73 of 160

74 The CCG Primary Care and the Vanguard teams will offer support and facilitation to the five GP locality meetings as needed during 2016/17. The Farnham and Yateley Plan are well developed. The Farnborough plan is beginning to take shape, Aldershot have a set of initial priorities that need support to work up with discussions just starting in Fleet. From 2017/18 we believe that general practice needs to be able to undertake its own (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 29 of 48 Overall Page 74 of 160

75 provider development. The CCG will continue to work with Salus and Farnham Working Together to agree the framework for future locality plans, but general practice needs to be able to develop its own transformation capacity. This means that we want to adopt a provider-led development approach from April By this we mean that development is best provided within primary care as is already undertaken by large NHS organisations for themselves. We believe that change is better done by than done to and that development support delivered close to general practice will always understand the culture better and support GPs to work through what are profound changes they need to respond to for themselves. The diagram overleaf sets out the prime dimensions of primary care development that may be needed in the future for discussion and debate. This is primarily a strategic model that seeks to set out how general practice develops itself in line with the primary care strategy to: 1. plan proactively and segment to understand the needs of its population under the four programmes of prevention/self-care; urgent care; routine care and complex care SIZE 2. develop a collaborative model of care at locality level, identifying how practices can best collaborate with each other and with wider health and social care providers SHAPE 3. design the practical enabling services to deliver the model of care; workforce, information technology, estates, capacity/activity mapping, sustainable finance SUPPORT This third aspect of support needs the 23 practices, Salus, Farnham Working Together and the CCG to work together to consider the different options and organisational provider models to support extended primary care team employment, development of information technology and management of a changing buildings stock. This all needs to be underpinned by a primary care wide approach to quality, patient and public engagement and clinical leadership development. This is illustrated in the graphic below (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 30 of 48 Overall Page 75 of 160

76 1. Size Profiling, Segmenting And Programming Your Locality s Population Needs 2. Shape Interpreting The Model Of Care Delivery To Suit Your Locality 3. Support Taking Action on The Practical Enablers Scope The Size Of Each Of - Prevention and Self-Care -Urgent -Routine -Complex Care -MDT Design - Prevention Programmes - Access Model -Practice Collaboration -Workforce -Estate - Technology -Financial And Activity Plan QUALITY PATIENT & PUBLIC ENGAGEMENT CLINICAL LEADERSHIP Salus will have produced its draft Business Plan by the end of June 2016 and Farnham Working Together is just establishing itself as a legal entity. We will need to work with both organisations to ensure that the necessary provider development capacity is in place from during 2017/18. It will be crucial that primary care providers unlock the skills and power of primary care Practice Managers to make maximum use of the key experience skills they offer in terms of developing practice systems, governance and a shift in shared capacity/infrastructure across GP practices. This transition to primary care leading its own development is one that needs to be managed carefully. We will work collaboratively with both Salus and Farnham Working Together to continue to support during and manage the transition flexibly. 8. Engaging for success We can only implement this strategy successfully if the principle of co-design feels real and credible. Co-design needs to be with clinicians facing tight resources, high workloads and a workforce crisis and with patients and the public whose experience of engagement has been historically limited to formal public consultation towards the end of the process where decisions feel set and with partner organisations who are also facing the same challenges. We are therefore putting together an overall engagement plan to encourage real input into the implementation of this strategy, as well as detailed local engagement between clinicians and patients in the five localities to support them undertake the practical design of the new model of care in the nest way that suits local circumstances (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 31 of 48 Overall Page 76 of 160

77 The main planks of our engagement strategy are to work with: Our GP practices through the GP Federation, Salus and our well established locality, practice managers and GP Forum meetings Patients and the public by building an engagement network in each locality with the GP surgery Patient Participation Groups, Vanguard Community Ambassadors and Voluntary Sector user and carer networks Our partner organisations through the Vanguard Steering group, Vanguard Workstream and by linking with the two county-based Health and Wellbeing Boards and the local District Council based Health and Wellbeing Partnerships For more detail, see Appendix 7 9. Next Steps Considerable soft engagement has already taken place during the development of this strategy with over 250 people. This version of the strategy is now ready for formal engagement and will be finalised together with a supporting action plan by the end of September 2016 with primary care commissioning intentions produced for approval by the Governing Body in November The estates strategy will also need to be updated by September We will also work with the CCG s clinical leads to produce a series of one page key points of what the primary care strategy means for our priorities for each of older people; children and young people; mental health; learning disability and long term conditions/specific health conditions such as diabetes and cancer. Work to support the phase 1 locality action plans is just beginning which will support clinical and public engagement on the strategy within the five localities as we establish the five local public engagement networks. Clinical engagement will continue within locality meetings, with Salus and Farnham Working Together and through our Practice Council. We have received much clinical and public input and feedback already. All feedback is reviewed continuously and will be synthesised into the final document by the end of September These commissioning intentions will be defined by 10 foundation design principles which will be our essential decision-making criteria that all future primary care development and investment proposals will need to meet. These will be tested over the summer as follows. The overarching requirement is that primary care must fulfil the Vanguard Model of Care and Financial Affordability criteria. Clearly NHS Constitution commitments also have to be fulfilled (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 32 of 48 Overall Page 77 of 160

78 The principles are:- 1. GP practices working together at scale with a provider locality plan for 2017/18 to 2019/20 and associated model of care in place by April Each locality s plan to be supported by a population profile that segments and quantifies the scale of need under each of the four programmes of prevention/self-care; urgent care; routine care and long term conditions/frailty and the implications for the scale of admission avoidance and referral management changes by 31 st March All practices to participate in a viability health check with sustainability recommendations by 31 st March A Joint approach with the CCG to establish a locality engagement network of local Practice Participation Groups, Community Ambassadors and other local patient/carer key groups to co-design the model of care by 31 st March Each locality to develop its approach to quality under the three themes of safety, clinical outcomes and patient outcomes including prescribing clinical variation by 31 st March All primary care GP services over and above the GMS and PMS contracts to be commissioned at scale either at locality, CCG-wide or Strategic Transformation Plan level, not through individual practices. 7. Extended hours access delivered at locality level 8-8 Monday to Friday and 9-12 on Saturdays to be in place by April 2018 supported by a sustainable resources 8. Integrated Care Team 7 day working to be in place by April A Locality Estates Plan in place by 31 st March Impact on acute care to be included in all development and investment proposals including aligning consultant support in key specialties to localities, impact of primary care interventions on acute activity/ spend and ensuring that new investment follows with new activity into primary care (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 33 of 48 Overall Page 78 of 160

79 Appendix 1 Access to Primary Care Any credible Primary Care Strategy has to take a deeper look at access. The national priority is to deliver extended hours opening and some CCGs are delivering this early through the Prime Minister s Challenge Fund. Our view is that extended hours should be delivered across a locality as a minimum, not by each practice individually. As we develop our model, we will have to judge best to balance extended access to routine appointments with urgent needs. Practices are currently commissioned to open from 8.00am-6.30pm Monday to Friday. A large number of our GP practices also already offer extended opening to local patients through the Extended Hours Directed Enhanced Service (DES). We do not believe that this DES allows practices the flexibility to deliver extended hours at the time and in the manner best suited to meet patient need. For example, delivering extended hours on a locality basis rather than by each individual GP practice is likely to achieve the aims of the DES in a fuller sense. A redesigned DES may also be able to resolve some of the workforce issues being experienced by the Out of Hours service. We will, therefore, work with our GP practices and the Surrey and Sussex and Wessex Local Medical Committees to design an alternative to the DES to be offered to practices during the 2017/2018 financial year. This represents a shorter term initial step along the longer road to a systematic and resilient approach to extended access. 8am-8pm access 7 days a week Evidence for the success of 8am-8pm access 7 days a week is variable. The first report from the Prime Minister s Challenge fund demonstrates some successes but recognises the challenges of understanding the different possible models of extended access and selecting the one that will work best for local circumstances. It appears from the national evidence that patients tend not to want routine GP appointments on Saturday afternoons and Sundays, although our plans to engage with local people already set out in this strategy need to make sure we really do understand what local people think here. What we do know is that society is changing and that patients lifestyles and expectations are changing too. Many are no longer satisfied with a service that closes at 6.30pm. The Government have committed to every patient that they will have access to routine GP appointments during the evening and on the weekends by A voluntary contract has now been made available on a pilot basis for six providers nationally who are ready to implement this change sooner. It is not only primary care that is being driven to extend access. Secondary Care is also facing significant changes to ensure the level of service being delivered overnight and over the weekend is as high a quality as that being delivered during weekdays. Community services and social care are also extending provision and moving away from the traditional model of access. As a collaborative partner in a new model of care, primary care will need to embrace the challenge of extended access. The public are no longer content with the concept of in or out of hours services and expect an integrated approach where capacity is geared up and down according to need over the 24 hour period (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 34 of 48 Overall Page 79 of 160

80 Locally, we have not yet refreshed work undertaken in 2014 to analyse patient behaviour aspirations and in order to determine what kind of 8am-8pm service 7 days a week is required. Therefore, we are not yet in a position to understand in what form patients would best benefit from the extension of routine, or enhanced access to urgent care. This will be a priority piece of work in the engagement on the primary care strategy. In several localities 8am-8pm access 7 days a week is likely to be trialled during 2017/18. A robust evaluation of these trials is likely to provide additional information on the requirement for extended access ahead of a national directive. In particular we will analyse whether it might be the case that a specific cohort of patients are particularly likely to benefit from extended access to primary care such as the high risk patients with multiple long term conditions or frail older people who are identified using risk stratification tools. Using this information we will, by the 1 st April 2017, have in place a plan to commission extended access from primary care. We believe that we therefore need one overall extended hours plan for each locality and that the capacity and number of appointments needed should be calculated on a reasonable expectation of the number of consultations per weighted 1000 practices population. Nationally the average number of consultations per 1000 population is often said to be around 72 per 1000, with a need for something like 100 per This approach covers consultations with all members of the primary care team such as nurses and pharmacists, as well as GPs. This is why using a structured risk stratification tool is so important as practices need to be able to calculate how many urgent appointments are needed based on their new model of care. For example some appointments could be saved by managing their more complex patients through a forward planned year of care approach and some new appointments will be needed to cover population growth. Out of Hours Services Our access review work also needs to include a review of Out of Hours services where the staffing model is under extreme pressure and we know that there are opportunities to strengthen the interface with social care out of hours services, the 111 service and to consider links with accident and emergency services at Frimley Park and the GP service that now forms part of it. We also don t have a fully comprehensive 24 hour district nursing service covering the entire CCG area at present. We know that we need to consider the interface between individual locality approaches and the sustainability review of Out of Hours. We only have one primary care workforce and we need to be careful not to destabilise one approach at the expense of the other as we build services. Primary care is already delivered locally 24 hours a day, 7 days a week, 365 days a year. As above, the terms of the current primary care contract require GP practices to open from 8.00am-6.30pm Monday to Friday and the commissioned Out of Hours service provides access to urgent primary care during the evening and weekend period. GP practices locally vary in their supportive of the continuation of a locally staffed Out of Hours service and even where practice views are supportive we know that there are only a small group of practices whose GPs regularly work Out of Hours shifts.the workforce needed to fill the Out of Hours shifts are from the same pool as those working in hours. GP recruitment challenges combined with the rising workload and stress levels in primary care (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 35 of 48 Overall Page 80 of 160

81 are therefore posing a significant challenge for our Out of Hours provider, with shifts becoming harder to fill. We believe that more can be done to ensure the sustainability of our Out of Hours provider. Possible ideas include building a more blended workforce model drawing on primary, community and secondary care skills with a wider multidisciplinary team, especially nurses. The link between extending access through primary care providers and the sustainability of an Out of Hours service is therefore obvious. In all of our work relating to access we will carefully consider the impact. The risk of destabilising Out of Hours service provision must be considered and mitigated. For example, extended access to 8pm for routine care could be commissioned by the localities from the existing Out of Hours provider and supported by shared records, rather than commissioning each GP practice to deliver this service. The current Out of Hours service contract has been extended to enable a review to take place during 2016 and any new pattern of care to be commissioned and mobilised to start in by September (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 36 of 48 Overall Page 81 of 160

82 APPENDIX 2 GP Practices Working in Collaboration and at Scale The principles of integrated working have already been set out in the main document. This appendix explains in more detail just why this is so important. The Vanguard strategy describes a shift of service from the acute environment to closer to home settings; including primary care, supported by a change in funding mechanisms. The collaborative approach needs to be supported by funding for change based on the financial growth aspirations set out in the Vanguard 2016/17 Value Proposition and the NHS England GP Forward View. To enable this shift to occur, primary care needs to work more effectively in sustainable and durable collaboration with other providers, each using their specialist skills and knowledge to collectively provide the best possible care to patients. The traditional institutional barriers of providers must be removed to enable this to happen, enabled by new commissioning and contracting models such as accountable care organisations which adopt the formal principles of working as a joint venture with mutual accountability to each other to deliver care together under one contracting vehicle to the commissioner. Primary care has already started delivering some of this new way of working through the design and implementation of locality based integrated care teams. Through a new model of integrated primary and community care, GPs with other care professionals will identify those individuals at risk, develop a holistic care plan with each of these individuals, and proactively manage the health and social care needs of the population. These projects will be regularly reviewed and evaluated. Learnings will be collated and the model improved to fully achieve the aims of this new model of care. Primary care will also be involved in the development of specialist care in the community. Our programme of work to develop specialist care in the community is designed to provide better care, to avoid hospital admissions and admissions to care homes, and to enable earlier discharge from hospital. This includes: Bringing together services currently delivered by Frimley Health NHS Foundation Trust and Southern Health NHS Foundation Trust to establish a new Recovery, Rehabilitation and Reablement service linked to the Hampshire County Council REACT service; Enhancing the Diagnostic, Assessment & Treatment Centre at Farnham Hospital; Focussed collaboration to enable earlier discharge, to reviewing community bed provision, and to accelerate the Discharge to Assess Programme; and Development of virtual locality teams to link the generalists with the specialists and improve the care provided to patients in the community It is unlikely that all GP practices will be able to meet the rising needs and demands of patients and to respond to the challenges being presented by continuing to operate solely as small businesses. Operating at scale, either through the merger of businesses or by federating and collaborating, will help fortify future service provision. A new voluntary contract will to be made available in 2017 by NHS England for GP practices, groups of GP practices or GP federations. NHS England will commission providers with a population of at least 30,000, achieved through merging or federating, to deliver primary care services. This is being piloted by six providers elsewhere in the country during 2016/17. We will learn from these pilots before we finalise our own local plans. The CCG assumed full delegated responsibility for GP primary care commissioning from April 2016 and is gradually taking steps to encourage locality working, through for example investment of Personal Medical Services premium and Local Service Contracts (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 37 of 48 Overall Page 82 of 160

83 In order to deliver the terms of this planned new voluntary contract, and more importantly, to deliver the local Vanguard Model of Care, integration with community nursing and other healthcare professionals will be required. This contract is likely to see a removal of payments based on Quality and Outcomes Framework (QoF) achievement and a reuse of this funding to support the delivery of extended access at the weekends and in the evenings on a locality basis. The journey to integration for a GP practice is shown pictorially below. Currently GP practices are generally working independently GP practices will need to form a virtual hub covering populations of 30,000 and above and increase the work they collaborate on GP practices may progress to merging into a single legal entity, creating a hub covering populations of 30,000 and above The Clinical Commissioning Group is therefore starting to support primary care operating at scale by utilising opportunities to commission on a wider geographical basis such as localities or larger. We will also work with GP practices to identify the barriers to organisational change and provide proactive support to overcome these. This may take the form of understanding and overcoming challenges with property ownership, partnership agreements, levels of pay and profit and relationships. At times transitional financial support may be required to enable these changes to occur. An important step in operating at scale has already been made by our GP practices through the formation of a provider federation in 2015; Salus Medical Services. We anticipate that the role and function of Salus Medical Services will be clarified in future months. Their business plan, supported by member GP practices, will enable them to be clear on their place in the provider market. The CCG views the federating of general practice as a vital component in the provider landscape. We wish to see federated general practice succeed and grow into a self-sustaining primary care organisation. We believe that Salus should focus on ensuring the sustainability of current primary care service provision as well as looking to the future for new opportunities (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 38 of 48 Overall Page 83 of 160

84 Appendix 3 GP Practice Locality Map and List Sizes at April 2016 and Locality Map (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 39 of 48 Overall Page 84 of 160

85 Appendix 4 Strong and dependable workforce The pressures across the primary care workforce have already been described in this strategy, with recruitment, retirement, expensive locum fees and flexible working trends all pointing to a need for a radical rethink in the approach needed for future sustainability. Time for training, updating and personal development is at a premium and stress levels are high. According to the 2015 GP Workforce Census there are currently 104 full time equivalent general practitioners working in our 23 GP practices. These are supported by 47 full time equivalent practice nurses. There were 17 GP vacancies (headcount not full time equivalents) at the time of the January 2017 Salus survey, but we know that this stood at just under 20 in May Our practice support visits and Personal Medical Services (PMS) contract reviews are giving us more worrying evidence about planned retirements, stress and burnout. Morale is far from good. Of our GPs 40% are above the age of 50 and 70% of our nurses are above the age of 50. We can reasonably assume that within the next 10 years these valued clinicians will conclude their full time commitment to general practice. This presents a significant challenge in how primary care providers can continue to respond to patient need. This, combined with the challenges of recruitment, demonstrates the need for a new workforce model to be tested and implemented in primary care. In addition GP practices must work together, potentially through Salus Medical, to control locum fees and create a cohort of high quality and dependable GPs that can be utilised to provide additional capacity when required. The valuable skills of our GPs and Nurses must be used in a way that best supports the needs of patients. There are many routine tasks currently undertaken by these healthcare professionals that do not require their specialist skills. These skills could be better used to support the complex and/or elderly patients. New workforce models As an example, we know that 30% of GP consultations are about musculoskeletal problems. Pilots have shown the benefits of enabling self-referral access to physiotherapists. Many of our GP practices already host physiotherapy providers in their premises. Others are able to refer to local, conveniently based services. We will work with these providers to develop and implement a model of self-referral for patients. Similar self and direct referral models to practice pharmacists for minor ailments, and to further expanded practice based counselling services through the Improving Access to Psychological Therapies scheme could also be very valuable. We will therefore work with these other clinicians to trial a model where their specialist skills and knowledge can be used to support GPs in their day to day consultations. During 2016/2017 GP practices will be asked to identify their willingness to participate in a pilot introducing front line physiotherapists into the primary care workforce. Following the evaluation of this pilot we hope that a permanent model can be introduced. We recognise that, taking the leap, being innovative, and recruiting a relatively new role into the primary care workforce can be challenging and so, where possible, we would like to explore a financial contribution on a reducing basis to help practices get started, perhaps through Vanguard funding (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 40 of 48 Overall Page 85 of 160

86 There are examples around the country where GP practices have found the introduction of the clinical pharmacist role within a multi-disciplinary team to be clinically effective and good value for money. These patient-facing roles, in which clinical pharmacists have extended responsibility over and above their current ways of working, could include the management of care for people with self-limiting illnesses and those with long term conditions. Our local GP practice federation company Salus Medical Services Limited, in collaboration 15 of our GP practices, has been successful in obtaining funding through the NHS England Clinical Pharmacists in Primary Care pilot. The pilot will fund 1 senior and 5 clinical pharmacists. Through these pilots clinical pharmacists will deliver direct patient care and work with the wider practice team to improve quality and safety. They will use their skills to help people manage minor illnesses, get the most benefit from their medicines and effectively manage their long-term conditions. It is believed that such a role could in turn relieve pressure on GPs and free up their time to manage patients with more complex or acute illnesses. It will also demonstrate improvement in medicines optimisation from practices current baseline. The national Vanguard New Models of Care Team sets out interesting international examples where primary care is responding to the prevention and self-care agenda by creating new roles that deliver patient coaching, peer support and community development. Some of the early feedback on this strategy has been that if communities already are happy work together on local crime through Neighbourhood Watch, we could, through our community engagement work test the idea of a supportive Neighbourhood Health Watch where communities are enabled to keep an eye on vulnerable people and get them into services early and get support, perhaps from non-stigmatising voluntary organisations, to tackle issues such as smoking, alcohol consumption and healthy eating/obesity. Recruitment, retention, training and development The CCG will continue to provide an annual budget to support the training and development needed to maintain a strong and dependable primary care workforce. Through the introduction of a reshaped GP Forum in the shape of TARGET days in April 2016, including a practice nurse forum, we hope to support a growing number of primary care clinicians. The budget available to fund these days will be specifically used to address the gaps in knowledge and skills that are needed to support the changing needs of our patients. The CCG s own contribution is a relatively discrete and small element (12K). As a CCG cutting across two Health Education England Deanery Boundaries (Wessex and Kent, Surrey, Sussex) we appear to be missing out on funding to develop a more formal Community Education and Practice Network (CEPN) that would equip us to move beyond more transactional training to equip the workforce more sustainably with the development they need to deliver the new model of care. For example, we do not benefit from nursing student placements in general practice to raise awareness of primary care nursing as a professional career, we are not offering placements for new physician assistants and practice nursing and health care assistant training is rather fragmented. We need to use our Vanguard status to break down these artificial boundaries and build strategic alliances with further and higher education institutions to shape new curricula that will train new professionals ready for our new model of care. The immediate priority is our work to produce a short term workforce stability plan based on the proposed primary care provider-led viability health check. Longer term, our workforce development approach adds up to a five pronged approach to (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 41 of 48 Overall Page 86 of 160

87 workforce which would be wrapped up in enabling primary care to conduct the viability health check. The solutions include: - building the extended primary team by making better use of existing wider clinicians such as pharmacists - exploring new clinical roles such as physician assistants - exploring new non-clinical roles such as patient coaches and the voluntary sector - maximising workforce synergy and capacity and reducing duplication by building strong locality Integrated Care Teams with community, mental health and wider closer to home services and forging locality links with key acute hospital specialties - building a recruitment, retention training and development strategy (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 42 of 48 Overall Page 87 of 160

88 APPENDIX 5 Information and Communication Technology "The NHS cannot be the last man standing as the rest of the economy embraces the technological revolution. Only with world class information systems will the NHS deliver world class care. (Jeremy Hunt).Creating an NHS which is digitally fit for purpose in the 21st century is a key priority for the NHS. The national plan is that new investment of 1 billion in health technology will make sure that patients and staff can access the services they need, helping to free up time and reduce costs. Digital heath tools and information can help people to better manage their health and avoid unnecessary GP visits and hospital admissions. To support these aims the CCG produced an Information and Communication Technology Strategy in Primary care must be supported to improve its use of technology. Improved use of technology has two aims:- - to support GP practices improve their internal systems and processes therefore releasing capacity to focus on other priorities - to enable an improved experience of care for patients. The document was produced to provide an overview of the strategic direction that the CCG wishes to take regarding the use of Information and Communication Technology (ICT). It has the following key aims: To support patients in their right to access their own health data in a meaningful way and to enable services to engage patients in actively shaping and participating in their own care; To support accurate, convenient and appropriate recording and sharing of health information in order to ensure safe, effective and efficient care for our patients. Integral to this approach is the definition and development of communication between providers of clinical and social care to enable straightforward role based access to relevant data; The ICT strategy should ensure that procurement of IT systems in the future will not be carried out in isolation with the risk of duplicating investment in overlapping capabilities. We intend to use Information Technology to: - Identify patients at risk of deterioration in their health in order to enable proactive management - Enhance detection of patients at potential risk of adverse effects from treatment - Support health professionals with the information resources needed to manage certain conditions within our Clinical Commissioning Group area - Support commissioners in making informed business decisions - Build new models of patient access through WebGP and other digital means of delivering care - Make it easy for primary care services to seek advice and consultation from acute specialists, deliver shared care and deliver more care closer to home - Recommend or create apps for patients that support prevention and self-care - Capture safety, clinical effectiveness and outcome standards for the planned new Vanguard contracting arrangements (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 43 of 48 Overall Page 88 of 160

89 Key priorities for the development of Information and Communication Technology in primary care providers during 2016/2017 include: - Enabling and supporting people to access and interact with their individual health records, book appointments and request repeat prescriptions online should they wish to do so - Supporting GP practices in migrations to EMIS hosted systems - Working with providers to develop a user friendly e-referral service - Working with providers to develop electronic transfer of documents into primary care - Working with other providers to reach a specification for sharing data - Reviewing IT systems that have already been procured in order to ensure they are being used to the full potential (Eclipse Live, Risk Stratification tool, Regional Health Record) - Investigating mechanisms for sharing information securely with other providers With the contract for the Adastra system used in Out of Hours being extended until 2016, a replacement will be need to be chosen and commissioned that will need to allow interoperability with the Regional Health Record and GP practice systems. A system for recording and sharing Care Plans will be chosen that must fulfil the requirement for integration within GP practice systems without the need to record relevant data more than once (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 44 of 48 Overall Page 89 of 160

90 APPENDIX 6 Commissioning and Contracting Models There is widespread consensus that substantial changes will need to be made to existing commissioning and contracting arrangements to better enable the delivery of new models of integrated care. Through the future Vanguard aspiration to implement a new commissioning model, North East Hampshire and Farnham CCG, NHS England, Hampshire County Council and Surrey County Council aim to pool health and social care resources for the local population. The introduction of long term outcome and capitation based contracts with providers will align incentives and funding in the system to enable the delivery of the new model. This will mean that there will be one capitated budget based on an understanding of patient population need, one main joint contract mechanism delivered by all providers working together in one joint venture approach. The contract will not specify how services should be delivered but will be outcome based with the key dimensions of this focussing on: - safety - clinical effectiveness - clinical outcomes - patient defined outcomes - better value for money - delivery of NHS Constitution standards The Vanguard is currently scoping the capitated budget and the services covered by it. The outcomes framework and how outcomes will be captured as part of routine clinical practice is an important priority for development during 2016/17 for 2017/18. Whilst moving towards this more new longer term commissioning model, the CCG will quickly introduce a new commissioning model for the services beyond the core GP General Medical Services (GMS) and personal Medical Services (PMS) contracts that we currently commission from primary care. This means that from the 2016/2017 financial year onwards the CCG will fund less of primary care through separate allocations that sit outside the core GP contract. Funding will be provided on a population basis with clear and measurable outcomes for each of these services. Where it will prove beneficial to patient care, our preference will be to commission on a locality basis as a minimum. In addition our preference is to commission extended primary care services through a federated approach, as and when federated GP working develops sufficiently to take this on. There is also a debate to be had about how the core GMS and PMS contracts should work in future. Vanguard areas may wish to take opportunities to offer alternatives to these contracts that are outcome based. This is bound to be linked to the national process for negotiating a new GP contract. Some Vanguards are choosing to move to piloting outcome based contracts on a locality or CCG-wide basis for GPs as an alternative to GMS and PMS, with an agreed route back to GMS to encourage this kind of experimentation. For example, Tower Hamlets CCG has implemented locality contracts for many long term conditions which incentivise groups of GPs at a locality level and pay on the achievement of population-wide, not individual practice outcomes (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 45 of 48 Overall Page 90 of 160

91 42 6. (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 46 of 48 Overall Page 91 of 160

92 Appendix 7 Our Approach to Engagement We are seeking to work in an integrated way to engage on the development of the primary care strategy, drawing together into one programme all our collaborative work with primary care clinicians, patients/local people and the partner organisations with whom we work. The prime, but not exclusive, focus is on bringing people together to engage and work together in localities. In summary, we are doing this as follows:- 1. with primary care through these channels:- - The local GP Federation (Salus) with bi-laterals at least monthly. The aim is that Salus develop their business plan to the same timescale at the Primary Care Strategy in June 2016 and respond to the CCG s commissioning intentions by December This focuses on the GP provider development perspective and how the localities can be supported to develop their response to the Vanguard model of care. - The CCG s own Practice Council which has just been relaunched and will work from a commissioning perspective, for example debating the services that the CCG needs to commission to support GPs to develop extended primary care in the localities and to reshape acute care key specialties to be more primary care facing, in the interests of easing access to secondary care advice and promoting shared care outside hospital - The five GP practice Locality Meetings where GPs and their teams are working together in practice to agree how they could collaborate at scale, consider workforce and premises local implications and work out which services to deliver together and which separately. - Practice Managers meetings focusing in particular on how practices could collaborate to release capacity and reduce workload by sharing back of house support services, infrastructure, information, preparing for Care Quality Commission inspections and policy development. - Our new Target Days for primary care which we have established to reinvigorate the former GP Forum by widening participation to all GPs and members of the extended primary and community care team. 1:1 engagement to test the priorities in this strategy has already taken place with CCG GP Governing Body members and the CCG s wider community of clinical leads. We will also engage with the representative bodies such as our Local Medical and Pharmaceutical Committees to test proposals early. 2. with patients and the public by forming locality based Local Engagement Networks:- - Bringing together the GP Patient Participation Groups (PPGs), Vanguard Community Ambassadors and voluntary sector user and carer networks in each locality with local clinical leaders to debate and shape the locality s implementation of the new model of care, using work in Farnham as the prototype (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 47 of 48 Overall Page 92 of 160

93 - Working with the Area Patient Group to guide and take an overview of this work - Energising our new cohort of some 80 Community Ambassadors to play a full part in shaping the strategy and, in some cases, perhaps in time offering peer support and coaching to patients as part of the prevention and self-care agenda - Accessing service user groups with a particular interest such as mental health, both through specially convened focus groups in each locality and working with already established user networks such as those for carers, older people and users of mental health services. - We also want to reach out to vulnerable people at home, perhaps using front-line care staff. The approach will be multi-channel, combining survey work, focus groups, individual and locality joint PPG meetings as well as outreach to public places such as supermarkets, leisure centres, schools and colleges. We will also work with Voluntary Action umbrella groups in Rushmoor, Hart and South West Surrey to access service users known to the voluntary sector 3. with our partner organisations through- - the Vanguard Board and Steering Group acting as a bridge into all partner organisations - our two County-based Health and Wellbeing Boards and the Hart Council-based Health and Wellbeing Partnership. This work is still to be shaped, but will need to include bringing together primary, community, social and secondary care front-line staff with senior leaders across the Vanguard to embed our locality based integrated care teams and complement them with strong aligned clinical advice and support from acute hospital teams. We will also test our proposals and engage with wider organisational partners such as the Fire Service, who can play a role in reaching out to vulnerable people at home. This work is based on a collaborative approach between the CCG s primary care and communications/engagement teams working closely with the Vanguard Team. The next steps are:- - to appoint a project manager to co-ordinate the engagement programme overall (achieved) - to develop a joint model of primary care support and development for the localities that joins up and makes best use of CCG, Vanguard, Salus and Local Medical Committee skills This document sets out the engagement work to date by locality in more detail. Work is furthest ahead in Farnham. Locality summary April 2016 adapted b (FINAL) June 0916 GB Primary Care Strategy Mike Attwood.pdf Page 48 of 48 Overall Page 93 of 160

94 Governing Body Date of Meeting 29 th June 2016 Agenda Item 7 Paper Number 7 Strategic Objective Number Author Lauren Pennington, Head of Primary and Planned Care Director Sponsor Clinical Sponsor Alison Edgington, Interim Director of Delivery Dr Steven Clarke Title: Any Qualified Provider Direct Access Adult (over 16) Musculoskeletal Physiotherapy Services Executive Summary: During the development of the Clinical Commissioning Groups (CCG) 2012/2013 Commissioning Intentions and the associated consultation and engagement process both local GPs and patients commented on the variable quality of physiotherapy being delivered by local providers. They strongly expressed their desire to re-commission high quality, outcome focussed services during 2013/2014. A procurement was subsequently undertaken and 8 providers were successfully accredited under an Any Qualified Provider framework to deliver Direct Access Adult Musculoskeletal Physiotherapy Services. Service delivery commenced on the 2 nd September 2013 for North East Hampshire GP practices and the 1 st January 2014 for Farnham GP practices. As the current contracts with providers are reaching their expiration date, the CCG should consider options about the future commissioning of this service. This paper provides an overview of activity and performance for these 8 providers and presents commissioning options for the CCG to consider. Clinical Executive have agreed the recommendation that Option 3 is agreed: Contracts with existing providers continue. It is recommended that services are commissioned for a further 3 years. This mirrors the original contract term. Governing Body are requested to support this recommendation from the Clinical Executive. Actions/ Recommendations Other Committee(s) where this paper or supporting information have been considered To Approve - An item of business that requires the Committee to take a formal decision To Ratify - An item of business where the Committee is required to ratify the action(s) taken of behalf of the Governing Body, for example by a formal committee established by the Governing Body. To Discuss - An item of business that requires discussion by the Committee prior to agreement of a formal resolution or a general policy steer to the executive officers. To Note - An item of business for which the Committee is required to give due regard to but for which there is not expected to be discussion. X Version 3 7. (FINAL) GB pdf Page 1 of 14 Overall Page 94 of 160

95 Date 8 th June 2016 Version 3 7. (FINAL) GB pdf Page 2 of 14 Overall Page 95 of 160

96 Any Qualified Provider Direct Access Adult (over 16) Musculoskeletal Physiotherapy Services 1. Background 1.1. During the development of the Clinical Commissioning Groups (CCG) 2012/2013 Commissioning Intentions and the associated consultation and engagement process both local GPs and patients commented on the variable quality of physiotherapy being delivered by local providers. They strongly expressed their desire to re-commission high quality, outcome focussed services during 2013/ A briefing paper was therefore submitted to the CCG Shadow Governing Body in November 2012 requesting approval to procure Direct Access Musculoskeletal (MSK) Physiotherapy through an Any Qualified Provider (AQP) framework. This approval was provided and notice was subsequently issued to the existing 5 providers Activity at the time totalled 8,222 first attendances and 23,520 follow up attendances. The value of this activity was approximately 1,400,000 per annum with variation in the payment structure between providers. 2. Service redesign 2.1. A new service specification was developed in consultation with local GPs, Practice Managers, potential new providers and the existing providers through 3 interactive and well attended local workshops. Best practice example specifications were used as the basis of the document, with further clinical input and research required to ensure the specification was detailed and accurate A key area of improvement was the maximum waiting time to the first appointment. For urgent patients this was set at 10 working days from the date of receipt of the referral letter and for routine patients this was set at 30 working days from the date of receipt of the referral letter. 3. Service procurement 3.1. The AQP Direct Access MSK Physiotherapy procurement commenced in January 2013 with the publication of an advert and service specification on the Supply2health website Following evaluation of 30 submitted bids the following 8 providers were awarded an AQP contract to deliver direct access MSK physiotherapy services: Frimley Park Hospital NHS Foundation Trust Healthshare Limited Premier Health and Sports Therapy Royal Surrey County Hospital NHS Foundation Trust 1 7. (FINAL) GB pdf Page 3 of 14 Overall Page 96 of 160

97 Southern Health NHS Foundation Trust Thorpes Physiotherapy Limited Virgin Care Wallington Physio Ltd (trading as Surrey Physio) 4. Service mobilisation 4.1. The new services mobilised over the summer of 2013 and commenced service delivery on the 2 nd September 2013 for North East Hampshire GP practices and the 1 st January 2014 for Farnham GP practices The 8 providers were commissioned to deliver services from 22 convenient and accessible locations. Many providers are hosted in GP practices. Others are based at Hospital sites or Community Leisure Centres. These sites are shown in the map below. Further information is contained in Annex 1: 4.3. GP practices were issued with a standard referral form and protocol to use when accessing the service. Indicative activity levels were also provided based on weighted population list sizes. 5. Contract terms and requirements 5.1. The contracts were issued inclusive of the following terms and conditions: Contract term Expiry date Funding model 3 years 31 st August 2016, no ability to extend included in the original contract 40 for a new attendance 30 for a follow up attendance Indicative limit of 5 follow up attendances per patient 2 7. (FINAL) GB pdf Page 4 of 14 Overall Page 97 of 160

98 Reporting Contract monitoring Monthly reporting of activity and key performance indicator achievement Annual provider monitoring review workshops with commissioner 5.2. It was assumed that savings would be achieved through the implementation of a consistent funding model. This has been achieved with more patients being seen for a lower overall budget than prior to the procurement. As activity has grown the 2014/2015 and 2015/2016 annual budgets have been set based on the previous year s outturn. 6. Contract monitoring 6.1. Contract monitoring has been a consistent challenge with this service. Due to the resource required it has not been possible to actively monitor each of the 8 providers on a monthly basis. Instead this has been done on an exception basis. In addition for some time each provider was using a slightly different version of the reporting template making comparison across providers time consuming and resource intensive; this has since been addressed. 7. Overall service review 7.1. Activity has grown since 2013/2014 but is now relatively stable and the average value of activity being undertaken each month is 13, The total spend in each financial year since service commencement is shown in the table below: Financial year 2013/2014 (Month 6-12) Total Blue 2014/2015 (Month 1-12) Total Green 2015/2016 (Month 1-12) Total Turquoise CCG total 535,060 1,226,959 1,285, The percentage share of activity by provider (based on invoice values) is shown in the tables below: Healthshare Thorpes Premier Surrey Physio FPH RSCH SHFT Virgin 18% 16% 12% 11% 12% 1% 9% 21% 3 7. (FINAL) GB pdf Page 5 of 14 Overall Page 98 of 160

99 Financial year Healthshare Thorpes Premier Surrey physio FPH RSCH SHFT Virgin CCG total 2013/2014 (Month 6-12) Total Blue 2014/2015 (Month 1-12) Total Green 2015/2016 (Month 1-12) Total Turquoise 94,850 61,310 52,370 54, ,630 4,700 63, , , , , , , ,610 7, , ,960 1,226, , , , , ,621 9, , ,368 1,285, (FINAL) GB pdf Page 6 of 14 Overall Page 99 of 160

100 7.5 The growth in expenditure over the contract period is shown by the graph below: 5 7. (FINAL) GB pdf Page 7 of 14 Overall Page 100 of 160

101 8. Individual provider service review GP Practice 8.1. A provider by provider service review was recently undertaken to consider current activity and achievement against key performance indicators. This review used the activity and performance reports from months 1-10 in the 2015/2016 financial year. A summary of findings from these reports are explained below This table shows the variation in the number of first attendances referred by GP Practices: Health share Thorp es Premie r Surrey Physio FPH RSCH SHFT Virgin Total Percentag e of activity ALEXANDER HOUSE SURGERY % 35 BRANKSOMEWOOD H/CARE CTR % 44 CRONDALL NEW SURGERY % 24 DOWNING STREET GROUP PRACTICE % 33 FARNHAM DENE MEDICAL PRACTICE % 48 FLEET MEDICAL CENTRE % 33 GIFFARD DRIVE SURGERY % 40 HARTLEY CORNER MEDICAL PARTNERSHIP % 36 HOLLY TREE SURGERY % 27 JENNER HOUSE SURGERY % 39 MAYFIELD MEDICAL CENTRE % 30 MILESTONE SURGERY % 36 MONTEAGLE SURGERY % 70 NORTH CAMP SURGERY % 27 PRINCES GARDENS SURGERY % 46 RICHMOND SURGERY % 32 RIVER WEY MEDICAL PRACTICE % 53 SOUTHLEA GROUP PRACTICE % 34 SOUTHWOOD PRACTICE % 47 Activity per 1000 patients 6 7. (FINAL) GB pdf Page 8 of 14 Overall Page 101 of 160

102 THE BORDER PRACTICE % 43 THE FERNS MEDICAL PRACTICE % 44 THE OAKLANDS PRACTICE % 52 THE WELLINGTON PRACTICE % 21 VICTORIA PRACTICE % 36 Grand Total % The average first to follow up ratio is As the table below shows this varies between providers: Number of first attendances Number of follow up attendances Ratio Healthshare Thorpes Premier Surrey Physio FPH RSCH SHFT Virgin Total The percentage of patients referred as urgent cases differs between providers and is shown below: Healthshare Thorpes Premier Surrey FPH RSCH SHFT Virgin Total Physio 11% 16% 7% 9% 26% 5% 34% 23% 17% 7 7. (FINAL) GB pdf Page 9 of 14 Overall Page 102 of 160

103 9. Key Performance Indicators achievement 9.1. Achievement against the following key performance indicators (KPIs) are reported on a monthly basis: 95% of urgent patients to be seen within 10 working days of receipt of referral 90% of all routine patients to be seen within 30 working days of receipt of referral DNA rate not to exceed 6% 100% of patients to be offered information leaflets prior to and during their treatment 100% of patients to complete a Patient Reported Outcome Measure (PROM) pre-treatment questionnaire during their initial assessment 100% of patients attending their final appointment to complete a Patient Reported Outcome Measure (PROM) post-treatment questionnaire prior to discharge 100% of discharge letters to be sent to the referrer within 5 working days of discharge 9.2. Average achievement against the two main key performance indicators for months 1-10 of the 2015/2016 financial year are shown in the table below: 95% of urgent patients to be seen within 10 working days of receipt of referral Healthshare Thorpes Premier Surrey FPH RSCH SHFT Virgin Physio 63% 94% 62% 98% 90% 67% 55% 67% The main reasons cited by providers for missing this target include patient choice of appointment date and low number of patients identified as an urgent referral adversely affecting reported performance 90% of all routine patients to be seen within 30 working days of receipt of referral 93% 98% 97% 98% 94% 92% 36% 86% The main reason cited by providers for missing this target was patient choice of appointment date 8 7. (FINAL) GB pdf Page 10 of 14 Overall Page 103 of 160

104 9.3. A review of average and maximum waiting times provides some context to this reported performance: Average time to initial assessment, urgent patients Average time to initial assessment, routine patients Maximum time to initial assessment, urgent patients Maximum time to initial assessment, routine patients Healthshare Thorpes Premier Surrey Physio FPH RSCH SHFT Virgin All other key performance indicators are consistently achieved by providers with very few occasions of non-achievement reported (FINAL) GB pdf Page 11 of 14 Overall Page 104 of 160

105 10. Patient feedback Providers are contractually required to obtain patient feedback as part of the KPI reported monthly as Patient Reported Outcome Measures (PROMS) All providers meet the KPI relating to PROMS and there is a high satisfaction level reported by patients In addition the number of complaints received is also monitored. In the period reviewed only 2 complaints were received and these were about administrative processes, not the quality of clinical care provided Over the life of the contract a number of patients contacted the CCG or referring GP practice directly to give their complements on the service being provided. 11. Provider challenges Through our annual monitoring review workshops providers are able to formally raise and discuss any issues that they are experiencing in delivering the commissioned service. On occasion items such as appropriateness of referrals have been raised as an issue. However, generally the number of issues being raised is very limited For one provider, Southern Health, the change in their activity profile has proven a particular challenge. Prior to the AQP contracts commencing, Southern Health were one of 5 local providers. Their activity totalled approximately 10,000 attendances a year. This equated to about 30% of the activity locally. Since AQP has been introduced this share of the activity has reduced to less than 10% with approximately 3,000 attendances a year. As a result of this change in activity Southern Health issued notice to the CCG in January Following engagement with local patients and stakeholders, this notice was revoked in December 2015 and service delivery has continued. However, as the table on page 8 shows performance about key indicators is poor. Further conversations with Southern Health are required to support them in making a firm decision about the continuation of this service. 12. Commissioning options As the current contracts with providers are reaching their expiration date, the CCG should consider options about the future commissioning of this service There are three options to be considered: Option Benefit Risk Option 1 Do nothing; AQP contracts expire None This is not a viable option. This service was removed from the existing contracts with secondary care and is commissioned separately. If the AQP contracts expire without an alternative being put in place there will be no service for patients to be referred to 7. (FINAL) GB pdf 10 Page 12 of 14 Overall Page 105 of 160

106 Option 2 Reopen AQP accreditation window Option 3 Contracts with existing providers continue for a further time period This may condense the number of providers operating under the framework; focussing on those with the biggest quantum of activity and best achievement of the key performance indicators This maintains the current range of providers who, overall, provide a high quality service to our patients This option does not require the diversion of resource to manage a procurement and mobilisation process Patients already enjoy access a wide range of providers. Reopening the AQP accreditation window may extend this further. The risk with this occurring is the time and resource required to manage additional contracts. In addition it is possible that spend may increase as a result of the increased number of access points for referrers If this option was to be pursued it is likely that a small extension to existing contracts would be required This maintains the current range of providers, a number of whom have experienced challenges in achieving the core key performance indicators relating to waiting times 13. Advice from NHS South of England Procurement Services Advice obtained from NHS South of England Procurement Services confirms that option 3 in the above table is permissible Guidance from Monitor states that AQP contracts can be rolled over year on year provided that the key components of the arrangements remain unchanged or are subject to very minor tweaks to reflect lessons learnt or changes in national guidance and legislation. These key components are the specification, funding model and terms and conditions The guidance states: Acute elective care and other services where any qualified provider can provide services to patients. Once a provider has been qualified to offer its services to patients, a commissioner should not run a new process to re-qualify the provider when its contract with the provider comes to an end, unless there are specific reasons for doing so (for example, because the commissioner has already raised concerns as part of the contract management process that the provider is not meeting required quality standards, or because the commissioner has decided to change the quality criteria). If, for example, a provider of acute elective care wants to continue to offer services at the relevant tariff and the commissioner is satisfied that the provider continues to meet the necessary quality standards, it should simply extend or renew the contract (FINAL) GB pdf Page 13 of 14 Overall Page 106 of 160

107 13.4. Contracts should be extended with all AQP providers who have an existing agreement regardless of whether they have received any or minimal referral numbers due to the exercising of patient choice. 14. Clinical Executive recommendation Clinical Executive have agreed the recommendation that Option 3 is agreed: Contracts with existing providers continue. It is recommended that services are commissioned for a further 3 years. This mirrors the original contract term It is also recommended that prior to a contract extension being agreed with those providers consistently failing the key performance indicators for waiting times e.g. Southern Health and Virgin, an action plan to address and improve performance is submitted and agreed by the Commissioner. In the event that this action plan cannot be agreed, an offer of a contract extension will be withdrawn and the contracts will expire Governing Body are requested to support this recommendation from the Clinical Executive (FINAL) GB pdf Page 14 of 14 Overall Page 107 of 160

108 Minutes of the NHS North East Hampshire and Farnham Clinical Commissioning Group Governing Body Part I meeting held in Public on Wednesday 20 April 2016 between 2pm and 4.30pm at Farnham Town Council Offices, Farnham Present: In attendance: Apologies for Absence: Kathy Atkinson, Lay Member with Patient and Public Involvement Portfolio Dr Peter Bibawy, Medical Director and Clinical Director for Urgent Care, GP, Southlea Practice Elaine Budd, Lay Member Dr Steven Clarke, Clinical Director for Primary Care and Planned Care, GP, Branksomewood Healthcare Centre Peter Cruttenden, Chair of Audit & Risk Committee and Lay Member with Governance Portfolio and Vice Chair Dr Jane Dempster, Clinical Director for Community Care, Integration & Safeguarding, GP, Farnham Dene Medical Centre Dr Olive Fairbairn, Clinical Director for Mental Health, Maternity & Children, GP, Alexander House Practice Mark Hammond, Lay Member Ros Hartley, Director of Strategy and Partnerships Emma Holden, Director of Quality and Nursing Maggie MacIsaac, Chief Officer Sarah McBride, Director of Delivery and Commissioning Dr Ed Palfrey, Secondary Care Consultant Roshan Patel, Chief Finance Officer Dr Edward Wernick, Clinical Director for Quality, Patient Experience and Patient Engagement Dr Andy Whitfield, Clinical Lead, and Chair, GP, Southwood Practice Dr Sallie Bacon, Interim Director of Public Health for Hampshire County Council Jean Boddy, Area Director North and East Hampshire, Surrey County Council Mike Attwood, Lead for Primary Care Justina Jeffs, Head of Governance Paul Gray, Vanguard Programme Director Mary-Jane Steijger, Governance Manager (minutes) Diane Woods Associate Director Commissioning Mental Health & Learning Disabilities for the Surrey CCG Collaborative Michelle Stickland, Interim Associate Director - Children and Maternity Commissioning Collaborative (Hampshire 5 CCGs) Claire Hook, Area Director for North East Hampshire Adults Services, Hampshire County Council 1 Welcome and Introductions Andy Whitfield welcomed Sarah Casemore, Deputy Director of Operations and Transformation at Frimley Health NHS Foundation Trust, Michelle Stickland from West Hampshire CCG (for item 8 Transforming Care for People with Learning Disabilities and Autism) people in attendance and members of the public to the meeting. Apologies for absence were noted. 2 Register and Declarations of Interests There was one change to the Register of Interests. Dr Kay Oskiga had moved away and was no longer a Clinical Lead and GP at Fleet Medical Centre his name would be removed. No Conflicts of Interest were noted. 8. Draft GB Minutes Public - 20 April 2016.pdf Page 1 of 10 Overall Page 108 of 160

109 The Governing Body noted the paper. 3 CCG Objectives 2016/17 Ros Hartley introduced the updated CCG Objectives for 2016/17 for discussion and approval by the Governing Body. The Governing Body was updated on the work which was being done to underpin objective 2 deliver the actions within our improvement programmes to improve the quality, outcome and performance of our services. The Governing Body confirmed that it would monitor progress against achievement of the Objectives on a quarterly basis. The Governing Body approved the CCG Objectives for 2016/17. 4 Vanguard Programme 2016/17 and update on acute work stream Paul Gray introduced a presentation which updated the Governing Body on the Vanguard Programme for 16/17 - summarising the progress on the introduction of the new model of care which was comprised of three key areas: (1) self-care and prevention (2) joined up community care and (3) acute care. The Governing Body noted the work that was being undertaken within the self-care and prevention work stream new social prescribing, local access to Recovery College courses which provided educational intervention for people with long term conditions. Joined up community care was testing new approaches to linking primary care, community care, mental health and social care. Paul Gray confirmed that the CCG s plans for the second year of the vanguard programme had received national support. Dr Peter Bibawy introduced a presentation on the acute work stream and highlighted the following points: The presentation had been co-designed with Dr Prem Premachandran, Chief of Service Emergency Department at Frimley Health NHS Foundation Trust. The aim of the acute work stream was to support people with acute needs in the community, reducing avoidable admissions to hospital and to long term care; support the efficient flow and processes within hospital and reduce avoidable delays for discharge from hospitals. Frimley Park Hospital consultants were supporting complex care in the community and GPs were involved in the care and discharge of patients from Frimley Park Hospital. There were eight separate acute care work streams underpinning this work. Work was being undertaken on (1) first contact and emergency care exploring new ways of meeting people s needs who attend the Accident and Emergency Department using primary care skills within the hospital (2) clinical partnership working on the wards bridging the care in the hospital with primary and community care (3) community based urgent care redesigning the support that it is offered to the community overnight and over the weekend. Dr Andy Whitfield thanked Paul Gray and Dr Peter Bibawy for an informative 8. Draft GB Minutes Public - 20 April 2016.pdf Page 2 of 9 Page 2 of 10 Overall Page 109 of 160

110 presentation and invited questions from member of the Governing Body. Ros Hartley asked whether enough communication and engagement work was taking place within each of the eight acute care work streams. Dr Peter Bibawy confirmed that he was working with Dr Ed Wernick on the engagement strategy for the acute care work stream and Community Ambassadors had been embedded within each of the work streams. Roshan Patel asked what the top clinical priority was for the acute care work stream. Dr Bibawy stated that it was to further integrate multidisciplinary team working for community services. The Governing Body noted the presentation. 5 Draft Primary Care Strategy Mike Attwood introduced a presentation which provided the Governing Body with an update on development of the Primary Care Strategy and summarised the context of the Five Year Forward View: Over the next five years the NHS would invest more in primary care. CCGs would have more control of primary care budgets through the introduction of delegated commissioning which would enable a shift in investment from acute to primary and community services. The number of GPs in training would be increased. The Primary Care Strategy aims to address (1) increasing demand as people live with more complex needs (2) the gap in outcomes for the population (3) the gaps in services for local people (4) the financial gap in 5 years. The focus was to enhance primary care, and locality based integrated multi-disciplinary teams to ensure that general practices increasingly worked together with each other and with other partners in the CCG s five localities. There was improved local access to specialist expertise and care. A Shared Care Record was being developed which enabled patients and care professionals to access a shared care record wherever and whenever required. The development of the Primary Care Strategy was closely linked to the Vanguard Programme Work Streams which had been discussed in the previous item. Dr Steven Clarke stated that the member practices were working much more closely together within localities and also with the CCG - increasingly the view of member practices was that they needed to ensure the sustainability of all practices within the locality. There were some remaining cultural barriers for GPs to work collaboratively across practices - these were being addressed through ongoing local facilitation. The Governing Body was informed that the first draft version of the Primary Care Strategy (based on engagement with over 250 people) had now been circulated for wider discussion amongst the 24 member practices. The proposals within the Primary Care Strategy were subject to early testing and challenge and real debate was needed on how best to shape primary care provider development. Work was ongoing to develop the Primary Care Strategy which the Governing Body would approve at its next meeting on 29 June Action: MA The Governing Body noted the paper. 8. Draft GB Minutes Public - 20 April 2016.pdf Page 3 of 9 Page 3 of 10 Overall Page 110 of 160

111 6 Delegated Primary Care Commissioning Committee Terms of Reference Mark Hammond introduced the draft Terms of Reference for the Delegated Primary Care Commissioning Committee which had met in shadow form earlier in the day. At its earlier inaugural meeting the Delegated Primary Care Commissioning Committee had further considered its Terms of Reference (which had been based on the NHS England Template) in particular, it had reviewed the composition of its membership and how it managed conflicts of interest. Furthermore, the Delegated Primary Care Commissioning Committee had agreed to establish a separate sub-committee - the Primary Care Programme Board which would report to it on a regular basis. Following discussion, the Governing Body provided its approval for the Delegated Primary Care Terms of Reference which would be reviewed on an annual basis. Mike Attwood informed the Governing Body that the CCG had now received the final signed version of the Primary Care Delegation Agreement from NHS England. 7 Quality Improvement Committee Terms of Reference The Governing Body was asked to approve updated Terms of Reference for the Quality Improvement Committee. The Quality Improvement Committee had reviewed its own Terms of Reference at its meeting on 9 March 2016 and had made updated its (1) membership (2) quoracy and (3) responsibilities and reporting lines. The Governing Body approved the updated Quality Improvement Committee Terms of Reference. 8 Transforming Care for Children, Young People in transition, People with Learning Disabilities and Autism Diane Woods and Michelle Stickland introduced a presentation which updated the Governing Body on the development of Transforming Care Partnerships for Surrey and Southampton, Hampshire and the Isle of Wight for children, young people in transition, people with learning disabilities and autism. It was noted that because of its geography the North East Hampshire and Farnham CCG was part of the Surrey and the Southampton, Hampshire and Isle of Wight Transforming Care Plans. Across the country 49 Transforming Care Partnerships had been established to transform care for people these partnerships were collaborations of key stakeholders comprised of local authorities, CCGs and NHS England s commissioners. Michelle Stickland provided the Governing Body with a brief overview of the Southampton, Hampshire and Isle of Wight Transforming Care Plan which had a population of 1.9 million people, spanning four local authorities and eight CCGs. The Governing Body noted the Southampton, Hampshire and Isle of Wight plan on page diagram. Diane Woods provided the Governing Body with a brief overview of the Surrey Transforming Care Plan which had a population of 1 million people, covered by one county council and five CCGs. The Governing Body noted the Surrey plan on page diagram. The Governing Body noted NHS England s vision and planning assumptions for children, young people in transition, people with learning disabilities and autism which stated that a full range of support would be in place across the country no later than March Surrey had already remodelled its health system and the Southampton, 8. Draft GB Minutes Public - 20 April 2016.pdf Page 4 of 9 Page 4 of 10 Overall Page 111 of 160

112 Hampshire and Isle of Wight would be in place by March The Governing Body noted the progress which had been made with these Transforming Care Plans, however, it recognised that more work was still required to ensure that care was transformed for vulnerable patients (especially those with challenging behaviours) for children, young people in transition, people with learning disabilities and autism. The Governing Body endorsed the development of the Transforming Care Plans for Surrey and Southampton, Hampshire and the Isle of Wight that were submitted to NHS England on 11 April Sign Up to Safety Pledges Emma Holden introduced the paper which provided the Governing Body with an overview of the national Sign up to Safety campaign and the five proposed North East Hampshire & Farnham CCG pledges and pledges in action. The five national and local pledges were as follows: (1) putting safety first ensure that patients and the public are central to everything the CCG does (2) continually learn actively listen, respond to and involve patients and the public in planning, design development and delivery of the service we commission (3) being honest actively promote the involvement of patients, ensure health priorities are driven by honesty and candour (4) collaborating promote a culture of reflective learning and improvement (5) being supportive identify, reduce and learn from patient safety incidents identified through incident reporting and soft intelligence. The Governing Body approved the CCG s Sign Up to Safety Pledges. 10 Hampshire and Surrey Better Care Funds Sarah McBride introduced a paper which provided the Governing Body with an update on the development of the CCG s plans, key timescales and sign off arrangements for the Hampshire and Surrey Better Care Funds. Sarah McBride summarised the background to the Better Care Fund (a national programme, announced by the Government in the June 2013 spending round which aimed to encourage the NHS and local government to work closely together around integrated services). The North East Hampshire and Farnham CCG has two Better Care Funds for its population: Hampshire (this is a county wide pooled budget between Hampshire County Council and the 5 CCGs) Surrey (this is a pooled budget with Surrey County Council and the Farnham population; there are separate pooled budgets for each CCG population) The Better Care Fund plans are expected to support the ambitions of the Five Year Forward View, linking with local plans and Sustainability and Transformation Plans. The Better Care Funds for the CCG will support its plans for the Primary and Acute Care System Vanguard model of care which is aligned with its ambition for a whole population health and care approach with a particular focus on (1) strengthening focus on self-care and prevention (2) enhancing primary care and multi-disciplinary locality teams The Better Care Fund pooled budget In Hampshire for 2016/17 will total 73.1m ( 66.2m revenue, 6.9m capital). For the CCG population of North East Hampshire, the 2016/17 revenue budget will be 9.6m. 8. Draft GB Minutes Public - 20 April 2016.pdf Page 5 of 9 Page 5 of 10 Overall Page 112 of 160

113 In Surrey for 2016/17 the Better Care Fund will total 73.1m ( 66.2m revenue, 6.9m capital). For our CCG population of Farnham, the 2016/17 revenue budget will be 2.5m. The Better Care Funds Plans have to be signed by the CCG, the Councils and the Hampshire and Surrey Health and Wellbeing Boards. The Governing Body is asked to delegate final sign off for submission on 25 th April 2016 to the Chair, Chief Officer and Chief Finance Officer of the CCG. The Governing Body approved the Better Care Funds for Surrey and Hampshire and provided its delegated authority to the Chair, Chief Officer and Chief Finance Officer, as outlined above. 11 Minutes from the meeting on 10 February 2016 The minutes of the previous meeting on 10 February 2016 were approved without amendment. The Governing Body approved the minutes of the previous meeting. 12 Action Tracker from the meeting on 10 February 2016 The Governing Body noted the completed actions from the last meeting which were shown in green. There was one remaining outstanding action relating to the Governing Body undertaking an in-depth review of Vanguard Projects and Continuing Health Care. It was noted that these issues would be discussed at a forthcoming Governing Body Seminar Session which was scheduled on 18 May 2016 the action would be updated and closed. The Governing Body noted the report. 13 Integrated Performance Report Month 10 Roshan Patel presented the Integrated Performance Report for Month 10 (performance data for January 2016 and finance data for February 2016) and briefly summarised performance against constitutional targets, Quality Innovation Productivity and Prevention (QIPP) initiatives and the financial position of the CCG. A & E performance in January was challenging and pressures continued into February and March. Frimley Health NHS Foundation Trust had met its quarter 3 targets with 95.6% - however, the Frimley Park site was significantly below target at 90.9%. Delayed Transfers of Care continued to increase at the Frimley Park site. The System Resilience Group had worked to develop an improvement plan for 2016/17 to address the current delays - this would involve a collaborative system approach between Health and Social care as part of the Better Care Fund. Diagnostic performance at Frimley Health NHS Foundation Trust had improved, however, due to delays for patients including a small number from North East Hampshire and Farnham patients at Royal Surrey County Hospital the CCG marginally missed the constitutional target in December. Royal Surrey County Hospital had been issued a remedial action plan by Guildford and Waverley CCG. Referral to Treatment waiting list continued to increase with 930 patients waiting over 18 weeks for treatment since initial referral. The CCG is currently evaluating demand and capacity as part of the 2016/17 planning process. 8. Draft GB Minutes Public - 20 April 2016.pdf Page 6 of 9 Page 6 of 10 Overall Page 113 of 160

114 Quality, Innovation, Productivity and Prevention Savings of 6.18m had been achieved in line with plan which included the recognition of 1.1m of remedial actions. The largest financial pressures were the Hampshire Continuing Health Care and prescribing costs. The Governing Body expressed its ongoing concern about South East Coast Ambulance response times and noted that the Finance & Performance Committee planned to undertake a deep-dive analysis of ambulance response times. A representative from the North West Surrey CCG (who managed the South East Coast Ambulance Coast contract on behalf of the collaborative) would be invited to provide the Finance & Performance Committee with assurances on the actions that were being taken to manage South East Coast Ambulance Service under-performance. In the event that the Finance & Performance Committee remained concerned about ambulance response times then it was agreed that Andy Whitfield would escalate the matter further and write to his opposite number at North West Surrey CCG to seek assurances on behalf of North East Hampshire and Farnham CCG. The Governing Body noted the report. 14 Governing Body Assurance Framework Roshan Patel introduced the updated Governing Body Assurance Framework. The Governing Body noted the two Red rated risks: (1) constitutional targets and (2) a new risk in respect of the management of collaborative commissioning arrangements for Children and Maternity Services and Mental Health Services. Dr Steven Clarke asked if more detailed risks around the out of hours service should be added to the Governing Body Assurance Framework. Sarah McBride confirmed that risks around the out of hours service were included within Risk 3 Providers and or Partner Failure. Following discussion, it was agreed that the Governing Body Assurance Framework would be further updated with key strategic commissioner risk data - for example more specific links to out of hours provision and accident & emergency performance would be added. Action: RP The Governing Body asked for its Sub-Committees to provide it with a greater level of assurance in respect of risk management. It was agreed that each Sub-Committee would review and update its own Risk Register. The Chairs of the respective Governing Body Sub-Committees would meet to determine the alignment of upward reporting and escalation from Committee Risk Registers onto the Governing Body Assurance Framework. This work would be co-ordinated by the Governance Team. Action: RP The Governing Body noted the paper. 15 Quality & Safety Report for March 2016 Emma Holden informed the Governing Body of the key highlights regarding quality for the period of March 2016: Safeguarding The Quality Leads for Hampshire and Surrey CCG networks continued to work together collaboratively to ensure safeguarding arrangements for children and adults. 8. Draft GB Minutes Public - 20 April 2016.pdf Page 7 of 9 Page 7 of 10 Overall Page 114 of 160

115 Transforming Care arrangement regarding adults with a learning disability who were placed out of area continued to be monitored. The CCG had established a Safeguarding Committee which would report to the Quality Improvement Committee. Serious Incidents - March 2016 The CCG had been notified by Frimley Park Hospital of 17 serious incidents between March 2015 and March 2016 which had involved a North East Hampshire and Farnham patient. A total of 7 other incidents had been reported by Surrey and Borders Partnership NHS Trust; 25 incidents by Southern Health. Emma Holden confirmed that the Quality Improvement Committee continued to monitor the ongoing problems with South East Coast Ambulance and their failure to attain the agreed performance targets set out within their contract. The Governing Body noted the positive work which had been undertaken to reduce waiting times for assessment by Sussex Partnership Child and Adolescent Mental Health Service. Complaints The CCG had a total of 5 open complaints. The Friends and Family Test The Governing Body noted the results of the published Friends and Family Test data for its 24 member practices. Practices that had submitted fewer than 5 responses were recorded as not applicable due to the limited sample size. Work was ongoing with all member practices to increase Friends and Family Test responses. Community Services The Quality Improvement Committee continued to closely monitor the ongoing concerns relating to community services commissioned by the CCG from Southern Health - in particular concerns about staffing levels at the community inpatient facility at Fleet Hospital. The Governing Body noted the report. 16 Conflicts of Interest Briefing Paper Justina Jeffs introduced the paper which updated the Governing Body on the work that was being undertaken to ensure that the CCG complied with the new Guidance on the management of Conflicts of Interest which had been issued by its external regulator NHS England From 1 st April 2016 North East Hampshire & Farnham CCG had delegated responsibility for primary care commissioning and, as such, was likely to be subject to an increased level of scrutiny regarding the management of real and perceived conflicts of interest. The Governing Body noted the actions and next steps outlined in the paper. It was agreed that further should be undertaken by a Working Group which would be led by Roshan Patel - Clinical Directors on the Governing Body would be invited to join this Conflicts of Interest Working Group. Action: RP The Governing Body approved the actions and next steps outlined in the paper. 8. Draft GB Minutes Public - 20 April 2016.pdf Page 8 of 9 Page 8 of 10 Overall Page 115 of 160

116 17 Summary Updates from Governing Body Sub-Committees The Governing Body Sub-Committee updates were noted. 18 Questions received from members of the public Cllr Mike Roberts from Rushmoor Borough Council asked the following question: What views have the CCG expressed to South Health and South East Coast Ambulance Service as to their very poor performances. Dr Andy Whitfield referred to the detailed discussions which had taken place earlier in the meeting regarding Southern Health and South East Coast Ambulance Service and in particular to the work of the Finance and Performance and the Quality Improvement Committees which were both undertaking detailed scrutiny of the issues. Cllr Roberts confirmed that his question had been adequately addressed. 19 The meeting closed at 4.30pm 8. Draft GB Minutes Public - 20 April 2016.pdf Page 9 of 9 Page 9 of 10 Overall Page 116 of 160

117 8. Draft GB Minutes Public - 20 April 2016.pdf Page 10 of 10 Overall Page 117 of 160

118 Action Tracker from: Governing Body meeting held in Public on 20 April 2016 Minute Reference 20 April 2016 Agenda Topic Summary of Action Required Responsibility for Action Due Date and Status 14 Governing Body Assurance Framework (GBAF) Triangulate key strategic commissioner risk data onto the Governing Body Assurance Framework for example add more specific links to out of hours provision and accident & emergency performance RP Key strategic risks are identified and managed through the Governing Body Assurance Framework. A new Corporate Risk Register is being developed in order to provide a more detailed analysis of risks which will underpin the strategic risks on the Governing Body Assurance Framework. Further work to be undertaken to align upward reporting / escalation from Sub-Committee Risk Registers to the Governing Body Assurance Framework. RP Action Completed. Governance Team overseeing development of the Governing Body Sub-Committee Risk Registers to ensure strong linkages and upward reporting of risks. Chairs of the Governing Body Sub-Committees are leading on discussions within their respective committees on risk management. 16 Conflicts of Information Briefing Clinical Directors on the Governing Body would be invited to join the Conflicts of Interest Working Group. RP Action complete. Two Governing Body Clinical Directors have joined the Working Group. The Working Group met on 9 th June 2016 to review the guidance requirements. An Action plan is being developed to ensure that all new requirements are met. The final guidance has not been issued from NHSE (23/6/16). Copies of the plan and final guidance will be circulated to Governing Body members. 9. Action Tracker GB public 20 April v 23 June.pdf Page 1 of 1 Overall Page 118 of 160

119 Governing Body Date of Meeting 29/06/2016 Agenda Item 10 Paper Number 10 Strategic Objective Number 3) Ensure local people receive high quality services Author Quality Team Director Sponsor Emma Holden Director of Quality and Nursing Clinical Sponsor Dr Edward Wernick Clinical Director for Quality and Patient Experience and Public Engagement Title: Executive Summary: Quality Report This report reflects the quality priority areas considered and identified through the Quality Improvement Committee and the Clinical Quality Review Meetings for all providers of care services in May To note: Four Serious Incidents uploaded onto the national database in March 2016 involving North East Hants and Farnham CCG patients. The CCG s Primary Care Operational Group will now review Friends and Family Test results on a monthly basis. Southern Health Foundation Trust staffing levels and recruitment will continue to be monitored closely given continuing challenges around permanent nursing staff numbers. The Quality Team undertook a quality visit to Calthorpe Ward in Fleet Community Hospital which gave assurance that the ward was providing safe and effective care for patients. Frimley Health presented their performance report indicating twelve 12 hour trolley beaches. Sussex Partnership Foundation Trust Child and Adult Mental Health Service have seen an increase in clinical contacts. The Care Quality Commission carried out a planned inspection of South East Coast Ambulance Service in the first week of May and the Quality Hospital Handover audit was carried out on the 2nd June. Actions/ Recommendations Other Committee(s) where this paper or supporting information have been considered Date To Approve - An item of business that requires the Governing Body to take a formal decision To Ratify - An item of business where the Governing Body is required to ratify the action(s) taken of behalf of the Governing Body, for example by a formal committee established by the Governing Body. To Discuss - An item of business that requires discussion by the Governing Body prior to agreement of a formal resolution or a general policy steer to the executive officers. X To Note - An item of business for which the Governing Body is required to give due regard to but for which there is not expected to be discussion. Supporting information for this paper will be considered at the Quality Improvement Committee on 8 th June (FINAL) Quality Report (Public) June 2016.pdf Page 1 of 11 Overall Page 119 of 160

120 Quality Report 1. Introduction 1.1. North East Hampshire and Farnham Clinical Commissioning Group have a duty to ensure continuous improvement of the quality and outcomes of the services they commission The content of this report provides a summary of key quality issues. 2. Quality Improvement Committee 2.1. The Quality Improvement Committee met on the 8 th of June The key areas considered by the Committee are detailed below: The committee received a presentation outlining a review of Children s Services for the CCGs locality. Of note the committee discussed in detail; the improved waiting times for children and adolescent mental health waiting times within Sussex Partnership NHS Trust; and the impact of the proposed closure of Children s Centres. A Serious Incident report was received and reviewed outlining the themes and learning from reported incidents in quarter four for the last financial year. The Quality and Safeguarding risk register was reviewed. 3 Safeguarding 3.1 Section 11 audit for Hampshire and Surrey Children s Safeguarding Completed and submitted. 3.2 The Safeguarding Committee met in May and June The CCG continues to work with Southern Health Foundation Trust with regards to delivery of their action plan post the Mazars report in December In partnership with the five Hampshire CCGs proposals have been made to change the recruitment criteria for the vacant Looked After Children s Doctor Position in Hampshire. The current position has been vacant for six months and despite a proactive recruitment campaign no candidates have been sourced. If the proposed changes are accepted recruitment to this position is expected. 4. Friends and Family Test 4.1. The results below show the percentage of the patients surveyed who would be happy to recommend the service to a friend or family member. NHS England is yet to publish the April 2016 Friends and Family Test data. Page 1 of (FINAL) Quality Report (Public) June 2016.pdf Page 2 of 11 Overall Page 120 of 160

121 Frimley Health NHS Foundation Trust The Trust achieved a percentage recommendation of 91% in Accident and Emergency, 97% in Inpatient services and 97.5% in Maternity services. Royal Surrey County Hospital NHS Foundation Trust The Trust achieved a percentage recommendation of 85% in Accident and Emergency, 95% in Inpatient services and 97% in Maternity services Surrey and Borders Partnership NHS Foundation Trust The Trust achieved an overall percentage recommendation of 90%. Southern Health NHS Foundation Trust Southern Health NHS Foundation Trust achieved an overall percentage recommendation of 93%. Please note that these percentages are for organisational wide performance, not that of their respective local divisions General Practice The Friends and Family Test has been expanded to include primary care services. General Practices were required to implement the test from December 2014 and NHS England has begun to publish data. The table below shows the results for the Clinical Commissioning Groups member practices in April 2016 (May data not available); Note: Practices with less than 5 responses are recorded as not applicable due to the limited sample size Practice Number of Responses % Recommended THE FERNS MEDICAL PRACTICE 8 100% DOWNING STREET SURGERY 18 94% RIVER WEY MEDICAL PRACTICE 7 100% HOLLY TREE SURGERY 31 90% FARNHAM DENE MEDICAL PRACTICE 25 80% GIFFARD DRIVE SURGERY 6 100% VICTORIA PRACTICE 39 97% THE OAKLEY HEALTH GROUP 41 90% SOUTHLEA GROUP PRACTICE No data n/a MILESTONE SURGERY 18 94% RICHMOND SURGERY No data n/a FLEET MEDICAL CENTRE 65 82% ALEXANDER HOUSE SURGERY No data n/a JENNER HOUSE SURGERY No data n/a BRANKSOMEWOOD H/CARE CTR 5 100% THE BORDER PRACTICE 6 100% Page 2 of (FINAL) Quality Report (Public) June 2016.pdf Page 3 of 11 Overall Page 121 of 160

122 PRINCES GARDENS SURGERY 34 94% MAYFIELD MEDICAL CENTRE No data n/a SOUTHWOOD PRACTICE 72 86% THE WELLINGTON PRACTICE No data n/a MONTEAGLE SURGERY No data n/a CRONDALL NEW SURGERY 9 89% NORTH CAMP SURGERY 6 100% The CCG s Primary Care Operational Group that first met in May 16 will now review Friends and Family Test results on a monthly basis with a view to trends and themes, and addressing both low scores and practices who fail to submit data on a monthly basis. The Friends and Family Test results will also feature during discussions at Practice Support Visits throughout the year. An update from the Primary Care Operational Group on the Friends and Family Test will feature in this report moving forwards. 6 Complaints & Concerns 6.1 There are 3 complaints open. All new complaints have had acknowledgment of receipt of their complaint within 3 working days. The Quality Team aims to investigate and respond to complaints within 20 working days but acknowledges that complex complaints may take longer. Each complaint is reviewed on receipt and given a completion date dependant on complexity. There have been 2 concerns raised, both regarding GP surgeries. 7 Serious Incidents 7.1 In May 2016 four Serious Incidents have been reported involving North East Hampshire and Farnham patients. Seventeen other incidents have been reported by providers for whom the Clinical Commissioning Group is the host commissioner. 8 Themes / learning 8.1 From May 2015 to the end of May 2016 Frimley Park Hospital have recorded a total of 38 incidents including 4 never events. 20 incidents reported by Frimley Park Hospital involved North East Hampshire and Farnham Clinical Commissioning Group patients. All Serious Incidents continue to be monitored and closed through the Serious Incident Panel on a monthly basis. 8.2 From May 2015 to the end of May 2016 Surrey and Borders Partnership Trust have recorded a total of 114 incidents; the primary incident type is Apparent/actual/suspected self-inflicted harm meeting SI criteria. A total of 9 incidents reported by Surrey and Borders Partnership NHS Trust involved North East Hampshire and Farnham Clinical Commissioning Group patients. Page 3 of (FINAL) Quality Report (Public) June 2016.pdf Page 4 of 11 Overall Page 122 of 160

123 8.3 From May 2015 to the end of May 2016 Sussex Partnership Foundation Trust Child and Adolescent Mental Health Service (CAMHS) have recorded a total of 10 incidents, one of which involved a patient of the North East Hampshire and Farnham Clinical Commissioning Group. 9 Clinical Quality Review Meetings Key issues arising from Clinical Quality Review Meetings include: 9.1 Acute Services Frimley Health NHS Foundation Trust - Frimley Park Hospital (FPH) Site (Lead Commissioner) Good News Stories CQC have posted a you tube clip of Frimley Park Hospital demonstrating excellent leadership skills as a Trust ( Frimley Health as a trust has had more members of staff starting with the trust than leaving. The trust has been working to remove all agency staff and has agreed enhanced rates to encourage bank staff. Junior Doctor Strike From the junior doctor strikes there were lessons to be learned and things that could be done differently. It highlighted that more senior doctors were needed on the front line especially during winter. It was noted that the numbers of patients attending A&E were reduced during the strike with no increase in activity for General Practitioners. End of Life Frimley Park Hospital presented their End of Life One Chance to get it Right strategy. There is a new care plan which is due to be launched in August 2016 to coincide with the start of new doctors and nurses. This would be launched with a trust wide approach. The plan would be audited twice yearly. End of life training is included in the corporate induction for all staff members, clinical and non-clinical and has had positive feedback. Work was ongoing to align written information across Frimley Health. The trust had secured funding for enhanced communication training for bands 7 and 8 staff members. Staff at other levels would receive basic training to improve communication skills. 12 Hour Trolley Breaches At the Contract Review Meeting on the 10 th May, Frimley Health presented their performance report indicating twelve (12) x 12 hour trolley beaches which had occurred in March These are a direct breach of the National Quality Requirements as set out in the Standard National Contract 2015/16. These had not been reported to the CCG as lead commissioner for the contract. A contract performance notice was issued and to ensure patient safety had not been compromised, the CCG have requested a root cause analysis be conducted. Page 4 of (FINAL) Quality Report (Public) June 2016.pdf Page 5 of 11 Overall Page 123 of 160

124 Unfortunately, Frimley Park Hospital have had a further three more 12 hour trolley breaches which are being monitored through the Contract Review Meeting and the Clinical Quality Review Meeting. The commissioners will continue to work with the provider to ensure we understand the issues to prevent further re-occurrence. 9.2 Community Services Southern Health NHS Foundation Trust - North East Division (Local Contract) Calthorpe Ward, Fleet Community Hospital Staffing - The Trust continue to experience significant gaps in trained nurses at the community inpatient facility at Fleet Hospital. May s Clinical Quality Review Meeting saw a focus on Calthorpe Ward, the community rehabilitation ward at Fleet Hospital. The CCG s Quality Team conducted an announced visit to the ward on 18 May and the Trust s Area Manager and Divisional Clinical Director followed this up with an unannounced visit on 19 May. The Trust also provided a review on Calthorpe Ward at the Clinical Quality Review Meeting covering key achievements, areas for development, key quality indicators, occupancy and delayed transfers of care, length of stay, incidents, patient experience and staff levels. Both visits to the ward, feedback from CCG GPs, the presentation and subsequent discussion revealed a number of lower level areas for improvement but overall reported that the ward provides safe and effective care to patients. Staffing levels and recruitment will continue to be monitored closely given continuing challenges around permanent nursing staff numbers. Virgin Care Services Limited (North West Surrey Clinical Commissioning Group are the lead commissioners) Band 6 District Nurse Leadership Programme The Surrey nursing team nominated in the Leadership category at the Royal College of Nursing s RCNi awards was announced as the winner. Tracy Harman, the lead nurse for the programme has also been featured in the Nursing Standard magazine and the June edition of Nurse Management. This programme will be run again in the autumn and is also being adapted for Band 5 nurses. Internal CQC Review, Farnham Community Nursing As part of their internal CQC review programme, the Farnham Community Nursing Team received a Good rating. Areas of good practice included good documentation and use of Total Mobile, excellent team working at handovers and general support and all staff being up to date with appraisals. Areas for improvement included awareness of business continuity and increasing completion rates of mandatory training. 9.3 Mental Health Services North East Hampshire and Farnham Clinical Commissioning Group is the lead commissioner for Adult Mental Health Services for the Surrey Six Clinical Page 5 of (FINAL) Quality Report (Public) June 2016.pdf Page 6 of 11 Overall Page 124 of 160

125 Commissioning Groups Collaborative and for Child and Adolescent Mental Health Services (CAMHS) for the Hampshire Five Clinical Commissioning Groups. Sussex Partnership Child and Adolescent Mental Health Service (Hampshire) An increase in clinical contacts - In April 2016 the total first and follow-up appointments offered in our area by Sussex Partnership Child and Adolescent Mental Health Service (Hampshire) was 611. This compares to 463 in April 2015 and 343 in April This increase in activity correlates with the investment Commissioners made to support the waiting list reduction. Waiting Times - Across Hampshire Sussex Partnership Child and Adolescent Mental Health Service (Hampshire) continues to prioritise reducing waiting times for assessment and treatment. However, they are finding this challenging in the context of the recent cap on agency spending which has been introduced nationally. This is impacting on their ability to fill vacancies short term and retaining agency staff to support the waiting list initiative. The table below shows the current waiting times in our CCG area. Please note that the contractual target for 2015/16 was 8 weeks for assessment and 18 weeks for treatment. Since April these targets have become 4 and 8 respectively. Waiting Times For Assessment (from Referral) For Treatment (from Referral) Referrals received up to 31/03/2016 Referrals received since 01/04/2016 Referrals received up to 31/03/2016 Referrals received since 01/04/ weeks weeks weeks weeks weeks weeks Total Average wait in weeks Surrey and Borders Partnership NHS Foundation Trust (Adult Mental Health Services for the Surrey Clinical Commissioning Groups and Child and Adult Mental Health Services for Farnham) At North East Hampshire and Farnham CCG s last Quality Improvement Committee meeting in May the relatively high number of Serious Incidents for Surrey and Borders Partnership NHS Foundation Trust in April 2016 was noted. See graph below: Page 6 of (FINAL) Quality Report (Public) June 2016.pdf Page 7 of 11 Overall Page 125 of 160

126 Serious Incidents Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 Assurance around these figures was sought at the May Serious Incident Review Panel. The Trust said that the increase in Serious Incidents was a consequence of their recently introduced mortality assurance processes. This new process, which includes searching the Spine, was identifying deaths that they may otherwise not have been aware of. Some of these deaths met the Serious Incident criteria. The Spine is a collection of national applications, services and directories which support the health and social care sector in the exchange of information in national and local Information Technology systems. The majority of the April Serious Incidents (ten) were unexpected deaths, of which two occurred in April. Only one of the unexpected deaths involved a person from our CCG area. The Serious Incident Review Panel saw the new process as a positive piece of work. South East Coast Ambulance Service (999) North West Surrey Clinical Commissioning Group are the lead commissioners for Surrey for this contract Unified Recovery Plan South East Coast Ambulance Foundation Trust Service submitted the first draft of their unified recovery plan. Overall Commissioners felt it required significant refinement as it does not have the detail or granularity which we would have expected to see against each action. It appears not to have robust clear actions for the concerns which was raised, and the plan fails to address some of the key quality requirements that have been clearly defined, with the focus being on mitigation for poor performance across the 999 and 111 services. Commissioners are engaging with South East Coast Ambulance Foundation Trust Service in order to support the delivery of their performance trajectory, while still offering reassurance to commissioners that not only performance is improving but that patient care is not suffering as a result of the lower levels of performance. There is particular concern to the current on-going lack of assurance in relation to governance, risk assessment, grading and mitigation linked to patient care delivery Page 7 of (FINAL) Quality Report (Public) June 2016.pdf Page 8 of 11 Overall Page 126 of 160

127 and decision making. It is disappointing that given the length of time since this issue was raised, that it is not adequately addressed as to how this element will gain rapid improvement. CQC carried out a planned inspection of SECAmb in the first week of May; commissioners have not yet received feedback from following the inspection. SECAmb expect to get written feedback from CQC by May 20 th, and plan to arrange a meeting with commissioners following this to give feedback and advice on next steps. Quality Hospital Handover audit was carried out on the 2nd June 2016 the planned visit allowed the Quality Lead to ascertain areas of improvement in patient handover in Accident and Emergency at Frimley Park Hospital. A further planned visit is to be scheduled, in order to gain further detail analysis when the department is at full activity. The contract for 2016/17 is now signed with outstanding items due for completion by the longstop of the end of June 2016 South Central Ambulance Service (111) (Portsmouth Clinical Commissioning Group are the lead commissioners for this contract) The weekly report noted that South Central Ambulance Service (111) achieved Top 5 Best Performing 111 providers in the region on the week of 23 rd May. There are no escalations this month. CQC planned visit to South Central Ambulance Service NHS Foundation Trust will take place in May 2016, this visit will also include the NHS 111 service feedback report will be given in June 2016 North Hampshire Urgent Care After a long period of working with RADAR to develop a bespoke risk management system, North Hampshire Urgent Care (NHUC), in conjunction with East Berkshire Out of Hours to share the costs, NHUC is planning to give notice to this work as it has failed to deliver as expected and hoped for. North Hampshire Urgent Care (NHUC) are planning to undertake the use of Datix for their risk management system. NHUC is ready to take up its role within access to Child Protection-Information System (CP-IS) and is liaising with appropriate parties to ensure this happens. The target date for this has moved to July 2016 due to Health & Social Care Information Centre, and Clinical Patient Management Systems (Adastra). NHUC understands (Adastra) will link directly to the CP-IS however there is a pressing matter that needs to be addressed as to whether the clinicians will have to use smartcards. Page 8 of (FINAL) Quality Report (Public) June 2016.pdf Page 9 of 11 Overall Page 127 of 160

128 Combining the Contract Review Meeting & Clinical Quality Review Meeting The proposed joint meetings have now merged and the final Terms of Reference have been distributed to the members. The combining of the Contract Review Meeting and the Clinical Quality Review Meeting will commence from September Care Homes The Care Quality Commission has not published any new reports on care homes within North East Hampshire and Farnham CCG within the last month. The care home forum is due to take place on 13 th medication and the risk of falls in elderly people. July 2016 with the theme of 11 Primary Care The table below sets out the most recent findings of primary care Care Quality Commission inspections. New Style Inspections Practice Overall Safe Effective Caring Responsive Well Lead Crondall New Surgery Farnham Dene Medical Practice Ferns Medical Practice (The) Border Practice (The) Fleet Medical Centre Giffard Drive Surgery Jenner House Surgery Monteagle Surgery Princes Gardens Surgery Richmond Surgery Victoria Practice North Camp Surgery Alexander House Surgery Branksomewood Healthcare Centre Good Good Good Good Good Good Good Requires Improvement Good Good Good Good Good Good Good Good Outstanding Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Requires Improvement Requires Improvement Outstanding Good Outstanding Outstanding Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Good Requires Improvement Requires Improvement Good Good Good Requires Improvement Good Good Good Good Good Good Requires Improvement Good Good Requires Improvement Requires Improvement Requires Improvement Good Good Good Requires Improvement Good Good Good Good Good Good Good Good Page 9 of (FINAL) Quality Report (Public) June 2016.pdf Page 10 of 11 Overall Page 128 of 160

129 12 Recommendations The Governing Body is requested to consider and note the report. Page 10 of (FINAL) Quality Report (Public) June 2016.pdf Page 11 of 11 Overall Page 129 of 160

130 Governing Body Date of Meeting 29 June 2016 Agenda Item 11 Paper Number 11 Strategic Objective Number Author Lisa Mercer/Ollie White Assistant Chief Finance Officer Director Sponsor Clinical Sponsor 3 support delivery of CCG Strategy 4 implement 5 year plan Roshan Patel Chief Finance Officer n/a Title: Integrated Performance Report Month 1-12 Executive Summary: To report to the Governing Body on performance for the Clinical Commissioning Group for the period from April 2015 to March This includes: Performance Indicators including performance against the NHS Constitution targets 2015/16 Improvement Programmes including Quality Innovation Productivity and Prevention (QIPP) initiatives and other savings Financial position o o o o Income and expenditure Contract performance Running costs Financial risks and mitigations The Governing Body is asked to: Review and note the performance for the period as set out in the report. Actions/ Recommendations Other Committee(s) where this paper or supporting information have been considered Date 16 June 2016 To Approve - An item of business that requires the Governing Body to take a formal decision To Ratify - An item of business where the Governing Body is required to ratify the action(s) taken of behalf of the Governing Body, for example by a formal committee established by the Governing Body. To Discuss - An item of business that requires discussion by the Governing Body prior to agreement of a formal resolution or a general policy steer to the executive officers. To Note - An item of business for which the Governing Body is required to give due regard to but for which there is not expected to be discussion. The Paper has been reviewed by the following: Finance and Performance Committee X 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 1 of 24 Overall Page 130 of 160

131 OPERATIONAL PERFORMANCE Page 1 INTEGRATED PERFORMANCE REPORT 2015/16 Monitoring Report Covering the following period: Performance - March 2016 Finance - March (FINAL) Integrated Performance Report month 1 GB.pdf Page 2 of 24 Overall Page 131 of 160

132 EXECUTIVE SUMMARY Page 2 1 Executive Summary 1.1 This report covers financial data to April 2016, and performance data to March Key achievements 2015/16 Financial position successfully delivered, with the CCG achieving a surplus of 3.93m in line with plan 92.1% of CCG patients have been waiting for less than 18 weeks for treatment Delivery of Mental Health Access standards Key challenges facing the Organisation Cap & Collar agreement not agreed with Frimley Health for 2016/17, with the contract reverting to a standard PbR arrangement which will not mitigate the organisation against failure to deliver its QIPP/demand management programmes Ongoing growth in Continuing Healthcare expenditure in Hampshire Patient flow through Frimley Health resulting in poor performance against the 4 hour A&E target and increased numbers of delayed transfers of care. For the first time in 2 years, in March 12 patients waited at the Frimley Park site for more than 12 hours in A&E. Ambulance response times continue to fail to meet NHS Constitutional requirements Continued delays for patients waiting for a diagnostic test at Royal Surrey County Hospital resulting in the CCG missing its NHS Constitutional requirement The number of patients waiting for treatment continues to increase for our CCG although access to treatment is being held marginally above the constitutional requirement 1.2 This report contains the latest information available. Financial information is subject to audit. 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 3 of 24 Overall Page 132 of 160

133 PERFORMANCE AT A GLANCE Page 3 Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel Q U A L I T Y P E R F O R M A N C E Friends and Family Test Score Friends and Family Test (Response Rate) % 15.0% 24.2% 22.6% 23.8% 23.7% 24.5% Mixed Sex Accomodation Breaches No MRSA bacteraemia (CCG) No Clostridium Difficile (CCG) No MRSA bacteraemia (FPH) No Clostridium Difficile (FPH) No weeks referral to treatment times - admitted % 90.0% 73.8% 69.6% 69.3% 69.3% 80.5% 18 weeks referral to treatment times - non-admitted % 95.0% 82.5% 83.9% 83.0% 83.0% 89.2% 18 weeks referral to treatment times - incompletes % 92.0% 92.3% 92.1% 92.1% 92.1% 93.5% Number of incomplete patients w aiting more than 52 w eeks No Cancer: 2 w eek breast symptoms % 93.0% 93.6% 96.2% 100.0% 96.3% 94.8% Cancer: 2 w eek urgent GP referral % 93.0% 94.9% 95.8% 95.5% 95.4% 95.4% Cancer: 31 days diagnosis to treatment % 96.0% 97.4% 92.4% 98.8% 96.3% 97.9% Cancer: 31 days subsequent treatment - Chemo/Drug % 98.0% 100.0% 100.0% 100.0% 100.0% 99.7% Cancer: 31 days subsequent treatment - radiotherapy % 94.0% 100.0% 97.6% 96.6% 97.9% 96.8% Cancer: 31 days subsequent treatment - surgery % 94.0% 100.0% 94.1% 92.9% 95.5% 96.4% Cancer: 62 days screening referral % 90.0% 92.3% 83.3% 100.0% 92.1% 94.2% Cancer: 62 days urgent referral to treatment % 85.0% 90.0% 75.0% 71.4% 80.0% 85.5% Cancer: 62 days consultant decision to upgrade % 86.0% 100.0% 100.0% 100.0% 100.0% 82.6% Diagnostics 6 week w aits % 1.0% 1.3% 1.4% 1.0% 1.0% 1.0% GP Referrals No. 35,769 3,375 3,666 3,800 10,841 39,558 Total Elective Spells No. 26,768 2,264 2,357 2,300 6,921 26,227 Total Outpatient Attendances No. 174,185 17,029 16,871 16,612 50, ,063 Key: NHS Constitution Quality Premium Both1 Last 3 Months Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel A&E 4 hour w ait (FHFT) % 95.00% 92.31% 92.28% 90.43% 91.64% 94.67% A&E Attendances No. 63,341 5,172 5,059 5,546 15,777 62,777 P Non-Elective spells - all specialties E No. 23,422 1,916 1,963 2,100 5,979 23,338 R Category A 19 minute transportation time (SECAmb) % 95.00% 93.53% 91.33% 88.44% 91.14% 93.93% F Category A Red 1 Ambulance response times (SECAmb) O % 75.00% 71.99% 65.45% 62.57% 66.93% 71.68% R Category A Red 2 Ambulance response times (SECAmb) % 75.00% 62.79% 57.68% 50.48% 57.07% 68.21% M Delayed transfers of care w ith NHS responsibility A Days 3, ,514 5,206 Proportion of older people (65 and over) w ho w ere still at N home 91 days after discharge into rehabilitation and offered % C Estimated Diagnosis rate for people w ith dementia E % 70.0% 66.4% 66.4% 67.1% 67.1% 67.1% Improving access to psychologial therapy - roll out % 6.3% 29.7% 26.9% 25.0% 27.2% 20.5% Q I P P W O R K F O R C E Last 3 Months Improving access to psychologial therapy - recovery rate % 50.0% 48.5% 57.8% 46.6% 51.0% 49.9% Prevention & Self Care QIPP, (35) (40) Urgent & Integrated Care QIPP,000 2,239 5 (121) (275) Planned & Specialist Care QIPP,000 3, (364) (2) 423 Other QIPP Schemes,000 1, ,750 6,935 TOTAL QIPP,000 7, ,157 7,604 Permanent Staff in Post FTE Staff Turnover % 11.0% 12.7% 12.6% 13.9% 13.9% 13.9% Sickness Rate % 3.5% 3.2% 4.4% 3.8% 3.7% 2.5% Statutory & Mandatory Training % 85.0% 29.4% 29.4% 29.4% 29.4% 29.4% Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel F I N A N C E Last 3 Months Programme Expenditure, ,209 20,400 20,292 22,149 62, ,242 Running Costs,000 4, ,186 4,694 Surplus / (Deficit),000 2, ,695 3,926 Vanguard Expenditure,000 3, ,755 2,609 3,383 Better Payment Code % 95.0% 93.5% 95.7% 0.0% 94.7% 95.0% Capital Expenditure, (FINAL) Integrated Performance Report month 1 GB.pdf Page 4 of 24 Overall Page 133 of 160

134 QUALITY Page 4 2 Quality Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel Q U A L I T Y Last 3 Months Friends and Family Test Score Friends and Family Test (Response Rate) % 15.0% 24.2% 22.6% 23.8% 23.7% 24.5% Mixed Sex Accomodation Breaches No MRSA bacteraemia (CCG) No Clostridium Difficile (CCG) No MRSA bacteraemia (FPH) No Clostridium Difficile (FPH) No Frimley Health NHS Foundation Trust has further divided this threshold to be site specific: Frimley Park Hospital (FPH) site 11 Heatherwood and Wexham Park site 20 C.Diff DH Li mi t Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Tota l FHFT RSCH NEHF Mixed Sex Accommodation Breaches There have been no mixed sex accommodation breaches this month. Although Frimley Health have had 39 cases of C-Diff, for the target of the lapses in care Frimley Park Hospital have had 10 out of a target of MRSA Bacteraemia The nationally set threshold for 2015/16 remains zero tolerance. 2.4 Care Quality Commission Outcome of published reviews released in past month MRSA DH Limit Apr- 15 May- 15 Jun- 15 Jul- 15 Aug- 15 Sep- 15 Oct- 15 Nov- 15 Dec- 15 Jan- 16 Feb- 16 Mar- 16 Total Nursing/Residential Home: Manor Place Nursing Home: FHFT RSCH NEHF No cases of MRSA Bacteraemia reported during the past month. 2.3 Clostridium Difficile (C.Diff) The DH thresholds for 2015/16 for C Diff acquisition have been set at: North East Hampshire and Farnham CCG member practices - 33 Frimley Health NHS Foundation Trust- 31 Royal Surrey County NHS Foundation Trust - 21 Concerns included: Safe The provider s recruitment procedure was not sufficiently robust and action was taken following the inspection to meet regulatory requirements. Environmental risks were not always managed safely because regular equipment checks were not in place. Effective The service was found to be mostly effective. Training in mandatory 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 5 of 24 Overall Page 134 of 160

135 QUALITY Page 5 topics had not been completed by all staff. Actions to address this were planned to ensure people s needs were met. Nursing/Residential Home: Freeland s Croft Nursing Home: Concerns included Safe - The service was not consistently safe. Some improvements were still needed to ensure people s medicine administration records were completed promptly. The provider was also still working at improving the coordination of shifts. Effective The service was not consistently effective. Staff supervision and appraisals needed to become routine. People s decision specific mental capacity assessments were not always recorded in people care plans. Responsive The service was not consistently responsive. The service was still making changes to the activities programme for people to ensure it met the social and recreational needs of people living with dementia. Well-led The service was not consistently well-led. Improvements to the management and running of the service were evident and staff had a better understanding of their roles and responsibilities. 2.5 Serious Incidents Sussex Partnership Jan-16 Feb-16 Mar-16 CAMHS Top four themes for 2015/ 2015 Slips / trips / falls (Frimley Park Hospital) Apparent/actual/suspected self-inflicted harm (Surrey& Borders NHS Trust) Failure to obtain or lack of an appropriate bed (Sussex Partnership NHS Trust) Pressure ulcers meeting serious incident criteria (Southern Health Foundation Trust) 2.5 Items to Note Frimley Park Hospital Surrey and Borders Partnership Southern Health (NED) The closure of Colgate s Nursing Home continues as planned. No quality issues flagged. In April Care Quality Commission (CQC) issued Southern Health NHS Foundation Trust with a warning notice to improve its governance arrangements. The notice sets out the necessity for the Trust to ensure that robust investigations and learning occur following on from incidents and deaths. o Monitor subsequently stated that they intend to put in place an additional condition on the Trusts license to provide NHS Services. o Local concerns includes staffing, and timeliness of investigations Two local practices have also received Requires Improvement outcomes following Care Quality Commission inspections, Richmond Surgery and North Camp Surgery. 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 6 of 24 Overall Page 135 of 160

136 U R G E N T & I N T E G R A T E D C A R E OPERATIONAL DELIVERY Page 6 3 Operational Delivery This section of the report provides an update on the operational performance of the CCG including progress against the six improvement programmes. Targets are based on a combination of nationally set targets, CCG targets as set out in the 2015/16 operating plan, and historical performance. A summary of key drivers for variance from plan, actions and updates on previous actions are provided below on an exception basis. 3.1 Urgent Care Constitution Targets Last 3 Months Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel A&E 4 hour w ait (FHFT) % 95.00% 92.31% 92.28% 90.43% 91.64% 94.67% Category A 19 minute transportation time (SECAmb) % 95.00% 93.53% 91.33% 88.44% 91.14% 93.93% Category A Red 1 Ambulance response times (SECAmb) % 75.00% 71.99% 65.45% 62.57% 66.93% 71.68% Category A Red 2 Ambulance response times (SECAmb) % 75.00% 62.79% 57.68% 50.48% 57.07% 68.21% Trolley w aits in A&E not longer than 12 hours (FHFT) No years with them all occurring at the Frimley Park site. The Trust has sited patient volumes, coupled with bed shortages and staff sickness. The Quality team have been made aware of 3 of the cases and work is underway to understand the remaining cases Category A Ambulance response times SECAmb performance for Red 1 and 2 calls has continued to deteriorate into March 2016, as the service continues to struggle with recruitment and is impacted upon by handover delays at Emergency Departments across the region. A new recovery plan and trajectory is being negotiated with North West Surrey CCG, as the lead commissioners for this contract, with a deadline set for 13 th May SECAmb are now also implementing their Immediate Handover Procedure, in line with other ambulance trusts, and North East Hampshire and Farnham CCG are working alongside Frimley Park Emergency Department to understand and reduce handover times locally. The service is currently being inspected by CQC and both Monitor and NHS England are actively monitoring performance of the trust A&E 4 hour wait Urgent Care - Supporting Measures Performance against the A&E 4 hour target continues to be a significant challenge for the Frimley Health system, with flow through the Frimley Park site the main cause of the deterioration as highlighted by the increase in delayed transfers of care. Unvalidated data for April shows that the Trust is unlikely to have met the target, although performance through the early weeks of May has improved. Work is being undertaken within Vanguard and the SRG to develop a series of project to help to alleviate the challenges including working with the out of hour s provider North Hampshire Urgent Care, and with the three primary local authorities to reduce delays through the Trust. The Vanguard programmes are also looking at increasing GP input into the Trust to help improve discharge Hour trolley waits in A&E In March Frimley Health NHS Foundation Trust reported 12 patients that waited in A&E for more than 12 hours. This is the first time the Trust has had breaches in the past 2 Last 3 Months Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel U A&E 4 hour w ait (FHFT South) % 95.00% 90.94% 90.76% 87.92% 89.81% 93.77% R G E A&E 4 hour w ait (FHFT North) % 95.00% 93.56% 93.69% 92.80% 93.34% 95.52% N T A&E Attendances No. 63,341 5,172 5,059 5,546 15,777 62,777 & I Non-Elective spells - all specialties No. 23,422 1,916 1,963 2,100 5,979 23,338 N T E Delayed transfers of care - Days Days 5, ,235 7,888 G R A Delayed transfers of care - Patients Patients T E D Delayed transfers of care w ith NHS responsibility Days 3, ,514 5,206 C A Total 999 Activity No. 27,645 2,339 2,208 2,470 7,017 26,981 R E Delayed Transfers of Care Delayed transfers of Care at Frimley Park hospital have significantly increased through 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 7 of 24 Overall Page 136 of 160

137 OPERATIONAL DELIVERY Page /16, with patients living in Hampshire causing the greatest increase in delay. Analysis undertaken suggests that this is in part due to the increased number of emergency admissions into the Trust, but is also due to the timeliness of processing continuing healthcare applications and the ability to source nursing home placements. The CCG have developed an action plan and will be discussed as part of local planning with the Frimley System Resilience Group. where issues can be escalated regarding performance of the service. This group will lead on drafting a CHC service specification in June 2016 with input from the 5 Hampshire CCGs. A performance scorecard has been designed and the CHC QA+ database is now live meaning that NEHF CCG can access CHC data and run performance reports locally. For 2016/17 the CCG have developed a trajectory to reduce the rate of delayed transfers of care at the Trust back to the nationally set rate of 3.5%, from current performance levels at 3.9% Continuing Health Care Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel C O N T I N U I N G H E A L T H C A R E Hampshire CHC,000 10,152 1,017 1, ,972 12,042 Surrey CHC,000 2, ,349 Hampshire FNC,000 2, ,463 Surrey FNC, Other Continuing Care services, Delayed transfers of care due to aw aiting assessment or care package in ow n home Last 3 Months Days 2, ,174 Continuing Healthcare QIPP, Continuing Health Care for North East Hampshire patients continues to be a key financial risk for the CCG and a number of work programmes are in place to understand and mitigate the issues as well as support the delivery of the 2016/17 QIPP Programme. A deep dive presentation for CHC is planned for the June 2016 Finance and Performance meeting to explore current issues and actions taken to address. Two new fixed term CHC posts will start in June 2016 to lead our work to realise further savings against our QIPP and lead our plans for the local transformation and integration of CHC. West Hampshire CHC has introduced monthly Performance and Governance meetings 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 8 of 24 Overall Page 137 of 160

138 P L A N N E D & S P E C I A L I S T C A R E OPERATIONAL DELIVERY Page Planned Care Constitutional Targets Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel 18 weeks referral to treatment times - admitted % 90.0% 73.8% 69.6% 69.3% 69.3% 80.5% 18 weeks referral to treatment times - non-admitted % 95.0% 82.5% 83.9% 83.0% 83.0% 89.2% 18 w eeks referral to treatment times - incompletes % 92.0% 92.3% 92.1% 92.1% 92.1% 93.5% Number of incomplete patients waiting more than 52 w eeks No No urgent operation should be cancelled for a second time (FHFT) Diagnostics 6 Week Waits Diagnostic performance for patients treated at Frimley Health NHS Foundation Trust continues to meet national standards. Performance at Royal Surrey however continues to deteriorate as a result of lost MRI capacity resulting in the CCG failing to achieve the target. As part of the remedial action plan agreed with Frimley at the end of 2015 the CCG committed to working with Frimley to develop a sustainability plan for diagnostics and has also agreed to expand the access to ultrasound diagnostics provided by Inside Vue in Farnham to our entire population. 2016/17 activity plans have also been set to reflect continued growth in this area weeks RTT performance incompletes No. Last 3 Months Diagnostics 6 week waits % 1.0% 1.3% 1.4% 1.0% 1.0% 1.0% The number of patients waiting for treatment continues to increase for our CCG although access to treatment is being held marginally above the constitutional requirement. 2016/17 contracts are being finalised and activity levels commissioned reflect sufficient levels to maintain performance above target. The CCG have identified a number of areas where Frimley benchmark high for activity levels and are working with the Trust to normalise this activity in order to release capacity. replacement, are the key sub specialties driving this pressure. General Surgery and Urology are the other two failing specialties at the Trust. There are currently 25 patients waiting of 36 weeks for treatment, 11 of these are waiting in the Trauma & Orthopaedics specialty, with further patients waiting for ENT, and Plastic Surgery Planned Care Supporting Measures Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel P L A N N E D & S P E C I A L I S T C A R E Daycase elective spells - G&A No. 22,345 1,879 1,952 1,879 5,710 21,502 Ordinary elective spells - G&A No. 4, ,211 4,725 Total Elective Spells No. 26,768 2,264 2,357 2,300 6,921 26,227 All first outpatient attendances No. 55,966 6,022 6,004 6,022 18,048 66,280 All subsequent specialties No. 118,219 11,007 10,867 10,590 32, ,783 Total Outpatient Attendances No. 174,185 17,029 16,871 16,612 50, ,063 GP Referrals No. 35,769 3,375 3,666 3,800 10,841 39,558 Other Referrals No. 17,549 1,482 1,510 1,558 4,550 19, GP Referrals Last 3 Months Frimley Health has implemented a referral triage service for Trauma and Orthopaedics and this appears to have resulted in duplicate referrals being reported. The CCG have queried the legitimacy of these referrals and are awaiting a response from the Trust. Excluding this activity reduces GP Referrals to growth of 3% which is in line with planned levels with Cancer two week rules continuing to improve with a 15% increase compared to last year. Non-two-week rule referrals are currently tracking marginally above our assumed demographic growth assumption of 1.5% at 1.8% compared to 2014/15. 3 Specialties are failing to meet the RTT target at Frimley Health with Trauma & Orthopaedics continuing to be the most challenged specialty. Frimley Park have advised that patients waiting for spinal surgery, total knee replacement and total hip 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 9 of 24 Overall Page 138 of 160

139 OPERATIONAL DELIVERY Page Achievement of the 8 Constitutional Cancer targets Last 3 Months Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel P L A N N E D & S P E C I A L I S T C A R E Cancer: 2 w eek breast symptoms % 93.0% 93.6% 96.2% 100.0% 96.3% 94.8% Cancer: 2 w eek urgent GP referral % 93.0% 94.9% 95.8% 95.5% 95.4% 95.4% Cancer: 31 days diagnosis to treatment % 96.0% 97.4% 92.4% 98.8% 96.3% 97.9% Cancer: 31 days subsequent treatment - Chemo/Drug % 98.0% 100.0% 100.0% 100.0% 100.0% 99.7% Cancer: 31 days subsequent treatment - radiotherapy % 94.0% 100.0% 97.6% 96.6% 97.9% 96.8% Cancer: 31 days subsequent treatment - surgery % 94.0% 100.0% 94.1% 92.9% 95.5% 96.4% Cancer: 62 days screening referral % 90.0% 92.3% 83.3% 100.0% 92.1% 94.2% Cancer: 62 days urgent referral to treatment % 85.0% 90.0% 75.0% 71.4% 80.0% 85.5% Cancer: 62 days consultant decision to upgrade % 86.0% 100.0% 100.0% 100.0% 100.0% 82.6% Patients waiting 104 days for cancer treatment At the end of April Frimley reported 6 patients waiting across the entire Trust a steady improvement compared to performance through January to March. The CCG are working with the Trust to ascertain the drivers for this increase and Frimley will be undertaking a Root Cause Analysis after the patient has been treated. The England average is holding steady between 8-9 patients. 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 10 of 24 Overall Page 139 of 160

140 OPERATIONAL DELIVERY Page Prescribing budget update Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel P R E S C R I B I N G Last 3 Months PPSA Prescribing,000 27,797 2,481 2,358 2,416 7,255 29,104 Central Drugs, ONPOS Dressings, Oxygen, Prescribing QIPP,000 1,008 (70) risk patients with AF by utilising the GRASP-AF risk stratification tool. Identifying additional AF patients at risk of stroke will increase the prescribing of anticoagulants however it is hoped that better anticoagulation will reduce stroke admissions and make long-term cost savings Antimicrobial prescribing The CCG is currently below target for both Antibiotic Quality Premium indicators; antibacterial items/star-pu for the 12 months to February 2016 has reduced by 1% or greater and % items of the 4C s antibiotics is below the target amount of 11.3%. This update was written on the 12th May 2015, at which time the full year to date prescribing data was not available. A full summary of this will be available in next month s Integrated Performance Report. In February actual spend increased by 10% compared to February 2015, the national increase in the same period was 6%. Cost/ASTRO-PU was up by 9% compared to 4% national in the same period of time. Key growth areas are in drugs in diabetes (16% vs 13% national), anticoagulants (58% vs 48%). Whilst prescribing on diabetes has increased, data from the LSC Diabetes audit has shown an increase in the number of type 2 and type 1 patients under 55 years reaching a target of HbA1c < 60mmol/mol. Whilst benefits on mortality and morbidity and any outcome benefits will not be seen for many years. Any reduction in HbA1c is likely to reduce the risk of complications, with the lowest risk being in those with HbA1c values in the normal range. Within anticoagulants the newer oral anticoagulant drugs (NOACs) the Cost/ASTO-PU has increased by 82% vs 87% nationally. Latest data from the NHS Medicines Optimisation Dashboard to February 2016 shows that for the CCG, NOAC items made up 12.74% of all anticoagulant items prescribed. This is still lower than the Wessex average of 21% and the England average of 19%. The Medicines Management team are continuing to work with practices to identify at Selected CCG: Selected CCG Current Value England CCGs median NORTH EAST HAMPSHIRE AND FARNHAM Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 #### #### #### #### #### #### #### #### #### #### /16 Target Value (FINAL) Integrated Performance Report month 1 GB.pdf Page 11 of 24 Overall Page 140 of 160

141 OPERATIONAL DELIVERY Page 11 Indicator Savings Generic atypical antipsychotics 31,034 Sip feeds 12,955 Selected CCG: Selected CCG Current Value England CCGs median NORTH EAST HAMPSHIRE AND FARNHAM Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb Savings to date /16 Target Value 10.4 For the financial YTD (April 2015 February 2016), the following savings have been made across a range of indicators compared to expenditure for the same period in the previous year (this list is not definitive). The areas in yellow were dedicated medicines management projects or areas of work completed in 2015/ below Oral Nutritional Supplementation 12,955 Generically available dementia drugs 8,677 Low cost generic angiotensin receptor blockers 7,207 Generic breast cancer drugs 4,327 Omega-3 and other fish oils 4,254 Antifungal nail paint 3,324 Amiodarone 2,673 Prednisolone standard tablets 2,156 Ezetimibe & Ezetimibe with Simvastatin 2,092 Woundcare 1,958 Dosulepin 1,784 Doxazosin MR 1,724 Tramacet (combination products paracetamol with tramadol) 1,713 Generic low cost statins 1,195 Gluten free spend 898 Coversyl arginine and branded coversyl 735 Gluten free items excl. all bread, flour & mixes 645 Travel vaccines not prescribable on the NHS 486 Eflornithine cream (vaniqua) for hirsutism 417 Cough and cold remedies 412 The Oral Nutritional Supplementation project has delivered significant savings over the current 12 months. Sarah Colson, Community Dietician has provided support to our member practices and care homes and developed a wealth of resources of information, including a care pathway and formulary guidelines. Presently Sarah is on maternity leave, although prescribing continues to be monitored for any concerning trends or anomalies. 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 12 of 24 Overall Page 141 of 160

142 OPERATIONAL DELIVERY Page Mental Health Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel M E N T A L H E A L T H Estimated Diagnosis rate for people w ith dementia % 70.0% 66.4% 66.4% 67.1% 67.1% 67.1% Improving access to psychologial therapy - roll out % 6.3% 29.7% 26.9% 25.0% 27.2% 20.5% Improving access to psychologial therapy - recovery rate % 50.0% 48.5% 57.8% 46.6% 51.0% 49.9% The proportion of people that w ait 6 w eeks or less from referral to entering a course of IAPT treatment against the The proportion of people that w ait 18 w eeks or less from referral to entering a course of IAPT treatment against the People experiencing a first episode of psychosis treated w ithin tw o w eeks of referral Number of patients in inpatient beds for mental and/or behavioural healthcare w ho have either learning disabilities and/or autistic spectrum disorder (inc. Asperger's syndrome) Number of admissions to inpatient beds for mental and/or behavioural healthcare w ho have either learning disabilities and/or autistic spectrum disorder (inc. Asperger's syndrome) Transforming Care Learning Disabilities: Number of patients discharged to community settings Transforming Care Learning Disabilities: Patients w ithout a care coordinator Transforming Care Learning Disabilities: Patients not on the register Transforming Care Learning Disabilities: Patients w ithout a review in the last 26 w eeks Last 3 Months % 75.0% 82.4% 91.4% 84.3% 86.0% 81.4% % 95.0% 98.6% 100.0% 99.0% 99.2% 98.2% % 50.0% 80.0% 0.0% 0.0% 0.0% 76.6% No No No No No No Estimated diagnosis rate for people with dementia Interim performance data in March 2016 shows that the CCG is achieving 67.1%, against a national target of 66.7%. However, the CCG remains below its target of achieving a stretch target of 70% by end of March Final performance for the year will be confirmed later in May IAPT Recovery Rate The CCG narrowly missed the recovery target in March. We have asked the provider to review the month s recovery figures as there were a number of drop outs from treatment and a number of people that missed recovery by only one point to ensure that these have been correctly recorded. Final data is submitted at the end of May. 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 13 of 24 Overall Page 142 of 160

143 FINANCE Page 13 4 QIPP & Delivery Programme Board updates This section of the report provides an overall summary of the CCGs QIPP programme. Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel Q I P P Prevention & Self Care QIPP, (35) (40) Urgent & Integrated Care QIPP,000 2,239 5 (121) (275) Planned & Specialist Care QIPP,000 3, (364) (2) 423 Other QIPP Schemes,000 1, ,562 6,746 TOTAL QIPP,000 7, ,968 7, Summary QIPP Performance With the close of the 2015/16 year end the CCG has successfully delivered its QIPP programme of 7.4m. Despite this, the CCG has been unable to deliver the levels of demand management planned for their acute contracts with the Cap & Collar agreement supporting the delivery of the in-year financial position. 2015/16 QIPP Programme Target 'm Last 3 Months Actual 'm Variance 'm Prevention & Self Care: Falls Pathway, Respiratory LES Urgent & Integrated Care: Integrated Out of Hospital Care Continuing Healthcare Planned & Specialist Care: Pathway Redesign Non-Frimley Activity Reductions Cancer Strategy & Heart Failure Community Nurse Prescribing Other Schemes: Corporate Costs Property Services Frimley Cap & Collar Remedial Actions (Inc. BCF) Total 2015/16 Saving Programme /17 Programme The 2016/17 Operating plan set out the projects that the CCG has developed for delivery through the new financial year and these are aligned to the 6 improvement programmes. The 46 projects developed through the planning cycle are split as follows; 1) Vanguard projects within the Vanguard programme 2) Strategy projects - projects from existing strategies 3) Commissioning projects standalone CCG projects 4) Collaborative projects projects as a result of the Mental Health collaborative and Children s collaborative 11 Projects ( 5 Project initiation documents produced as part of planning process) Strategies identified: Cancer Futures in Mind Medicines Optimisation Estates Information Technology 27 Project initiation documents, 7 schemes in development 6 Project initiation documents /17 Programme Monitoring Programme monitoring will be split into three levels; monthly exception reporting; quarterly updates; and annual reviews. Monthly exception reports will focus on delivery of plans against the milestones identified by each project and will be escalated to the Finance & Performance committee as required. QIPP Programmes The CCG outlined a QIPP programme totalling 7.5m for 2016/17. Two programmes; Allocative efficiency ; and Corporate Costs worth 1.75m in total have been adjusted 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 14 of 24 Overall Page 143 of 160

144 FINANCE Page 14 within opening budgets and will not be monitored in year. The remaining schemes relate to 5 of the projects outlined above with the Vanguard GP Practice Locality bids the single largest project worth 2.7m. QIPP relating to CHC worth 1m is made up of two equal elements; price savings delivered by West Hampshire through market management, and volume savings through increased assessments and reviews although this element of the programme is yet to be fully scoped. 5 Finance Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel F I N A N C E Last 3 Months Programme Expenditure, ,209 20,400 20,292 22,149 62, ,242 Running Costs,000 4, ,186 4,694 Surplus / (Deficit),000 2, ,695 3,926 Vanguard Expenditure,000 3, ,755 2,609 3,383 Better Payment Code % 95.0% 93.5% 95.7% 0.0% 94.7% 95.0% Capital Expenditure, Finance Summary The CCG has finalised the 2015/16 accounts and has delivered the planned surplus of 3.93m subject to confirmation from Audit. In line with NHS England guidance the CCG also ensured that minimal cash was held at the 31 st March /17 Plan The 2016/17 detailed financial plan was submitted to NHS England as part of the wider planning submissions. This set out a plan to maintain the current surplus as well as setting aside 0.5% contingency and a further 1% non-recurrent reserve. Unlike previous years the use of the 1% reserve is subject to national approval and the CCG are awaiting details behind this process. The plan also includes 26.5m of delegated Primary Care spend. demand management schemes are not only paramount for the operational delivery of the system, but are also crucial for the maintenance of the CCGs financial position. The Finance and Contracting teams are working to develop a robust challenge process for Frimley Health that will ensure the CCG only pays for valid activity. We will also ensure that operational pathways developed through previous years under the cap and collar arrangement are correctly documented and will ensure that these pathways are consistent with nationally set PbR tariffs. 5.4 Vanguard The North East Hampshire and Farnham Vanguard programme incurred costs totalling 3.4m in 2015/16 as set out in the table below, the programme are developing a finance plan for the new financial year. Authorised By Steering Board Pending Full Business Cases Value Proposition Category 15/16 Budget 1. Backfill 850, , Pump Prime 1,000, , Communication 175, , Evaluation 75,000 84, Behavioural Change 175, , PMO 500, , Other Enabling Costs 608, ,042 0 Total 3,383,000 3,383, Risks The movement of the Frimley Health Contract to a Payment by Results (PbR) contract significantly changes the risk profile of the organisation and means that delivery of 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 15 of 24 Overall Page 144 of 160

145 Workforce Page 15 6 Workforce Indicator Unit YTD Target Jan-16 Feb-16 Mar-16 QTD YTD Travel W O R K F O R C E Last 3 Months Permanent Staff in Post FTE Staff Turnover % 11.0% 12.7% 12.6% 13.9% 13.9% 13.9% Sickness Rate % 3.5% 3.2% 4.4% 3.8% 3.7% 2.5% Statutory & Mandatory Training % 85.0% 29.4% 29.4% 29.4% 29.4% 29.4% 6.1 Staff in Post There has been a minimal decrease in staffing levels over the previous 3 months at the CCG by 0.21 Full Time Equivalent (FTE). As at 31 st March 2016 the CCG has a headcount of 95 (81.25 FTE) staff members (which includes Governing Body Members but excludes Bank/Honorary/Agency/Interim staff) consisting of 68 FTE full time staff and FTE part time staff. There has been a minimal decrease in staffing levels over the previous 3 months at the CCG by 0.21 Full Time Equivalent (FTE). As at 31 st March 2016 the CCG has a headcount of 95 (81.25 FTE) staff members (which includes Governing Body Members but excludes Bank/Honorary/Agency/Interim staff) consisting of 68 FTE full time staff and FTE part time staff. In the current structure the FTE within bands 8a and above plus Other (including Very Senior Managers and Clinical Leads) account for 68% of the workforce. Those represented as other in Figure 1 are all staff members not currently on Agenda for Change bandings such as VSMs and Governing Body Members. Staff in Post (FTE excl. temp and Interim) In the current structure the FTE within bands 8a and above plus Other (including Very Senior Managers and Clinical Leads) account for 68% of the workforce. Those represented as other in Figure 1 are all staff members not currently on Agenda for Change bandings such as VSMs and Governing Body Members. 6.2 Staff Turnover As at 31 st March 2016 the annual staff turnover is recorded as 13.87%. That value has slightly increased when compared to the 13.03% at the end of December 2015, as outlined in the previous report. This increase put the CCG slightly above the national target of 13% and it is recognised that the measures continues to be put in place to mitigate the effects higher turnover has on staff and the CCG. 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 16 of 24 Overall Page 145 of 160

146 Workforce Page 16 Leavers by length of service & reason 6.3 Sickness Rate Recorded sickness absence rates across the CCG have been fluctuating marginally with one visible spike in November 2015 and February Although month by month the overall trend was increasing in the Q3, it was showing a decreasing trend in Q4 and the quarterly sickness absence rate currently stands at 3.79% 11. (FINAL) Integrated Performance Report month 1 GB.pdf Page 17 of 24 Overall Page 146 of 160